Title: Manual de Enucleación Prostática HoLEP en Bloque Author: Fernando Gómez Sancha Publisher: Simed Software Pages: 354 ISBN: 978-84-09-42726-0 Edition: 1st edition

Official website — manualholep.icua.es — full information, table of contents, and direct order— worldwide shipping available

Professional activity in 0 países 2026 ▶ 2002 2026

Milestones & activities

All Surgery Congresses Training Publications Milestones All years

Dr. Fernando Gómez Sancha's Blog in English

I AAU International Course on Anatomical Prostatic Enucleation — Jerez, 21-22 May 2026

2026-05-23T11:47:23.000+02:00

Technology adds value when it is integrated around a clear anatomical concept. Without that concept, changing lasers is just changing labels. With it, any serious platform delivers comparable results — and understanding the underlying physics stops being an academic luxury and becomes a clinical tool.

The simultaneous live surgery format, with honest comparison between international and national schools, raises the level of every conversation in the room. There is nowhere to hide: decisions are visible, mistakes are visible, corrections are too. That is real training.

The institutional dimension is decisive. The joint presence of heads of service from Andalusia's public urology network at the closing session turns this course into a platform for transformation, not just technical dissemination. The AAU has done something unusual here: aligning training, evidence and healthcare management in the same room.

Thanks to Álvaro Juárez Soto and the team at Hospital Universitario de Jerez for the organisation, to the AAU for supporting this format, to the sponsors for participating as educational partners rather than protagonists, and, above all, to Belén Barba and Miguel Ugidos for proving that the course subtitle was not rhetorical. A special and deeply felt mention to all the invited speakers and surgeons, national and international: Cesare Marco Scoffone, Martin Kanne, Jean Baptiste Roche, Thiago Hota, Alfonso Gimeno, Javier Sánchez Macías, Moisés Rodríguez Socarrás, Julio Fernández del Álamo, Nelson Canales, Javier Amores and each of the moderators who covered the sessions with surgical judgement and without seeking the spotlight. You travelled, you operated in someone else's theatre, you taught openly and you discussed every technical decision without hiding anything. That generosity — which is far from trivial in this field — is what turns a well-programmed course into a memorable one. I know what it means to leave your hospital, your team and your routine to come and operate and teach without a safety net, and I am personally grateful for it.

And above all to the 75 registered urologists who filled the room for both days. You did not come to watch: you asked questions, you debated, you pushed with uncomfortable challenges during the breaks and each of you left with one concrete idea for Monday morning's clinic. Without an audience that engaged like yours, this format does not work; with one like yours, it becomes a real instrument of change.

We all go home with the same feeling: euphoric, energised, determined to keep pushing. The goal has not changed and it is very clear — that every patient in Spain, regardless of their hospital or their postcode, should have access to this remarkable technique. That is why we came, that is why we keep publishing, training and operating live, and that is why we will return to Jerez. And wherever else is needed. We keep going.

Four conclusions I take home, which justify the AAU consolidating this format as an annual event:

Anatomical en bloc enucleation can be learned during residency. Belén Barba and Miguel Ugidos proved it live, operating as primary surgeons in front of an international faculty. This is not a theoretical argument.
Expert tutoring on the ground — not on video, not in a wet lab — is the single factor that most compresses the learning curve. Javier Amores fulfilled that role with a level of discretion and effectiveness that deserves explicit recognition.
Technology adds value when it is built around a clear anatomical concept. Without that concept, changing lasers is just changing labels. With it, any serious platform delivers comparable results.
The simultaneous live surgery format, with honest comparison between schools, raises the level of debate. There is nowhere to hide: decisions are visible, mistakes are visible, corrections too. That is real training.

Live HoLEP from Bulgaria: four cases, 25 countries, 300 urologists

2026-05-12T09:32:00.004+02:00

On May 7–9 we were at Hill Clinic in Sofia, Bulgaria, performing live HoLEP surgery. Observers in the operating room had traveled from Kyrgyzstan, Kazakhstan, Italy and Algeria.

Four of the cases were simultaneously streamed to four global regions, each with a dedicated audience:

Europe: Italy, Spain, Portugal, Netherlands, Greece, Romania, Poland, Finland, Lithuania, Latvia, Armenia
Latin America: Mexico (58 physicians), Ecuador (52), Brazil, Uruguay, Panama, Colombia, Chile, Argentina, Peru and others — over 120 physicians connected in group settings
Asia-Pacific: China, Malaysia, Singapore, Cambodia, India
Middle East & Africa: broadcast from Saudi Arabia, with participants from Kazakhstan, Russia and Armenia

Total estimated attendance: approximately 300 specialist urologists from more than 25 countries — combining individual connections and group viewings from hospitals and conference facilities.

Sixteen years coming to Hill Clinic. The operating room keeps getting smaller. The audience keeps getting larger.

Ten HoLEPs in Two Days with Colleagues from Brazil

2026-04-29T09:10:47.869+02:00

This week we had the pleasure of welcoming a group of urologists from Brazil to ICUA.

Two full days. Ten prostatic enucleations. And plenty of conversations worth having.

There is no better way to learn HoLEP than watching it live, case after case, with time to ask questions, pause, and discuss what just happened in the operating room. Books and videos have their place — but surgery is learned next to someone who does it every day.

What I enjoy most about these visits is not just teaching the technique. It is the exchange. Every colleague brings their own experience, their own doubts, their own patients in mind. And that always enriches the way I operate and think.

Brazil has an outstanding urological community and a growing interest in prostatic enucleation. Seeing that enthusiasm in person is always deeply rewarding.

Thank you for coming. I hope what you observed will be useful when you return to your patients.

Not All LISTs for BPH Are Trying to Solve the Same Problem

2026-04-18T12:48:00.005+02:00

ICUA Viewpoint · BPH & prostate surgery

Minimally invasive treatments for benign prostatic hyperplasia are often discussed as if they belonged to one coherent family. In reality, some are designed to preserve function and reduce treatment burden, while others aim to deliver more durable deobstruction. Treating them as equivalents creates more confusion than clarity.

Over the past few years, the treatment landscape for benign prostatic hyperplasia has become increasingly crowded with acronyms, devices, and promises. UroLift, Rezūm, iTIND, Aquablation, PAE, TPLA, Optilume… These procedures are often grouped under a single umbrella: MISTs or LISTs, meaning minimally or least invasive surgical treatments.

The problem is that once everything is placed under the same label, a misleading idea quickly follows: that all of these options are competing in the same therapeutic space and differ only in technology. That is not true.

The reality is more uncomfortable, but also more clinically useful: these procedures are not trying to solve the same clinical problem.

The problem with the umbrella label

When we talk about LISTs for BPH, we often mix procedures with very different goals.

Some are primarily designed to offer lower burden, less impact on ejaculation, a more acceptable patient experience, and faster recovery. Others aim to go further and deliver stronger and more durable deobstruction, coming much closer to what we expect from effective surgery. And some are still trying to define their true role.

This is the central weakness of the current field: the phrase “minimally invasive” has become too broad and too comfortable. It may help marketing, but it does not always help explanation.

The right question is not “which technique is best”

The right question is this:

What problem is each technique actually trying to solve, and what functional or therapeutic price does it ask the patient to pay in return?

Because in BPH treatment there is always a trade-off. No technique gives everything to everyone.

In general, the less invasive a treatment is, the more likely it is to depend on favorable anatomy, to sacrifice some deobstructive power, and to make durability and retreatment more important.

In other words, many of these techniques do not truly compete with enucleation. They compete with something else: fear of surgery, the desire to preserve ejaculation, the wish to avoid anesthesia or hospitalization, or the search for symptom relief that is “good enough” without committing to definitive surgery.

That is not a flaw. It is a different clinical proposition.

Functional compromise procedures

This group clearly includes techniques such as UroLift and iTIND.

Their main attraction is not maximal deobstruction. It is a combination of low procedural burden, better ejaculatory preservation, and relatively fast recovery.

They do have a real niche, especially in carefully selected patients with small or moderate prostates, favorable anatomy, and a very strong priority to preserve sexual function or avoid a more ablative treatment.

But that is precisely why we should be honest: these procedures do not appear to be designed to compete with prostate enucleation in terms of deobstructive strength and long-term durability.

They are not meant to solve every form of BPH. They are meant to solve a specific form of BPH in a specific kind of patient.

The intermediate space: Rezūm

Rezūm probably occupies the most interesting niche in the current LIST field.

It is not just a compromise treatment like an implant or a mechanical remodeling device. But neither is it a high-powered deobstructive procedure on the level of enucleation. It sits somewhere in between.

That is why it generates so much interest. It offers a compelling proposition: real tissue treatment, a lower-burden narrative, reasonably attractive functional outcomes, and good patient and physician acceptance.

The problem is not its original niche. The problem appears when the technique is pushed beyond that niche.

Over the past few years, there has been a clear movement toward larger prostates. That is precisely where caution matters most. A procedure may be feasible in expert hands without having established a convincing comparative role against more powerful options.

Rezūm has a place. But that place should be defined by honest comparison, not by enthusiasm alone.

The important exception: Aquablation

If there is one technique that breaks the conceptual umbrella of LISTs, it is Aquablation.

It is often presented alongside other minimally invasive therapies, but clinically it behaves very differently. It is not simply a friendlier or more function-preserving option. It is a procedure with much stronger deobstructive potential, and medium-term data place it closer to effective surgery than to compromise treatments.

That is why discussing Aquablation on the same plane as UroLift or iTIND creates confusion.

Not because it does not share the ambition of reducing morbidity, but because its therapeutic proposition is different: not merely to ease symptoms, but to deliver substantial deobstruction while trying to preserve a more favorable functional profile than some traditional surgeries.

The main driver of the market: sexual function

A large part of the success of this field cannot be explained by flow rates or IPSS scores alone. It is explained by something far more human and far more powerful: the preservation of sexual function, especially ejaculation.

And that matters. Greatly.

The mistake would be to treat this endpoint as a minor detail. It is not. For many patients, preserving ejaculation is not a luxury. It is a central priority.

But the opposite mistake is just as common: talking about sexual outcomes as if they could be separated from all the other outcomes.

The key question is not “which technique best preserves ejaculation?”. The key question is: what is the patient willing to trade in order to preserve it?

Because the price may be lower deobstructive power, more retreatment, greater dependence on favorable anatomy, or less robust outcomes when obstruction is significant.

Anatomical selection: where honesty is won or lost

This is one of the most important points in the entire debate.

LISTs should not be discussed as if they were interchangeable options chosen by taste. In practice, success depends heavily on prostate size, the presence of a median lobe, the severity of obstruction, bladder function, and patient priorities.

The more this is simplified in commercial messaging, the further the conversation drifts from real medicine.

A procedure can be excellent in one patient and unconvincing in another without saying anything negative about the procedure itself. It simply means that not everything is suitable for everyone.

So what is the real role of LISTs versus HoLEP?

Our view is that most LISTs do not truly compete with HoLEP in complete and durable deobstruction.

They compete in another arena: acceptability, lower perioperative burden, ejaculatory preservation, and lower perceived aggressiveness.

That is their value. And that value is legitimate.

But precisely because it is legitimate, it does not need to be exaggerated or presented as if it were equivalent to enucleation.

The partial exception is Aquablation, which enters much more clearly into the territory of strong deobstructive efficacy. The rest, in different ways, mostly inhabit the space of balance and functional compromise.

Conclusion

The modern discussion of LISTs for BPH should not begin with technology. It should begin with a simple clinical question:

What is the patient willing to give up in exchange for lower treatment burden?

In some cases, the answer will be durability. In others, deobstructive power. In others, ejaculation. And in others, the desire to avoid a more invasive surgical pathway.

Understanding that does not weaken the role of LISTs. On the contrary, it gives them a more honest and more useful place.

Because the future of this field will not depend only on how much technology it accumulates, but on how clearly it explains the real trade-off it offers the patient.

ICUA take-home message
Most LISTs are not “small HoLEPs”. They are different tools for different patients, with real benefits, real limitations, and a role that only becomes clear when their trade-offs are discussed honestly.

The Next Wave of LISTs for BPH: How Much Is Innovation, How Much Is Hype

2026-04-18T12:45:14.010+02:00

ICUA Viewpoint · Innovation & BPH

The second generation of LISTs is no longer selling only “less invasiveness”. It is selling anatomy-tailored care, better functional preservation, and a friendlier overall treatment experience. The real question is how much of that promise will translate into meaningful patient benefit and how much is simply a better narrative.

The field of minimally invasive treatment for BPH is entering a second phase.

The first phase was defined by the consolidation of recognizable names: UroLift, Rezūm, iTIND, PAE, Aquablation. Each had a relatively clear value proposition, a plausible niche, and a progressively identifiable evidence base.

The second phase is different.

New generations of devices and concepts are now appearing with a more ambitious promise: lower treatment burden, better anatomical adaptation, better sexual preservation, lower perioperative disruption, and an overall more acceptable patient experience.

That sounds appealing. And part of it may prove to be true.

But it is also exactly the kind of territory where real innovation and hype can begin to look uncomfortably similar.

What the new generation is promising

The new wave of LISTs no longer wants only to be “less invasive”. It wants to be more precise, more functional, more anatomically personalized, more acceptable to surgery-averse patients, and, ideally, durable enough to avoid becoming a temporary compromise.

That is a much stronger promise than the first wave offered.

Because it is no longer just selling a procedure. It is selling a vision of the future: better treatment with less penalty and more individualization.

In both market terms and clinical storytelling, that is a very powerful proposition.

Why this evolution makes sense

It would be unfair to dismiss it outright.

The BPH field still carries several unresolved tensions: how to achieve meaningful deobstruction without imposing so much sexual penalty, how to avoid overtreatment in patients who do not want high-powered surgery, how to individualize treatment better according to anatomy and patient priorities, and how to reduce the psychological and logistical burden of intervention.

In that sense, the emergence of new technologies is not arbitrary fashion. It responds to real unmet needs.

The question is not whether there is room for innovation. The question is how much of that innovation will be clinically meaningful and how much will mainly represent an improved narrative.

The new candidates

Among the names now entering the conversation are Optilume BPH, Zenflow Spring, Butterfly, ProVee, Urocross, and FloStent.

They all belong to a second-generation storyline: lower burden, more personalization, potentially more comfort, and a stronger promise of preserving function.

That makes them interesting. But for now, in most cases, they still matter more as a signal of where the field wants to go than as fully established additions to clinical practice.

Where there may be genuine innovation

1. Better anatomical matching

Many of the shortcomings of the first wave came from applying “minimally invasive” procedures to patients or anatomies for which they were never truly ideal.

If a new generation of LISTs can genuinely improve matching according to prostate size, median lobe configuration, bladder neck anatomy, and type of obstruction, that would represent meaningful progress.

2. A better balance between function and durability

This is the deeper promise of the field.

Until now, BPH innovation has largely lived with a fracture line: the more function is preserved, the greater the risk of sacrificing deobstructive power or durability.

If any new technology can materially shift that balance, it will deserve real attention.

But that threshold is high. It is not enough to look elegant. A procedure has to prove that it changes the equation in clinically meaningful terms.

3. Lower burden without drifting into undertreatment

The challenge is not simply to do less. It is to do less without doing too little.

That is one of the central uncertainties of the entire field.

Where hype is most likely

1. “Minimally invasive” as an emotional shortcut

The label has enormous psychological force. It suggests less pain, less risk, less regret, and less disruption.

But “less invasive” does not automatically mean “better” or even “enough”. Sometimes it simply means that the therapeutic cost is displaced elsewhere: more retreatment, lower efficacy, or greater dependence on ideal anatomy.

2. Sexual preservation as the dominant storyline

Ejaculatory preservation is one of the great engines of the LIST field, and rightly so.

But it is also an easy territory for overemphasis. When a technology foregrounds sexual function almost exclusively, we should ask: what happens to durability? what happens to deobstructive power? what happens in real-world outcomes? what happens when anatomy is less than ideal?

If those questions are not answered, then the result is not truly patient-centered care. It is selective storytelling.

3. High visibility with limited maturity

This is especially relevant for several of the newer remodeling or stent-like concepts.

The fact that a device appears in reviews, meetings, or “future of BPH” conversations does not mean it has already earned a stable role in practice.

In some cases, what grows first is not the evidence base, but the expectation.

4. Highly active adoption networks

Every innovation needs clinical leaders. That is normal and often beneficial.

But the more device-driven a field becomes, the more important it is to distinguish legitimate enthusiasm from early adoption and from independent validation.

A technology may look very promising within an adoption network and still not have demonstrated a sufficiently robust, independent benefit.

The case of Optilume BPH

If one name currently deserves special attention in this second wave, it is Optilume BPH.

It is probably one of the most advanced candidates in the emerging block. It offers a clear narrative: low burden, preserved function, and an interesting hybrid therapeutic concept.

That deserves attention.

But for exactly that reason, it should be asked the same hard questions as everything else: in which anatomy does it perform best? what is its true durability? where does it sit relative to Rezūm, PUL, or iTIND? where does it sit relative to Aquablation or HoLEP? is its value mainly functional, logistical, or genuinely therapeutic?

Until those questions are answered with more maturity, the right response is interest combined with restraint.

What any new LIST should be required to prove

Before a new technique claims a stable role, it should be able to answer five questions clearly:

What anatomy is it really for?
What is the retreatment burden at meaningful follow-up?
What does it add over existing LISTs?
What does it add over Aquablation or HoLEP?
Is its main value functional, logistical, or truly therapeutic?

If it cannot answer those questions, it is probably still closer to a promise than to a standard.

So how should we read what is coming?

With curiosity, yes. But also with discipline.

Innovation in BPH care is necessary. Not everything new is smoke, and the field still needs better solutions for patients who currently feel caught between treatments that are too weak and surgeries they perceive as too aggressive.

But that is precisely why the standards should be demanding.

It is not enough for a technology to be new. It is not enough for it to be elegant. It is not enough for it to preserve ejaculation better. It is not enough for it to have a modern personalization narrative.

It has to show that it truly improves the balance between deobstruction, function, durability, and treatment burden.

Conclusion

The next wave of LISTs may bring real innovation. But it may also bring an inflation of promises.

The line between those two possibilities will not be drawn by marketing or by device sophistication. It will be drawn by a very simple question:

Does this technology add something clinically meaningful that we cannot already achieve with existing options, and does it do so without merely shifting the problem elsewhere?

Until that becomes clear, this field deserves attention—but not automatic admiration.

Because the future of LISTs will not be decided by novelty alone. It will be decided by whether they can genuinely improve patients' lives without promising more than they can deliver.

ICUA take-home message
The second generation of LISTs deserves serious attention, but not automatic enthusiasm. The relevant innovation will be the one that truly improves the balance between efficacy, function, and treatment burden—not the one that simply refines the language in which it is presented.

EEP Made Practical: Expert Lessons from the BEAM 2025 Meeting

2026-04-09T16:44:51.993+02:00

A new expert consensus paper has just been published in the World Journal of Urology (April 2026), bringing together practical recommendations from international high-volume surgeons — each with more than 1,000 endoscopic enucleation of the prostate (EEP) procedures — based on structured panel discussions held at the BEAM 2025 meeting (Belgian Endourological Association Meeting) in Ghent, Belgium.

