Erectile and ejaculatory outcomes after holmium laser enucleation of the prostate: A comprehensive narrative review

Abstract

Holmium laser enucleation of the prostate (HoLEP) has emerged as a widely adopted surgical technique for the management of benign prostatic hyperplasia (BPH), regardless of prostate size; however, its impact on male sexual function—particularly in terms of erectile and ejaculatory outcomes—remains a subject of ongoing debate. The aim of this study is to critically evaluate the effects of HoLEP on male sexual function (SF), with emphasis on erectile and ejaculatory outcomes, intraoperative considerations, and comparative effectiveness versus other surgical treatments for BPH. The narrative review was conducted using PubMed, Web of Science, and Google Scholar to identify English-language clinical studies, cohort trials, randomized controlled trials, and meta-analyses published between January 2000 and May 2025. Included studies evaluated SF before and after HoLEP using validated tools such as the International Index of Erectile Function (IIEF) and the Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD). The literature indicates that HoLEP has a neutral to modestly favorable effect on erectile function (EF). Transient declines may occur in the early postoperative period, with most patients returning to baseline by three to six months. In contrast, retrograde ejaculation is a frequent and expected outcome, with incidence rates typically ranging from 74% to 78%. While various surgical modifications—such as modified enucleation techniques and partial apical preservation—have demonstrated potential in preserving ejaculatory function, outcomes remain inconsistent and poorly standardized. HoLEP is an effective and durable treatment for BPH with a stable EF profile but a high likelihood of ejaculatory dysfunction. Although promising ejaculation-sparing techniques exist, robust evidence supporting their routine use is lacking. Future research should focus on standardized intraoperative strategies, validated patient-reported outcome measures, and personalized approaches to optimize both urinary and sexual outcomes.

Keywords

benign prostatic hyperplasia / ejaculation - preserving HoLEP / ejaculatory dysfunction / holmium laser enucleation of the prostate / sexual dysfunction

1 INTRODUCTION

Benign prostatic hyperplasia (BPH) is a common, age-related condition characterized by nonmalignant prostate enlargement. Histological changes often begin in the fourth decade, and by age 80, up to 80% of men are affected[1,2]. BPH may lead to lower urinary tract symptoms (LUTS), which in turn can contribute to impaired quality of life, sleep disturbances, reduced mobility, increased anxiety and depression, and sexual dysfunction[3,4]. Both pharmacological and surgical treatments are effective in improving symptoms and quality of life[5,6].

For patients with moderate-to-severe LUTS unresponsive to medical therapy, surgery remains the gold standard. Among available options, holmium laser enucleation of the prostate (HoLEP) offers durable and size-independent efficacy with favorable safety; consequently, its role among surgical treatments for BPH is expanding, and it is being performed with increasing frequency[7]. Nonetheless, its potential impact on sexual function (SF)—particularly erectile and ejaculatory outcomes—continues to raise clinical concern. While alleviating LUTS may improve SF[8], surgical intervention near neurovascular and ejaculatory structures can also lead to deterioration. Therefore, prostate-directed therapies may exert dual—beneficial or adverse—effects on sexual health. As HoLEP is being performed more frequently, it has become increasingly important to examine its effects on SF.

In addition, there is a lack of consensus on optimal techniques for preserving ejaculation, and comparative data across surgical modalities remain inconclusive. Given the increasing emphasis on postoperative quality of life in men undergoing HoLEP, a comprehensive and clinically relevant synthesis of current evidence is warranted to inform surgical decision-making regarding erectile and ejaculatory outcomes. This narrative review aims to address this gap by integrating recent findings, highlighting key intraoperative considerations, and providing practical insights to guide surgical decision-making.

2 MATERIALS AND METHODS

This narrative review was conducted to evaluate the impact of HoLEP on male SF, with a specific focus on erectile and ejaculatory outcomes. A comprehensive literature search was performed in PubMed, Web of Science, and Google Scholar databases for articles published between January 2000 and May 2025. Only peer-reviewed studies written in English were considered.

Search terms included: “HoLEP,” “Holmium laser enucleation of the prostate,” “benign prostatic hyperplasia surgery,” “erectile dysfunction,” “ejaculatory dysfunction,” “sexual function,” “lower urinary tract symptoms,” and “postoperative outcomes.” Boolean operators and Medical Subject Headings (MeSH) terms were used to refine search results. Reference lists of included studies and relevant reviews were manually screened to identify additional eligible articles.

Clinical studies, including randomized controlled trials, prospective and retrospective cohort studies, and systematic reviews or meta-analyses, were included if they evaluated erectile or ejaculatory outcomes before and after HoLEP using validated instruments such as the International Index of Erectile Function (IIEF) or the Male Sexual Health Questionnaire–Ejaculatory Dysfunction Short Form (MSHQ-EjD-SF).

Due to the heterogeneity in outcome measures, follow-up durations, and surgical techniques across studies, a quantitative meta-analysis was not feasible. Instead, data were synthesized narratively, with particular emphasis on trends in functional outcomes, intraoperative techniques, and comparisons with alternative BPH surgical modalities. The review adhered to best practices for narrative synthesis of evidence in surgical urology. No formal risk of bias assessment was performed.

3 UNDERLYING MECHANISMS OF SEXUAL DYSFUNCTION IN BPH

3.1 Mechanisms linking BPH and erectile dysfunction (ED)

BPH, LUTS, and ED frequently coexist in aging men, and an expanding body of evidence supports their interconnected pathophysiology. Several mechanisms have been proposed to underlie LUTS associated with BPH, including autonomic nervous system overactivity, nitric oxide (NO)–cyclic guanosine monophosphate (cGMP) signaling impairment, chronic inflammation with RhoA/Rho-kinase activation, and pelvic atherosclerosis[9,10]. These contribute to increased smooth muscle tone, tissue hypoxia, neural damage, and bladder dysfunction[11]. Through these interrelated mechanisms, LUTS can develop as a consequence of impaired neural and endothelial function in the lower urinary tract.

