Inside HoLEP: Irina Jaeger, MD, discusses patient selection and technique

In a recent interview with Urology Times, Irina Jaeger, MD, a urologist with extensive experience performing holmium laser enucleation of the prostate (HoLEP) for the treatment of benign prostatic hyperplasia (BPH), discussed the nuances of patient selection, technical considerations, training, and emerging innovations surrounding the procedure.

During the discussion, Jaeger emphasized that the ideal HoLEP candidate is any patient with bothersome lower urinary tract symptoms due to BPH, including those with urinary retention or intolerance to medication. HoLEP can be safely performed on prostates of nearly any size, including very large glands of more than 200 g, provided the surgical team is experienced and adequately prepared. For patients who are on an anticoagulant, Jaeger prefers to pause therapy when medically feasible to reduce both intraoperative and delayed bleeding. However, she noted strong evidence supporting HoLEP’s safety in this population. In older patients with comorbidities, efficiency and multidisciplinary coordination are key to minimizing fluid absorption and cardiac stress.

Jaeger noted that HoLEP’s symptom relief and durability rival those of open or robotic simple prostatectomy while offering a minimally invasive approach with faster recovery. Compared with transurethral resection of the prostate (TURP), HoLEP provides longer-lasting results, especially for larger prostates. Although newer minimally invasive options such as Rezūm and prostatic urethral lift preserve ejaculation, their efficacy and retreatment rates remain less favorable. HoLEP, she said, offers extremely low retreatment rates—typically in the single digits—with data supporting excellent durability beyond 10 years.

The learning curve for HoLEP is steep—often 25 to 100 cases before independent proficiency. Jaeger described her own training as "humbling," emphasizing the value of simulation labs, mentorship, and a dedicated, well-trained surgical team. Tracking one’s own metrics, such as enucleation times and energy use, helps refine technique. She shared practical pearls for morcellation efficiency and safety, such as ensuring optimal visualization, maintaining bladder distension, and thoroughly training assistants.

Jaeger typically uses 24-hour catheterization and same-day discharge protocols. Most postoperative incontinence is transient and resolves within weeks, aided by early pelvic floor therapy. Erectile function is preserved in most patients, though retrograde ejaculation is nearly universal and should be clearly discussed preoperatively. With careful hemostasis and team coordination, bleeding and bladder injuries are rare.

Jaeger encourages residency exposure to HoLEP but cautions that mastery requires substantial time and commitment. Technological advances—such as high-power lasers with simultaneous cutting and cauterization, enhanced digital scopes, and improved morcellators—are making the procedure more efficient and accessible. However, significant barriers remain, including the steep learning curve, costly equipment, and lack of institutional familiarity. Misinformation among referring primary care physicians also limits referrals. Education, mentorship, and technological refinement, Jaeger concluded, are essential to expanding HoLEP adoption and ensuring more patients benefit from this durable, minimally invasive BPH solution.

Jaeger is a urologist at University Hospitals and an assistant professor of urology at Case Western Reserve University School of Medicine in Cleveland, Ohio.

Urology Times: What are the ideal patient profiles for HoLEP, and how do you approach cases that fall outside the typical selection criteria; for example, very large prostates, patients on anticoagulants, or those with significant comorbidities?

Jaeger: The ideal patient for HoLEP is any patient who has significant lower tract symptoms that are bothersome and are interfering with their lifestyle, whether they have failed medication or they just don't want to take a daily medication for the rest of their lives. [Another factor is] a history of recurrent urinary retention. HoLEP can be performed on prostates of most sizes. The only time I try not to use HoLEP is when the prostate is very small. The majority of prostates are very HoLEP friendly, even very large ones—more than 200 g.

In terms of patients...with very large glands, it just requires a bit more planning, longer operative time, and setting up different expectations in terms of how long the incontinence [will last]. In terms of the technicality of bigger prostates, there are certain tricks that we can do to minimize the trauma to the sphincter and [improve] patient outcomes. The most important thing for large prostates is to make sure you have a team trained in these techniques and troubleshooting; [for example,] the morcellator can be very temperamental. [The team needs to be] prepared if you need to make an incision [and] retrieve the adenoma, or if there's bleeding. You make sure that you schedule patients [with more challenging cases] on a day when you have the right staff, and you have dedicated time to do longer cases.

