Cochrane: HoLEP's proven advantage over TURP is transfusion, and that is the list

Design

Cochrane systematic review and random-effects meta-analysis with GRADE certainty assessment

Population

52 randomised trials, 6,242 men over 40 with IPSS 8 or above and prostate volume 20 mL or more

Primary outcome

urological symptom score, quality of life and major adverse events versus TURP at up to 12 months

Effect

IPSS MD −0.67 (95% CI −1.20 to −0.14, low certainty); major adverse events RR 0.75 (0.35 to 1.58); transfusion RR 0.19 (0.09 to 0.42, moderate certainty)

Fifty-two randomised trials and 6,242 participants, searched to April 2026, comparing holmium laser enucleation of the prostate against other surgical treatments for benign prostatic hyperplasia. The review prioritised the comparison against TURP at up to 12 months, because TURP remains the reference standard.

On the critical outcomes, HoLEP may make little to no difference: IPSS mean difference −0.67 (95% CI −1.20 to −0.14, I² 93 per cent, low certainty) on a 0 to 35 scale; quality of life −0.04 (−0.23 to 0.15, low certainty); major adverse events RR 0.75 (0.35 to 1.58, low certainty). On the important outcomes, it likely makes little difference to re-treatment (RR 0.45, 0.14 to 1.50) or erectile function (MD −0.03, moderate certainty), and no ejaculatory function data were found at all. It likely reduces blood transfusion: RR 0.19 (0.09 to 0.42, I² 0 per cent, 15 studies, moderate certainty).

The authors state plainly that transfusion is the only advantage the randomised evidence supports as clinically important, and that there was insufficient evidence for men with larger prostates or on anticoagulation — which is precisely where HoLEP is usually argued for. That is not an argument against the procedure; it is an argument that the case for it rests on populations the trials did not recruit.

• Do not counsel patients that HoLEP gives better symptom relief than TURP — the evidence does not show it
• Do counsel that it substantially reduces the chance of needing a transfusion
• Note that no trial reported ejaculatory function, the outcome patients most often ask about
• The large-prostate and anticoagulation cases where HoLEP is usually favoured are untested in randomised trials
• An IPSS difference of 0.67 on a 0 to 35 scale is not a difference a patient would notice

Why it matters

It separates what HoLEP has been shown to do from what it is routinely claimed to do.

Don't overread it

Absence of evidence in men with very large prostates or on anticoagulants is not evidence that HoLEP offers nothing there.

The statistics, in plain English

An I² of 93 per cent on the symptom score means the trials fundamentally disagree, which is why a statistically significant mean difference is still rated low certainty and read as 'little to no difference'. The transfusion result is the opposite picture — I² of 0 per cent across 15 studies and a confidence interval well away from 1 — which is why it is the one finding the authors will stand behind.

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