Ejaculation-preserving holmium laser enucleation of the prostate: a systematic review of techniques, functional outcomes, and safety
Abstract
Context Holmium laser enucleation of the prostate (HoLEP) is a guideline-endorsed, size-independent surgical standard for benign prostatic hyperplasia (BPH). However, conventional HoLEP is frequently associated with loss of antegrade ejaculation (AE), an outcome of increasing importance for sexually active patients. Anatomically informed modifications aimed at preserving peri-ejaculatory structures have been proposed, yet the evidence supporting antegrade ejaculation-preserving HoLEP (EP-HoLEP) remains fragmented. Objective To systematically review and synthesize the contemporary evidence on ejaculation-preserving HoLEP techniques, focusing on ejaculatory outcomes, urinary function, and surgical safety. Evidence Acquisition A systematic literature search of PubMed and Embase was conducted in accordance with the PRISMA 2020 guidelines to identify studies evaluating EP-HoLEP techniques published through December 2025. Randomized controlled trials, prospective comparative studies, and retrospective cohorts reporting ejaculatory outcomes were eligible. Risk of bias was assessed using RoB 2, ROBINS-I, and MINORS tools as appropriate. Evidence Synthesis Ten studies encompassing 1,675 patients were included, comprising three randomized controlled trials, four non-randomized comparative studies, and three single-arm case series. EP-HoLEP techniques were categorized as ejaculatory hood–sparing, mucosal and sphincter-sparing (including modified two-lobe and Double-n techniques), and…
How strong is the evidence?
Evidence Hub reads this as a systematic review, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 1,675 participants or records.
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