In terms of patients [who are on an anticoagulant], there's plenty of literature out there that [indicates] it is a feasible option to do these procedures while they're on an anticoagulant. I prefer not to. As long as it's medically safe, I usually stop anticoagulation [medication] prior. We don't just see increased bleeding in patients [who are on an anticoagulant] during the surgery; it can also sometimes be delayed bleeds once they restart anticoagulation. These patients are great candidates for HoLEP, because the bleeding is actually a lot less than in other modalities. [Still,] we just need more careful, more intense follow-up to make sure that they're doing well, and that they know exactly when to restart it and when to hold it. We have a system in place that takes care of that.

BPH is a condition of our [older] population, so you have more frail, more sick patients. That requires a lot of coordination with their cardiologist, pulmonologist, and internist to make sure that the patient is optimized. Then the big thing with these [older] patients is that I always try to watch my efficiency, to minimize the fluid absorption, because we use a lot of these fluids that we run through the bladder during the procedure. You want to try to shorten your operative time so they don't absorb it, especially patients who have cardiac issues.

Urology Times: How would you say HoLEP compares with other surgical options for BPH, such as TURP, robotic simple prostatectomy, Aquablation, or prostatic urethral lift, in terms of efficacy, durability, and complication rates?

Jaeger: HoLEP and simple prostatectomy kind of go hand in hand in terms of relief of symptoms, efficacy, and the longevity of outcomes. Obviously, the advantage of HoLEP is that it is endoscopic. There's no incision; the recovery is quicker. With TURP, it's very much size dependent. If you do a TURP vs a HoLEP on a smaller prostate, they will probably do equally well. There's a lot of evidence out there that for larger prostates, TURP or simple prostatectomy is definitely a winner in terms of sustaining the relief of symptoms. [With] the minimally invasive options that have come out in the past several years, such as Rezūm and the prostatic urethral lift, for patients who feel that preservation of ejaculation is very important, those are fantastic options [for] the right prostate. It has to be the right size, it has to be the right shape, and the patients also need to be counseled appropriately because the outcomes and improvement may not be as drastic as you see after HoLEP. Also, we worry about retreatment rates; they are significantly higher after these minimally invasive procedures, as opposed to HoLEP. [You have to] take into consideration what the patient's wishes and priorities are; it's a joint decision that we make together. [You have to be] transparent on what [they should] expect. We offer all these modalities [at my institution].

Urology Times: HoLEP is technically challenging. How steep is the learning curve in your experience, and what strategies or training opportunities do you recommend for surgeons who are adopting this procedure?

Jaeger: I am one of those cases who, about 10 to 12 years into practice, said, "I'm going to learn HoLEP," and then I really was not a kind person to anyone for about 6 months, because it's a very humbling, very stressful process. The learning curve is quite steep. When our residents are exposed to HoLEP in their training, that's different, because we're still morphing them into surgeons, as opposed to someone who is a fully trained urologist who says, "I can do this. It can't be that hard." Well, guess what? It is. It was a very humbling experience.

The learning curve [that is frequently cited is] about 25 to 50 cases. I probably wasn't fully comfortable [working] independently until about 100 cases. Even now, when I'm hundreds in, on every case, I still learn something new. [Prostates are not identical]; they're all very different. Volume, obviously, is helpful with the learning curve. The drop-out rates in terms of learning curve for established urologists are staggering, so the majority who attempt it decide not to pursue it. The most stubborn ones stick to it.

In terms of helping with the learning curve, it's great to have a proctor. I was lucky enough that, when I decided to learn HoLEP, I had 2 people in my institution who were fully trained HoLEP surgeons, so the 2 of them kind of babysat me through the first 20 and then said, "Go ahead; you're ready." There are simulation models that you can do in the laboratory, which are very realistic. We use them for teaching residents. Those are fantastic. Like I mentioned before, when you're going through that learning curve, the last thing you want is for your morcellator not to work properly because your team is not familiar with the equipment. You're not the only one who's learning; you're all learning together. It's very important to have a dedicated team. In my hospital, I have a team that does HoLEPs, and they can troubleshoot, and they know how to handle these situations. If you're brand new to this and you're just trying to figure out where to point the laser, the last thing you want, obviously, is your equipment malfunctioning.

