Holmium laser enucleation of the prostate (HoLEP): a narrative review of sexual side effects

Introduction

Benign prostatic hyperplasia (BPH) is one of the most prevalent urological conditions, with an estimated annual healthcare cost of approximately $1.1 billion in the United States (1). BPH is a leading contributor for the development of lower urinary tract symptoms (LUTS) in men as they age. It is estimated that the prevalence of BPH at autopsy is as high as 50% to 60% for males in their 60s and that rate increases to 80% to 90% for men over the age of 70 years (2).

Holmium laser enucleation of the prostate (HoLEP) has emerged as a durable, effective, and minimally invasive treatment option for men with BPH (3,4). Despite the success of HoLEP in men with BPH, it is not without postoperative side effects. Both sexual and non-sexual related side effects have been documented (5,6). Additionally, growing awareness of these sexual consequences has contributed to the development of minimally invasive surgical therapies (MISTs), such as UroLift, Rezūm, and Aquablation, which emphasize preservation of antegrade ejaculation, albeit with trade-offs in long-term durability (7).

Given the increasing importance of sexual outcomes in patient-centered decision-making, a focused review of the sexual side effects of HoLEP is needed. This review synthesizes current evidence on HoLEP-related ejaculatory, erectile, and orgasmic changes and evaluates their clinical relevance within the broader landscape of BPH surgical options. We present this article in accordance with the Narrative Review reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-735/rc).

Methods

A search of the medical literature was carried out in PubMed and Medline to identify peer-reviewed, original research and systematic reviews on the side effect profile of HoLEP, particularly the sexual side effect profile. The search included all publications from database inception through October 2025. The strategy combined both Medical subject headings (MeSH) and free-text keywords to capture three conceptual domains: (I) BPH (including terms such as “prostatic hyperplasia”, “benign prostatic hyperplasia”, “BPH”, “prostate enlargement”, and “lower urinary tract symptoms”); (II) the HoLEP procedure (including “holmium laser enucleation of the prostate”, “holmium laser enucleation”, “HoLEP”, and variations of the procedural terminology); and (III) postoperative sexual function (including MeSH terms and keywords related to “sexual dysfunction”, “erectile dysfunction”, “ejaculation”, “orgasm”, “penile erection”, “libido”, “sexual satisfaction”, and “sexual side effects”).

These three domains were combined using Boolean operators to ensure that all retrieved studies specifically addressed sexual outcomes following HoLEP. No limits were applied for study design, comparator group, or publication type. Language limits were not applied during the initial search; instead, English-language availability was determined during screening. The search identified 243 records, all of which were screened after deduplication. Studies were included if they (I) evaluated HoLEP; (II) reported sexual function outcomes using patient-reported measures or validated instruments; and (III) provided original data. Screening was performed by one author. After screening, 216 records were excluded. Twenty-seven full texts were assessed, and 1 were excluded as an editorial commentary. Twenty-six studies were included in the qualitative synthesis (Figure 1, Table 1).

Figure 1 PRISMA flow diagram.

The narrative review summarizes the findings from studies deemed to be most relevant and impactful in understanding the sexual side effects associated with HoLEP. The literature is summarized in Table 2.

Discussion

Ejaculatory dysfunction

Retrograde ejaculation (RE) is a known side effect of transurethral procedures for outlet obstruction, with rates of RE up to 70–80% following transurethral resection of the prostate (TURP) (8). HoLEP is no exception and has reported rates of RE up to 96%, which is significantly higher than TURP (9).

There are two predominant theories for the mechanism of ejaculatory dysfunction in endoscopic surgery for BPH. The first is that under normal anatomy, retrograde passage of semen is prevented by reflex closure of the bladder neck. Endoscopic surgeries for BPH disrupt this mechanism and thus lead to RE (10). The second theory is that paracollicular and supracollicular tissues, often described as muscularis ejecularis, which are located 1 cm proximal to the verumontanum, are responsible for anterograde ejaculation (11).