I had the privilege of contributing to this collaborative effort alongside colleagues Martin Kanne, Cesare Marco Scoffone, Felipe Figueiredo, Thomas Herrmann, Peter Schatteman, Thomas Tailly, Carl Van Haute, and Pieter Uvin, coordinated by Gaëtan Devos.

Why does this paper matter?

Endoscopic enucleation of the prostate — whether performed with Holmium laser (HoLEP), Thulium laser (ThuLEP), or other energy sources — is now recognised as the gold standard for surgical treatment of benign prostatic obstruction (BPO), regardless of prostate size. Both the AUA and EAU guidelines endorse it. Yet its adoption worldwide remains limited, primarily because the learning curve is considerably steeper (30–50 cases) than that of traditional TURP (~10 cases).

This paper was born from a simple premise: if the most experienced EEP surgeons in the world could distil their collective know-how into practical, actionable guidance, we could help shorten that learning curve and make EEP safer and more accessible.

Key recommendations

1. EEP is not TURP — adopt the right mindset. EEP is an anatomical dissection along the prostatic surgical capsule, not a debulking technique. Unlike TURP, EEP cannot be interrupted once initiated — it must be completed. Surgeons must embrace anatomical variability and adapt to each case rather than imposing a uniform approach.

2. Train the entire ecosystem. Preparation goes well beyond the surgeon. The full operating room team — nurses, anaesthesiologists, sterilisation units, biomedical engineers — must understand the instruments, the laser, the morcellation device, and common troubleshooting scenarios. Institutional support from the department chair is essential.

3. Respect the learning curve. Start with prostates of 50–60 g with no previous treatments. Limit yourself to no more than two cases per surgical day during the initial phase. Avoid expert-level cases early on: post-radiotherapy prostates, glands >120 g, morbid obesity (BMI >35), or patients with penile implants. Communicate openly with the OR team that the first procedures will take longer.

4. En-bloc technique with early apical release. Although there is no single standard enucleation technique, growing evidence supports the en-bloc approach as faster and more efficient than multi-lobe techniques. Importantly, regardless of whether a multi-lobe or en-bloc technique is used, performing an early apical release may reduce the risk of postoperative stress incontinence by minimising overstretching of the external urinary sphincter. This is a point we have consistently advocated from our experience at ICUA.

5. Choose the right dissection plane. One of the most frequent errors during apical enucleation is hesitating to initiate the dissection sufficiently distal to the verumontanum due to fear of sphincter injury. However, particularly in larger prostates, the optimal apical plane is often located well distal to the veru. A plane that is too proximal leads to false planes, bleeding, residual tissue, and frustration. Trust visual cues — fibrous bands, capsular glistening — over depth assumptions.

6. Invest in proper equipment. A high-power laser, an appropriate morcellator (oscillating devices demonstrate superior morcellation efficiency), continuous-flow resectoscope, heated irrigation fluid, adequate camera anti-fogging protection — these are not luxuries but essentials for delivering high-standard care and managing the learning curve.

7. Know when to stop or convert. When disoriented or facing poor vision, pull back the scope and reassess. The problem is almost always behind you. Converting to TURP is not a failure — it is a wise decision. Patient safety always takes priority over surgical ego.

8. Monitor your outcomes — always. Record your procedures. Use validated questionnaires such as the IPSS. Review your own videos even after 1,000+ cases. Discuss your results and complications with peers. Continuous self-assessment is what separates good from excellent.

Managing challenging anatomy

The paper provides detailed guidance on difficult scenarios: very large prostates (where instrument reach, intravesical protrusion and satellite nodules pose unique challenges), small prostates (<30 g, where the surgical capsule is poorly developed), and large median lobes (where the dissection plane near the bladder neck lies dangerously close to the ureteral orifices). Preoperative MRI assessment of anterior apical angulation and posterior base curvature is highlighted as a useful tool for estimating procedural difficulty.

Morcellation tips

Morcellation is often taught first because it seems simple, but serious complications — including bladder lacerations and even vesico-sigmoidal fistulas — can occur. The paper emphasises: meticulous hemostasis before morcellation, dual irrigation sources to prevent unexpected bladder emptying, eyes fixed on the screen at all times, and immediate pedal release if bladder injury is suspected.

Complication prevention

Key postoperative complications addressed include clot retention, transient stress incontinence, urethral stricture (most commonly bulbar), and bladder neck contracture. Prevention is paramount: adequate lubrication, adapting instrument size to urethral calibre (not vice versa), and performing en-bloc EEP with early apical release. The main risk factor for bladder neck sclerosis is a small prostate (<54–55 ml).

Full reference

Devos G, Kanne M, Gómez Sancha F, Scoffone CM, Figueiredo F, Herrmann T, Schatteman P, Tailly T, Van Haute C, Uvin P. Endoscopic enucleation of the prostate made practical: lessons from experts from the BEAM25 meeting. World J Urol. 2026;44:282.
doi:10.1007/s00345-026-06384-3

Dr. Fernando Gómez Sancha — Medical Director, ICUA (Instituto de Cirugía Urológica Avanzada), Clínica CEMTRO, Madrid. Pioneer of the en-bloc HoLEP technique with early apical release. Over 10,000 EEP procedures. International training programme for urologists from 60+ countries.

En Bloc HoLEP with Vesical Mucosal Release: A Technical Refinement for Safety

2026-04-07T22:22:22.704+02:00

Just published in World Journal of Urology: a paper that is particularly close to me. Dr. Francisco Gomez-Regalado, urologist at Hospital Angeles del Carmen in Guadalajara, Mexico, proposed an elegant idea: protect the ureteral orifices by incising the vesical mucosa before en bloc enucleation.

I liked it from the start. During en bloc HoLEP, especially in large prostates, the bladder neck dissection can get dangerously close to the ureteral orifices. The vesical mucosal release creates a safety margin that allows more confident enucleation without risking ureteral injury.

What does the study show?

A retrospective analysis of 194 consecutive patients operated between January 2024 and October 2025:

Median prostate volume: 80 mL
Median enucleated tissue: 37 grams
Median operative time: 83 minutes
Vesical mucosal release successful in 100% of cases
Overall complications: 1.5%
Ureteric orifice injury: 0.5% (1 patient)
Transient stress incontinence at 1 month: 2% — at 3 months: 0%

Why does this matter?

The best surgical innovations come from daily operating room experience, not from a lab. A surgeon who operates every day identifies a risk, designs a solution, and tests it. That is exactly what Dr. Gomez-Regalado did.

The most telling finding: laser power (50W vs 100W) was not independently associated with enucleation time. What matters is the technique, not the laser power.

A simple step that adds safety

This refinement adds seconds to the procedure and potentially prevents a serious complication. It is the kind of incremental innovation that advances surgical technique: practical, reproducible, and evidence-based.

Proud to be part of this work with the team from Guadalajara.

Reference: Gomez-Regalado F, Munoz-Lopez Y, Perez-DuPond E, Figueroa-Garcia A, Tejeda-Andrade C, Castro-Zazueta S, Gómez-Sancha F. En bloc HoLEP with vesical mucosal release: a technical refinement for safety and operative efficiency. World J Urol. 2026;44(1):287. PubMed | DOI

www.drgomezsancha.com

The Bladder Matters too: A Friendly Critique of the Defenders of the Detrusor

2026-04-03T18:55:05.689+02:00

The Bladder Matters Too: A Friendly Critique of the Defenders of the Detrusor

Analysis · BPH & Bladder Health

The Bladder Matters Too: A Friendly Critique of the Defenders of the Detrusor

A friendly critique of the "Defenders of the Detrusor": what the science supports, what still needs proving, and the research we actually need.

Scientific literature analysis · April 2026

A couple of years ago I came across an initiative that has been generating some genuinely interesting conversations in the urology world. It is called the "Defenders of the Detrusor", born from the work of Dr. Wayne Kuang in the United States, and its central message is as simple as it is provocative: we are treating the prostate and forgetting about the bladder.

I will admit the idea felt refreshing. And also incomplete. Both things at once, without contradiction.

The idea worth listening to

BPH — benign prostatic hyperplasia — affects virtually every man who ages. For decades, the dominant paradigm has been pharmacological: alpha-blockers to relax the bladder neck, 5-alpha reductase inhibitors to shrink the prostate, and wait. The AUA and EAU clinical guidelines reflect this, for good reasons backed by clinical trial data.

But Dr. Kuang and his colleagues point to something those same guidelines only acknowledge in passing: the prostate is not the only organ at stake. In 2023 they published an editorial in Prostate Cancer and Prostatic Diseases with a title that captures it perfectly: "When you say 'Prostate', don't forget to say 'Bladder'!" ^[1]. The bladder, forced to work against rising resistance for years, undergoes a silent remodelling. First it hypertrophies in compensation, then destabilises, and finally — in the most advanced cases — its muscle fibres are progressively replaced by collagen.

The molecular science of recent years confirms this process with a precision we did not previously have. A single-cell transcriptomics study published in 2024 showed that chronic obstruction triggers a cascade running from initial inflammation to smooth muscle hypertrophy, excessive extracellular matrix accumulation and eventual fibrosis — with a urodynamic pattern that shifts from "high pressure, low flow" to "low pressure, low flow" ^[2]. That is solid science. That matters. And there is every reason to say it more loudly.

The "Five Stages of Bladder Health" model proposed by Kuang is, in essence, a pedagogical tool: a way of explaining to a patient that their symptoms have a direction, that direction may be irreversible, and that the timing of intervention matters.

Where the evidence does not hold up

Here comes the part a critically minded physician cannot overlook — even if delivered with goodwill.

The problem of medications framed as mere "band-aids". The initiative tends to describe BPH medications as nothing more than temporary measures masking symptoms while silent damage accumulates. This narrative is an oversimplification. The MTOPS trial — 3,047 patients, 4.5 years of follow-up — demonstrated that combination therapy with doxazosin and finasteride significantly reduced the risk of overall BPH clinical progression more than either drug alone, and that both the combination and finasteride alone reduced the long-term risk of acute urinary retention and the need for prostatic surgery ^[3]. They do not "cure" the anatomical obstruction — granted — but they are not passive placebo while the bladder quietly fails.

The five-stage model still lacks prospective validation. The fact that something has pathophysiological logic does not mean it predicts what will happen in the individual patient in front of you. The most recent review developing the concept — published in Current Urology in 2025 — explicitly describes itself as a "hypothesis-generating review" ^[4]. That is a scientific starting point, not a finishing line.

The "window of curability" does not yet have a clock. The concept is intuitively powerful. There is observational evidence to support it — we know that patients operated on after episodes of acute urinary retention have worse outcomes, with a significantly higher 10-year treatment failure risk when surgical delay exceeds 12 months ^[5]. But we still do not have data answering the practical question with precision: when exactly? With which biomarkers? At what threshold of post-void residual, bladder wall thickness, or maximum flow rate? Without those answers, the "window" remains an illuminating metaphor rather than an actionable clinical guide.

Early surgery is not without risk. The literature documents that endoscopic prostatic surgery carries ejaculatory dysfunction in a significant proportion of patients, postoperative retention in 3–9% of cases, urethral stricture in 2–9%, and iatrogenic incontinence in around 0.5% ^[6]. For a 60-year-old man with moderate symptoms and still-preserved bladder function, the risk-benefit equation of early surgery versus active surveillance with medication is unresolved.

A note on the editorial's origins. The initiative's reference editorial in Prostate Cancer and Prostatic Diseases ^[1] is, by its own nature, an opinion piece. One of its three authors is Dr. Kuang himself — founder of ManVsProstate and author of the book the editorial reviews. This overlap does not invalidate the arguments, but it does call for the careful reading that any publication with a declared interest deserves.

The research we actually need

The real problem is not that the "Defenders of the Detrusor" are wrong about their concern — they are not. The problem is that they are asking us to change how we practise medicine without yet having the evidence to make that change safely. So what would it take?

1 Prospective validation of the five-stage model. Recruit a large cohort of men with BPH, classify them according to the model with strict operational criteria and follow them for at least five years measuring urodynamic bladder function, quality of life and progression to detrusor underactivity or retention. Until that is done, the five stages remain useful pedagogy, but not clinical staging ^[4].
2 Define the thresholds of the "window of curability". A randomised controlled trial — or at minimum a prospective cohort study with propensity score analysis — comparing early surgical intervention guided by objective biomarkers versus protocolised medical management with active surveillance, with long-term detrusor function as the primary endpoint.
3 Studies of damage reversibility. How far along the remodelling pathway can bladder function recover after deobstruction? A 2024 meta-analysis of TURP in patients with preoperative detrusor underactivity showed significant improvements in maximum flow rate, IPSS, and bladder contractility index ^[7], and a molecular study showed that deobstruction partially reverses transcriptional changes ^[8]. We need larger cohorts and longer follow-up to define what is reversible, in whom, and for how long.
4 Cost-effectiveness analysis of the proposed objective diagnostics. If we are going to recommend routine cystoscopies and bladder wall thickness measurements across the BPH population, we need to know the cost to the health system, the risks those procedures carry, and whether the information they generate genuinely changes clinical decisions and patient outcomes.

A strength worth highlighting: technological agnosticism

Something the initial analysis did not adequately capture: the initiative does not advocate for any specific surgical technology. The book mentions no device by name — no Urolift, no Rezum, no iTind, no Aquablation. It acknowledges the explosion of minimally invasive surgical options (MISTs) and uses them as a favourable point of comparison against medication, but deliberately leaves the technical choice to an individualised shared decision-making process — what Dr. Kuang calls the Trifecta: prostate size, prostate shape, and the detrusor function of each specific patient.

This technological agnosticism is intellectually honest and makes the paradigm more robust. This is not a device looking for a market — it is a philosophy of timely intervention with the best available tool for each case. In a field where many "initiatives" have a commercial technology behind them, that deserves explicit recognition.

A closing thought

The "Defenders of the Detrusor" have done something genuinely difficult: they have put an uncomfortable question on the table that urology has been skirting for years. Are we letting the bladder deteriorate while we busy ourselves controlling symptoms? That question deserves a serious scientific answer — not a hasty one in either direction.

The initiative deserves credit for identifying the problem and for creating accessible language to communicate it with patients. What it still needs is the evidence that converts a clinically coherent hypothesis into a safe medical recommendation.

And that, fortunately, is something that can be built. It just requires someone to do it with the rigour that the bladder — that silent, forgotten muscle — deserves.

✉️

Author's note

Dr. Wayne Kuang kindly sent me his book Man vs Prostate: Preserving Bladder Health for BPH (2025), and reading it led me to revisit and nuance several points in this analysis. I am genuinely grateful for the gesture — it reflects the spirit of open dialogue that defines this initiative. And it is precisely that spirit which makes the Defenders of the Detrusor one of the most refreshing and original proposals the BPH field has seen in years: not only for what it argues, but for how it does so — with accessibility, honest acknowledgement of its own limitations, and a genuine commitment to changing the conversation between clinicians and patients.

References

1Cindolo L, Rubilotta E, Kuang W, Antonelli A. When you say "Prostate", don't forget to say "Bladder"! Prostate Cancer Prostatic Dis. 2024;27(1):5–6. PubMed 37872252
2Chen J, Peng L, Chen G, et al. Single-cell transcriptomics reveal the remodeling landscape of bladder in patients with obstruction-induced detrusor underactivity. MedComm. 2024;5(3):e490. PubMed 38414668
3McConnell JD, Roehrborn CG, Bautista OM, et al.; MTOPS Research Group. The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia. N Engl J Med. 2003;349(25):2387–98. PubMed 14681504
4Kuang WW, Cindolo L, Alsaboy T, Chughtai BI. Tackling the progression of BPH/BPO: Deobstructing within the "window of curability" (a hypothesis-generating review). Curr Urol. 2025. PubMed 41058768
5Frendl DM, et al. Early vs Delayed Transurethral Surgery in Acute Urinary Retention: Does Timing Make a Difference? J Urol. 2023. Journal of Urology
6Marra G, Sturch P, Oderda M, et al. Is Early Surgical Treatment for BPH Preferable to Prolonged Medical Therapy: Pros and Cons. Urol Int. 2021. PMC8069902
7Zou P, Liu C, Zhang Y, et al. Transurethral surgical treatment for BPH with detrusor underactivity: a systematic review and meta-analysis. Syst Rev. 2024;13(1):93. PubMed 38520009
8Matak L, et al. De-obstruction of bladder outlet in humans reverses organ remodelling by normalizing the expression of key transcription factors. BMC Urol. 2024. BMC Urology

Relevant links

🛡️

ManVsProstate — Defenders of the Detrusor

Dr. Wayne Kuang's official site: educational resources, the Five Stages model and the global awareness campaign on bladder health in BPH.

📄

Original editorial in Prostate Cancer and Prostatic Diseases (2023)

Cindolo L, Rubilotta E, Kuang W, Antonelli A. "When you say 'Prostate', don't forget to say 'Bladder'!" — PubMed 37872252.

🔬

"Window of Curability" Review — Current Urology (2025)

Kuang WW et al. Proposes the window of curability framework and the five-stage system. Self-described by its authors as a hypothesis-generating review.

📋

EAU Guidelines: Non-neurogenic Male LUTS

Updated European Association of Urology guidelines on the management of male lower urinary tract symptoms, including BPH.

New training session in Sofia with visitor from Belgium!

2026-03-29T14:10:00.001+02:00

Another productive training session at Hill Clinic in Sofia, Bulgaria. This time, I had the pleasure of hosting Dr. Hannes Van Den Bossche, a urologist from AZ West Hospital in Veurne, Belgium, who traveled to Bulgaria to learn about the en bloc HoLEP technique.

Over the course of the weekend, I performed 30 procedures. the kind of dedication that makes these training programs worthwhile.

Unfortunately, a group of urologists from Iraq who had registered for the program were unable to attend due to transportation difficulties caused by the ongoing conflict in their region. It's a sobering reminder that while surgical technique continues to evolve, not everyone has equal access to education and training opportunities.

Hill Clinic remains one of the most active international centers for HoLEP training. Over the past 16 years, urologists from more than 30 countries have come here to lears. Each visit reinforces why training matters.

The 2026 SIU-ICUD Consultation on Male LUTS: A Structural Conflict of Interest Analysis

2026-03-27T10:06:00.004+01:00

Fernando Gómez Sancha · ICUA Madrid · March 2026

In March 2026, the Société Internationale d'Urologie published the SIU-ICUD Consultation on Individualized Management of Male LUTS, edited by Dean Elterman, Stavros Gravas, and Andrea Tubaro ^[1]. At 420 pages, with seven committees and contributors from across the world, it is a serious and comprehensive document that will serve as a reference for urologists worldwide. I read it carefully, and I believe it deserves an equally careful critical reading.