Notably, similar mechanisms are implicated in the development of ED. The NO–cGMP pathway is essential for penile smooth muscle relaxation and erection; its disruption, along with Rho-kinase overactivation, leads to impaired vasodilation and corporal smooth muscle contractility[12]. In parallel, heightened sympathetic tone via α1-adrenergic receptor activation may exacerbate penile vascular resistance. Pelvic atherosclerosis reduces penile arterial inflow, compromising tissue perfusion and erection quality[13]. In addition, shared systemic risk factors—including metabolic syndrome, insulin resistance, hypertension, obesity, and dyslipidemia—promote endothelial dysfunction and microvascular compromise in both the prostate and penile vasculature[14]. These overlapping vascular and neurogenic abnormalities contribute to the coexistence and bidirectional relationship between LUTS and ED.

The recognition of these shared pathways has led to the development of dual-target treatment strategies. Notably, phosphodiesterase type 5 inhibitors (PDE5-Is), originally introduced for ED, has shown efficacy in relieving LUTS by enhancing NO-mediated smooth muscle relaxation across the bladder, prostate, and penile tissue[15]. Tadalafil 5mg once daily is currently the only PDE5-I approved for the concurrent treatment of ED and LUTS.

3.2 Mechanisms linking BPH and ejaculatory dysfunction (EjD)

EjD is a frequently underrecognized yet highly prevalent consequence of both BPH and its surgical management. EjD encompasses a spectrum of disorders, including retrograde ejaculation (RE), anejaculation, reduced ejaculate volume, and painful ejaculation—all of which may significantly impair sexual satisfaction and overall quality of life[16].

The physiological mechanisms underlying normal ejaculation—and, by extension, the pathophysiology of EjD—are complex and not fully elucidated. Ejaculation consists of two coordinated phases:

Emission—The movement of sperm and seminal fluid from the distal epididymis, vas deferens, seminal vesicles, and prostate into the prostatic urethra.

Expulsion—The forceful ejection of semen through the urethral meatus.

These phases are governed by the sympathetic, parasympathetic, and somatic nervous systems, and involve rhythmic contractions of smooth and striated muscles in the reproductive tract[17].

In a multinational study conducted across five European countries involving 927 men aged 36–92 years with LUTS associated with BPH, EjD, defined as reduced semen volume or absence of ejaculation, was reported in 63% of participants. In contrast, pain or discomfort during ejaculation was less commonly reported, occurring in 23% of cases[18]. In the context of BPH, the pathophysiology of EjD is multifactorial. The prostatic urethra, ejaculatory ducts, and verumontanum are anatomically situated within the transition zone of the prostate. As the prostate enlarges due to hyperplasia, mechanical compression, or disruption of these structures may occur, potentially interfering with both the emission and expulsion phases of ejaculation. Additionally, bladder outlet obstruction can impair bladder neck closure and neuromuscular coordination, contributing to retrograde flow of semen into the bladder or ineffective ejaculatory propulsion.

4 HOLEP AND SEXUAL FUNCTION: CURRENT EVIDENCE

4.1 HoLEP and erectile function (EF)

Recent studies evaluating the impact of HoLEP on EF have yielded mixed but generally reassuring results. Deslandes et al. reported no statistically significant difference in median IIEF-5 scores at 3 months and 12 months following HoLEP, suggesting minimal impact on short- to mid-term EF[19]. Similarly, in a prospective study involving 277 patients with a 12-month follow-up, no significant change in EF was observed, with a modest mean improvement of +1.8 points in IIEF-5 scores[20]. In a study with a relatively longer follow-up period, Klett et al. documented a slight decline of -1.5 points in IIEF-5 scores at 36 months in a cohort of nearly 400 patients, though this change was not considered clinically meaningful[21]. In a controlled study comparing HoLEP patients to those undergoing cystoscopic surveillance, a decrease in EF was noted in both groups, but no significant difference was observed between them, suggesting that the decline may not be attributable solely to a surgical intervention such as enucleation[22].

Several studies have reported outcomes not only based on mean EF scores but also by emphasizing the proportion of patients experiencing clinically meaningful individual changes. In a study by Placer et al., no substantial shift in group-level EF scores was observed; however, a ≥ 5-point increase or decrease in IIEF-5 score was reported by 6.9% and 12.4% of patients, respectively[23]. Similarly, another investigation using the Erection Hardness Score (EHS) found no statistically significant change in overall scores, yet 35.2% of patients experienced some degree of worsening in erection quality following HoLEP. A preoperative prostate volume greater than 100 cm³ was identified as an independent predictor of this decline[24]. Meng et al. provided further insights by evaluating the frequency of spontaneous early morning erections, which increased significantly from 45% preoperatively to 62% at six months postoperatively (p < 0.01), reflecting potential improvements in sexual well-being[25].

Interestingly, some studies have reported significant improvements in EF within the first three months after HoLEP. In a large cohort of 427 patients, a mean increase of +5.6 points in IIEF-5 scores was observed at the 3-month follow-up. This early improvement was attributed to the relief of neurovascular bundle compression caused by prostatic enlargement and to enhanced voiding function. Notably, patients who achieved better postoperative urinary outcomes were also more likely to report improvements in EF, suggesting a potential interplay between LUTS resolution and sexual health[26].

In a long-term follow-up study involving 135 patients over a 10-year period, a significant decrease of -3.9 points in IIEF-EF domain scores was reported. This decline was more prominent among older patients. Only nine patients (6.7%) experienced a minimum clinically important difference (MCID) improvement in EF following surgery. Interestingly, lower baseline IIEF-EF scores and higher baseline International Prostate Symptom Score (IPSS) emerged as independent predictors of postoperative EF improvement, whereas higher baseline IPSS and longer follow-up duration were identified as predictors of EF decline. These findings suggest that effective relief of BPH/LUTS may also positively influence SF, particularly in patients with severe baseline urinary symptoms. Indeed, the greater the LUTS severity, the more pronounced the postoperative improvement in EF appeared to be[27].