RE is variably defined in the literature. Some define RE as reduced volume of anterograde ejaculate during sexual climax, others would define RE as complete absence of semen fluid or detection of semen on a post-ejaculatory urine sample (12-15). As such, there can be a heterogeneity in the reported literature as it pertains to the rates of RE after HoLEP. Because studies use inconsistent definitions, assessment tools (validated vs. non-validated questionnaires), and follow-up intervals, the reported rates of RE after HoLEP vary widely and are not directly comparable across studies. This methodological heterogeneity limits the ability to draw definitive conclusions about the true incidence of RE and complicates interpretation of the literature.

Gild et al. evaluated the prevalence of RE after HoLEP in one of the largest cohorts and found 92.5% of patients experienced RE after HoLEP (16). Other studies, with smaller cohorts, have found the prevalence of RE after HoLEP to range between 70% and 83% of patients (6,16). Other authors who have assessed sexual outcomes after HoLEP, although not directly measuring postoperative rates of RE, have anecdotally reported a high prevalence and even counsel their patients that the incidence of RE approaches 100% following the procedure (17).

Male sexual health is multifaceted and includes erectile function, libido, capability of orgasm, and ejaculatory function amongst other components. Importantly, the current body of literature contains relatively few prospective studies designed specifically to evaluate sexual function outcomes following HoLEP. Most data are derived from retrospective cohorts or studies where sexual outcomes were secondary endpoints. Moreover, some studies may rely on databases and registry data which use diagnosis codes only, that can underreport, inaccurately code, or not capture nuanced sexual outcomes postoperatively. As such, definitive conclusions should be drawn with caution. Nevertheless, despite the high rates of RE after HoLEP, its mere presence does not seem to have adverse impacts on overall sexual function (18,19).

Several studies have demonstrated declines in orgasmic function associated with postoperative RE. Kim et al. reported a high rate of RE following HoLEP and found that more than half of affected men experienced decreased orgasmic intensity (8). Similarly, Briganti et al. observed a significant decline in orgasmic function attributable to postoperative RE (6). However, larger cohort studies indicate that RE itself is not independently predictive of diminished sexual satisfaction; rather, satisfaction decreases primarily among men who report being bothered by the loss of antegrade ejaculation (16). Moreover, prospective evaluations of sexual outcomes after HoLEP have shown that although RE is common, overall sexual function and satisfaction generally remain stable postoperatively (17,20).

It is important to counsel patients regarding the high prevalence of RE following HoLEP. A subset of patients—particularly those who are bothered by ejaculatory changes—may experience reductions in orgasmic quality or sexual satisfaction. However, urologists should also recognize that RE, in isolation, does not significantly affect overall sexual function in men.

Erectile dysfunction (ED)

ED is a recognized potential complication following TURP. Penile erection is mediated by parasympathetic activation of the cavernosal nerves, which release nitric oxide and trigger a cGMP-dependent cascade leading to smooth muscle relaxation, arterial dilation, and cavernosal engorgement (21). The development of ED after TURP is thought to result primarily from direct or thermal injury to these nerves responsible for erectile function during the resection of prostate tissue. Reported rates of new-onset ED after TURP vary across studies but generally range from 4% to 14% of patients (22-25).

There are conflicting reports in regards to the development of ED after HoLEP. However, the majority of the literature seems to indicate that there is little to no impact on erectile function after HoLEP. Some studies, such as those by Elshal et al. and Deslandes et al., which were a prospective control trial and a multicenter retrospective study, respectively, have identified a small subset of men—particularly those with normal preoperative erectile function—who may experience a mild but statistically significant decrease in erectile function scores after surgery (25,26). Capogrosso et al., who performed long-term follow-up on post-HoLEP patients, noted that up to 37% of patients worsened by at least one International Index of Erectile Function (IIEF) category postoperatively. However, these patients were significantly older, and the decline in erectile function was attributed to age (27). Multiple studies have documented transient ED following prostate biopsy. Similar to HoLEP, prostate biopsy is a non-thermal, non-electrosurgical procedure with no obvious mechanistic effect on erectile anatomy (28). This phenomenon underscores the complex interplay between psychological and anatomical factors in ED.