Full disclosure: I have performed over 10,000 holmium laser enucleations of the prostate (HoLEP). I have trained more than 600 urologists in this technique across 60 countries, and that training generates direct professional income. I published the technique of en-bloc HoLEP with early apical release in 2019 ^[9], subsequently studied in a global multicenter registry of 6,193 patients ^[2]. I have received speaking fees and proctoring arrangements from Quanta System, Richard Wolf, and Andromeda Surgical — manufacturers of HoLEP equipment. I receive no payment from any manufacturer of devices discussed in this article, but I have a direct professional and commercial interest in the wider adoption of HoLEP. Any reader should weigh my perspective with this in mind.

I am not a neutral observer. Neither, as I will argue with specific evidence, is this document.

I. The Declared Sponsors and the Conflict Architecture

The document's copyright page states: "The SIU-ICUD Committee would like to acknowledge the support of the following partners: Boston Scientific, GSK, Laborie, Pierre Fabre Laboratoires, PROCEPT BioRobotics, and Teleflex." ^{[1, p. 2]}

The alignment between each sponsor and its covered technology is exact:

Boston Scientific → Rezūm water vapor thermal therapy (dedicated chapter, procedural video)
Teleflex (NeoTract) → UroLift prostatic urethral lift (dedicated chapter)
PROCEPT BioRobotics → Aquablation / HYDROS system (dedicated chapter, 4 corporate images, procedural video)
GSK → Dutasteride (Avodart/Duodart), covered in the pharmacological management chapter

Every sponsor's product appears in the clinical recommendations. This alignment is not a coincidence to be acknowledged and set aside — it is the structural condition under which the document was produced.

What follows is more specific than a general concern about industry funding.

II. The Named Positions: A Structural Analysis

The 2026 SIU-ICUD Consultation does not include a declarations-of-interest section for any committee member. In a 420-page document published in 2026, this absence stands in contrast to the declared standards of the EAU Guidelines, whose published COI policy requires individual financial disclosures and restricts panel members from voting on recommendations for technologies in which they hold significant interests ^[10]. Whether or not the SIU is formally bound by EAU policy — it is not — the comparison illustrates a transparency gap that clinicians using this document as a reference should be aware of.

The following biographical facts are drawn from publicly verifiable sources — the document itself, PubMed author records, and published trial registries:

Peter Gilling serves as Co-Chair of Committee 4 (Invasive Surgical Treatments), which is responsible for the Aquablation chapter ^{[1, p. 152]}. He is also the first or senior author of the WATER randomised controlled trial and the WATER II single-arm study — the two pivotal trials that establish the evidence base for Aquablation and that are cited six times in the Aquablation chapter ^[3,4]. Both trials were conducted with device support from PROCEPT BioRobotics, as declared in their published disclosures.

To be clear about what this means structurally: the investigator who led the manufacturer-supported trials that validated Aquablation co-directed the committee that evaluated those trials and produced the recommendation for Aquablation, in a document whose production was financially supported by that manufacturer. This arrangement raises legitimate questions about the management of conflicts of interest, regardless of the scientific integrity of any individual involved. Gilling is also one of the world's foremost experts on HoLEP — a genuine authority on both technologies — which is precisely what makes the structural arrangement worth examining rather than dismissing.

Dean Elterman is the Editor of the entire consultation ^{[1, cover page]}. He is also first author of "Focal bladder neck cautery associated with low rate of post-Aquablation bleeding" (Elterman DS et al., Can J Urol, 2021), cited as Reference 9 in the Aquablation chapter ^{[1, p. 212]}. That paper is cited in the specific passage addressing the most significant safety signal in the Aquablation evidence base: the 9.9% pre-discharge bleeding rate and 5.9% transfusion rate documented in WATER II ^[4]. A publication authored by the document's editor addresses a complication of the sponsor's technology, within a chapter that the same editor oversaw. Readers should be aware of this layering when evaluating how the WATER II safety data is contextualised.

Elterman's consultancy and investigator relationship with PROCEPT BioRobotics is not a matter of inference — it is declared explicitly in his published papers, including the REAP global multicenter registry (World J Urol, 2023), where his disclosures read: "Dean Elterman is a consultant/investigator for… Procept BioRobotics…" ^[2]. This makes the absence of any equivalent declaration in the SIU-ICUD Consultation — a document he edited — the more conspicuous.

Kevin Zorn serves as Co-Chair of Committee 5 (BPH Minimally Invasive Treatments) ^{[1, p. 348]}, which covers Rezūm, UroLift, and Optilume — three technologies whose manufacturers are declared sponsors. His authorship on the Aquablation same-day discharge paper cited as Reference 5 in the Aquablation chapter, and his co-authorship on multiple papers on Rezūm cited in that chapter, are verifiable through PubMed author records.

These positional overlaps — between editorial authority and prior commercial research relationships — are presented here as structural observations, not as accusations of misconduct toward any individual.

III. The Quantitative Asymmetry

The AEEP/HoLEP chapter and the Aquablation chapter cover surgical procedures for the same clinical indication. Some editorial asymmetry is expected: Aquablation is a newer technology with more technical complexity to describe. But the nature — not only the magnitude — of the difference is worth examining:

	AEEP/HoLEP	Aquablation
Approximate word count	~1,875	~2,747
References	15	21
Sponsor-funded trial references	0	6 (WATER family)
Industry-supplied images	0	4 ("courtesy of PROCEPT BioRobotics")
Trademarked product names in text	0	2 (Aquabeam®, FirstAssist AI™)
Procedural video (SIU Academy)	None	Yes — Aquablation®
Level of Evidence	I (Ho:YAG)	II
Grade of Recommendation	A	B

The additional length in the Aquablation chapter is not composed of clinical evidence — it is composed in part of corporate image descriptions and promotional language. No other surgical technique in Committee 4 uses images from a device manufacturer. No other chapter reproduces trademarked marketing terminology in a figure caption.

IV. Corporate Images as Scientific Figures

Four figures in the Aquablation chapter carry the credit line "Image courtesy of PROCEPT BioRobotics Corporation." ^{[1, pp. 191–194]} One presents PROCEPT's HYDROS system with a caption describing it as featuring "AI-powered treatment planning with FirstAssist AI™, advanced image guidance, and a more streamlined workflow." ^{[1, p. 192]}

The term FirstAssist AI™ — with trademark symbol — appears verbatim in a clinical consultation published under the SIU imprimatur. The EAU Guidelines do not include manufacturer-supplied promotional images. The AUA Guidelines do not. This document does, for exactly one technology, whose manufacturer is a declared sponsor.

V. Opening Paragraphs as Evidence of Register

The Aquablation chapter opens ^{[1, p. 191]}:

"Aquablation has become an integral treatment option for surgeons to effectively manage BPH while minimizing possible side effects. Not only has the literature proved the success of Aquablation, but Aquablation has also been endorsed by all major society guidelines."

The AEEP chapter opens ^{[1, p. 178]}:

"Anatomical endoscopic enucleation of the prostate (AEEP) is a highly effective surgical technique used to treat BPH… These advancements have significantly improved patient outcomes, particularly for men with large prostate glands, by reducing morbidity, improving efficacy, and minimizing complications."

The second is technical and contextual. The first is a positioning statement structured around endorsement and market adoption. The Aquablation chapter closes ^{[1, p. 196]} describing "profound long-term outcomes" — the word profound does not appear in the conclusions of any other chapter in the surgical treatment section.

VI. Procedural Videos: The Most Objective Asymmetry

The document's preface highlights its procedural videos as an innovation ^{[1, p. VI]}. The procedures with SIU Academy® videos are: Aquablation® (PROCEPT BioRobotics — sponsor), Rezūm™ (Boston Scientific — sponsor), and Optilume® ^{[1, pp. 197, 270]}.

HoLEP — the procedure with Level I, Grade A evidence, the highest recommendation in the surgical section — has no procedural video. It is possible that logistical or licensing factors explain this absence; I have no access to the document's internal editorial communications. But the outcome is that the educational resource most effective for driving surgical adoption — video training — is provided exclusively for the procedures of declared sponsors, and not for the procedure with the strongest evidence base.

VII. The Volume Restriction: An Evidence Gap That Requires Explanation

The document's recommendation table stratifies by prostate volume as follows ^{[1, pp. 168, 183, 196]}:

Procedure	Recommended volume	LoE	GoR
TURP	30–80 mL	I	A
Aquablation	30–80 mL	II	B
AEEP/HoLEP	> 80 mL only	I	A

HoLEP is the only major endoscopic procedure in this table restricted to the large-prostate segment. This restriction is not explained in the chapter, and it is not consistent with the available evidence. Multiple Level I randomised controlled trials and meta-analyses include prostates well below 80 mL and demonstrate equivalent or superior outcomes for HoLEP versus TURP across the full volume range ^[5,6,7,8,9]. The 2024 EAU Guidelines on Non-neurogenic Male LUTS do not impose a lower volume threshold for endoscopic enucleation ^[10].

A case can be made for clinical caution: HoLEP's learning curve (~50 cases) is real, and in smaller prostates where TURP is technically straightforward, some clinicians consider enucleation less necessary. This is a legitimate clinical discussion. What is absent from the document is any explanation of why this restriction was applied to HoLEP but not to TURP — which also has a learning curve and a complication profile in smaller prostates. The absence of justification is what makes the restriction notable, not the restriction itself.

The practical consequence is significant. Prostates between 30 mL and 80 mL represent the majority of the BPH surgical population. The recommendation as written places HoLEP outside the volume range where Aquablation — a sponsor's technology with lower evidence grade — is recommended. An evidence-based justification for this asymmetry should have been provided.

VIII. The Neutralisation of the Bhatia Meta-Analysis

The document cites Bhatia et al. (2024), a network meta-analysis comparing Aquablation and HoLEP ^[11]. The document summarises its findings as follows ^{[1, p. 195]}:

"At 12 months, the HoLEP procedure was associated with better outcomes in terms of IPSS, QoL, PVR, and Qmax improvements, though it was associated with higher rates of incontinence. There was a higher risk of hemoglobin loss and risk of blood transfusion with Aquablation as well as higher rates of retreatment."

This is the document's own summary: HoLEP is superior in four primary functional outcomes; Aquablation has more bleeding complications and higher retreatment. The sentence that immediately follows ^{[1, p. 195]}:

"Despite the difference in functional outcomes, Aquablation operative time and hospital stays were significantly lower, presenting a compelling alternative in the outpatient setting."

The word despite performs significant editorial work here. It subordinates superiority across four functional measures to an operational scheduling consideration. This framing — where logistical advantage is positioned to offset clinical inferiority — merits scrutiny given the document's sponsorship structure. A methodological caveat is warranted: the Bhatia NMA covers 12-month outcomes, which is sufficient for functional comparison but does not capture the long-term durability advantage of HoLEP that emerges in studies with 7–10 year follow-up ^[4,5]. Even with that caveat, the document's characterisation of the evidence does not reflect the hierarchy of outcomes that patients typically prioritise.

IX. Technical Attribution: An Observation on Academic Practice

The document credits Peter Gilling and Fraundorfer as the developers of HoLEP using the Ho:YAG laser ^{[1, p. 179]}. This is historically accurate. The document then describes the en-bloc enucleation technique as follows ^{[1, p. 221]}:

"The en bloc technique for AEEP, which involves enucleating the entire transition zone adenoma as one tissue block, is increasingly being utilized for AEEP due to its improved enucleation efficiency and some reports of better early continence."

"Increasingly being utilized" and "some reports" are language choices that suggest an emerging, informally validated trend. In the same document, Gilling receives specific nominal credit as HoLEP's originator and six citations for the WATER trials. The contrast in attribution practices — named credit for the originating technique, anonymous treatment for a major technical evolution — is a pattern worth noting as a matter of academic convention, independent of any other argument in this article.

X. What the Document Contains That Is Valuable

The evidence grades in this document are real and correctly applied. The Level I, Grade A recommendation for HoLEP is present. The retreatment data for UroLift — 8–15% at five years ^[12] — is in the UroLift chapter. The superior functional outcomes for HoLEP in the Bhatia meta-analysis are cited. The WATER II bleeding data is present. The document does not fabricate evidence.

What it does is construct an editorial architecture around evidence that exists — through opening language, image selection, video provision, volume-restricted recommendations, and sentence-level framing choices — that consistently favours the technologies of its declared sponsors over the procedure with the highest level of evidence. This is how industry influence on clinical documents typically operates at present. The mechanism is present in the structure regardless of the intentions of any individual contributor.

The word unrestricted in the sponsor acknowledgment ^{[1, p. VI]} is doing significant work. The sponsors are named. Their products are covered. Their images are reproduced. Their videos are distributed under the SIU Academy label. Their funded-trial investigators co-chair the committees that evaluated their products. Individual authors do not declare conflicts of interest. These facts coexist in the same document.

XI. Recommendations for Clinicians and Health Systems

Use this document. It is comprehensive and largely accurate within the limits described above. Apply the following questions:

On evidence grades: HoLEP is Grade A, Aquablation is Grade B. This hierarchy is correctly stated. It should inform procurement and training decisions.

On the volume restriction for HoLEP: The >80 mL restriction is not supported by a body of evidence that excludes smaller prostates. Clinicians and health systems should consult the 2024 EAU Guidelines ^[10], which do not impose this restriction, before using this document's recommendation to exclude HoLEP from their treatment pathway for moderate-volume BPH.

On retreatment rates: Assemble and compare them independently. Published data, with appropriate caveats for different follow-up durations and study populations: HoLEP 0–1.4% at 7–10 years ^[4,5]; TURP 14.7% at 8 years ^{[1, p. 168]}; Rezūm 4–5% at 5 years ^[13]; UroLift 8–15% at 5 years ^[12]. These figures should be in any informed consent discussion.

On conflict-of-interest transparency: The 2024 EAU Guidelines ^[10] and the 2023 AUA/SUFU BPH Guideline ^[14] both publish individual COI declarations with specific financial disclosures. Cross-referencing this document's committee members against those declarations provides additional context.

XII. A Note on Formal Response

If the concerns raised in this article are shared by other clinicians and educators in this field, the most effective formal response would address three specific, documentable issues: (1) the absence of individual COI declarations, benchmarked against EAU and AUA policy; (2) the structural position of committee chairs with disclosed relationships to the technologies their committees evaluated; and (3) the absence of evidentiary justification for the >80 mL volume restriction on HoLEP recommendations, given the available Level I evidence across the full prostate volume range.

These are arguments that can be made on the basis of published evidence and documented policy comparisons, without requiring access to the document's internal editorial communications.

References

Elterman D, Gravas S, Tubaro A (Eds). SIU-ICUD Consultation: Individualized Management of Male LUTS. Société Internationale d'Urologie. March 2026. ISBN 978-1-0688136-1-0.
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients to refine endoscopic anatomical enucleation of the prostate (REAP). World J Urol. 2023;41(11):3033–3040. doi:10.1007/s00345-023-04626-2
Gilling P, Barber N, Bidair M, et al. WATER: A double-blind, randomized, controlled trial of Aquablation® vs transurethral resection of the prostate in benign prostatic hyperplasia. J Urol. 2019;201(5):965–973. doi:10.1097/JU.0000000000000076
Desai M, Bidair M, Bhojani N, et al. WATER II (80–150 mL) procedural outcomes. BJU Int. 2019;123(1):106–112. doi:10.1111/bju.14360
Elmansy HM, Kotb A, Elhilali MM. Holmium laser enucleation of the prostate: long-term durability of clinical outcomes and complication rates during 10 years of followup. J Urol. 2011;186(5):1972–1976. doi:10.1016/j.juro.2011.07.015
Placer J, Gelabert-Mas A, Vallmanya F, et al. Holmium laser enucleation of prostate: outcome and complications of self-taught learning curve. Urology. 2009;73(5):1042–1048. doi:10.1016/j.urology.2008.10.074
Tan AHH, Gilling PJ, Kennett KM, et al. A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction. J Urol. 2003;170(4 Pt 1):1270–1274. doi:10.1097/01.ju.0000085341.13190.5e
Ahyai SA, Gilling P, Kaplan SA, et al. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. Eur Urol. 2010;58(3):384–397. doi:10.1016/j.eururo.2010.06.005
Saitta G, Becerra JEA, Del Álamo JF, et al. En bloc HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol. 2019;37(11):2451–2458. doi:10.1007/s00345-019-02671-4
Gravas S, Gacci M, Gratzke C, et al. EAU Guidelines on Non-neurogenic Male Lower Urinary Tract Symptoms. European Association of Urology. 2024 Edition. uroweb.org/guidelines
Bhatia A, Titus R, Porto JG, et al. Comparing outcomes of Aquablation versus holmium laser enucleation of prostate in the treatment of benign prostatic hyperplasia: a network meta-analysis. BJUI Compass. 2024;5(12):1231–1245. doi:10.1002/bco2.454
Roehrborn CG, Barkin J, Gange SN, et al. Five year results of the prospective randomized controlled prostatic urethral L.I.F.T. study. Can J Urol. 2017;24(3):8802–8813. PMID:28646935
McVary KT, Rogers T, Roehrborn CG. Rezūm water vapor thermal therapy for lower urinary tract symptoms associated with benign prostatic hyperplasia: 4-year results from randomized controlled study. Urology. 2019;126:171–179. doi:10.1016/j.urology.2018.12.031
Sandhu JS, Bixler BR, Dahm P, et al. Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline (2023 Update). J Urol. 2023;210(1):11–19. doi:10.1097/JU.0000000000003698

Dr. Fernando Gómez Sancha is Medical Director of ICUA (Instituto de Cirugía Urológica Avanzada) at Clínica CEMTRO, Madrid. He has performed over 10,000 HoLEP procedures and trained urologists across 60 countries, generating direct professional income from that training. He discloses speaking and proctoring arrangements with Quanta System, Richard Wolf, and Andromeda Surgical — manufacturers of HoLEP equipment. He receives no payment from any manufacturer of devices discussed in this article. The author's direct interest in the broader adoption of HoLEP should be considered when evaluating the arguments presented here.

@fgomsan · ICUA.es · LinkedIn

En-Bloc HoLEP Manual — The Definitive Guide to Prostate Enucleation

2026-03-24T08:09:00.003+01:00

After performing over 10,000 prostate enucleations and training urologists in more than 50 countries, I have published what I believe is the most comprehensive resource available on en-bloc HoLEP: the Manual de Enucleación Prostática HoLEP en Bloque.

354 pages distilling two decades of real surgical experience. Not abstract theory. Real cases, step-by-step technique, complication management, and everything a urologist needs to master this procedure.

Why an en-bloc HoLEP manual?

Benign prostatic hyperplasia (BPH) affects over 50% of men older than 60. Holmium laser enucleation of the prostate — HoLEP — has established itself as the gold standard for large prostates. Both EAU and AUA guidelines recommend it as a first-line option regardless of prostate size.

