Holmium Laser Enucleation of the Prostate (HoLEP) with Ejaculatory Preservation technique sparing specific mucosal and muscular structures to reduce retrograde ejaculation and urinary incontinence
Target Population
Sexually active men with BPH, prostate size 40-80g, IPSS >20, Qmax <10 ml/s, normal erectile function (IIEF-5 >22), without systemic disease or neurological disorders affecting ejaculation
Care Setting
Single-center surgical setting with experienced urologists performing HoLEP under spinal anesthesia
Key Highlights
Standard HoLEP is associated with high rates of retrograde ejaculation (~64.7%) and transient urinary incontinence (3.3% to 26%).
Ejaculatory Preservation (EP) HoLEP technique involves preserving mucosal strips and muscular structures near the verumontanum and bladder neck to maintain antegrade ejaculation.
Prospective randomized study comparing EP HoLEP to standard HoLEP with primary endpoints of early postoperative continence and retrograde ejaculation rates.
Guideline-Based Recommendations
Diagnosis
Assess prostate size by transrectal ultrasound (TRUS).
Evaluate symptoms using International Prostate Symptom Score (IPSS) and uroflowmetry (Qmax).
Assess sexual function with International Index of Erectile Function-5 (IIEF-5) and Male Sexual Health Questionnaire-Ejaculatory Dysfunction Short Form (MSHQ-EjD-SF).
Exclude patients with systemic diseases or neurological disorders affecting ejaculation.
Management
Perform HoLEP under spinal anesthesia with prophylactic intravenous antibiotics.
Standard HoLEP follows Gilling’s technique for enucleation.
EP HoLEP preserves approximately 10mm proximal to verumontanum and 5mm paracollicular mucosa, sparing mucosal attachments at bladder neck (5, 7, 2, 10 o’clock positions) to preserve ejaculation.
Use 26F continuous flow resectoscope with 100W holmium-YAG laser set at 1.5–2 J and 40–50 Hz.
Monitoring & Follow-up
Follow-up at 1, 3, and 6 months postoperatively.
Monitor urinary continence using ICIQ-UI SF questionnaire.
Assess LUTS relief with IPSS, Qmax, and quality of life (QoL) scores.
Evaluate sexual function and ejaculation with IIEF-5 and MSHQ-EjD-SF scores.
Record perioperative adverse events including stress and urge urinary incontinence.
Risks
Transient urinary incontinence occurring in 3.3% to 26% of patients, usually resolving within one year.
High incidence of retrograde ejaculation (~64.7%) following standard HoLEP.
Potential perioperative complications related to surgical technique and patient comorbidities.
Patient & Prescribing Data
Men with symptomatic BPH, prostate size 40-80g, sexually active with preserved erectile function, without systemic or neurological contraindications.
EP HoLEP technique may reduce rates of retrograde ejaculation and improve early postoperative continence compared to standard HoLEP, potentially enhancing patient satisfaction and sexual quality of life.
Clinical Best Practices
Careful patient selection excluding those with systemic or neurological conditions affecting ejaculation.
Use of standardized assessment tools (IPSS, ICIQ-UI SF, IIEF-5, MSHQ-EjD-SF) pre- and postoperatively for comprehensive evaluation.
Meticulous surgical technique preserving key anatomical structures (mucosal strips at bladder neck and near verumontanum) to maintain antegrade ejaculation.
Experienced surgeons with high procedural volume to minimize complications.
Regular postoperative follow-up to monitor continence, sexual function, and LUTS relief.