Larger cohort studies by Klett et al. and Roper et al. together evaluated nearly 700 men undergoing HoLEP and found no significant change in erectile function from baseline when assessed with validated IIEF instruments. These studies also provide some of the longest available follow-up, with Klett et al. assessing erectile function up to 36 months postoperatively and Roper et al. reporting outcomes through 12 months (18,29).

Overall, there seems to be a very small but non-negligible risk of worsening erectile function after HoLEP.

Effects on orgasm

We have thus far discussed HoLEP and its association with postoperative RE and ED. Both of these outcomes directly influence the male orgasm, which is a complex experience involving erectile function, ejaculatory function, and libido.

Multiple studies have evaluated orgasmic perception and sexual satisfaction in men following HoLEP (6,17,25). These studies consistently report that HoLEP results in high rates of RE, which can lead to a measurable decline in orgasmic sensation or ejaculatory function. However, overall sexual satisfaction and erectile function are generally not adversely affected (6,17,25). Importantly, most men do not find the loss of antegrade ejaculation particularly bothersome, and their overall satisfaction with sexual life remains stable. In our practice, it is also important to note that a number of these men will have preoperative RE or anejaculation due to the size of their prostates, age-related decline, or the side effects of BPH medications (30,31).

Elshal et al. performed a prospective study examining sexual function in men undergoing HoLEP (25). They examined 80 patients after HoLEP at 1 year and found that there was a significant reduction in orgasm perception, although there was no difference compared to control in overall intercourse satisfaction (25). Similarly, Meng et al. studied 108 men at 6 months post-HoLEP using standardized sexual function questionnaires (17). They observed a significant increase in the incidence of RE but no significant change in overall sexual function scores (17). Briganti et al. also examined sexual function in 60 perioperative HoLEP patients at baseline, 12, and 24 months. Similarly, the authors found high rates of RE, which they reported had no negative effect on sexual function (6). Overall, HoLEP frequently affects ejaculation and may alter orgasmic quality, and while most patients report acceptable sexual outcomes, clinically meaningful changes occur in a subset of men.

Men undergoing HoLEP should be counseled that RE is common and may influence orgasmic perception. Although many men maintain stable overall sexual satisfaction, a proportion will experience declines in orgasmic quality or erectile function, particularly if they find the loss of ejaculation bothersome. Thorough preoperative counseling and attention to patient expectations are essential to reducing postoperative regret.

Incontinence and non-sexual side effects

Complications after HoLEP are not limited to sexual side effects. In general, non-sexual complications following HoLEP are reported to occur between 0.3% to 6% (4).

The most common complications after HoLEP are urinary stress incontinence and urge incontinence. Urinary continence is maintained by the coordinated function of the internal urethral sphincter and the external urethral sphincter, both of which provide urethral coaptation and prevent leakage during increases in abdominal pressure. These sphincteric structures are supported by the puboprostatic ligaments, endopelvic fascia, and levator ani complex, which stabilize the bladder neck and urethra and maintain continence through a dynamic “sling” mechanism. Disruption or irritation of these anatomic supports—from surgical manipulation—can transiently impair sphincter function and contribute to postoperative stress incontinence (21). These symptoms are most prevalent during the first few months following surgery. However, their frequency decreases significantly over time (32). One study found the incidence of urinary incontinence post HoLEP was 43%, 15%, and 5.8% at 6 weeks, 3 months, and 1 year follow-up, respectively (33). According to Krambeck et al., the prevalence of both stress and urge incontinence drops dramatically by 12 months post-surgery, affecting as few as 2% of patients (4).

Other notable complications following HoLEP include urethral stricture and bladder neck contracture (BNC), though both are relatively uncommon. The incidence of urethral stricture after HoLEP is low, with most studies reporting rates between 1.2% and 5% (4,34). Similarly, BNC occurs infrequently, with reported rates typically ranging from 0.8% to 6.7% (34).

Evidence suggests that smaller prostate gland size may increase the risk of BNC after surgery, prompting some surgeons to routinely incise the bladder neck in prostates smaller than 40 g to reduce this risk (4).