En-bloc HoLEP takes this a step further. Instead of enucleating the prostate in multiple fragments (the classic trilobular approach), en-bloc technique removes the entire adenoma in a single piece. The advantages are clear:

Shorter operative time — fewer steps, less tissue manipulation
Superior hemostasis — better visualization throughout the procedure
More intuitive learning curve — the anatomical plane guides the surgeon

What you will find in this manual

This is not a theoretical textbook. It is a surgical manual built in the operating room:

Detailed surgical anatomy — the dissection planes that make the difference between a clean enucleation and a complicated one
Step-by-step technique — from initial incision to morcellation, with intraoperative images
Complication management — what to do when things do not go as planned
Learning curve — how to structure your training, how many cases you need, which mistakes to avoid
Special cases — prostates over 200 grams, patients on anticoagulants, complex anatomies
Outcomes and evidence — long-term follow-up data from thousands of patients

Who is this book for

Any urologist looking to incorporate HoLEP into their practice or improve their results with the en-bloc technique. Whether you are starting your learning curve or already experienced with the trilobular approach, this manual provides the perspective of someone who has operated in over 50 countries and trained hundreds of urologists live.

It is also a useful reference for urology residents who want to understand the technique before facing the laser for the first time.

Book details

Title: Manual de Enucleación Prostática HoLEP en Bloque
Author: Fernando Gómez Sancha
Publisher: Simed Software
Pages: 354
ISBN: 978-84-09-42726-0
Edition: 1st edition

Where to get it

Official website — manualholep.icua.es — full information, table of contents, and direct order— worldwide shipping available

The experience behind the manual

I have spent over 20 years refining the en-bloc HoLEP technique. I have operated in more than 50 countries — from university hospitals in Europe and the Americas to surgical centers in Asia and Africa. Every live surgery, every complex case, every question from a colleague in training has contributed to shaping this manual.

At ICUA, our center in Madrid, we perform HoLEP as our reference procedure. The results speak for themselves: reoperation rates below 1%, average catheterization of 24 hours, and patients recovering their quality of life within days.

This manual is my way of sharing everything I have learned. If you perform HoLEP or are considering adding it to your practice, I hope you find it as useful as it would have been for me at the beginning of my career.

Dr. Fernando Gómez Sancha
Co-owner of ICUA — Clínica CEMTRO, Madrid
@fgomsan | LinkedIn

My professional journey: 32 years in urology, 52 countries, 10.000+ procedures

2026-03-21T13:35:00.001+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

I have spent 32 years in urology. I began my residency at Hospital de la Princesa in Madrid in 1994, completed my training at the Institute of Urology in London under Prof. Mundy, and in 2002 founded ICUA with my brother Santiago. We currently operate across 6 hospitals in Madrid, Cádiz, Jaén and Seville.

Since then, my career has revolved around two things: operating and teaching. I have performed over 10,000 laser prostate enucleation procedures — first with GreenLight (photoselective vaporisation and GreenLEP), then with holmium (en bloc HoLEP with early apical release). I have operated or provided training in 52 countries, and more than 600 urologists from around the world have visited our operating theatre to learn the technique.

This interactive timeline captures that journey. It is built from the real data of this blog, my Twitter archive, and my scientific publications — over 2,400 documented events between 2002 and 2026. You can filter by category (surgery, congresses, training, publications), by year, and watch how our international reach has expanded over time using the animated map.

The technical evolution

My path in laser prostate surgery has followed a constant evolution. I started with GreenLight photoselective vaporisation in 2003, developed the GreenLEP technique (green laser enucleation) which I first presented as a video at the EAU congress in 2010 and published as a full paper in World Journal of Urology in 2015, and since 2011 have been working with the holmium laser to perfect en bloc enucleation with early apical release — the technique we perform daily at ICUA and have published in series of 137, 754, and 6,193 patients.

Training as a mission

I have always believed that every urology department in the world should be able to offer endoscopic enucleation to its patients. Since 2007, our training programme at ICUA has received over 600 visiting urologists. Many of them now perform enucleation routinely at their own centres, and several have published their own results with the technique.

In 2010 I began my collaboration with the Hill Clinic in Sofia, Bulgaria, which has become another reference centre for enucleation training, with over 4,000 laser procedures performed there.

The manual

In 2026 I published the En Bloc HoLEP Manual (ISBN 978-84-09-81888-4), a 352-page book born from the questions and challenges that visiting surgeons raise in the operating theatre. It is not an evidence-based manual in the classical sense — it is an experience-based manual drawn from over 10,000 cases.

Contact

If you are a urologist interested in training in en bloc HoLEP, or a patient looking for a surgeon with proven experience, you can reach us at:

📞 +34 91 435 28 44 · ✉ icua@icua.es
Coordination: Vanesa Cuadros · vcr@icua.es

→ What Is HoLEP? A Complete Guide to Holmium Laser Enucleation of the Prostate
→ En Bloc HoLEP with Early Apical Release: The Gómez Sancha Technique
→ HoLEP Training: Courses, Proctoring and the ICUA Training Programme

HoLEP Training: Courses, Proctoring and the ICUA Training Programme

2026-03-20T12:21:00.010+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

Every urology department in the world should be able to offer endoscopic enucleation to its patients. This is the conviction that has driven my dedication to training for over 15 years. The technique is not easy, but it is teachable and reproducible — and the data prove it.

If you are a urologist who wants to incorporate en bloc HoLEP into your practice, or if you already enucleate and want to refine your technique, this article explains the training options we offer at ICUA and the learning curve data you should know before you begin.

The HoLEP learning curve: what the data say

The learning curve has historically been the main argument against adopting HoLEP. "It's too difficult", "you need 50 cases to become competent", "I don't have enough volume". I have heard these objections hundreds of times. Let us look at what the data actually show.

In a comparative learning curve study, the en bloc enucleation technique showed a shorter curve than the classic three-lobe technique: 14–30 cases versus 22–40 cases to achieve competence, with shorter operative times despite enucleating somewhat larger prostates (Peyronnet, 2017).

An independent study of 500 consecutive cases using the en bloc technique (Wenk et al., World J Urol 2024) demonstrated that, with structured training, the learning curve is significantly shorter than traditionally attributed to HoLEP. A study with beginners (Li et al., 2023) confirmed that the technique is feasible from the earliest cases when adequate mentorship is provided.

The key is not individual talent — it is structured training, clear anatomical principles, and sufficient case volume under supervision.

The ICUA Training Programme

Since 2007, we have received over 600 visiting urologists from more than 60 countries at ICUA. Our training programme operates at several levels, adapted to each surgeon's experience and needs.

Operating theatre observership — Madrid

This is the foundational experience. The visiting urologist spends an afternoon in our operating theatre at Clínica CEMTRO, where we schedule five operations with varied cases: different prostate sizes, patients with prior treatment, prostates after TURP, after UroLift, and so on.

The goal is not merely to demonstrate the technique — it is to inspire. For the visitor to see a well-practised team executing the operation with fluency, to understand the principles (early apical release, sphincteric mucosa preservation, incision-free dissection) and to leave with a clear objective to implement at their own hospital.

Traditionally, after the surgical session we go to dinner together. It is an opportunity to talk, get to know each other better, and understand the specific challenges each surgeon faces in adopting the technique in their environment.

Operating theatre observership — Hill Clinic, Sofia (Bulgaria)

My collaboration with the Hill Clinic in Sofia has been a true school of learning and a teaching centre where many urologists who are now international figures in the field began their enucleation experience. It is another site where visiting urologists can observe the technique in a high-volume setting.

On-site proctoring at your hospital

For surgeons who have completed the observership and want to implement the technique, we offer on-site proctoring: I travel to your hospital and accompany you through your first cases. Having an experienced surgeon alongside you during the initial procedures drastically shortens the learning curve and increases patient safety.

I have provided proctoring at hospitals across Europe, Latin America, Asia, the Middle East, and Africa. Every hospital is different — equipment, surgical team, patient mix — and adapting the training to the specific environment is an essential part of the process.

Video-based training and remote consultation

For surgeons who are already enucleating and have questions about specific cases or wish to improve particular technical aspects, we offer video consultation. We can review surgical videos together, discuss strategies for complex cases, and troubleshoot technical problems in a personalised way.

The manual: a complementary resource

In 2026, I published the Manual de HoLEP en Bloque (ISBN 978-84-09-81888-4), a 352-page book born precisely from the questions and challenges that visitors raise in the operating theatre. It is not an evidence-based manual in the classical sense — it is an experience-based manual reflecting the thought process of a surgeon obsessed with simplifying the procedure to make it reproducible and teachable.

The manual covers everything from anatomical fundamentals to complex situations (previously operated prostates, catheterised patients, incidental cancer, associated stricture), with detailed step-by-step illustrations. If the reader finds a useful detail or adopts any of the ideas reflected within, it will have been worthwhile.

+600 surgeons trained across 60+ countries

Our visitor database includes more than 600
urologists from over 60 countries who have gone through our training programme since 2007. Many of them now perform enucleation routinely at their centres, and several have published their own results — confirming that the technique is reproducible in the hands of appropriately trained surgeons, with outcomes comparable to ours.

This global network of surgeons trained in our technique also benefits patients: when a patient from another country contacts me, I can often refer them to a colleague trained at their own city who performs the technique with proven competence.

For urologists who wish to refer patients

If you are a urologist and have a patient who needs enucleation but you do not have the technique or the equipment at your centre, you can refer them to ICUA. We commit to keeping you informed throughout the process and to returning the patient to your care with a comprehensive report. We work in collaboration, not in competition.

My philosophy on training: I have always tried to improve, learn, share, and contribute to making things better. What I know is the fruit of interactions with my teachers, my colleagues, and the specialists I have met in my travels around the world. We all learn from each other. If this training programme helps more patients in more countries gain access to quality enucleation, it will have fulfilled its purpose.

Are you a urologist interested in training in en bloc HoLEP?

Contact us to arrange your visit or request information about proctoring.
📞 +34 91 435 28 44 · ✉ icua@icua.es
Coordination: Vanesa Cuadros · vcr@icua.es

Scientific references

Saitta G, Becerra JEA, Del Álamo JF, Gómez Sancha F, et al. 'En Bloc' HoLEP with early apical release. World J Urol. 2019;37:2451-2458. PubMed
Wenk MJ, Hartung FO, Egen L, Netsch C, Kosiba M, Grüne B, Herrmann J. The long-term learning curve of HoLEP in the en-bloc technique: a single surgeon series of 500 consecutive cases. World J Urol. 2024;42:436. PubMed
Li S, et al. En bloc HoLEP: feasibility for beginners. BMC Urol. 2023;23:56. PMC
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
Gómez Sancha F, et al. Manual de HoLEP en Bloque. ISBN 978-84-09-81888-4. 2026. 352 pages.

Tamsulosin, Dutasteride and BPH Medications: When to Stop Pills and Consider Surgery

2026-03-20T12:02:00.005+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

If you have found this article, you are probably taking pills for your prostate. Perhaps tamsulosin, perhaps dutasteride, perhaps both. You were prescribed the medication, your symptoms improved a little at first, and since then you have been taking it every day for months or years without anyone asking when you will stop needing it — or whether a definitive alternative exists.

I will explain how these drugs work, what side effects they can cause, when there are clear signs that medication is no longer enough, and what happens when you decide to resolve the problem once and for all with surgery.

How BPH medications work

Alpha-blockers: tamsulosin, silodosin, alfuzosin

These are the first-line treatment and the most commonly prescribed drugs for prostatic symptoms. They work by relaxing the smooth muscle of the prostate and bladder neck, making it easier for urine to flow. They do not reduce the size of the prostate — they simply relax the "fist" that squeezes the urethra.

They act quickly (within days), which gives the impression that they "work" from the start. But their effect disappears as soon as you stop taking them. They cure nothing — they control symptoms for as long as you take them.

5-alpha-reductase inhibitors: dutasteride, finasteride

These drugs do reduce the size of the prostate by blocking the conversion of testosterone to dihydrotestosterone (DHT). The effect is slow — it takes 3 to 6 months to notice — and the volume reduction is modest (around 20–25%). They also halve the PSA, which must be accounted for in prostate cancer monitoring.

Combination therapy

The combination of an alpha-blocker with a 5-alpha-reductase inhibitor (the most common is tamsulosin + dutasteride, marketed as Combodart/Duodart) is more effective than either drug alone, particularly for large prostates. But it also combines the side effects of both.

The side effects nobody told you about

When you were prescribed the medication, you were probably told it was "well tolerated". And for many patients it is. But there are side effects that are mentioned in passing and that for some men are very significant.

Alpha-blockers

Anejaculation: tamsulosin and especially silodosin can cause absent ejaculation in a significant proportion of patients. This is the same effect attributed to surgery, but caused by a pill; the mechanism is different, though. The pill inhibits the contraction of the prostate and seminal vesicles, and so it affects the quality of orgasm, which is reduced. After surgery, ejaculation takes place, but the semen stays in the bladder and does not come out, the orgasm is usually more normal.
Dizziness and orthostatic hypotension: particularly when getting up in the morning or standing quickly. In older patients it can cause falls.
Nasal congestion: bothersome but not serious.
Intraoperative floppy iris syndrome (IFIS): if you need cataract surgery, tamsulosin can complicate the eye operation. It is important your ophthalmologist knows. This effect can persist for months after stopping the drug.

5-alpha-reductase inhibitors

Erectile dysfunction: experienced by 5–8% of patients.
Decreased libido: a similar proportion notice reduced sexual desire.
Gynaecomastia: breast enlargement or tenderness.
Post-finasteride syndrome: although controversial and debated, some patients report the persistence of sexual effects (erectile dysfunction, decreased libido, orgasm problems) after stopping the drug. The European Medicines Agency (EMA) acknowledges this possibility in the product information.

An important observation: I frequently see patients who have been taking dutasteride for years to "avoid surgery" and preserve ejaculation, yet they already have erectile dysfunction and absent libido from the medication itself. They are suffering exactly the side effects they feared from surgery, but without the benefit of a definitive solution.

Signs that medication is no longer enough

Medication can be appropriate for a time, but BPH is progressive — the prostate continues to grow, and there comes a point when drugs can no longer compensate for the obstruction. The signs that this point has arrived:

Symptoms have worsened despite medication: more nocturia, weaker stream, more urgency.
PSA keeps rising: in a patient on dutasteride, PSA should be low. If it rises progressively, the prostate is still growing.
Post-void residual has increased: if ultrasound shows significant urine remaining in the bladder after voiding, the bladder is losing the battle against obstruction.
You have had an episode of urinary retention: if you were ever unable to urinate and needed a catheter, medication is no longer sufficient.
Recurrent urinary infections: residual urine in the bladder is a breeding ground for bacteria.
The side effects bother you more than the symptoms themselves: if the medication causes dizziness, erectile dysfunction, or absent ejaculation, you are paying a high price for a partial benefit.

What if I simply have surgery and stop all the pills?

This is the question many patients ask themselves but few doctors actively raise with them.

After HoLEP, the vast majority of patients stop all prostate medication: alpha-blockers, 5-alpha-reductase inhibitors, antimuscarinics. They do not need them because the problem is solved. There is no adenoma to obstruct, no need to relax a muscle that is no longer squeezing, no need to shrink tissue that is no longer there.

It is a paradigm shift: moving from managing a chronic condition with daily pills to solving the problem once.

The cumulative cost of chronic medication

This is rarely mentioned, but it is worth doing the sums. The tamsulosin + dutasteride combination costs roughly €30–40 per month in Spain. Over 10 years, that amounts to €3,600–4,800 — not counting follow-up visits, periodic PSA tests, and control ultrasounds. And after those 10 years, the prostate is still there, probably larger than when you started.

Definitive surgery has a higher upfront cost but resolves the problem once, eliminates the need for chronic medication, and has a retreatment rate below 2%. When you calculate the total long-term cost, the equation almost always favours surgery.

As I often tell my patients: "Medication is like paying rent — it works while you pay. Surgery is like buying the house — you pay once and the problem is solved."

Does this mean medication is useless?

Not at all. Medication is useful and appropriate in many situations: when symptoms are mild to moderate, when the patient does not want or cannot have surgery at that moment, or as a bridge while surgery is being planned. What makes no sense is maintaining chronic medication with side effects indefinitely when a definitive, safe, and durable surgical solution exists.

If your urologist prescribed medication and your symptoms are controlled without significant side effects, there is no urgency. But if you have been medicated for years, symptoms are not improving, or side effects are affecting your quality of life, it is worth asking: "Does it make sense to carry on like this, or is there a way to resolve this for good?"

Been taking prostate medication for years and wondering if there is something better?

At ICUA we explain all the options honestly and personally.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to BPH: AUA guideline amendment 2023. J Urol. 2024;211:11-19. DOI
EAU Guidelines on Management of Non-neurogenic Male LUTS. 2025 Edition. EAU Guidelines
Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed

Prostate Surgery Failed: Can HoLEP Fix a Previous Incomplete Procedure?

2026-03-20T11:54:00.003+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

It is a more common situation than you might think: you had your prostate treated — with TURP, GreenLight laser, Rezum, UroLift, iTIND — and now the symptoms have returned. Or they never fully improved. Your stream is still weak, you are getting up at night again, perhaps you have had an episode of urinary retention. You were told the procedure would fix the problem, and for a while it seemed to. But now you are back where you started, or worse.

If this sounds familiar, you are not alone. And most importantly: there is a solution.

Why does a prostate treatment fail?

"Fail" is not always the most accurate word. In many cases, the procedure was technically correct — the issue is that the technique used has inherent limitations that prevent a durable result.

Incomplete resection (TURP, GreenLight)

TURP works by shaving prostatic tissue from the inside. The surgeon removes tissue until the channel seems wide enough, but the entire adenoma is not removed — a variable amount of living tissue remains, capable of growing. The same applies to GreenLight vaporisation: it vaporises the surface, but the depth is limited, particularly in large prostates.

The retreatment rate after TURP is estimated at 10–15% at 8–10 years. I have seen many patients who had TURP at 55–60 and who, at 75–80, develop severe obstruction from adenoma regrowth. It is what I call "the prostate that complicates old age".

Minimally invasive treatments that do not solve the problem (Rezum, UroLift, iTIND, stents)

I am seeing an increasing number of patients who have been through one or more minimally invasive treatments before reaching us. It is a growing phenomenon that deserves an honest explanation.

These treatments are commercially positioned as alternatives that preserve ejaculation and allow rapid recovery. And it is true that they offer those advantages. But the objective improvement in urinary flow is significantly less than with enucleation, durability is limited, and many patients will eventually require retreatment.

Personally, I have so far limited my practice to enucleation and have not adopted any minimally invasive treatment. One consequence of performing enucleation regularly is that you become accustomed to seeing happy patients after surgery, with excellent flow rates and complete bladder emptying. When you see the results of these minimally invasive treatments, the objective improvement is much smaller and much less predictable.

The treatment cascade: It is not uncommon — particularly in the United States, where economic incentives favour outpatient procedures — to see a patient who first had an iTIND, then a few months or years later required a first UroLift, and when the result was unsatisfactory had a second UroLift (sometimes ending up with an absurdly high number of staples), then had a GreenLight vaporisation, and subsequently a TURP. It is the living expression of failure in our goal as urologists, where the patient becomes a victim of the system.