A transient decline in EF is commonly observed within the first month after HoLEP; however, most patients experience a return to baseline levels by the third postoperative month. A recent comparative study evaluating three different HoLEP techniques reported a transient decline in EF (as measured by IIEF scores) in all groups at one month postoperatively. The greater reduction observed in the standard HoLEP group was attributed to a higher incidence of postoperative urinary incontinence. However, as LUTS improved over time, IIEF scores returned to baseline levels by the third postoperative month. No significant improvement in EF was observed during the extended follow-up period at 6 and 11 months[28]. In a study involving 133 preoperatively sexually active patients who underwent HoLEP performed by experienced surgeons, a significant decline in IIEF scores was observed at one month postoperatively. However, EF gradually improved over time, with scores returning to baseline levels at 6 months and 12 months. The proportion of patients reporting improvement in EF increased from 53% at 1 month to 85% at 12 months[29].

4.2 HoLEP and ejaculatory function

During emission and expulsion, RE is thought to be prevented by a not yet fully understood mechanism involving the contraction of the bladder neck and surrounding structures. Also, at the same time the pelvic floor muscles—particularly the bulbospongiosus and ischiocavernosus—play a key role in the expulsion phase of ejaculation[30]. Although the exact mechanism remains unclear, anatomical alteration and loss of functional integrity in the prostatic urethra following BPH surgery are thought to contribute to the loss of antegrade ejaculation. This may result in retrograde ejaculation or reduced ejaculatory volume. Additionally, ablation or excessive thermal injury to the ejaculatory ducts may lead to anejaculation or painful ejaculation.

EjD is frequently reported following HoLEP. RE, characterized by complete absence of antegrade ejaculation due to bladder neck incompetence, may present with cloudy post-ejaculatory urine. In men with low ejaculate volume (< 1.4 mL), as per the WHO 6th edition criteria (2021), partial RE may be suspected and is referred to as reduced ejaculatory volume. Anejaculation, in contrast, results from failure of emission and is defined by the absence of both antegrade and retrograde ejaculation.

In cases where antegrade ejaculation is absent, the presence of ≥ 10–15 spermatozoa per high-power field or a concentration >1 million/mL in post-ejaculatory urine can confirm RE[31]. However, in the absence of a sexual disorder warranting further investigation (e.g., fertility concerns), differentiation among RE, reduced ejaculatory volume, and anejaculation following BPH surgery is typically based on clinical history and validated questionnaires rather than invasive diagnostic methods[32].

Numerous studies have documented high rates of RE following HoLEP. Placer et al.[23] reported complete loss of antegrade ejaculation in 70.3% of patients after HoLEP. Another study found a reduction in ejaculate volume in 95.6% of patients, including total loss in 76.9% of cases. Despite this, 73.6% of affected patients reported that they tolerated the dysfunction well due to significant improvement in voiding symptoms[32]. Overall, the incidence of RE after HoLEP is generally accepted to be in the range of 74%–78%[33].

Painful ejaculation is a less common complication compared to RE. Briganti et al. reported an incidence of 3.3% at 12 months postoperatively, which had resolved by 24 months[34]. In a more recent study, the rate of painful ejaculation was similarly reported as 3.8%[35].

In a recent study, mean MSHQ-EjD scores declined from 15.9 preoperatively to 11.0 postoperatively[26]. Further analysis of MSHQ-EjD domains in another recent prospective study revealed that at 12 months postoperatively, patients reported worse outcomes in ejaculatory frequency, control, and volume/force. Interestingly, however, overall satisfaction with ejaculation improved after surgery[20]. Similarly, another study reported an RE rate of 92.5%, yet found that RE had no significant impact on overall satisfaction with sexual life[36].

In summary, while RE is a common and expected outcome after HoLEP, current evidence suggests that it may not significantly affect patient-reported sexual satisfaction in most cases.

5 COMPARATIVE SEXUAL OUTCOMES: HOLEP VERSUS OTHER BPH SURGERIES

Surgical management of BPH has evolved considerably over the past two decades, with HoLEP emerging as a minimally invasive, size-independent alternative to transurethral resection of the prostate (TURP) and other laser or bipolar enucleation techniques. This section aims to contextualize the impact of HoLEP on SF, including erectile and ejaculatory outcomes, by comparing it with other established surgical modalities.

5.1 EF outcomes

TURP remains the historical gold standard for surgical management of BPH, especially in men with prostates < 80 cc[7]. Initial reports, such as those by Mebust et al., cited ED rates as high as 13% following TURP[37]. More recent observational studies from the 1990s have suggested lower rates, ranging from 6% to 7%[38]. Nevertheless, TURP is generally regarded as having a neutral effect on EF, with no significant improvement or deterioration consistently observed across multiple prospective and retrospective series[39].

Several comparative studies have evaluated EF outcomes between HoLEP and TURP. In a randomized trial by Kuntz et al., patients assigned to either TURP or HoLEP demonstrated no significant difference in erectile outcomes at 12 months, with 11.2% of HoLEP patients and 10.5% of TURP patients reporting some degree of SF decline[40]. Similarly, prospective studies with both non-randomized and randomized controlled designs, including long-term follow-ups of up to 7 years, as well as meta-analyses, have consistently found no significant difference in erectile outcomes between the two techniques[34,41–43]. A recent comprehensive review reported no significant differences in EF after TURP, laser procedures including HoLEP, and other minimally invasive therapies[44]. However, a limited number of focused analyses, including one based on 10 studies involving 1435 patients, have suggested that endoscopic enucleation techniques such as HoLEP may be associated with significantly better IIEF scores compared to TURP[45].

A small number of studies have reported differences in EF outcomes when comparing HoLEP to other laser-based or endoscopic procedures. In one study comparing HoLEP, holmium laser ablation (HoLAP), and photoselective vaporization of the prostate (PVP/GreenLight), postoperative declines in IIEF-15 scores were more pronounced in the HoLAP and GreenLight groups, while the HoLEP group showed better preservation of EF, despite similar baseline scores. This finding may be explained by differences in energy delivery and laser characteristics. Specifically, the energy-to-prostate volume ratio was lower in HoLEP (2.51 kJ/mL) compared to HoLAP (6.4 kJ/mL) and PVP (4.6 kJ/mL), suggesting less thermal burden on surrounding tissues. Additionally, GreenLight lasers penetrate deeper into tissue (0.8 mm) than Ho:YAG lasers used in HoLEP (0.4 mm), potentially causing more collateral thermal damage to nearby neurovascular structures[46].