Bladder injury related to morcellation is rare. For example, in a series of over 1,000 HoLEP cases, only a single bladder injury (0.01%) was reported during morcellation (4). Currently, the most commonly used morcellators include the Wolf Piranha ™ and the Lumenis VersaCutTM. Early series using the Lumenis VersaCut™ mechanical morcellator reported superficial bladder mucosal injury rates between 0.7% and 5.7% and bladder perforation in approximately 0.1–1.5% of cases (35). Comparative studies of the Wolf Piranha™ vs. VersaCut™ and other devices suggest that Piranha™ generally achieves higher or comparable morcellation efficiency (5–6 g/min) with similarly low bladder injury rates (1–2%), whereas VersaCut™ may have somewhat higher mucosal injury rates in some series (36,37). Although morcellation-related bladder injury is an important and distinctive complication of HoLEP, it is infrequent when modern morcellators are used with good visualization and appropriate technique.

Lastly, other complications from HoLEP include bleeding requiring transfusion and the need for reoperation due to regrowth of prostatic tissue. The reported rate of bleeding requiring transfusion after HoLEP ranges from approximately 0.8% to 5%, depending on the patient population and anticoagulation status (38,39). The reported rate of reoperation following HoLEP is low, indicating a durable response. He et al. reported a reoperation rate at 5 years to be around 6.6% (40). Another large retrospective study of around 1,000 patients reported a reoperation rate of around 3.7% at 5 years (41).

Although the above complications are traditionally classified as non-sexual, several can have important secondary effects on sexual health and overall well-being. Transient or persistent urinary incontinence may lead to embarrassment, avoidance of sexual activity, and reduced sexual confidence (42). Urethral stricture, while uncommon, can cause voiding dysfunction, discomfort, and patients typically report poor force of ejaculation, reduced ejaculatory volume, and reduced pleasure (43). Thus, while non-sexual in nature, these complications may still exert meaningful indirect effects on postoperative sexual outcomes and should be considered during preoperative counseling.

Surgical approaches to reduce sexual side effects

As discussed, RE is a known side effect of TURP and HoLEP. To address this, surgical modifications have been developed to minimize the risk of postoperative RE. These surgical approaches have paralleled the transition in HoLEP techniques, which have evolved from three- and two-lobe to en bloc enucleation techniques (44). One such approach involves a limited resection, targeting only the median lobe of the prostate (45). This technique has recently been adapted for use with HoLEP. In a retrospective study, Press et al. reviewed 55 men with a median prostatic lobe who underwent HoLEP with selective enucleation of the median lobe. Postoperative assessment included patient-reported rates of RE. Remarkably, 90% of those who received the limited resection technique preserved anterograde ejaculation (46).

Another surgical technique proposed has been an ejaculatory hood-sparing technique to HoLEP. One small study examined 26 patients who underwent a limited HoLEP resection where tissue >1 cm proximal to the verumontanum was preserved. However, there was no difference in preservation of ejaculatory function between these men and men undergoing standard HoLEP (47). An additionally modified 2-lobe technique has been discussed in the literature where the mucous membrane of the bladder neck, circular fibers of the internal urinary sphincter, and urethral membrane from the 11 to 1 o’clock position are preserved (48). The authors of this paper found that the prevalence of RE after HoLEP dropped from around 64% to 33% (45).

Other modified surgical techniques that attempt to minimize RE include an omega-shaped pre-transection of the prostate apex and preservation of the bladder neck as described by Zhang et al. In their study, 165 men underwent HoLEP with this modified technique with a reported rate of RE of 11.52% (49). These modified surgical techniques to preserve antegrade ejaculation extend beyond HoLEP into urethral-sparing modifications to robot-assisted simple prostatectomy (RASP). Porpiglia et al. described a urethral-sparing RASP (usRASP) technique in a prospective cohort of 92 men with large prostates (>80 mL), demonstrating preservation of antegrade ejaculation in 81% of sexually active men at 12 months while achieving effective deobstruction and symptom improvement (50).

Although these emerging techniques are promising with respect to ejaculatory preservation, they share several important limitations. Most reports are retrospective, single-center series with relatively small, selected populations, and the procedures are highly operator-dependent. In many cases, follow-up is short, and long-term urinary outcomes, de-obstructive efficacy, and reoperation rates are not well established. By intentionally limiting the extent of resection or altering the classical HoLEP plane, there is a theoretical risk of higher residual obstruction or need for reintervention, which may offset the benefits of ejaculation preservation for some patients.