What I found really helpful in terms of the learning curve is tracking my data. The more [procedures] you do, the more your energy usage goes down because you're more efficient. Your enucleation times go down; your risk of postoperative incontinence decreases. These are all important things to track to encourage yourself to keep going.

Urology Times: What does the evidence show about the long-term durability of HoLEP outcomes, and how do you counsel patients regarding retreatment rates compared with other modalities?

Jaeger: The data are out there. [There are] studies that have 10-plus years [of follow-up]. HoLEP, for sure, in the long term is the way to go. The retreatment rates are extremely low; I think they're in the single digits. That's what I tell my patients. Obviously, it is a personal decision, because you pretty much guarantee retrograde ejaculation, so [you need to be transparent] with the patient, but HoLEP has been around for a long time. It has kind of come back in the past few years because the quality of our lasers has improved, which makes these procedures a lot less challenging to learn. It's still quite challenging, but it's a lot more approachable. Retreatment rates are extremely low. It is still a minimally invasive option. That's how I counsel my patients. "This is a minimally invasive option. Yes, you will get retrograde ejaculation, but your risk of needing another procedure down the road is extremely low," and that's usually a no-brainer for them.

Urology Times: How do you approach perioperative management in HoLEP, especially anticoagulation, catheterization time, and same-day discharge protocols?

Jaeger: I do all my HoLEPs in one hospital. My preoperative evaluation is very important, because a lot of these patients are [older] patients with comorbidities, so we all work as a team to optimize [the patients]. In terms of anticoagulation, like I said, we try to hold [the medication] if we can. If that's not possible, we just make sure that these people have very, very close follow-up with us.

In terms of catheterization time, my standard of care is 24 hours for most prostates. If patients are anticoagulated, I'll leave the catheter in longer. For patients who are [older] or have difficulty getting back to the office, sometimes we'll leave them in a bit longer, but usually, our goal is to have the catheter out within 24 hours.

My standard of care is same-day discharge. My patients very rarely get admitted overnight, and I almost never admit patients overnight for HoLEP-related issues. It's usually them waking up from anesthesia and having cardiac or pulmonary issues because they are [older]. I am very meticulous about hemostasis, so I make sure that before they wake up, their urine is crystal clear. Usually, admission overnight is not for HoLEP-related reasons; it's because of something else.

Urology Times: What are the most common complications you see with HoLEP, and how do you prevent and manage issues such as stress urinary incontinence, bladder injury, or urethral stricture?

Jaeger: The biggest thing is transparency. When you counsel the patient before you schedule their surgery, you want to be transparent. Yes, postoperative incontinence is very common. Yes, it's usually transient. Yes, it's scary because nobody wants to end up living in diapers. Usually, the more experienced you are, the better your incontinence rates are, and the quicker the patients become continent. In my hands at this point, patients are usually continent within 2 weeks. Sometimes, if the anatomy is challenging, it can linger for a few months.

Also, very importantly, we have a good relationship with a local physical therapy facility, so if [a patient is] not dry as soon as we want them to be, we refer them. There's no delay. They know how to handle our patients, and they communicate with us. That support is very, very important. I tell everybody, "It is transient, but you will get [incontinence]." The risk of permanent incontinence is extremely low; it's about 1%. As long as you set the expectations, they do really well.

Obviously, things can bleed when you cut into them, especially in patients who are on anticoagulants. The beauty of our technology now is that the lasers have evolved to the point where the hemostasis is fantastic, as long as you are very careful, and you spend time cauterizing as much as you can and not waking up the patient until you are positive that the urine is clear. It prevents a lot of the take-backs. It prevents a lot of these delayed bleeds. Now, of course, once in a while, it will happen, but very rarely.