However, other studies have not demonstrated significant differences in erectile outcomes between HoLEP and alternative techniques. A randomized trial comparing bipolar resection, HoLEP, and GreenLight laser vapo-enucleation found no statistically significant difference in IIEF-5 scores over a three-year follow-up[47]. Similarly, in a comparison between Bipolar Enucleation of the Prostate (BipoLEP) and HoLEP involving 64 patients, no significant postoperative change in IIEF-5 scores was observed in either group[48]. A prospective cohort study by Peyronnet et al. comparing HoLEP and GreenLEP also reported no significant difference in IIEF-5 outcomes, despite higher baseline erectile scores in the GreenLEP group[49]. In line with these findings, a meta-analysis of randomized controlled trials comparing HoLEP and PKEP reported no significant difference in EF scores after surgery[50].

In summary, HoLEP appears comparable to other BPH surgical modalities in terms of preserving EF. Minor variations may exist based on prostate size, energy settings, and surgical experience, but no approach has demonstrated consistent superiority.

5.2 Ejaculatory function outcomes

Numerous studies have compared HoLEP with other standard surgical treatments for BPH, particularly TURP, with respect to postoperative ejaculatory outcomes. In a randomized prospective trial, RE was observed in 70% of patients undergoing HoLEP and 79% of those treated with TURP, with no statistically significant difference between the two groups[40]. Another randomized trial with a two-year follow-up reported a RE rate of 78.3% in both cohorts[34]. These findings were corroborated by a recent meta-analysis, which concluded that postoperative RE rates did not significantly differ between HoLEP and TURP[51].

When compared to other BPH surgeries, excluding minimally invasive surgical therapies (MIST), HoLEP generally demonstrates comparable rates of RE. However, studies have begun to emphasize that while the quantitative incidence of RE may be similar, qualitative aspects of ejaculatory function—such as physical discomfort, pain during ejaculation, and perceived satisfaction—may differ.

For instance, in a prospective study comparing HoLEP and bipolar transurethral enucleation of the prostate (B-TUEP), both procedures yielded similar rates of antegrade ejaculation preservation. Nonetheless, patients in the HoLEP group reported higher rates of ejaculatory pain and reduced pleasure during the early postoperative period[52]. These findings suggest that enucleation techniques, although comparable in quantitative ejaculatory outcomes, may exert different qualitative impacts on patients' sexual experience.

Furthermore, RE appears to have a limited effect on overall patient satisfaction with sexual life when substantial improvements in voiding symptoms are achieved. Despite high rates of RE, several studies have found that patients continue to report acceptable levels of satisfaction, suggesting that ejaculatory function, while important, may be deprioritized by patients when weighed against symptomatic relief.

In summary, although HoLEP and other standard surgical options such as TURP and B-TUEP exhibit similar rates of RE, interpreting these findings remains challenging due to heterogeneity in definitions and outcome measures. Notably, many studies inconsistently differentiate between complete absence of ejaculation and reduced ejaculatory volume, which may lead to ambiguity in reported RE rates. Rather than solely focusing on numerical incidence, greater emphasis should be placed on evaluating patient-reported outcomes using validated instruments such as the Male Sexual Health Questionnaire-Ejaculatory Dysfunction (MSHQ-EjD). These tools can provide more nuanced insights into the subjective experience of EjD and its impact on quality of life.

6 INTRAOPERATIVE AND TECHNICAL CONSIDERATIONS

6.1 Considerations for preserving EF

ED following TURP has been primarily attributed to unintended injury to the nerve fibers responsible for penile erection[53]. In contrast, the risk of nerve injury during HoLEP appears to be lower, largely due to the properties of holmium:YAG laser energy. This laser operates in an ultra-pulsed mode with a shallow penetration depth of approximately 0.4 mm[54]. The resulting coagulative zone in prostatic tissue is thinner than the surrounding pseudocapsule (typically 1000–2000 µm)[23,55], which helps limit unintended damage to nearby structures.

Most of the enucleation during HoLEP is performed mechanically by following the natural plane between the adenoma and the surgical capsule. Laser energy is mainly used to coagulate blood vessels. However, dissection near the apical lobes requires particular caution, as this area lies close to the external urethral sphincter and the neurovascular bundles. Reducing laser energy and maintaining precise capsular tracking in this region are key steps in minimizing thermal spread. Preserving the apical anatomy not only supports EF but also helps maintain continence.

Although high-quality studies focusing specifically on intraoperative predictors of erectile outcomes are limited, some theoretical risks have been identified. In large prostates, unnoticed thinning or small perforations of the capsule—especially when high-energy settings are used—may result in temporary nerve injury. These risks are likely to be lower when procedures are performed by experienced surgeons familiar with the anatomy and surgical technique.

Unlike monopolar TURP, HoLEP uses normal saline for irrigation instead of glycine, eliminating the risk of chemical neurapraxia associated with non-physiologic solutions. Still, attention to detail remains critical, particularly in large prostates, to ensure complete removal of adenomatous tissue without damaging the capsule.

In summary, the preservation of EF during HoLEP depends on careful apical dissection, controlled use of laser energy, and surgeon experience. Tailoring the surgical approach based on prostate size and patient anatomy can further reduce the risk of sexual dysfunction[56].

6.2 Considerations for preserving ejaculatory function

Sexual function remains a key concern for many patients undergoing surgical treatment for BPH, with a strong desire to preserve these functions postoperatively. Regardless of age, up to 92% of patients consider preservation of ejaculatory function an important factor prior to undergoing BPH surgery. Moreover, approximately 72% report significant concern about the potential impact of surgery on sexual function, with this proportion increasing among younger men[57]. In general, men tend to prefer treatment options that are effective in relieving bothersome symptoms such as urgency incontinence and nocturia, but that carry a lower risk of sexual side effects[58]. This presents a challenge for both patients and urologists when determining the optimal surgical approach for BPH.