When a patient insists on one of these methods, I refer them to colleagues experienced in that specific procedure. It would not be the first time they come back to my clinic months or years later, asking me to resolve their urinary problem. After suffering poor results and failing to achieve their quality-of-life goals, they often put the ejaculation issue in perspective and tell me they would rather not ejaculate but solve the problem once and for all.

The industry behind these treatments: Medical device companies invest enormous sums in convincing us that what our patients need is their product. These are powerful lobbies that subsidise clinical studies, fund training courses, sponsor international speakers, and market directly to patients. As urologists, we should be advisors to our patients, not sales representatives for any company.

HoLEP as a definitive solution after any previous procedure

After TURP or GreenLight vaporisation

The prostatic capsule — the "peel of the orange" — remains intact after these techniques, and the dissection plane between the adenoma and the capsule is still there. HoLEP works along that capsular plane: we find the capsule and peel away all the residual adenoma. There may be areas of scarring that make dissection slightly more challenging, but it is manageable for an experienced surgeon.

After UroLift

The UroLift system does not remove tissue — it leaves metallic staples within the prostate that mechanically retract the lobes to open the channel. When the effect is insufficient or fades over time, enucleation is perfectly feasible. The capsular plane is usually good. During surgery, we encounter the sutures connecting the metallic elements — they cut easily with the holmium laser — and the staples themselves, which must be managed during morcellation. The metal can damage the morcellator blade, but these are technically straightforward cases.

After Rezum

Rezum injects steam into the adenoma, producing tissue necrosis. Over time, a cavitation forms within the adenoma. But often this cavitation is not uniform: some areas of tissue have been destroyed while others persist intact. Some patients experience insufficient improvement or, worse, recurrent infections from the presence of necrotic tissue. En bloc enucleation removes all remaining adenomatous tissue without difficulty, completely cleaning the area.

After iTIND or other temporary devices

The iTIND is placed temporarily in the prostatic urethra to remodel tissue. When removed, it leaves marks on the adenoma but does not extract tissue. Subsequent enucleation presents no special technical challenges. The same applies to prostatic stents: the adenomatous tissue remains in place, the capsule is intact, and enucleation proceeds normally.

After an incomplete enucleation at another centre

If you had a complete enucleation (HoLEP, ThuLEP) at an experienced centre, the retreatment rate is below 2%. But if it was incomplete — something that can happen at centres with less experience — the residual adenoma continues to cause problems and the enucleation can be completed.

This is not a second chance — it is a definitive solution

Many patients who arrive after a failed procedure do so with resignation: "I was already treated and it didn't work — why would it work this time?" The answer: because this time, the entire adenoma will be removed.

The difference is conceptual. TURP shaves from the inside, leaving residual tissue. Vaporisation evaporates the surface. Devices like UroLift and iTIND remove no tissue at all. Rezum destroys tissue partially. Stents simply hold open a channel that closes again. Enucleation peels the entire adenoma from the capsule, complete. It is the only approach that ensures no tissue remains to regrow.

If you had a prostate procedure and the symptoms persist or have returned: do not resign yourself. Do not assume "that's just how it is". Seek a second opinion from a surgeon experienced in enucleation. The problem very likely has a definitive solution — and this time, for real.

Had a prostate procedure that didn't work as expected?

Request a second opinion. We will explain whether HoLEP can resolve your case definitively.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
Rücker F, Lehrich P, Gilfrich C, et al. HoLEP in three different techniques: a comparison of 600 patients. World J Urol. 2021;39:4063-4069. DOI
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
Tricard T, Xia M, Trambert C, et al. Open prostatectomy is dead — long live endoscopic enucleation of the prostate! World J Urol. 2023;41:1457-1463. DOI

Living with a Catheter Due to BPH: Can HoLEP Help?

2026-03-20T11:37:00.005+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

If you are reading this with a urinary catheter in place, I understand what you are going through. The catheter is uncomfortable, it restricts your mobility, you worry about infections, and every passing day feels like your life is on hold. Perhaps you have been told to wait, that you will be placed on a waiting list, or that your prostate is too large for endoscopic surgery.

I want you to know something important: the catheter can be removed. In the vast majority of cases, HoLEP can resolve the obstruction definitively and restore the patient's ability to urinate normally, even after months or years of catheterisation.

Why is a permanent catheter placed?

A permanent urinary catheter is placed when a patient cannot urinate on his own — what we call urinary retention. This happens when the prostate has grown to a point where it completely blocks the outflow of urine. Sometimes it occurs acutely (from one day to the next, often after a heavy meal, a long journey, or a cold), and sometimes it is the end point of progressive deterioration.

In A&E, the catheter is placed as an emergency measure. The problem is that, afterwards, the patient can remain in limbo: an attempt is made to remove the catheter with medication (alpha-blockers), and if it fails, the catheter is replaced. And so it continues — weeks or months with a catheter, waiting for a surgical solution that sometimes takes far too long to arrive.

What the catheter does to your quality of life

You do not need me to explain this — you live it every day. But it is worth naming the consequences to underscore the urgency of resolving the situation:

Recurrent urinary infections — every catheter change carries a risk of infection.
Constant discomfort, urethral irritation, bladder spasms.
Limitations on travel, exercise, and normal daily activities.
Psychological impact: loss of independence, embarrassment, social withdrawal.
Risk of urethral damage from prolonged catheterisation.

Can the catheter be removed permanently?

Yes. In the vast majority of cases, yes.

HoLEP removes all the prostatic tissue causing the obstruction, regardless of its size. By eliminating the cause of the retention, urine can flow freely again. In our experience, patients who were catheterised before surgery are the ones who experience the most dramatic change in quality of life — they go from depending on a catheter to urinating normally, often with a flow rate better than anything they had experienced in years.

It does not matter if your prostate weighs 80, 120, or 200 grams. It does not matter if you have been catheterised for weeks or months. What matters is that the bladder still has the ability to contract — and this is something we can assess before surgery.

The surgical challenge of the catheterised patient

I must be honest: operating on a patient who has been catheterised for a long time is not exactly the same as operating on someone who walks in from the outpatient clinic. There are specific considerations that must be managed carefully.

Infection and sepsis

The catheterised patient almost always has bacteria in the urine — it is virtually inevitable with a foreign body permanently in the urinary tract. If not managed properly, surgical manipulation can cause bacteraemia or, in the worst case, sepsis.

This is a risk I take extremely seriously. At ICUA, we have developed a rigorous preventive protocol: we change the catheter in clinic days before surgery and send the tip to the laboratory for culture. We begin targeted antibiotic therapy based on the sensitivity pattern at least 4 days before the operation. If the organisms are multidrug-resistant and there are no oral options, we admit the patient for intravenous antibiotics beforehand. Applying this protocol, we have not seen cases of postoperative sepsis.

The deteriorated bladder

This is the factor that most influences the final result. A bladder that has spent years fighting against obstruction can lose its ability to contract. If the bladder can no longer push, removing the obstruction will not restore normal voiding — the patient may be left with high residual volumes or may even need intermittent self-catheterisation.

The good news is that many bladders that appear "exhausted" recover some of their function after surgery, sometimes surprisingly so. A study involving 50,000 subjects demonstrated that bladder deterioration is progressive but that a window of opportunity exists before the damage becomes irreversible. This is why I insist that every month with a catheter is a month of potential additional bladder damage.

Important: Not all catheterised patients will have the same outcome. If the bladder is severely deteriorated, surgery will resolve the obstruction but bladder function may not fully recover. This is something we assess and explain before surgery, so that your expectations are realistic.

Raised PSA in the catheterised patient

Often, the catheterised patient has an elevated PSA. This may be due to prostate size, inflammation from the catheter, or — occasionally — an underlying prostate cancer. It is essential to rule out cancer before performing an enucleation.

At ICUA, we have developed a rapid resolution protocol for these patients: we perform a transperineal biopsy under spinal anaesthesia as an outpatient procedure, using our MRI-fusion and micro-ultrasound protocol. Our pathologist processes the samples overnight and has the result ready first thing the following morning.

If the biopsy is negative, the patient is readmitted that same day and we proceed with HoLEP. In this way, a process that at other centres can take weeks is resolved in two days. For the catheterised patient, who lives every day as an ordeal, this speed makes an enormous difference.

Act now: time is not on your side

I will be direct: if you have a permanent catheter due to prostatic obstruction, every week that passes without resolving the situation is a week of potential additional bladder deterioration. The bladder does not wait indefinitely. The sooner the obstruction is resolved, the greater the chance that the bladder will recover its function.

I have seen too many patients who arrived too late — men in their 80s who had been catheterised for years and whose bladder could no longer contract. We removed the entire adenoma, the urethra was completely clear, but the bladder simply would not push. It is a sad situation and, in many cases, one that was avoidable had action been taken sooner.

If you or a family member has a permanent catheter due to the prostate: do not accept that situation as final. In most cases it can be resolved. But time matters — every month of waiting is a month of potential bladder deterioration.

Do you have a permanent catheter and want to know if it can be resolved?

Send us your medical records. We respond within 48 hours with an initial assessment and an action plan.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
Tricard T, Xia M, Trambert C, et al. Open prostatectomy is dead — long live endoscopic enucleation of the prostate! World J Urol. 2023;41:1457-1463. DOI

Robotic Urological Surgery in Madrid: Radical Prostatectomy and Beyond

2026-03-20T11:29:00.002+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

When a patient receives a diagnosis of localised prostate cancer, one of the first things they search for is "robotic surgery". And they are right to do so: robot-assisted radical prostatectomy is today the standard surgical treatment for localised prostate cancer at most leading centres worldwide.

But not all robotic prostatectomies are the same. The surgical technique, the surgeon's experience, and the philosophy of anatomical preservation determine whether the patient, in addition to being cured of cancer, will retain urinary continence and sexual function. In this article, I explain what we do at ICUA and why our results are what they are.

What is robotic urological surgery?

Robotic surgery is not performed by a robot. It is performed by a surgeon seated at a console, controlling articulated arms that replicate his movements with precision that exceeds that of the human hand. The Da Vinci system — which is what we use at Clínica CEMTRO — offers magnified three-dimensional vision, instruments with a 360-degree range of movement, and tremor elimination. This enables more precise dissection of the structures surrounding the prostate: the erectile nerves, the urinary sphincter, and the bladder neck.

The result is a surgery that combines the oncological radicality of open surgery with minimal invasiveness: sub-centimetre incisions, minimal bleeding, a 2–3 day hospital stay, and rapid recovery.

Radical prostatectomy by lateral approach: the technique we use

Several techniques exist for performing robot-assisted radical prostatectomy. At ICUA, we use the lateral approach, a technique developed by Dr. Richard Gaston in Bordeaux, France, which differs from conventional approaches in several fundamental respects.

What does the lateral approach involve?

Rather than approaching the prostate from the front — dissecting the space of Retzius and dividing the dorsal venous complex — the lateral approach accesses the prostate from the side, through a lateral "buttonhole". This allows:

Complete preservation of the anterior pubovesical complex: the anatomical structure connecting the bladder to the pubic bone, containing muscle fibres and nerves critical for continence and potency. In conventional techniques, this structure is partially or completely divided.
Direct access to the seminal vesicle: without needing to mobilise anterior structures, allowing cleaner dissection of the vascular pedicles and neurovascular bundles.
Minimal use of thermal energy: the nerves are dissected bluntly (without heat), avoiding thermal damage that can cause temporary or permanent erectile dysfunction.

The incision is longitudinal — like a "buttonhole" — less disruptive than the transverse incisions of other techniques across the fibres of the anterior complex.

The collaboration with Dr. Richard Gaston

Dr. Gaston is one of the pioneers of robotic urological surgery in Europe and the creator of this technique. Our collaboration began over 16 years ago. I learned the technique directly from him, working side by side through hundreds of procedures. It was not a weekend course or an online video — it was direct, case-by-case learning with the inventor of the procedure.

This relationship has continued over the years. Dr. Gaston has operated regularly at Clínica CEMTRO as part of our team, and together we have built the experience that underpins our published results.

Our published results: 513 patients

In 2023, we published our complete series of radical prostatectomy by lateral approach in the journal Cancers (Rodríguez Socarrás et al., 2023). The study includes 513 consecutive patients operated between January 2015 and March 2021 by two surgeons: Dr. Gaston (289 patients) and Dr. Gómez Sancha (224 patients). The primary endpoint was reproducibility — demonstrating that a second surgeon can achieve results equivalent to those of the technique's creator.

Results — Robot-assisted radical prostatectomy by lateral approach (513 patients)

Urinary continence (completely dry, no pad):
At catheter removal (day 0): 86% and 85%
At 1 month: 93% and 91%
At 1 year: 96% and 98%

Sexual potency (satisfactory intercourse):
At 3 months: 60% and 66%
At 1 year: 73% and 72%

Oncological control:
Significant positive surgical margins (>2 mm): 5.9% and 7.6% (p = 0.67 — no statistical difference)
Biochemical recurrence: 11.7% and 12%
Positive lymph nodes: 4.5% and 4.9%

Safety:
Clavien III/IV complications: 3.8% and 2.2%
Transfusion: 3.1% and 2.2%
Mean hospital stay: 2.8 and 3.3 days

No statistically significant difference between the two surgeons in any oncological, functional, or complication parameter.

These results deserve context. According to data from specialised tertiary centres, approximately half of patients report erectile dysfunction before radical prostatectomy, 80% are continent at catheter removal, and only 53% recover full sexual function. Our immediate continence rate of 85–86% (completely dry, no pad whatsoever) and potency at one year of 72–73% place our series in the upper range of published results worldwide.

What does "reproducible" mean?

It means that the results of Dr. Gómez Sancha, having learned the technique from Dr. Gaston, are statistically equivalent to those of the technique's creator. This is significant because it demonstrates that the technique does not depend on unrepeatable individual talent but on clear anatomical principles that, with appropriate training, can be taught and reproduced. The Kaplan–Meier curves for continence, potency, and biochemical recurrence show no significant difference between the two surgeons.

When is robot-assisted radical prostatectomy indicated?

Radical prostatectomy is a treatment for localised prostate cancer. It is not a treatment for benign prostatic hyperplasia (that is what HoLEP is for). The main indications are:

Localised prostate cancer (stages T1–T2) with a life expectancy of at least 10 years.
Selected locally advanced cancer (T3a) in appropriate patients.
Patients who prioritise definitive treatment over active surveillance or radiotherapy.

The decision between surgery, radiotherapy, and active surveillance is complex and must be individualised. In our clinic, we use the Madrid Protocol — a combination of multiparametric MRI, fusion biopsy, and micro-ultrasound — to characterise the tumour with maximum precision before recommending treatment. This allows us to plan a personalised surgery: deciding whether to spare one or both neurovascular bundles, how much margin to take at each site, and adapting the technique to the exact tumour location.

Other robotic procedures at ICUA

Although radical prostatectomy is the most common robotic procedure, at ICUA we perform the full spectrum of robotic urological surgery:

Robotic partial nephrectomy: for kidney tumours, preserving the maximum amount of healthy renal tissue.
Robotic radical cystectomy: for invasive bladder cancer.
Reconstructive procedures: pyeloplasty, ureteral reimplantation, and pelvic floor surgery.

Technology and team at Clínica CEMTRO

We operate with the latest-generation Da Vinci Xi system, with AirSeal insufflation for stable, comfortable pneumoperitoneum. The surgical team comprises surgeons with specific experience in the lateral approach, anaesthetists specialising in robotic urological surgery, and dedicated nursing staff.

Clínica CEMTRO is a leading private hospital in Madrid with over 30 years of track record and comprehensive hospital infrastructure: ICU, blood bank, advanced diagnostic imaging, and histopathology laboratory.

An important point: At ICUA, we treat both benign prostatic hyperplasia (with HoLEP) and prostate cancer (with robotic surgery). This gives us a comprehensive perspective on prostatic pathology that few centres offer. When a patient presents with urinary symptoms and we discover incidental cancer, or when a cancer patient also has obstruction from BPH, we can address both problems with the most appropriate technology and expertise for each.

Have you been diagnosed with prostate cancer and are looking for the best surgical option?

At ICUA we offer a comprehensive assessment and personalised surgery with published results.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Rodríguez Socarrás M, Gómez Rivas J, Reinoso Elbers J, ..., Gastón R, Gómez Sancha F. Robot-Assisted Radical Prostatectomy by Lateral Approach: Technique, Reproducibility and Outcomes. Cancers. 2023;15:5442. DOI
Asimakopoulos AD, Annino F, D'Orazio A, et al. Complete Periprostatic Anatomy Preservation During RALP: The New Pubovesical Complex-Sparing Technique. Eur Urol. 2010;58:407-417. DOI
Rodríguez Socarrás ME, Gómez Rivas J, Cuadros Rivera V, et al. Prostate Mapping for Cancer Diagnosis: The Madrid Protocol. J Urol. 2020;204:726-733. DOI

International Patients: Prostate Surgery in Madrid with Dr. Gómez Sancha

2026-03-20T11:15:00.004+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

If you are reading this from outside Spain and considering where to have your prostate surgery, you have probably done a fair amount of research already. Perhaps you have a very large prostate and your urologist has recommended open surgery. Perhaps you have been offered a TURP but have read that retreatment is common. Or perhaps you simply want access to one of the most experienced HoLEP surgeons in the world, and your search has led you here.

At ICUA, we have been receiving patients from around the world for over 15 years. We have developed a streamlined process so that coming to Madrid for surgery is straightforward, safe, and free of surprises.

Why patients from around the world choose ICUA

The short answer: experience, technique, and results.

Over 10,000 HoLEP procedures performed by Dr. Gómez Sancha — one of the largest individual series in the world.
A proprietary technique published in peer-reviewed journals: en bloc enucleation with early apical release, with verifiable results in 754 consecutive patients.
International training reference centre: over 400 urologists from 60+ countries have trained in our technique at ICUA.
Dedicated team: multilingual coordination, preoperative video consultation, fixed all-inclusive quote before you travel.
Clínica CEMTRO: a leading private hospital in Madrid with state-of-the-art technology.

But beyond the numbers, what our international patients value most is direct communication with the surgeon throughout the entire process. At ICUA, you speak directly with Dr. Gómez Sancha during your preoperative video consultation. Not with an intermediary, not with a call centre.

The process step by step

Step 1 — First contact and medical records
You write to us by email or WhatsApp. You send your medical records: prostate ultrasound (with volume), blood test with PSA, flowmetry if available, and any additional investigations. Our team reviews the documentation and confirms whether you are a candidate for HoLEP.

Step 2 — Video consultation with Dr. Gómez Sancha
A 20–30 minute video consultation in which we review your tests together, I explain which technique is most appropriate for your case, answer all your questions, and set realistic expectations about the outcomes.

Step 3 — Fixed quote and planning
We send you a detailed, fixed quote that includes everything: surgery, anaesthesia, hospital stay, disposable materials, histopathology, and follow-up. No hidden extras. Our coordinator, Vanesa Cuadros, helps with travel planning: surgery dates, accommodation near the clinic, and logistics.