Specific to HoLEP, bladder injury or injury to a ureteral orifice has been reported. We morcellate tissue, and morcellation is a very stressful part of this case, because you can have a perfectly amazing enucleation—efficient, fast, minimal bleeding—and then the morcellator malfunctions, or your staff is not keeping an eye on the fluids, the bladder deflates, and you take a chunk of mucosa out, which is not ideal. There are ways to prevent these injuries.

Urethral stricture and bladder neck contracture are rare, but they do happen. Fortunately, I'm in a tertiary care institution, so if these patients develop recurrent urethral structure, we have a specialist with whom I have a really good relationship who [handles] that. Bladder neck contractures are rare, but we've been very successful just cutting them with a laser, and usually these patients do fine afterward. As long as you're open and transparent about the complication rates that are specific to you as a surgeon—because they may be different from the practitioner down the street—then the patients do fine, and they trust you.

Urology Times: Morcellation can be a bottleneck when performing HoLEP. What pearls can you share about optimizing morcellation efficiency and safety?

Jaeger: The No. 1 rule is, do not put the morcellator in the bladder until your visualization is perfect. If the adenoma is out, you're oozing everywhere. [If] you put the morcellator in there, that's just screaming for bladder injury, because you can't see what you're doing. Maintaining bladder distension, obviously, is the biggest thing, and it's tricky because your eyes are on the morcellation, on the screen, on the tissue, so you are very much dependent on your staff to keep track of fluids. The last thing you want is to turn your head side to side, saying, "Is the fluid still going?" I am very lucky that my staff is very, very careful when it comes to this, so we've not had these issues at all.

There are certain tricks to morcellation. There are some adenomas that just don't morcellate very well. You can decrease the speed with which the blade moves, and it holds on to the tissue better. The orientation of the blade is important. You don't want to be too close to the bladder mucosa, so you want to keep your eye on where the adenoma sits. Training your assistants how to help you [is important]. These things are not obvious until you actually start doing them; [for example,] the morcellator switch takes several steps, and you want to be efficient, because if you take too long, you lose pressure in the bladder, and your visualization gets worse. We developed a system where I hand [my assistant] the cord for the light, and I hand her the camera. She switches in a morcellator, and then it's a quick [transition], which does not cause any significant delay. In addition, morcellators are heavy, and my assistant knows that, with me being a 120-pound woman, she's going to hold the blade for me until the morcellator clicks all the way into the bladder. Little things like that really help. If you're efficient with that step, then your visualization is much better, and your morcellation goes very smoothly. The trick is training people to know how to assist you.

Also, morcellators are very temperamental, so I have a backup morcellator. Knock on wood, I've not had to use it, but I have 2 units, because the worst thing that can happen is, you have a perfect case and then there is a morcellator malfunction. People do different things when that happens. They can wake up the patient and irrigate the bladder overnight. It softens the adenoma, and then you can come back the next day and morcellate it, which is not ideal. Some people will just open the bladder and get the adenoma out, but that defeats the whole purpose of the minimally invasive approach.

Urology Times: How do postoperative outcomes such as continence and sexual function compare with other BPH surgeries, and what do you tell patients to expect during recovery?

Jaeger: I'm very big on early pelvic floor exercises. I tell patients, "As soon as the hematuria resolves, go for it." Incontinence rates are higher, obviously, compared with the minimally invasive procedures. But again, it's transient, as long as you set these expectations, it's not as devastating. Yes, there are certain cases when there's permanent incontinence, which is devastating for everyone involved. I always tell patients, "This is fixable. We can put a sphincter in there. We can put a sling underneath," so at least they know that it's not a hopeless situation. Having a relationship with a local pelvic floor clinic where they are familiar with your patients [is important] because for a male patient to find a pelvic floor therapy place is usually a huge undertaking. There are plenty of pelvic floor therapists out there, but they mostly specialize in female patients. We're lucky to have the place that we work with because we know they're well trained and equipped to deal with our patients.

In terms of sexual function, erectile function is usually preserved after HoLEP. There are plenty of studies out there to back that up. There is a super-low rate of worsening [erectile dysfunction]. The key here is, if you stay within the capsule, within the plane, then the risk of injury to the neurovascular bundle is very low. There is retrograde ejaculation. I tell patients, "You're going to get it. If you don't, you're very lucky," but the majority will. Some patients do say that the intensity of orgasm is not the same as before surgery. You just have to counsel them appropriately, so that you can make that joint decision.