EjD, particularly RE, is a well-recognized and common outcome following surgical treatment for BPH, including HoLEP. Efforts to preserve antegrade ejaculation in BPH surgery date back to the early 1990s. In a seminal study published in 1994, Vernet et al.[59] proposed that bladder neck contraction is not essential for ejaculation. Instead, they observed that during emission, the verumontanum undergoes a brief caudal shift and makes contact with the opposing urethral wall, facilitating semen release from the ejaculatory ducts. This finding emphasized the role of the muscular structures surrounding the proximal verumontanum, which the authors referred to as the “high-pressure ejaculation zone.” According to this model, ejaculation may be preserved even with an open bladder neck, provided that this anatomical region remains intact.

More recent consensus statements have acknowledged the difficulty of preserving this high-pressure zone during enucleation procedures, due to the extent of tissue removal inherent to the technique[60,61]. Nevertheless, several studies have proposed and tested ejaculation-preserving modifications to standard HoLEP, with varying degrees of success.

Although HoLEP is not primarily designed to preserve ejaculation, some surgical strategies may help minimize functional loss. The modified two-lobe HoLEP technique described by Xu et al. involved preservation of the bladder neck mucosa, the circular fibers of the internal sphincter, and the urethral mucosa between the 11 and 1 o'clock positions. Using this approach, the incidence of RE was significantly reduced compared to the standard three-lobe technique (13.3% vs. 50%)[62]. In another study involving 40 sexually active patients with prominent median lobes but minimal lateral lobe obstruction, selective enucleation of only the median lobe resulted in preserved antegrade ejaculation in 35 patients (87.5%)[63]. Similarly, Depaquit et al. reported a 12.5% de novo RE rate following selective median lobe enucleation in patients with large median lobes, although 14.5% of patients eventually required reoperation due to persistent LUTS[64]. Li et al. retrospectively analyzed 213 patients and reported a retrograde ejaculation rate of 11.7% at 12 months postoperatively using an en-bloc enucleation and bladder neck preservation technique, with 43.6% experiencing decreased ejaculatory volume[65]. Table 1 provides an overview of selected studies assessing the impact of modified HoLEP techniques on ejaculatory outcomes.

In a recent study[66], the Ejaculation-Preserving HoLEP (EP-HoLEP) technique was performed by sparing approximately 10 mm of tissue proximal to the verumontanum and preserving 5 mm of paracollicular tissue on each side of the lateral lobes. Patients who underwent EP-HoLEP achieved higher total MSHQ-EjD-SF scores at both 3- and 6-month follow-ups compared to those treated with the conventional technique. Similarly, a modified enucleation procedure that preserved bladder neck and prostatic urethral mucosa reported a significantly lower rate of RE (31% vs. 65.7%) compared to standard techniques[69]. A broader review analyzing laser enucleation techniques found that RE rates were significantly lower in modified ejaculation-preserving methods (27.2% ± 18.1%) compared to standard approaches (71.3% ± 16.1%)[70].

While some modified techniques have demonstrated lower rates of RE, not all studies have shown a clear benefit. In a comparative study, the incidence of de novo RE was similar between En Bloc HoLEP performed with early apical release using MOSES technology (En Bloc MoLEP) and classic En Bloc HoLEP (42.3% vs. 42.5%)[68]. Another study suggested that in patients with small prostate glands, where meaningful preservation of apical tissue is more feasible, ejaculation-preserving techniques may be more applicable. In this context, given that HoLEP is designed to achieve complete adenoma removal, the authors concluded that when preservation of ejaculatory function and sexual satisfaction is a primary concern, TURP using ejaculation-sparing modifications may be a more appropriate treatment option than ejaculation-preserving HoLEP[71]. In a study where paracollicular and supracollicular tissue less than 1 cm proximal to the verumontanum was preserved, the overall success rate of ejaculation preservation was 46.2% in the modified technique group and 26.9% in the conventional HoLEP group (p = 0.249). The authors attributed the lack of a significant difference primarily to the inherent nature of HoLEP, which involves removal of apical tissue[67].

Establishing transparent communication from the initial clinical encounter is essential to understanding individual patient priorities. Patients often may confuse the terms erection, ejaculation, and orgasm, underscoring the need for clear education and counseling. Through adequate patient guidance, individuals can develop more realistic expectations regarding the potential ejaculatory side effects of their chosen treatment.

Using the term ejaculatory dysfunction rather than retrograde ejaculation may facilitate broader discussions around the spectrum of postoperative ejaculatory changes. This patient-centered approach can enhance confidence in treatment selection and alleviate anxiety about potential sexual side effects. In sexually active men with concerns about ejaculatory dysfunction, the option of ejaculation-preserving techniques may be discussed. However, patients should be provided with accurate success rates to prevent unrealistic expectations. In cases where preservation of ejaculatory function is a top priority, referral to minimally invasive surgical therapies may be appropriate.

In conclusion, a wide range of techniques have been described with the goal of preserving ejaculation following HoLEP. Reported success rates vary widely, and many of these modifications lack standardization. Given the heterogeneity of methods and outcomes, there is a clear need for consensus guidelines and prospective comparative studies to establish effective and reproducible ejaculation-preserving surgical strategies.

7 FUTURE RESEARCH PRIORITIES AND UNMET NEEDS

While current evidence indicates that HoLEP does not result in significant long-term deterioration of EF in most patients, several critical knowledge gaps remain—particularly in relation to ejaculatory outcomes and patient-reported sexual quality of life. Future research should focus on well-designed, prospective, multicenter randomized controlled trials utilizing extended follow-up durations and stratification based on key variables such as age, prostate volume, baseline SF, and comorbidities.

Importantly, further investigation is needed to evaluate the impact of specific intraoperative factors—including energy settings, apical dissection techniques, and surgeon experience—on both erectile and ejaculatory outcomes. Standardized surgical protocols and detailed intraoperative documentation may help clarify which modifications offer the greatest functional benefit. Definitions of EjD vary widely, with inconsistent differentiation between total anejaculation, reduced volume, and changes in force or satisfaction. Future research should aim to establish standardized definitions and determine clinically meaningful thresholds—such as the minimal clinically important difference (MCID)—for parameters like ejaculatory volume loss and patient-reported bother.