Step 4 — Arrival in Madrid and surgery
We recommend arriving the day before surgery. The operation is performed at Clínica CEMTRO. Most patients stay one night in hospital and return to their hotel the following day with their urinary catheter in place.

Step 5 — Recovery in Madrid (5–7 days)
The catheter is removed at a follow-up visit a few days later. We perform a control flowmetry and ensure everything is in order before you return home. Madrid is a comfortable city for recovery: good weather, excellent food, and your hotel will be minutes from the clinic.

Step 6 — Remote follow-up
Once you are home, we follow up by video consultation. We provide a comprehensive clinical report in your language and a detailed medical invoice to facilitate reimbursement from your insurer or healthcare system.

Practical information

Getting to Madrid

Madrid-Barajas Airport has direct flights to and from all major European cities, the Middle East, Latin America, and many destinations in Asia and North America. Clínica CEMTRO is in north-west Madrid, well connected by public transport and surrounded by several hotels within a short distance. We can recommend nearby accommodation with special rates for patients.

Languages

Dr. Gómez Sancha is fluent in Spanish and English. Coordination with Vanesa Cuadros and the ICUA team is available in Spanish, English, and for many patients, Portuguese. For other languages, we arrange translation assistance as needed.

Cost and billing

The quote is fixed and in euros. It includes everything needed for surgery and initial postoperative follow-up. We issue a detailed medical invoice and a comprehensive clinical report to facilitate reimbursement in your country. The cost of HoLEP in Spain is significantly lower than in the United States, the United Kingdom, Switzerland, or the Gulf states, with outcomes comparable to or better than leading international centres.

Do I need a visa?

Citizens of the European Union, the United Kingdom, the United States, Canada, Australia, Japan, and most Latin American countries do not need a visa for stays of up to 90 days in Spain. For patients who do require one, we provide medical documentation to support the visa application.

Common questions from international patients

How long do I need to stay in Madrid?

Plan for 5–7 days in total: arrive the day before surgery, one night in hospital, and 3–5 days at a hotel while we monitor your recovery and remove the catheter. Most patients fly home comfortably within a week of surgery.

Can my partner or family come with me?

Absolutely. Many patients travel with their partner. Madrid offers plenty for a companion to do while you recover — it is one of Europe's great cities for food, culture, and walking. Some couples treat the trip as a short holiday once the medical part is complete.

What if something goes wrong after I return home?

Complications after HoLEP are rare, but we are always available. You will have direct contact with our team by email and WhatsApp. If a situation arises that requires in-person attention, we coordinate with a local urologist in your area or arrange your return to Madrid if necessary. In over 15 years of treating international patients, this has been an exceptional occurrence.

My prostate is very large — can I still have HoLEP instead of open surgery?

This is one of the most common reasons international patients come to us. Many have been told they need open surgery because their prostate is over 100, 150, or even 200 grams. In our experience, prostate size is not a limitation for HoLEP — in fact, larger prostates often benefit the most from enucleation. Our published series includes prostates well over 200 grams, all operated endoscopically with excellent outcomes.

A personal note: Receiving a patient who has travelled from another country to be operated by me is an enormous responsibility. That person has placed their trust not only in my medical judgement but has also left their home, their family, and their support network to put themselves in my hands. I take that trust very seriously, and the care our international patients receive reflects that commitment.

Are you outside Spain and want to know if HoLEP is right for you?

Send us your medical records and we will respond within 48 hours with an initial assessment.
📞 +34 91 435 28 44 · ✉ icua@icua.es
WhatsApp: +34 91 435 28 44

Scientific references

Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release. World J Urol. 2019;37:2451-2458. PubMed
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed

En Bloc HoLEP with Early Apical Release: The Gómez Sancha Technique

2026-03-20T11:03:00.006+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

When a patient asks me what the operation involves, I draw an orange. Men are born with the peel — the prostatic capsule — and from the age of 30, the segments inside gradually grow. Since the urethra runs through the centre, it becomes progressively obstructed. What we do in an enucleation is remove the segments and leave the peel clean.

But how those segments are removed matters a great deal. Cutting them into pieces is not the same as peeling them out in one go. En bloc enucleation with early apical release is the technique I have developed and refined over two decades and more than 10,000 procedures. In this article, I explain what makes it different and why I believe it delivers better outcomes.

What does "en bloc" mean in prostate surgery?

In conventional holmium laser enucleation (HoLEP), the prostatic adenoma is typically divided into two or three lobes. Deep incisions are made to separate the lobes, and each fragment is then dissected from the capsule individually. It is a technique that works, but it involves multiple cuts through tissue and working with several separate pieces.

In en bloc enucleation, the adenoma is removed in a single piece — like peeling an entire orange, keeping all the segments attached. There are no incisions to fragment the adenoma. The surgeon peels the entire piece circumferentially from the capsule until it is freed as a whole into the bladder, where it is morcellated for extraction.

The advantages of this approach are several: less bleeding because the large vessels between the lobes are not transected, better tissue orientation for the pathologist (important if incidental cancer is found), and — most critically — more precise control of the urinary sphincter, the structure responsible for continence.

The evolution: from vaporisation to en bloc

This technique did not appear overnight. It was the result of an evolution that began over 20 years ago.

My beginnings in laser surgery were with GreenLight laser vaporisation in 2003. We quickly recognised the advantages of the endoscopic approach — minimal invasiveness, rapid recovery, low complication rates — but also understood the limits of vaporisation in large prostates.

The evolution was gradual: conventional vaporisation → anatomical vaporisation (identifying the capsule to take the vaporisation to that depth) → hybrid technique of lateral vaporisation with middle lobe enucleation → progressively less vaporisation and more enucleation → complete en bloc enucleation with GreenLight laser (GreenLEP). We published this evolution in 2015 (Gómez Sancha et al., World J Urol).

In 2011, I began working with the holmium laser. I initially learned the three-lobe technique, but quickly sought to reproduce the en bloc approach I had been performing for several years with the green laser. This led to the publication of our technique in 2019 (Saitta, Gómez Sancha et al., World J Urol): an incision-free en bloc enucleation with early apical release and sphincteric mucosa preservation, initially in 137 patients.

Early apical release: why it makes the difference

This is the core of what differentiates this technique from other enucleation methods. To understand why it matters, a brief lesson in anatomy is needed.

The external sphincter and its mucosa

The external urinary sphincter is the muscle that maintains continence — the one that allows a man to control when he urinates and when he does not. This sphincter is lined by a mucosa, a layer of tissue that functions as a watertight seal. Without this mucosa intact, the sphincter can be incontinent for weeks or months until the mucosa regenerates.

In many enucleation techniques, the apical dissection (the lowest part of the adenoma, just above the sphincter) is left until the end. The problem is that as the adenoma is peeled from above downwards, traction is generated on the sphincter. This traction strips the sphincteric mucosa, creating what is known as the "mucosal curtain" — a flap of tissue that indicates the sphincter's lining has been damaged.

What makes early apical release different

In our technique, the first step is to identify the "white line" — the boundary between the adenoma apex and the external sphincter. At that point, we release the adenoma from the sphincter at the beginning of the procedure, not at the end. By separating the adenoma from the sphincter early, we achieve three things:

We eliminate traction: when dissecting the rest of the adenoma circumferentially, we are no longer pulling on the sphincter because it has already been freed.
We preserve the sphincteric mucosa: without traction, the mucosa lining the sphincter remains intact, maintaining its sealing function.
We improve visibility: with the apex released from the outset, the surgical field throughout the remainder of the procedure is excellent.

Why does the sphincteric mucosa matter? A sphincter without its mucosa is like a tap without a washer — it may function, but it leaks. A de-epithelialised sphincter can be incontinent for weeks or months until the mucosa regenerates. This is the principal factor explaining the differences in early incontinence between enucleation techniques. The sphincteric mucosa is now recognised as an integral component of the continence mechanism.

No incisions: another key principle

Many enucleation techniques begin with deep incisions into the adenoma — at the 5 and 7 o'clock positions, or at 12 o'clock — to separate the lobes. These incisions transect vessels and cause bleeding, and divide the adenoma into fragments that must then be dissected separately.

In the en bloc technique, there are no initial incisions. The dissection is circumferential, peeling the adenoma from the capsule like peeling a fruit. The laser is used to coagulate feeding vessels (the pedicles) and to cut fibrous tracts when necessary, but the bulk of the separation is mechanical, with the tip of the endoscope.

The result is an adenoma removed in a single piece, with less bleeding and — crucially — perfectly orientable for the pathologist. If incidental cancer is present (which occurs in 5–8% of cases), the pathologist can assess the margins with the same precision as a conventional surgical specimen.

Published results

Our most recent series, published in World Journal of Urology in 2025, includes 754 consecutive patients operated by a single surgeon using this technique:

754-patient series — En Bloc HoLEP with early apical release

Efficiency: 3.1 g/min in large prostates (≥120 g) · Mean operative time 47 min (initial 137-patient series)

Continence (stress incontinence at 6 months): 0.15% for prostates <120 0.9="" br="" for="" g="" prostates="">
Functional outcomes: Qmax 24–28 ml/s postoperatively · PSA reduction 93–94%

Safety: Transfusion rate <1 div="" rate="" retreatment="">

To put the continence figure in context: a stress incontinence rate of 0.15% at six months means that of every 1,000 patients operated with prostates under 120 grams, only 1 or 2 would need a pad for stress incontinence at six months after surgery.

The REAP registry, a global multicentre registry of 6,193 patients operated by multiple surgeons using enucleation techniques with early apical release, confirmed that the principle of early apex release is associated with low incontinence rates even when performed by different surgeons at different centres.

Reproducibility: a technique taught worldwide

Any surgical technique, however good, has limited value if only one person can perform it. That is why reproducibility is a fundamental criterion.

Since 2007, we have received over 600 visiting urologists from more than 60 countries at ICUA to train in this technique. The training programme includes direct operating theatre observation, tutored practice, and subsequent follow-up. Many of these surgeons have implemented the technique at their own centres with published results.

In a published series of 500 patients with learning curve analysis (Wenk et al., 2024), it was demonstrated that the en bloc technique is reproducible and that the learning curve, when training is structured, is shorter than traditionally attributed to HoLEP.

It is not an easy technique — it requires specific training and sufficient case volume. But it is teachable and reproducible, and that is what matters.

For the patient: what does all this mean for you?

If you have read this far, you are probably an informed patient who researches before making a decision, or a urologist evaluating technical options. Either way, the key point is this:

Not all HoLEP procedures are the same. The surgical technique, the principles guiding the operation, and the surgeon's experience determine the outcomes in continence, complications, and the likelihood of needing reoperation. En bloc enucleation with early apical release and sphincteric mucosa preservation is the product of over 20 years of technical evolution, more than 10,000 cases, and a clear philosophy: remove the entire adenoma while maximally protecting the structures of continence.

Want to be operated using this technique?

At ICUA we perform this surgery daily. Request a consultation to evaluate your case.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Saitta G, Becerra JEA, Del Álamo JF, Gómez Sancha F, et al. 'En Bloc' HoLEP with early apical release in benign prostatic hyperplasia. World J Urol. 2019;37:2451-2458. PubMed
Iscaife A, Rodríguez Socarrás M, Talizin TB, Gómez Sancha F, et al. Contemporary results of En Bloc HoLEP for large prostates — a single surgeon series of 754 patients. World J Urol. 2025;43:401. PubMed
Gómez Sancha F, Rodríguez Socarrás M, Zorn K, et al. Common trend: move to enucleation — is there a case for GreenLEP? World J Urol. 2015;33:539-547. DOI
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
Wenk B, et al. En bloc HoLEP learning curve in 500 consecutive patients. World J Urol. 2024. PubMed
Gauhar V, et al. Early apical release during endoscopic enucleation of the prostate (EAR) — 4392 patients. Urology. 2024. DOI

How Much Does HoLEP Surgery Cost? Factors That Affect the Price

2026-03-20T10:42:00.002+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

It is a fair and necessary question. You have every right to know how much your surgery will cost before making a decision. And you have every right to understand what you are paying for and why prices vary so much from one centre to another.

I will be as transparent as possible about the factors that influence the cost of HoLEP surgery, what a serious quote should include, and why the lowest price is not always the most economical option in the long run.

Why does the price of HoLEP vary so much?

If you have been requesting quotes, you have probably encountered very significant differences between centres. This is because the cost of a HoLEP depends on multiple factors, and not every centre includes the same items in their quote.

Prostate size

A 40-gram prostate is not the same operation as a 180-gram one. With large prostates, surgical time is longer, more operating theatre time is needed, more anaesthesia time, and occasionally an extra night in hospital. Prostate size is the single factor that most influences the duration of the procedure and, therefore, the associated costs.

Type of anaesthesia

HoLEP can be performed under general anaesthesia or spinal anaesthesia. Spinal anaesthesia, when feasible, is safer in older patients, allows faster recovery, and slightly reduces costs. In our practice, most patients are operated under spinal anaesthesia.

Length of hospital stay

At ICUA, most patients stay one night in hospital and go home the day after surgery with their urinary catheter, which is removed at a follow-up visit a few days later. Some centres keep patients in hospital until catheter removal — this increases hospital costs without proven clinical benefit.

Surgeon experience

Let me be direct about this. The fees of a surgeon who has performed 10,000 procedures are not the same as those of one who has performed 50. And they should not be. Surgeon experience is the single factor that most influences HoLEP outcomes — complication rates, speed of recovery, likelihood of requiring retreatment, and continence preservation.

When comparing quotes, do not compare numbers alone. Compare what those numbers represent.

Equipment and technology

The holmium laser is a sophisticated piece of equipment that requires constant maintenance and disposable laser fibres of significant cost. A morcellator is also needed to fragment the tissue, along with an operating theatre equipped with a high-definition endoscopic tower. Centres with their own up-to-date equipment can offer greater efficiency than those that hire equipment on a per-procedure basis.

What should a HoLEP quote include?

A complete, honest quote must include all components with no hidden extras. At ICUA, we provide a fixed, itemised quote that includes:

Surgical team fees: surgeon, assistant, anaesthetist.
Operating theatre time: full surgical duration.
Disposable materials: laser fibre, morcellator, catheter, irrigation supplies.
Hospital stay: private room, medication, nursing care.
Histopathological analysis: examination of the removed tissue — essential to rule out incidental prostate cancer.
Postoperative follow-up: follow-up appointments, catheter removal, control flowmetry.

A word of caution when comparing quotes: Some centres offer an attractive initial price that does not include the anaesthesia, histopathological analysis, or follow-up visits. Always request a full breakdown before making comparisons. A quote that does not include pathology analysis of the removed tissue is, in my view, unacceptable — choosing not to analyse the tissue means choosing not to diagnose a possible incidental cancer.

Insurance and HoLEP

Private insurance in Spain

Most private insurers in Spain cover surgery for benign prostatic hyperplasia, including HoLEP, when there is a medical indication. However, conditions vary between companies and between policies. Some points to consider:

Some insurers require prior authorisation and may insist that medical treatment has been tried before approving surgery.
Reimbursement may be partial if the surgeon or facility is not within the insurer's approved network.
Co-payment policies may cover a variable percentage of the total cost.

At ICUA, we treat patients from all major Spanish insurers and manage the necessary authorisations. We recommend checking with your insurer before your first visit to understand the specific conditions of your policy.

International patients

We receive patients from all over the world — Europe, the Middle East, Latin America, Asia. For international patients, we provide a detailed medical invoice and a comprehensive clinical report that facilitates reimbursement from your insurer or healthcare system in your home country. The cost of HoLEP in Spain is significantly lower than in countries such as the United States, the United Kingdom, or Switzerland, with outcomes comparable to or better than the leading international centres.

The hidden cost: the surgery that needs repeating

This is the most important consideration in this article, and one that rarely appears when prices are being compared.

Transurethral resection (TURP) — the classic technique — has a retreatment rate of 10–15% at 8–10 years. This means that roughly one in seven or eight patients will need to be operated on again. That second operation is more complex, carries more risk, and naturally comes with an additional cost.

HoLEP, by removing the entire adenoma, has a retreatment rate below 2%. In our series of 754 patients with long-term follow-up, the likelihood of requiring reoperation due to regrowth is exceptional.

If a HoLEP costs somewhat more than a TURP but virtually eliminates the possibility of a second operation, which is truly the more expensive option? And that is without factoring in the cost to quality of life — going through surgery again, another period off work, another recovery.

The right question is not "how much does it cost to have surgery?" but "how much will it cost to solve this problem once and for all?" And the answer to that second question almost always favours HoLEP.

Why Spain? A note for patients travelling for surgery

Spain has become one of the leading destinations in Europe for prostate surgery, and for good reason. The combination of highly experienced surgeons, modern private hospital infrastructure, competitive pricing, and a pleasant climate for recovery makes it an attractive option for patients from countries where either the wait is too long, the cost is prohibitive, or the expertise in HoLEP is limited.

At ICUA, we have developed a streamlined pathway for international patients: remote consultation with review of imaging and blood tests, a fixed all-inclusive quote before you travel, surgery within days of arrival, and a detailed discharge report in your language for continuity of care back home, although we remain available for continued online follow-up.

How to request a personalised quote

Every case is different. Prostate size, the patient's medical conditions, and their insurance situation mean it is not possible to provide a single price for everyone.

What we can do is give you a fixed, detailed quote with no hidden extras after the first consultation, once we have the ultrasound and know your case. If you are coming from outside Madrid or from abroad, we can carry out an initial assessment by video consultation using the tests you already have, and provide an indicative quote before you travel.

Want to know how much your surgery would cost?

Request a consultation or video consultation. We will provide a fixed, personalised quote with no obligation.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
Rücker F, Lehrich P, Gilfrich C, et al. HoLEP in three different techniques: a comparison of 600 patients. World J Urol. 2021;39:4063-4069. DOI
Tricard T, Xia M, Trambert C, et al. Open prostatectomy is dead — long live endoscopic enucleation of the prostate! World J Urol. 2023;41:1457-1463. DOI

Does HoLEP Affect Erections and Sexual Function? What the Evidence Shows

2026-03-20T06:57:00.004+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

It is the question that concerns men most when considering prostate surgery. More than pain, more than anaesthesia, more than the hospital stay. "Doctor, will I still be able to have sex?" And the second question, often asked with more hesitation: "Will I still ejaculate?"

I will answer with complete honesty, because I believe a patient about to make a decision about his body deserves clear information — neither sugarcoated nor dramatised.

First and foremost: HoLEP does not affect erections

This needs to be said clearly from the start. Erections depend on two nerves — the cavernous or erectile nerves — that run along the back and sides of the prostate, outside the capsule. Prostatic enucleation works inside the capsule, peeling the adenoma away without touching these nerves at any point.

If a patient had normal erections before surgery, he will continue to have them afterwards. In fact, some patients report an improvement in their sex life after the operation, simply because the urinary symptoms that were limiting it — getting up four times a night, urgency, constant dribbling — have disappeared. When those problems go away, confidence and comfort improve, and with them, intimacy.