Urology Times: HoLEP is often highlighted as particularly effective for very large glands. How do you approach prostates larger than 150 to 200 g, and what technical modifications are necessary in these cases?

Jaeger: All my HoLEPs happen in our ambulatory surgery center. We have another HoLEP surgeon who operates in the hospital setting. We worked it out that [I send patients with bigger glands] to him, just because it's better to do those in a hospital setting. That way, you have the blood bank if you need it, and you have more support staff. In my institution, we've gone up to close to 200 g. The biggest thing with managing these very large prostates is to plan for longer time [in the operating room], and also make sure you have your team on that day.

With these big prostates, in terms of the technical difference, I make sure that I go very slowly. The reason I go very slowly is because once you remove this big adenoma, you're left with this giant open space, and if you have these bleeders, they're so hard to find because it's such a giant space. So, I learned to go with hemostasis as I go, as opposed to just letting them bleed and then coming back later. I found that has really cut down on the amount of time of the procedure. It's kind of counterintuitive because I move slower because I'm spending more time on hemostasis, but at the end, it does pay off.

I use the same technique with every case, whether it's a 30-g prostate or a 180-g prostate. I take the same steps; I just take my time and spend way more time on hemostasis. Now, with very big prostates [in patients on anticoagulation medication], I usually won't do those in the ambulatory surgery center, because the risk of bleeding is significantly higher. There are really no technical modifications other than slowing down because I have the same en bloc approach to every case that I do. Obviously, you have to think about enucleation efficiency, because the longer the case, the more fluid they absorb, and that can cause potential complications. Then, you have to counsel these patients that the catheter may need to stay in longer, and bleeding may take longer. Incontinence may last longer because you're going from a very obstructed, small space to a very large space. Again, as long as those expectations are set, usually it's not an issue.

Urology Times: As HoLEP becomes more widely adopted, how do you see it fitting into urology residency and fellowship curricula, and what skills should trainees focus on to prepare for it?

Jaeger: HoLEP is not for everyone. If a resident tells me, "I want to go into oncology," I'm going to say, "[Learning HoLEP is] a huge time investment, even during residency. You have to put in a lot of time and effort and spend time learning the steps. If you're not interested, just don't. It doesn't make sense." The way I learned it is the way I teach the residents: [in] little steps. You don't want to just jump in and feel like you can do the whole case, because you're just setting yourself up for disappointment. So, you start with step 1. When you get proficient with step 1, you move on to step 2, and then you progress until you can complete the entire case. These simulator labs are fantastic. We did one last year with Boston Scientific. They're pretty realistic. Those are very, very good for training. Again, [it's important to have] a supportive team that encourages the residents to learn—not just being emotionally supportive but also knowing what they're doing and how to troubleshoot. It has to be an exposure. Residents rotate through different rotations. Our chief residents have the luxury of picking which cases they want to do based on what [they're interested in]. Obviously, if you want to go out in the community and do HoLEP straight out of residency, then you need to spend more time with your HoLEP surgeons. Time commitment is important. Usually, [residents] get a good 50 to 100 cases during their training, and that usually is pretty good to go out there and start doing them on their own.

Urology Times: Are there any innovations, such as digital scopes, new laser platforms, or automated morcellation systems, that you see changing the way HoLEP is performed in the near future?

Jaeger: Our laser technology has exploded in the past 10 years. Now, we have these energy modulation lasers, such as Moses, which is what we use in our institution. They have what's called first pass hemostasis. What that means is that as you cut, it also cauterizes at the same time, so you don't have to go back a million times and hunt every bleeder. It cauterizes as you go. That has been very helpful, and that's what made HoLEP sort of "come back" and made them more approachable. Also, we used to use these lower-power lasers, so the HoLEP would take 6 hours. Now, we have much higher power lasers [that are] also very, very hemostatic. That's huge. These lasers are going to continue to evolve. There's another one coming out of Italy with a super hemostatic power that is like a combination of holmium and thulium in one. Those are great advancements, and HoLEP is going to become even more approachable as we move on with the evolution of these lasers.