In addition, the development of predictive models that incorporate clinical and procedural parameters could facilitate individualized surgical planning and enhance preoperative counseling. As patient expectations regarding postoperative SF continue to evolve, future studies should also address the long-term trajectory of ejaculatory function and its influence on overall satisfaction and quality of life. Establishing international consensus on ejaculation-preserving HoLEP techniques may further guide surgical practice and optimize functional outcomes in select patient populations.

8 CONCLUSION

HoLEP has become a widely utilized and durable surgical solution for BPH, offering effective relief of LUTS across various prostate sizes. Evidence indicates that EF is generally preserved, with most patients experiencing either stable or minimally changed outcomes in the long term. However, RE remains a frequent and largely unavoidable consequence of standard HoLEP techniques.

While numerous surgical modifications have been proposed to preserve antegrade ejaculation, their effectiveness varies considerably, and a lack of standardization persists. Importantly, the presence of RE does not appear to significantly reduce overall sexual satisfaction in most patients, particularly when urinary symptoms are well controlled.

Nonetheless, individual anatomy, surgical technique, and patient preferences all influence postoperative sexual outcomes. Optimizing SF preservation requires not only technical precision but also patient-centered preoperative counseling. As HoLEP continues to evolve, incorporating validated functional endpoints and refining ejaculation-sparing approaches should be prioritized to ensure holistic treatment outcomes for men undergoing surgery for BPH.

References

[1] Kim EH, Larson JA, Andriole GL. Management of benign prostatic hyperplasia. Annu Rev Med. 2016;67:137–151.

[2] Lerner LB, McVary KT, Barry MJ, Bixler BR, Dahm P, Das AK, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline part I—initial work-up and medical management. J Urol. 2021;206:806–817.

[3] Tokatli Z, Ferhat M, Ibis MA, Turkmen Sariyildiz G, Elhan A, Sarica K. Does the power of the laser devices matter for a successful HoLEP procedure? A prospective comparative study. Int J Clin Pract. 2021;75:e14531.

[4] D'Agate S, Wilson T, Adalig B, Manyak M, Palacios-Moreno JM, Chavan C, et al. Model-based meta-analysis of individual International Prostate Symptom Score trajectories in patients with benign prostatic hyperplasia with moderate or severe symptoms. Br J Clin Pharmacol. 2020;86:1585–1599.

[5] Faraon B, Garces J, Ahmad S, Mahmoud S, Danzinger M, Shabsigh R, et al. The impact of the treatment of benign prostatic hyperplasia with lower urinary tract symptoms on quality of life, a scoping literature review aided by AI. J Mens Health. 2024;20:8–14.

[6] Ibis MA, Tokatlı Z. Does the use of a small-size resectoscope during enucleation prevent transient urinary leakage and urethral stricture following holmium laser enucleation of the prostate? Low Urin Tract Symptoms. 2022;14:86–91.

[7] Ibis MA, Cayan S, Tokatlı Z, Orhan I, Ascı R, Kocamanoglu F, et al. Trends in benign prostatic hyperplasia surgery over the years: a multicenter 14-year retrospective study. Turk J Urol. 2021;47:501–508.

[8] Ozayar A, Zumrutbas AE, Yaman O. The relationship between lower urinary tract symptoms (LUTS), diagnostic indicators of benign prostatic hyperplasia (BPH), and erectile dysfunction in patients with moderate to severely symptomatic BPH. Int Urol Nephrol. 2008;40:933–939.

[9] Gacci M, Eardley I, Giuliano F, Hatzichristou D, Kaplan SA, Maggi M, et al. Critical analysis of the relationship between sexual dysfunctions and lower urinary tract symptoms due to benign prostatic hyperplasia. Eur Urol. 2011;60:809–825.

[10] Park HJ, Won JEJ, Sorsaburu S, Rivera PD, Lee SW. Urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) and LUTS/BPH with erectile dysfunction in Asian men: a systematic review focusing on tadalafil. World J Mens Health. 2013;31:193–207.

[11] Calogero AE, Burgio G, Condorelli RA, Cannarella R, La Vignera S. Lower urinary tract symptoms/benign prostatic hyperplasia and erectile dysfunction: from physiology to clinical aspects. Aging Male. 2018;21:261–271.

[12] Zewdie KA, Ayza MA, Tesfaye BA, Wondafrash DZ, Berhe DFA. systematic review on rho-kinase as a potential therapeutic target for the treatment of erectile dysfunction. Res Rep Urol. 2020;12:261–272.

[13] MacDonald SM, Burnett AL. Physiology of erection and pathophysiology of erectile dysfunction. Urol Clin North Am. 2021;48:513–525.

[14] Demir O, Akgul K, Akar Z, Cakmak O, Ozdemir I, Bolukbasi A, et al. Association between severity of lower urinary tract symptoms, erectile dysfunction and metabolic syndrome. Aging Male. 2009;12:29–34.

[15] Giuliano F, Ückert S, Maggi M, Birder L, Kissel J, Viktrup L. The mechanism of action of phosphodiesterase type 5 inhibitors in the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia. Eur Urol. 2013;63:506–516.

[16] Althof SE, McMahon CG. Contemporary management of disorders of male orgasm and ejaculation. Urology. 2016;93:9–21.

[17] Master VA, Turek PJ. Ejaculatory physiology and dysfunction. Urol Clin North Am. 2001;28:363–376.

[18] Vallancien G, Emberton M, Harving N, van Moorselaar RJA, Group A-OS. Sexual dysfunction in 1,274 European men suffering from lower urinary tract symptoms. J Urol. 2003;169:2257–2261.

[19] Deslandes M, Klein C, Marquette T, Comat V, Mallet R, Degraeve B, et al. Influence of holmium laser enucleation of the prostate on erectile function: results of a multicentric analysis of 235 patients. World J Urol. 2022;40:2747–2754.

[20] Roper C, Slade A, Caras R, Shelton T, Rivera M. Ejaculatory and erectile function outcomes following holmium laser enucleation of the prostate. Prostate. 2024;84:791–796.

[21] Klett DE, Tyson MD, Mmeje CO, Nunez–Nateras R, Chang Y-H, Humphreys MR. Patient-reported sexual outcomes after holmium laser enucleation of the prostate: a 3-year follow-up study. Urology. 2014;84:421–426.