If a patient already had erectile dysfunction before surgery (which is common at this age and with conditions such as diabetes or hypertension), the operation will not make it worse, but it will not cure it either — they are separate problems.

Retrograde ejaculation: what it is and why it happens

This is where I need to be completely transparent. After a complete prostatic enucleation — whether HoLEP, TURP, open surgery, or any other technique that removes the adenoma — most patients experience what we call retrograde ejaculation.

What does that actually mean?

During orgasm, the semen instead of coming out through the penis flows backwards, into the bladder. The orgasm is felt, the sensation of pleasure is there, but there is no expulsion of semen. When the patient urinates after orgasm, the urine comes out slightly cloudy — that is the semen mixed with urine. It is completely harmless.

Why does it happen?

The ejaculatory mechanism depends on a closure that occurs at the prostatic urethra during orgasm. This closure prevents semen from going towards the bladder and directs it outward. When the prostatic adenoma is removed, this closure mechanism is disrupted. This is an inherent consequence of all techniques that completely remove the adenoma — it is not specific to HoLEP.

How common is it?

In the published literature, the rate of retrograde ejaculation after HoLEP ranges from 70 to 90%. It is similar with TURP (75–80%) and with open surgery. In other words: it is the norm, not the exception.

Is it dangerous?

No. Retrograde ejaculation has no health consequences whatsoever. The semen is eliminated naturally with urine. It is painless, does not cause infections, and creates no problems.

Does it affect fertility?

Yes. If a man wishes to father children and preserving antegrade ejaculation is a priority, this must be discussed before surgery. Options exist for sperm banking before the procedure, and assisted reproduction techniques can use semen recovered from urine after orgasm. But if future fertility is important, it is a factor that may tip the balance toward a more conservative treatment.

What patients actually tell me

After thousands of enucleations and asking my patients directly about their experience, I can share what they convey:

When I ask whether they miss ejaculation, they often say yes. It is a different sensation — something is missing.

When I ask about orgasm, the answers vary. Some tell me it is more intense and satisfying than before. Others notice no significant difference. And others tell me, with some regret, that it has become a mild "tingle" — not as good as before.

But when I ask whether they would have the same operation again, the answer is almost unanimous: yes. They tell me that their life, overall, has improved enormously despite the retrograde ejaculation, and that they would do it again without hesitation.

An objective data point: In a prospective satisfaction study (Lee, 2017) of 397 patients at six months after HoLEP, only 3.3% were dissatisfied and 3.9% would not have had surgery if they could choose again. Notably, the reasons for dissatisfaction were not ejaculation — they were persistent urgency and nocturia not improving as much as expected.

Can ejaculation be preserved with prostate surgery?

Yes, but with important caveats that the patient must understand before deciding.

Minimally invasive treatments (Rezum, UroLift, iTIND)

These procedures have been commercially positioned as ejaculation-preserving options. And it is true that they preserve ejaculation in most cases. However, the improvement in urinary flow is significantly less than with enucleation, durability is limited, and many patients will eventually require retreatment.

Laser-based options that preserve ejaculation

In our practice, we have two minimally invasive laser-based options for carefully selected patients who prioritise ejaculatory preservation:

The first is bilateral bladder neck incision with laser, in younger patients with an elevated, narrow bladder neck. If the incisions are kept half a centimetre to one centimetre above the verumontanum, ejaculation is preserved consistently. In my personal experience, I have had only one case of antegrade ejaculation loss with this technique, and we perform it virtually every week. It is done under sedation, takes 3–4 minutes, and the patient goes home the same day with a catheter for removal the following day.

The second is isolated middle lobe enucleation in patients whose obstruction is mainly caused by middle lobe growth. If the tissue around the verumontanum is preserved, ejaculation is consistently maintained and there is a very significant improvement in urinary symptoms.

These two options strike me as quite competitive compared to other minimally invasive treatments, but not every patient is a candidate. Selection is crucial, and we perform a prior cystoscopy to confirm that the patient's anatomy is suitable.

Ejaculation-sparing HoLEP

Attempts have been published to perform complete enucleation while preserving tissue around the verumontanum to maintain ejaculation. Results to date are modest — success rates of around 50%. And there remains uncertainty about whether leaving adenomatous tissue behind compromises the procedure's durability, with the risk that this residual tissue may grow and cause obstruction again.

Putting things in perspective

When I advise my patients on this topic, I often share something I believe is important: most of the men we operate on are 55–65 years old or older. Over time, the importance of antegrade ejaculation tends to diminish, but being able to urinate properly will become increasingly important. I have seen too many patients who at 75–80 are admitted for a hip fracture and develop urinary retention because a conservative approach was chosen decades earlier.

The medical device industry has invested enormous sums in shifting our perception of the relative importance of ejaculation versus bladder function. And they have been extraordinarily effective in that marketing effort. But as urologists, we should be advisors to our patients, not sales representatives for any company.

The decision always belongs to the patient. But for it to be a truly informed decision, he needs to know all the facts — not just the ones the advertising highlights.

In summary:
Erections: not affected. The erectile nerves are not touched during surgery.
Ejaculation: in 70–90% of cases it will be retrograde (dry). Orgasm persists.
Overall satisfaction: over 96% of patients are satisfied and would have the surgery again.
Ejaculation-preserving options exist for selected patients, but with lower efficacy or durability.

Have questions about how HoLEP might affect your sex life?

At ICUA we will explain all the options honestly and personally.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
Kim M, Song SH, Ku JH, et al. Pilot study of the clinical efficacy of ejaculatory hood sparing technique for ejaculation preservation in HoLEP. Int J Impot Res. 2015;27:20-24. PubMed
Lee SW, Choi JB, Lee KS, et al. Satisfaction and quality of life after holmium laser enucleation of the prostate. Investig Clin Urol. 2017;58:35-41. DOI
Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release. World J Urol. 2019;37:2451-2458. PubMed
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed

Benign Prostatic Hyperplasia (BPH): Symptoms, Diagnosis and Treatment Options in 2026

2026-03-20T06:45:00.003+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

If you find yourself getting up several times at night to urinate, if your stream is not what it used to be, if you have the feeling that your bladder never fully empties — you are not alone. These symptoms are extraordinarily common in men over 50, and in most cases they have a benign, treatable cause: benign prostatic hyperplasia.

In this article, I explain exactly what this condition is, how it is diagnosed, what treatment options are available in 2026, and when it is time to consider surgery.

What is benign prostatic hyperplasia?

The prostate is a walnut-sized gland that surrounds the urethra — the tube through which urine exits the bladder. From the age of 30, prostatic tissue begins to grow slowly but progressively. This growth is benign (it is not cancer) and is called benign prostatic hyperplasia, or BPH.

Over time, this growth can compress the urethra and make it difficult for urine to flow. BPH affects 50% of men by the age of 60 and up to 80% by 70. Not all will experience symptoms, but many do — and for some, the symptoms are bothersome enough to seriously impact quality of life.

It is important to understand that BPH is not prostate cancer and does not evolve into it. They are two different conditions that can coexist, but one does not cause the other.

The symptoms: how to know if you have a prostate problem

BPH symptoms fall into two broad categories:

Obstructive symptoms (voiding)

These occur when the urethra is compressed and urine struggles to flow out:

Weak stream: you notice the force of your stream has diminished over time.
Hesitancy: you have to wait or strain before the flow begins.
Intermittent stream: the flow stops and starts.
Incomplete emptying: you finish urinating but feel there is urine left in the bladder.
Terminal dribbling: drops continue to fall after you think you have finished.

Irritative symptoms (storage)

These are caused by the bladder becoming overactive — when it detects obstruction, it contracts involuntarily hundreds of times a day trying to overcome the resistance:

Urgency: a sudden, compelling need to urinate that is difficult to control.
Frequency: urinating far more often than normal during the day.
Nocturia: getting up to urinate during the night — once, twice, three times or more.
Urge incontinence: not reaching the toilet in time and leaking urine.

Warning signs that require urgent attention:

Complete inability to urinate (acute urinary retention) — go to A&E immediately.
Blood in the urine (haematuria).
Fever with difficulty urinating — may indicate infection.
Lower back pain with urinary difficulty — may indicate kidney involvement.

When to see a urologist

If your symptoms are bothersome, limit your daily activities, affect your sleep, or restrict your ability to travel, a urological assessment is worthwhile. There is no need to wait until things become serious. In fact, it is preferable not to wait too long: BPH is progressive, and a bladder that has spent years fighting against obstruction can undergo functional deterioration that is sometimes not fully reversible.

In our clinic, the assessment is quick. Within 10 minutes — using an ultrasound, a flowmetry test, and a blood test with PSA — we have the information needed to advise the patient on the best course of action for their case.

Diagnosis: what tests will be done

Diagnosing BPH is straightforward and non-invasive:

Clinical history and IPSS questionnaire: a standardised form that quantifies symptom severity on a scale of 0 to 35.
Digital rectal examination (DRE): allows estimation of prostate size and consistency. It is a brief, painless examination that is optional. We never force anyone to have a rectal exam if they do not wish to have it.
Blood test with PSA: prostate-specific antigen helps rule out cancer and gives an indication of prostate size.
Ultrasound: visualises the prostate, bladder, and kidneys. Allows measurement of prostate size and checks whether urine remains in the bladder after voiding (post-void residual).
Flowmetry: the patient urinates into a device that measures flow speed. A peak flow below 15 ml/s suggests obstruction.

In some cases, if the flowmetry pattern suggests a urethral stricture, we perform a flexible cystoscopy in the same consultation to rule it out. And if nocturia is the predominant symptom, we request a voiding diary to determine whether it is nocturnal polyuria — a different problem that will not improve with prostate surgery.

Treatment options

1. Lifestyle changes

In mild cases, adjusting certain habits can make a significant difference: reducing fluid intake in the evening, limiting coffee, tea, and alcohol (especially beer), avoiding constipation, and exercising regularly. These changes do not cure BPH, but they can relieve symptoms enough to live comfortably without treatment.

2. Medical therapy

When lifestyle changes are not enough, several types of medication are available:

Alpha-blockers (tamsulosin, silodosin, alfuzosin): relax the smooth muscle of the prostate and bladder neck, making it easier for urine to flow. They act quickly (within days) but can cause dizziness, nasal congestion, and ejaculatory problems.
5-alpha-reductase inhibitors (finasteride, dutasteride): shrink the prostate by blocking the conversion of testosterone to dihydrotestosterone. They take months to take effect and can affect libido and erectile function.
Combination therapy: alpha-blocker + 5-alpha-reductase inhibitor. More effective than either drug alone, but also with more side effects.
Antimuscarinics or beta-3 agonists: to treat the associated overactive bladder.

Medical therapy is effective for many patients, but it has its limits. It does not cure BPH — it manages it. If the medication is stopped, the symptoms return. And some patients experience side effects that reduce their quality of life as much as, or more than, the prostatic symptoms themselves.

3. Minimally invasive treatments

Several procedures sit between medication and surgery: Rezum (steam therapy), UroLift (retractor implants), and iTIND (a temporary reshaping device). They are performed on an outpatient basis or with very short hospital stays, and their main appeal is ejaculatory preservation.

However, the improvement in urinary flow is more modest than with surgery, durability is limited, and the probability of requiring retreatment is significantly higher. I believe they are a good option for carefully selected patients who prioritise ejaculatory preservation over maximum efficacy, but they do not replace definitive surgical options.

4. Definitive surgery

When medication is insufficient, when complications have developed, or when the patient simply wants to resolve the problem once and for all, surgery is the answer. The main options are:

TURP (transurethral resection): the classic technique. Effective for medium-sized prostates but limited for large ones, with a retreatment rate of 10–15%.
GreenLight laser vaporisation: good for medium prostates, very safe regarding bleeding, but no tissue specimen and slow for large glands.
HoLEP (holmium laser enucleation): removes the entire adenoma regardless of size, with a retreatment rate below 2%. Recommended by EAU and AUA guidelines for any prostate size.
Open surgery: effective but invasive, with long hospital stay and prolonged recovery. Increasingly being replaced by HoLEP.

What if I do not have surgery? The risks of untreated BPH

Untreated BPH can lead to complications that go beyond mere urinary discomfort:

Acute urinary retention: complete inability to urinate, requiring emergency catheterisation.
Bladder damage: a bladder that has spent years working against obstruction loses its contractile ability. This damage may be irreversible.
Recurrent urinary infections: residual urine left in the bladder is a breeding ground for bacteria.
Bladder stones: form in stagnant urine.
Bladder diverticula: the bladder wall herniates, forming pouches.
Kidney damage: in advanced cases, obstruction can affect the kidneys (hydronephrosis).

A recent study involving 50,000 subjects demonstrated that the bladder muscle deteriorates progressively as obstruction advances, and that there is a window of opportunity to treat the patient before that deterioration becomes permanent. I do not say this to cause alarm, but to help you understand that postponing urological assessment indefinitely is not a wise strategy.

As I often tell my patients: "You don't have to be the first to have surgery, but you shouldn't be the last either."

Do you have urinary symptoms that concern you?

At ICUA we provide a complete assessment in a single visit. If treatment is needed, we will explain all the options.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to BPH: AUA guideline amendment 2023. J Urol. 2024;211:11-19. DOI
EAU Guidelines on Management of Non-neurogenic Male LUTS. 2025 Edition. EAU Guidelines
Egan KB. The epidemiology of benign prostatic hyperplasia associated with lower urinary tract symptoms. Urol Clin North Am. 2016;43:289-297. DOI
Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed

Very Large Prostate? Why En Bloc HoLEP Is the Best Option for Prostates Over 100 Grams

2026-03-20T06:35:00.001+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

If you have been told that your prostate is very large — 100, 150, 200 grams or more — and that you need surgery, you have probably been offered two options: open surgery (an abdominal incision) or living with a catheter. There is a third option that you may not have been offered, because not all centres can perform it: en bloc holmium laser enucleation of the prostate (HoLEP).

And it does not just work for large prostates — it is where it works best.

What is considered a large prostate?

Prostate size is usually measured in grams or millilitres (they are essentially equivalent). A useful classification:

Small: under 30 grams — rarely requires surgery.
Medium: 30–80 grams — most techniques work well.
Large: 80–150 grams — this is where many techniques start to struggle.
Very large: over 150 grams — territory where few techniques are viable.

Size matters because it determines which surgical techniques can be used safely and effectively. And it is precisely with large and very large prostates that the differences between techniques become most apparent.

The problem with large prostates and conventional techniques

TURP (transurethral resection)

TURP has a practical ceiling around 80 grams. Attempting to resect a 150-gram prostate with an electrical loop is like trying to empty a well with a bucket: it takes too long, there is too much bleeding, and you never manage to remove all the tissue. The risk of fluid absorption syndrome (TUR syndrome) increases with operating time. This is why the clinical guidelines do not recommend TURP for large prostates.

GreenLight laser

GreenLight vaporisation works well for medium-sized prostates, but for large ones it faces the same problem: vaporising 100 or 150 grams of tissue takes an excessive amount of time, and it is very difficult to ensure all the adenoma has been removed. The retreatment rate for large prostates treated with GreenLight can reach 9%.

Aquablation

Aquablation is approved for prostates between 30 and 150 ml. It has an upper size limit, and data in large prostates show significantly higher rates of postoperative bleeding. It is not an enucleative technique — it destroys part of the adenoma but does not remove it completely.

Open surgery

Open simple prostatectomy is effective for prostates of any size — the surgeon opens the abdomen and removes the adenoma with their fingers. It works, but at considerable cost to the patient: abdominal incision, significant bleeding, 5–7 day hospital stay, prolonged catheterisation, and 4–6 weeks' recovery. For over a century it was the only option for large prostates. It no longer needs to be.

Why en bloc HoLEP has no size limit

HoLEP follows the natural anatomical plane between the adenoma and the prostatic capsule — the very same plane that the surgeon's finger follows in open surgery. But it does so with laser precision, without incisions, and with minimal bleeding.

And here is the paradox: the larger the prostate, the more efficient en bloc enucleation becomes. Why? Because in large prostates the plane between adenoma and capsule is better defined — easier to find and follow. The adenoma is softer, more pedunculated, and peels away more readily. It is like peeling a large orange: the segments separate from the peel with less effort than in a small one.

Our published data on large prostates

In 2025, we published in World Journal of Urology the results of 754 consecutive patients operated with our en bloc technique. Of these, 110 had prostates of 120 grams or more (median 143.5 grams). We compared them with the 644 patients with smaller prostates.

Parameter	Prostate <120 g (n=644)	Prostate ≥120 g (n=110)
Size (median)	60 g	143.5 g
Enucleation time	25 min	40 min
Enucleation efficiency	1.9 g/min	3.1 g/min
Tissue removed	38.9 g	98.7 g
Stress incontinence 1 month	3.4%	8.2%
Stress incontinence 3 months	1.4%	1.8%
Stress incontinence 6 months	0.15%	0.9%
Transfusion rate	0.31%	0.9%
PSA reduction	92.9%	94.4%
Qmax at 3 months	24 ml/s	28 ml/s

Several findings deserve comment:

Efficiency doubles in large prostates. We enucleated at 3.1 g/min in the large group versus 1.9 g/min in the normal group. This confirms that the dissection plane is better defined in larger glands.

Continence at 6 months is excellent in both groups. At one month, the large prostate group does have slightly more transient incontinence (8.2% vs 3.4%), which is expected — more tissue has been manipulated near the sphincter. But by 3 months the figures are comparable, and by 6 months they are below 1% in both groups.

PSA reduction is 94.4% in large prostates — even higher than in the normal group. This demonstrates the completeness of the enucleation: virtually all the adenoma has been removed.

Postoperative urinary flow is actually higher in the large prostate group (28 ml/s vs 24 ml/s), because the cavity left after removing a large adenoma allows a wider urinary channel.

Beyond 150 grams: prostates of 200, 300, and even 500 grams

In our experience, we have operated on prostates of exceptional size — 300, 400, and even 500 grams — with excellent results. These are cases that historically could only be resolved with open surgery, with everything that entails for the patient.

A multicentre study published in World Journal of Urology in 2023 by Tricard and colleagues, boldly titled "Open simple prostatectomy is dead," demonstrated excellent HoLEP outcomes in prostates over 150 ml, confirming that there is no longer any justification for opening a patient's abdomen to operate on their prostate.

Specific advantages of the en bloc approach for large prostates

Shorter morcellation time: Removing the adenoma in a single piece means subsequent fragmentation is faster and more efficient than if two or three separate lobes had been pushed into the bladder.
Complete specimen for histopathology: All the tissue is sent to the pathologist, allowing a thorough histological assessment. This is particularly important in large prostates, where the probability of finding incidental cancer is low but not negligible.
Better orientation during surgery: Dissecting en bloc means the surgeon always has a clear anatomical reference. In a 200-gram prostate, getting lost inside the adenoma is easy with fragmented techniques — with en bloc, you always know where you are.