With digital scopes, the visualization is phenomenal. Again, if you have good hemostasis, the field is crystal clear. In terms of morcellator systems, we all dream of a perfect morcellator. I love my Richard Wolf morcellator. I love their equipment. It's phenomenal. But like I said, for me, morcellation is probably the most stressful part of the case because so many things can go wrong. There are so many different parts, so condensing [a morcellator] into a much more user-friendly option with fewer parts would be amazing. Then, when you're troubleshooting, you're not going in 50 different directions to figure out which part is not working. I know that people are working on better morcellators, so that's still to come. I know there are some disposable ones. They're still not perfect. So far, Richard Wolf wins, but new things are on the horizon. Recently, I was approached by [a group] that are doing a hybrid of robot-assisted HoLEP. I'm not exactly sure [about the details of] that yet; we're setting up a meeting to talk about it. That's exciting. That’s basically a robot mapping out the prostate for you and just guiding you with the planes and enucleation.

We didn't really touch on Aquablation. The reason Aquablation took off so fast is because you can treat these big glands, and you have the imaging [where] all you do is plug it in and then push the pedal. Simplifying HoLEP in that way probably will make it even more approachable for a lot of surgeons.

Urology Times: Despite strong evidence, HoLEP adoption remains uneven. What do you see as the main barriers—technical, financial, institutional—and how can the field address them to expand access?

Jaeger: It is very difficult to learn. If you're not trained in it during residency, if you're not exposed to it, then it's kind of disruptive to your established practice because you do have to take some time to learn this. That will affect your productivity and your efficiency. The other thing is, you have to be proctored for the first so-many cases. HoLEPs are not everywhere, so how do you find a proctor if there's not one in your area? There are only so many places you can fly to and observe. That's a major challenge. Now, luckily—and this is how I started to learn—there's a HoLEP surgeon in Spain, Fernando Gómez Sancha [, MD,] who has this incredible YouTube channel with hundreds of videos. He is a HoLEP rock star. He developed the en bloc technique. He developed the early sphincter preservation technique. When I first started to learn HoLEP, I literally spent every night watching videos. It's interesting because you can see his earlier videos and how his technique progressed over the years. So, even if you do not have a proctor in your proximity, for me, every night, I got on my Peloton and I watched HoLEP videos. That was a good start, because it really helps you understand the 3-dimensonal character of the surgery. It helps you understand how you visualize the planes and distinguish adenoma from the capsule. For me, that was super helpful and may be a way to alleviate some of the anxiety early on. Sancha is incredible. Every time I have an issue, I email him or reach out to him on X, and he's always very responsive and has a lot of advice. If it wasn't for him, I probably would have quit.

Another barrier is equipment. Equipment is expensive. It is an investment. Disposables are expensive. When we first started, we rented our instruments because we didn't know if it would take off. So, it is a significant investment. Lasers are super expensive. Renting lasers is not very efficient financially. Some hospitals probably don't have the budget, or they're not familiar with the procedure, so they may be hesitant to buy the equipment, and they encourage their surgeons to stick with what they already do. [Regarding] reimbursement, for me, it's [relative value units]. For private practice providers, it's reimbursement. I'm pretty sure that [reimbursement is] the same for a 250-g HoLEP vs a 50-g HoLEP. That's discouraging when you are trying to tackle a bigger gland and it will take a big chunk of your time and effort, and you're still going to get the same reimbursement as you would for a smaller HoLEP. This is not the case in the rest of urology. We bill our bladder tumors based on size; we bill bladder stones based on size. I know there's some back and forth going on right now. There are people trying to fight this, but so far, it's the same code for every HoLEP.

The biggest [obstacle] I've found is our primary care physicians [PCPs] are not very familiar with this procedure, and for some reason, HoLEP has the stigma of, "You're going to be impotent. You're going to be incontinent. Don't do it; go get the GreenLight laser. Don't do the HoLEP." I have done a ton of outreach to our PCPs. I've done a lot of talks for our primary care community. As long as you educate your doctors, when they start to understand the beauty of this procedure, then this is your referral base, so they're more likely to refer patients to you.