[22] Elshal AM, El-Assmy A, Mekkawy R, Taha D-E, El-Nahas AR, Laymon M, et al. Prospective controlled assessment of men's sexual function changes following Holmium laser enucleation of the prostate for treatment of benign prostate hyperplasia. Int Urol Nephrol. 2017;49:1741–1749.

[23] Placer J, Salvador C, Planas J, Trilla E, Lorente D, Celma A, et al. Effects of holmium laser enucleation of the prostate on sexual function. J Endourol. 2015;29:332–339.

[24] Sato R, Sano A, Watanabe K, Matsushita Y, Watanabe H, Tamura K, et al. Effects of changes in erectile function after holmium laser enucleation of the prostate on postoperative outcomes in patients with benign prostatic hyperplasia. In Vivo. 2022;36:2960–2964.

[25] Meng F, Gao B, Fu Q, Chen J, Liu Y, Shi B, et al. Change of sexual function in patients before and after Ho: YAG laser enucleation of the prostate. J Androl. 2007;28:259–261.

[26] Gurlen G, Aydamirov M, Vuruskan E, Aksay B, Karkin K. Evaluation of lower urinary tract symptoms and sexual functions after holmium laser prostate enucleation. Ir J Med Sci. 1971;2025(194):385–389.

[27] Capogrosso P, Ventimiglia E, Ferrari M, Serino A, Boeri L, Capitanio U, et al. Long-term sexual outcomes after holmium laser enucleation of the prostate: which patients could benefit the most? Int J impot Res. 2016;28:189–193.

[28] Gao Z, Wang P, Liu H, Ding Y, Xu L, Sun Z, et al. Technological innovation of HoLEP: a multicenter, randomized, controlled study for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. World J Urol. 2025;43:64.

[29] Capogrosso P, Ventimiglia E, Fallara G, Schifano N, Costa A, Candela L, et al. Holmium laser enucleation of the prostate is associated with complications and sequelae even in the hands of an experienced surgeon following completion of the learning curve. Eur Urol Focus. 2023;9:813–821.

[30] Giuliano F, Clément P. Physiology of ejaculation: emphasis on serotonergic control. Eur Urol. 2005;48:408–417.

[31] Konstantinidis C, Zachariou A, Evgeni E, Çayan S, Boeri L, Agarwal A. Recent advances in the diagnosis and management of retrograde ejaculation: a narrative review. Diagnostics. 2025;15:726.

[32] Kim JK, Cho MC, Son H, Ku JH, Oh SJ, Paick JS. Patient perception of ejaculatory volume reduction after holmium laser enucleation of the prostate (HoLEP). Urology. 2017;99:142–147.

[33] Marien T, Kadihasanoglu M, Miller N. Holmium laser enucleation of the prostate: patient selection and perspectives. Res Rep Urol. 2016;8:181–192.

[34] Briganti A, Naspro R, Gallina A, Salonia A, Vavassori I, Hurle R, et al. Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate: results of a prospective, 2-center, randomized trial. J Urol. 2006;175:1817–1821.

[35] Fang R, Wu Q, Li C, Li N, Huang Y, Zhao S. The efficacy of transurethral holmium laser enucleation of the prostate (HoLEP) in the preservation of the urethral ridge in the treatment of prostatic hyperplasia in patients aged 75 years or less. J Mens Health. 2024;20:35–41.

[36] Gild P, Dahlem R, Pompe RS, Soave A, Vetterlein MW, Ludwig TA, et al. Retrograde ejaculation after holmium laser enucleation of the prostate (HoLEP)—impact on sexual function and evaluation of patient bother using validated questionnaires. Andrology. 2020;8:1779–1786.

[37] Mebust WK, Holtgrewe HL, Cockett ATK, Peters PC. Transurethral prostatectomy: immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol. 1989;141:243–247.

[38] Madersbacher , Marberger . Is transurethral resection of the prostate still justified? BJU Int. 1999;83:227–237.

[39] Choi SB, Zhao C, Park JK. The effect of transurethral resection of the prostate on erectile function in patients with benign prostatic hyperplasia. Korean J Urol. 2010;51:557.

[40] Kuntz RM, Ahyai S, Lehrich K, Fayad A. Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. J Urol. 2004;172:1012–1016.

[41] Gilling PJ, Wilson LC, King CJ, Westenberg AM, Frampton CM, Fraundorfer MR. Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int. 2012;109:408–411.

[42] Pushkar P, Taneja R, Agarwal A. A prospective study to compare changes in male sexual function following holmium laser enucleation of prostate versus transurethral resection of prostate. Urol Ann. 2019;11:27–32.

[43] Montorsi F, Naspro R, Salonia A, Suardi N, Briganti A, Zanoni M, et al. Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. J Urol. 2004;172:1926–1929.

[44] Manfredi C, García-Gómez B, Arcaniolo D, García-Rojo E, Crocerossa F, Autorino R, et al. Impact of surgery for benign prostatic hyperplasia on sexual function: a systematic review and meta-analysis of erectile function and ejaculatory function. Eur Urol Focus. 2022;8:1711–1732.

[45] Light A, Jabarkhyl D, Gilling P, George G, Van Hemelrijck M, Challacombe B, et al. Erectile function following surgery for benign prostatic obstruction: a systematic review and network meta-analysis of randomised controlled trials. Eur Urol. 2021;80:174–187.

[46] Elshal AM, Elmansy HM, Elkoushy MA, Elhilali MM. Male sexual function outcome after three laser prostate surgical techniques: a single center perspective. Urology. 2012;80:1098–1104.

[47] Elshal AM, Soltan M, El-Tabey NA, Laymon M, Nabeeh A. Randomised trial of bipolar resection vs holmium laser enucleation vs Greenlight laser vapo-enucleation of the prostate for treatment of large benign prostate obstruction: 3-years outcomes. BJU Int. 2020;126:731–738.

[48] Habib E, Ayman LM, ElSheemy MS, El-Feel AS, Elkhouly A, Nour HH, et al. Holmium laser enucleation vs bipolar plasmakinetic enucleation of a large volume benign prostatic hyperplasia: a randomized controlled trial. J Endourol. 2020;34:330–338.