Emerging techniques in HoLEP—including limited median lobe resection, ejaculatory hood sparing, and the modified 2-lobe technique—demonstrate potential for preserving ejaculatory function. Although results vary, previous studies are limited by small populations, and results are bound to vary between surgeons. These emerging techniques illustrate an effort to balance optimal urinary outcomes with preserved sexual function. Surgeons must carefully weigh the potential for improved ejaculatory outcomes against the uncertain long-term durability of symptom relief. Until robust prospective data with longer follow-up are available, these approaches should be considered early-stage, operator-dependent adaptations, and patients should be counseled explicitly about the trade-off between ejaculatory preservation and de-obstructive durability.

Alternatives to HoLEP

BPH is among the most common urologic conditions, consuming substantial healthcare resources annually (1). Given the significant financial impact associated with BPH management and treatment, it is unsurprising that the range of therapeutic options continues to expand beyond TURP or HoLEP to address this growing clinical need.

There are multiple factors that are taken into consideration when assessing which outlet procedure would be most suitable for a given patient. This includes patient comorbidities, prostate volume, how invasive the procedure is, and patient desired side effect profile.

The American Urological Association (AUA) endorses several different minimally invasive treatment options for men who have gland size between 30 and 80 g. These options include Urolift, Rezum, and Aquablation (51). It is important to note that all three of these options are touted to preserve or at least have a lower risk of impacting sexual function. This includes erectile function and antegrade ejaculation (52,53). A systematic review examining outcomes of more minimally invasive options for BPH found an anejaculation rate of 3% with Rezum and 0% with Urolift. Additionally, the retreatment rate was low for these treatment options, although follow-up was only out to 24 months (54). While these options for BPH may not be as definitive as HoLEP, they do offer men an option if they are concerned about preserving ejaculatory function.

There are other alternatives for men with BPH who may be unfit for surgery. One option includes prostate artery embolization (PAE). There have been a large number of studies that have investigated PAE that have shown both technical and clinical success, which has been defined as improvement in the International Prostate Symptom Score (IPSS) (55-62). Various studies have reported the clinical success rate of around 85% at 12 months and 82% at 1–3 years. However, the literature also seems to indicate a high degree of reintervention rates around 30% to 60% in patients more than 5 years post PAE (63). Despite this, PAE remains a strong option for men with severe comorbidities who are not candidates for invasive procedures such as HoLEP.

Nevertheless, HoLEP consistently demonstrates high satisfaction scores (64). When compared with TURP, HoLEP has yielded superior IPSS and quality of life scores and greater long-term durability, as evidenced by a lower retreatment rate (65-67). Additionally, when compared directly to minimally invasive options such as Aquablation, HoLEP has been shown to have superior deobstructive efficacy as evidenced by a greater Qmax and PSA outcomes (68).

The armamentarium to treat BPH is large. With the numerous interventions that have come to market and the varying side effect profiles with each one, it is important for the urologist to consider the patient preference, patient comorbidities, durability of the treatment option, and specific side effect profiles to each intervention.

Conclusions

HoLEP is a durable, effective, and safe treatment for men with BPH. However, the current evidence evaluating sexual side effects—particularly RE, orgasmic changes, and the small but meaningful risk of postoperative erectile decline—is limited by several factors. Most available studies are single-center retrospective cohorts with relatively small sample sizes, heterogeneous definitions of sexual outcomes, and variable follow-up durations. As such, conclusions about the true incidence and clinical significance of sexual side effects must be interpreted with caution.

Although there is a non-negligible proportion of men who report bothersome RE, diminished orgasmic sensation, or, less commonly, declines in erectile function, most studies suggest that this side effect generally does not significantly diminish overall sexual satisfaction or well-being for the majority of patients.

Finally, the ability to decipher medical terminology by a patient should not be assumed. Orgasm and ejaculation are easily confabulated, and a careful discussion with the patient using laymen’s terms or non-medical terminology is essential to avoiding procedural regret, as postoperative sexual experiences may differ from preoperative expectations.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-735/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-735/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-735/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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