"The prostate complicates old age"

This is a concept I always explain to my patients. A man who at 60–65 has a large obstructive prostate and decides not to undergo surgery runs the risk that at 75–80, when admitted for a hip fracture or knee replacement, he will develop urinary retention that dramatically complicates his life. A large prostate does not stop growing, and the bladder deteriorates with every year of untreated obstruction.

The great advantage of enucleation is that it offers a very high probability of being the only treatment the patient will ever need. We are not "fixing a tooth" that will need retreating in a few years. We are solving the problem definitively.

Have you been told your prostate is too large for surgery?

Send us your medical reports for a second opinion. At ICUA, we operate on prostates of any size.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
Tricard T, Xia S, Xiao D, et al. Outcomes of HoLEP for very large-sized BPH (over 150 mL): open simple prostatectomy is dead. World J Urol. 2023;41:2249-2253. DOI
Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release. World J Urol. 2019;37:2451-2458. PubMed
Juliebø-Jones P, Gauhar V, Castellani D, et al. En-bloc vs non en-bloc for large and very large prostates: propensity score matched analysis. World J Urol. 2024;42:299. DOI
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
Gomez Sancha F, Rivera VC, Georgiev G, et al. Common trend: move to enucleation — Is there a case for GreenLight enucleation? World J Urol. 2015;33:539-547. DOI (Open Access)

Finding a good HoLEP Surgeon: What to Look for and Why Experience Matters

2026-03-20T06:25:00.004+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

HoLEP is arguably the most surgeon-dependent technique in urology. Having a good laser is not enough — you need to know how to use it. The learning curve is real, and the difference between an experienced surgeon and one who is just starting out can mean longer operating times, higher complication rates, and worse functional outcomes.

If you are looking for a surgeon to perform your prostate operation with HoLEP, this article will help you ask the right questions and understand what distinguishes a centre of excellence from one that simply has the equipment.

Why HoLEP depends more on the surgeon than on the machine

Laser enucleation of the prostate is not like programming a robot or pressing a button. It is a manual technique that requires three-dimensional understanding of prostatic anatomy, recognition of the plane between the adenoma and the capsule, sphincter protection, and real-time decision-making when the anatomy is not as expected. Every prostate is different, and the surgeon must adapt.

Published studies indicate that 20 to 50 procedures are needed to achieve basic competence with HoLEP, depending on the technique used and whether an experienced mentor provides supervision. But basic competence is not the same as mastery. A study from the University of Mannheim following 500 consecutive en bloc cases showed that surgeon efficiency continued to improve even after hundreds of procedures — without reaching a plateau.

In practical terms, this means: the more procedures your surgeon has performed, the better your outcome is likely to be.

Five questions you should ask your surgeon before deciding

1. How many enucleations have you performed?

This is the most important question. A surgeon who has done 50 enucleations does not have the same capability as one who has done 500, and that surgeon is not comparable to one who has done 5,000 or 10,000. Cumulative surgical volume is the best predictor of outcomes.

Do not just ask how many HoLEP procedures they do per year — ask how many they have done in total. A surgeon doing 100 per year for two years has a very different experience level from one who has been performing this technique for 20 years.

2. Have you published your own results?

Any surgeon can claim their outcomes are good. But publishing results in a peer-reviewed scientific journal means the data have been verified and validated by independent experts. Ask whether they have PubMed-indexed publications with their own HoLEP data — complication rates, continence outcomes, retreatment rates.

3. Do you train other surgeons?

A surgeon to whom other urologists come to learn has, by definition, a level of mastery that goes beyond competence. Teaching forces systematisation, an understanding of nuances, and the ability to solve problems that a less experienced surgeon has never encountered. Ask whether they receive visitors to their operating theatre, whether they run training courses, whether they proctor (supervise) at other hospitals.

4. Which technique do you use?

Not all HoLEP variants are equal. The en bloc enucleation technique with early apical release has been shown to be faster, more efficient, and to provide better continence protection than the classic three-lobe technique. Ask your surgeon which technique they use and why.

5. Can you operate on prostates of any size?

A HoLEP centre of excellence should be able to handle prostates of any volume — from small to very large, 200, 300 grams or more. If you are told your prostate is "too big for HoLEP," you are probably not at a centre with the necessary experience. One of HoLEP's greatest advantages is precisely that it has no size limit.

ICUA and Dr. Gómez Sancha: objective data

I do not intend this article to be a self-promotional exercise. What I will share are verifiable data — published in peer-reviewed international scientific journals, accessible on PubMed for anyone who wishes to check them.

Surgical experience

Over 10,000 prostatic enucleations performed since 2003.
Laser prostatectomy since 2003 — first with GreenLight, then with holmium laser (HoLEP).
We operate on prostates of any size, including the very largest (300–500 grams).

Published technique

GreenLight en bloc enucleation (GreenLEP): described and published in World Journal of Urology in 2015. The first description of en bloc enucleation with this energy source.
En bloc HoLEP with early apical release and sphincteric mucosal preservation: published in World Journal of Urology in 2019 (137-patient series). Mean operative time 47 minutes, stress incontinence 0.7% at 6 months.
754-patient consecutive series: published in World Journal of Urology in 2025. Stress incontinence at 6 months: 0.15% for normal-sized prostates, 0.9% for large prostates. Postoperative PSA reduced by 93–94%.

International registries

REAP Registry: co-author of the largest global multicentre database for prostatic enucleation — 6,193 patients from 10 centres in 7 countries, published in World Journal of Urology in 2023.
Multicentre early apical release study: co-author of a 4,392-patient study evaluating the impact of early apical release, published in Urology in 2024.

International training

Over 60 countries represented in our operating theatres in Madrid (ICUA, Clínica CEMTRO) and Sofia (Hill Clinic, Bulgaria).
Active training programme since 2007: weekly surgical sessions with 5 procedures per session, open to international visitors.
Training courses in Spain, Bulgaria, Mexico, Philippines, and other countries.
Invited regularly to perform live surgery in the European annual congress and other minor events
Published textbook: Manual de HoLEP en Bloque (ISBN 978-84-09-81888-4, 2026) — a 352-page practical manual with the step-by-step technique.

All of these data are verifiable. The publications are on PubMed, the visitors are real, the book has an ISBN. This is not marketing — these are facts.

What makes a centre of excellence?

A HoLEP centre of excellence is not simply a hospital that owns a holmium laser. It is a centre where several factors converge:

Volume: enough procedures per year to maintain and improve the team's skill.
Accumulated experience: the surgeon has long surpassed the learning curve and has operated on prostates of every description.
Published data: the centre has verifiable, published results — not just internal statistics.
Teaching capacity: other surgeons come to the centre to learn, demonstrating peer recognition.
Complete team: it is not just the surgeon — it is an anaesthesia, nursing, and follow-up team that knows the protocol inside out.

A personal note: Do not choose your surgeon based on the lowest price or the first Google search result. HoLEP, done well, solves the problem permanently. Done poorly, it can leave you with complications requiring further procedures. The difference between these two scenarios is, almost always, the experience of the person holding the endoscope.

Would you like us to evaluate your case?

At ICUA we treat patients from across Spain and around the world. Send us your medical reports for a personalised assessment.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol. 2019;37:2451-2458. PubMed
Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
Gomez Sancha F, Rivera VC, Georgiev G, et al. Common trend: move to enucleation — Is there a case for GreenLight enucleation? World J Urol. 2015;33:539-547. DOI (Open Access)
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
Gauhar V, Lim EJ, Fong KY, et al. Influence of early apical release on outcomes in endoscopic enucleation of the prostate: 4392 patients. Urology. 2024;187:154-161. DOI
Wenk MJ, Hartung FO, Egen L, et al. The long-term learning curve of HoLEP in the en-bloc technique: 500 consecutive cases. World J Urol. 2024;42:436. PubMed
Li P, Wang C, Tang M, et al. The en bloc method is feasible for beginners learning to perform HoLEP. Transl Androl Urol. 2023;12(3):379-390. PubMed Central

HoLEP Prostate Surgery: What to Expect Before, During and After

2026-03-20T06:10:00.004+01:00

Dr. Fernando Gómez Sancha · Medical Director, ICUA · Clínica CEMTRO, Madrid, Spain
Last updated: March 2026

If you have been recommended prostate surgery with HoLEP, or are considering it, it is natural to want to know exactly what will happen. This article describes the patient experience step by step — before, during, and after the procedure — as we carry it out daily in our operating theatre, after more than 10,000 enucleations.

Before surgery

The consultation: initial assessment

When a patient comes in for consultation, we ask them to bring a blood test with PSA and a urine analysis, and to arrive with a comfortably full bladder (we recommend not urinating for two hours beforehand and drinking 3–4 glasses of water an hour before). In the waiting room, we provide the IPSS questionnaire to assess symptom severity.

In the consultation room, we take a clinical history, review the blood work, perform an ultrasound of the urinary tract with a full bladder, and carry out a flowmetry test. We then check for post-void residual urine with ultrasound. With all this information, we can advise the patient on whether they need medical treatment, monitoring, or whether surgery should be considered.

When do we recommend surgery?

There are two situations. The first is when there is a mandatory indication for surgery: urinary retention requiring a catheter, bladder stones, prostatic bleeding, recurrent infections, or kidney damage. In these cases, surgery should not be delayed.

The second is when the patient meets surgical criteria without a mandatory indication: symptoms affect quality of life and medical treatment is insufficient. In these cases, I always tell the patient that it is important they are genuinely convinced that the operation is necessary, or at least advisable. Operating on a man who is not convinced is a bad idea — if something does not go perfectly, the burden of blame falls on whoever made the recommendation. When the patient actively participates in the decision, they navigate the postoperative period much better.

Medications you need to stop

If you take anticoagulants or antiplatelet agents, it is essential to communicate this. Depending on the type of medication:

Aspirin, clopidogrel (Plavix), ticlopidine: stop 7 days before surgery.
Warfarin/acenocoumarol: stop 3 days before and start low-molecular-weight heparin as directed by your surgeon.
Direct oral anticoagulants (rivaroxaban, apixaban, dabigatran): stop according to the specific protocol for each drug.

It is very important to coordinate this with your urologist and, if necessary, your cardiologist. The holmium laser has excellent haemostatic properties — in our series, the transfusion rate is below 1% — but proper preparation is essential.

The day of surgery

The patient is admitted in the morning, fasting (no food, drink, or smoking for 6 hours beforehand). Surgery is usually scheduled for the afternoon. Before the procedure, the anaesthetist will visit to explain the type of anaesthesia and answer any questions.

During the procedure

Anaesthesia

We generally use spinal anaesthesia (intradural), which numbs the body from the waist down. The patient is awake but feels absolutely nothing in the surgical area. A mild sedative is given so you feel relaxed, and you will likely doze off lightly during the procedure. In some cases, general anaesthesia is used — your anaesthetist will explain the advantages of each option.

How long does the operation take?

It depends on prostate size. In our series of 754 patients:

Normal-sized prostates (<120 g): 25 minutes of enucleation + 5 minutes of morcellation + haemostasis = approximately 45–60 minutes total.
Large prostates (≥120 g): 40 minutes of enucleation + 13 minutes of morcellation + haemostasis = approximately 70–90 minutes total.

These times reflect an experience of thousands of procedures. A surgeon at the beginning of their learning curve will require more time, but this does not affect safety or long-term outcomes.

What does the surgeon actually do?

An endoscope is inserted through the urethra to the prostate area. Using the holmium laser, the boundary between the adenoma and the urinary sphincter (the "white line") is marked to protect continence from the very first moment. The adenoma is then gradually peeled off the prostatic capsule circumferentially — like peeling an orange — until the entire piece is pushed into the bladder. There, it is fragmented with an instrument called a morcellator and suctioned out for histopathological analysis.

Finally, haemostasis is checked (ensuring there are no bleeding points) and a urinary catheter is placed.

After surgery

The first few hours

When you leave the operating theatre, you will have a urinary catheter with a slow continuous irrigation to keep the urine clear. After spinal anaesthesia, there is no pain — the only common complaint is being unable to move your legs for a couple of hours until the effect wears off. Most patients do not require painkillers.

The following morning: catheter removal

We follow an early catheter removal protocol that has proven very effective. The nurse flushes the catheter to clear any small clots that formed overnight, removes the catheter, and fills the bladder with saline. The patient gets up and urinates — usually 3–4 times during the morning. If all goes well, discharge is around midday.

With this protocol, approximately 5% of patients have difficulty voiding after removal. In those cases, the catheter is reinserted and the patient goes home with it, returning to the clinic 1–2 days later for removal. If we left the catheter in for 48 hours, 99% would void without trouble — but we prefer early removal so that 95% of patients do not spend an extra day with a catheter unnecessarily.

Discharge medication

We prescribe an anti-inflammatory for one week (usually dexketoprofen 25 mg three times daily) with a gastric protector, and a prophylactic antibiotic for one week. We advise patients to avoid constipation (no straining during bowel movements) and to drink plenty of fluids.

The first few weeks: what is normal

It is important to know what to expect so you do not worry unnecessarily:

Pinkish urine or mild bleeding for the first few days — this is normal and gradually clears.
Passing small clots or yellowish particles — these are normal remnants from the healing process.
Stinging when urinating at the beginning and end of the stream — transient, resolves within days.
Urgency and frequency — irritative symptoms may persist for up to 3–4 months. Interestingly, the first two to three weeks are often the best, and then urgency and nocturia reappear before improving definitively.

An important note: If you experience stinging or urinary urgency in the weeks following surgery, your GP may perform a urine dipstick test that comes back positive for red and white blood cells. This is completely normal for the first few months — the prostatic fossa is healing. It does not mean you have an infection. Many GPs are unaware of this and may prescribe unnecessary antibiotics.

One-month review

We see the patient after one month. Most already notice a very significant improvement in urinary flow. Some irritative symptoms may persist and will continue to improve.

Three-month review

At three months, the vast majority of patients feel very well. Irritative symptoms are resolved or nearly resolved. We perform a flowmetry, symptom questionnaire, and PSA test. If all is well, we recommend an annual PSA review with their GP.

Results: the numbers that matter

In our published series of 754 patients operated with the en bloc technique:

Urinary flow: from 8 ml/s preoperatively to 24–28 ml/s postoperatively — an immediate and dramatic improvement.
IPSS (symptom score): from 24 preoperatively to 3 at 12 months — virtually symptom-free.
PSA reduction: 93–94% — confirming complete adenoma removal.
Stress incontinence at 6 months: 0.15% (prostates <120 g) and 0.9% (≥120 g).
Transfusion rate: below 1%.
Hospital stay: 24–48 hours in most cases.

An important note for follow-up: PSA

After HoLEP, PSA should drop below 1 ng/mL. If at any future check-up your PSA rises above this level, it needs to be investigated — it may indicate residual adenomatous tissue or, in some cases, prostate cancer requiring further study. It is crucial that your GP knows that the reference value after an enucleation is not the standard "below 4 ng/mL" but below 1 ng/mL.

When can I return to normal life?

Light domestic activity: from the day after discharge.
Office work: after 2–3 days.
Driving: after one week.
Gentle exercise (walking): from day one. Intense exercise: after 4 weeks.
Sexual activity: after 3–4 weeks.
Long-distance travel: after 2–3 weeks, ensuring adequate fluid intake and regular voiding.

Considering HoLEP surgery?

At ICUA we will explain the entire process in a personalised consultation. In-person in Madrid or international video consultation.
📞 +34 91 435 28 44 · ✉ icua@icua.es

Scientific references

Iscaife A, Rodríguez Socarrás M, Talizin TB, et al. Contemporary results of En Bloc HoLEP for large prostates. World J Urol. 2025;43:401. PubMed
Saitta G, Becerra JEA, Del Álamo JF, et al. 'En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol. 2019;37:2451-2458. PubMed
Gauhar V, Gómez Sancha F, Enikeev D, et al. Results from a global multicenter registry of 6193 patients (REAP). World J Urol. 2023;41:3033-3040. PubMed
Gauhar V, Lim EJ, Fong KY, et al. Influence of early apical release on outcomes in endoscopic enucleation of the prostate: results from a multicenter series of 4392 patients. Urology. 2024;187:154-161. DOI

Dr. Fernando Gómez Sancha's Blog in English

I AAU International Course on Anatomical Prostatic Enucleation — Jerez, 21-22 May 2026

Live HoLEP from Bulgaria: four cases, 25 countries, 300 urologists

Ten HoLEPs in Two Days with Colleagues from Brazil

Not All LISTs for BPH Are Trying to Solve the Same Problem

The problem with the umbrella label

The right question is not “which technique is best”

Functional compromise procedures

The intermediate space: Rezūm

The important exception: Aquablation

The main driver of the market: sexual function

Anatomical selection: where honesty is won or lost

So what is the real role of LISTs versus HoLEP?

Conclusion

Suggested reading

The Next Wave of LISTs for BPH: How Much Is Innovation, How Much Is Hype

What the new generation is promising

Why this evolution makes sense

The new candidates

Where there may be genuine innovation

1. Better anatomical matching

2. A better balance between function and durability

3. Lower burden without drifting into undertreatment

Where hype is most likely

1. “Minimally invasive” as an emotional shortcut

2. Sexual preservation as the dominant storyline

3. High visibility with limited maturity

4. Highly active adoption networks

The case of Optilume BPH

What any new LIST should be required to prove

So how should we read what is coming?

Conclusion

Suggested reading

EEP Made Practical: Expert Lessons from the BEAM 2025 Meeting

Why does this paper matter?

Key recommendations

Managing challenging anatomy

Morcellation tips

Complication prevention

Full reference

En Bloc HoLEP with Vesical Mucosal Release: A Technical Refinement for Safety

What does the study show?

Why does this matter?

A simple step that adds safety

The Bladder Matters too: A Friendly Critique of the Defenders of the Detrusor

The idea worth listening to

Where the evidence does not hold up

The research we actually need

A strength worth highlighting: technological agnosticism

A closing thought

References

Relevant links

New training session in Sofia with visitor from Belgium!

The 2026 SIU-ICUD Consultation on Male LUTS: A Structural Conflict of Interest Analysis

I. The Declared Sponsors and the Conflict Architecture

II. The Named Positions: A Structural Analysis

III. The Quantitative Asymmetry

IV. Corporate Images as Scientific Figures

V. Opening Paragraphs as Evidence of Register

VI. Procedural Videos: The Most Objective Asymmetry

VII. The Volume Restriction: An Evidence Gap That Requires Explanation

VIII. The Neutralisation of the Bhatia Meta-Analysis

IX. Technical Attribution: An Observation on Academic Practice

X. What the Document Contains That Is Valuable

XI. Recommendations for Clinicians and Health Systems

XII. A Note on Formal Response

References

En-Bloc HoLEP Manual — The Definitive Guide to Prostate Enucleation

Why an en-bloc HoLEP manual?

What you will find in this manual

Who is this book for

Book details

Where to get it

The experience behind the manual

My professional journey: 32 years in urology, 52 countries, 10.000+ procedures

International reach

Professional activity by year (2,445 documented events)

Milestones & activities

The technical evolution

Training as a mission