[49] Peyronnet B, Robert G, Comat V, Rouprêt M, Gomez-Sancha F, Cornu JN, et al. Learning curves and perioperative outcomes after endoscopic enucleation of the prostate: a comparison between GreenLight 532-nm and holmium lasers. World J Urol. 2017;35:973–983.

[50] Pang KH, Ortner G, Yuan Y, Biyani CS, Tokas T. Complications and functional outcomes of endoscopic enucleation of the prostate: a systematic review and meta-analysis of randomised-controlled studies. Cent Eur J Urol. 2022;75:357.

[51] Zong HT, Peng XX, Yang CC, Zhang Y. The impact of transurethral procedures for benign prostate hyperplasia on male sexual function: a meta-analysis. J Androl. 2012;33:427–434.

[52] Bebi C, Turetti M, Lievore E, Ripa F, Bilato M, Rocchini L, et al. Sexual and ejaculatory function after holmium laser enucleation of the prostate and bipolar transurethral enucleation of the prostate: a single-center experience. Int J Impot Res. 2022;34:71–80.

[53] Lefaucheur JP, Yiou R, Salomon L, Chopin DK, Abbou CC. Assessment of penile small nerve fiber damage after transurethral resection of the prostate by measurement of penile thermal sensation. J Urol. 2000;164:1416–1419.

[54] Bach T, Muschter R, Sroka R, Gravas S, Skolarikos A, Herrmann TRW, et al. Laser treatment of benign prostatic obstruction: basics and physical differences. Eur Urol. 2012;61:317–325.

[55] Sattar AA, Noël JC, Vanderhaeghen JJ, Schulman CC, Wespes E. Prostate capsule: computerized morphometric analysis of its components. Urology. 1995;46:178–181.

[56] Ibiş MA, Özkaya MF, Yaman Ö. Alt Üriner Sistem Semptomları/Benign Prostat Hiperplazisi Cerrahi Tedavisinde Ejakülasyonu Koruma Yöntemleri. Turkiye Klinikleri Urology-Special Topics. 2024;17:82–86.

[57] Bouhadana D, Nguyen DD, Zorn KC, Elterman DS, Bhojani N. Patient perspectives on benign prostatic hyperplasia surgery: a focus on sexual health. J Sex Med. 2020;17:2108–2112.

[58] Malde S, Umbach R, Wheeler JR, Lytvyn L, Cornu JN, Gacci M, et al. A systematic review of patients' values, preferences, and expectations for the diagnosis and treatment of male lower urinary tract symptoms. Eur Urol. 2021;79:796–809.

[59] Gil-Vernet JM, Alvarez-Vijande R, Gil-Vernet A, Gil-Vernet JM. Ejaculation in men: a dynamic endorectal ultrasonographical study. Br J Urol. 1994;73:442–448.

[60] Sturch P, Woo HH, McNicholas T, Muir G. Ejaculatory dysfunction after treatment for lower urinary tract symptoms: retrograde ejaculation or retrograde thinking? BJU Int. 2015;115:186–187.

[61] Sokolakis I, Pyrgidis N, Russo GI, Sountoulides P, Hatzichristodoulou G. Preserving ejaculation: a guide through the landscape of interventional and surgical options for benign prostatic obstruction. Eur Urol Focus. 2022;8:380–383.

[62] Xu C, Xu Z, Lin C, Feng S, Sun M, Chen J, et al. Holmium laser enucleation of the prostate: modified two-lobe technique versus traditional three-lobe technique—a randomized study. BioMed Res Int. 2019;2019:1–8.

[63] Press B, Gardezi M, Kim DD, Lokeshwar S, Rahman S, Siev M, et al. Ejaculatory preserving holmium laser enucleation of the median lobe: preserving sexual function while improving urinary outcomes. Urology. 2023;173:175–179.

[64] Long Depaquit T, Baboudjian M, Chiron P, Corral R, Anastay V, Bastide C, et al. Modified holmium laser enucleation for benign prostatic obstruction to preserve sexual and ejaculatory function. Fr J Urol. 2024;34:102581.

[65] Li P, Wang C, Tang M, Han P, Meng X. Holmium laser enucleation of prostate by using en-bloc and bladder neck preservation technique: technical consideration and influence on functional outcomes. Transl Androl Urol. 2021;10:134–142.

[66] Eliwa A, Aldarraji A, Abdelwahab K, Salem E. Randomized prospective trial comparing ejaculatory preservation HoLEP versus standard HoLEP: the other face of the coin. World J Urol. 2025;43:145.

[67] Kim M, Song SH, Ku JH, Kim HJ, Paick JS. Pilot study of the clinical efficacy of ejaculatory hood sparing technique for ejaculation preservation in Holmium laser enucleation of the prostate. Int J Impot Res. 2015;27:20–24.

[68] Socarrás MR, Del Álamo JF, Espósito F, Elbers JR, Monsalve DC, Rivas JG, et al. En Bloc enucleation with early apical release technique using MOSES (En Bloc MoLEP) vs. classic En Bloc HoLEP: a single arm study comparing intra-and postoperative outcomes. World J Urol. 2023;41:159–165.

[69] Huang Y, WU H, HE G, Zhang C. The effect of transurethral plasma enucleation of prostate with bladder neck and prostatic apex urethral mucosa preservation on the ejaculation function in the treatment of benign prostatic hyperplasia. Chin J Urol. 2021;12:132–136.

[70] Guldibi F, Altunhan A, Aydın A, Sonmez MG, Çakır ÖO, Balasar M, et al. What is the effect of laser anatomical endoscopic enucleation of the prostate on the ejaculatory functions? A systematic review. World J Urol. 2023;41:3493–3501.

[71] Rouf MA, Kumar V, Agarwal A, Rawat S. Ejaculation preserving HoLEP/TURP for benign prostatic hyperplasia: myth or reality. J Clin Urol. 2022;15:315–322.

RIGHTS & PERMISSIONS

2026 The Author(s). UroPrecision published by John Wiley & Sons Australia, Ltd on behalf of Higher Education Press.