Radical Prostatectomy Following Holmium Laser Enucleation of the Prostate (HoLEP): A Systematic Review of Perioperative, Oncological, and Functional Outcomes

TL;DR

This review examines the outcomes of radical prostatectomy after HoLEP, finding it feasible and safe with comparable cancer control and functional recovery when done by experienced surgeons.

Contribution

The study provides a systematic review of the surgical, oncological, and functional outcomes of radical prostatectomy following HoLEP.

Findings

Radical prostatectomy after HoLEP is technically more demanding but safe with experienced surgeons.

Oncological outcomes and long-term functional recovery are comparable to primary prostatectomy.

Early continence recovery may be delayed, but functional outcomes are generally equivalent at 12 months.

Abstract

Holmium laser enucleation of the prostate (HoLEP) has become a gold-standard treatment for benign prostatic hyperplasia, and an increasing number of these patients are later diagnosed with prostate cancer requiring radical prostatectomy. However, prior HoLEP alters prostatic anatomy, raising concerns about surgical safety and functional recovery. This systematic review summarizes the available evidence on radical prostatectomy after HoLEP, evaluating perioperative, oncological, and functional outcomes across eight studies involving 202 patients. The findings demonstrate that the procedure is technically more demanding and often associated with longer operative times and the need for bladder-neck reconstruction, but major complications remain rare. Oncological control and long-term functional outcomes are comparable to primary prostatectomy, although early continence recovery may be delayed. Overall, radical prostatectomy after HoLEP is feasible, safe, and effective when performed by experienced surgeons in specialized centers.

Background: The widespread adoption of holmium laser enucleation of the prostate (HoLEP) has led to a growing number of men subsequently diagnosed with localized prostate cancer requiring radical prostatectomy (RP). However, anatomical alterations after HoLEP may increase surgical complexity and affect outcomes. This systematic review aimed to synthesize current evidence on perioperative, oncological, and functional outcomes of RP following HoLEP. Methods: A systematic literature search was conducted in PubMed, CENTRAL, and ClinicalTrials.gov through to September 2025 in accordance with PRISMA 2020 guidelines (PROSPERO CRD420251134483). Eligible studies included patients undergoing RP after HoLEP with reported perioperative, oncologic, or functional data. Methodological quality was assessed using the ROBINS-I tool, and results were synthesized narratively. Results: Eight retrospective studies comprising 202 patients were included. RP after HoLEP was technically feasible across open, laparoscopic, and robotic approaches. Operative time and the need for bladder-neck reconstruction were increased, reflecting post-enucleation fibrosis, but major complication rates (<5%) and blood loss were comparable to primary RP. Oncological outcomes were preserved, with positive surgical margin rates of 6–20% and biochemical recurrence rates of 7–15%, similar to those of primary RP. Functional recovery, particularly urinary continence, was slower initially but generally equivalent at 12 months. Erectile function outcomes were variable but satisfactory when nerve-sparing was feasible. Conclusions: Radical prostatectomy after HoLEP is a technically demanding yet safe procedure that achieves oncologic and long-term functional outcomes comparable to primary prostatectomy. Prior HoLEP should not preclude curative surgical management of prostate cancer, provided the operation is performed by experienced surgeons in high-volume centers.

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