The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on holmium laser prostatectomy in November 2003.

Further recommendations have been made as part of the clinical guideline on lower urinary tract symptoms published in May 2010, as follows:

If offering surgery for managing voiding lower urinary tract symptoms (LUTS) presumed secondary to benign prostatic enlargement (BPE), offer monopolar or bipolar transurethral resection of the prostate (TURP), monopolar transurethral vaporisation of the prostate (TUVP) or holmium laser enucleation of the prostate (HoLEP). Perform HoLEP at a centre specialising in the technique, or with mentorship arrangements in place.

Clinical and cost-effectiveness evidence was reviewed in the development of this guideline which has led to this more specific recommendation. More information is available from NICE guideline CG97. The IP guidance on holmium laser prostatectomy remains current, and should be read in conjunction with the clinical guideline.


This procedure is used to treat benign prostatic hyperplasia (BPH).

BPH is non-malignant enlargement of the prostate and is a common cause of bladder outlet obstruction and lower urinary tract symptoms in men over 40 years of age. The aetiology of BPH is still poorly understood.  It is prevalent in men over 50 years of age to the extent that two out of ten males will eventually require an operation to relieve the symptoms of BPH.

A syndrome of bladder decompensation can eventually develop if the bladder is unable to adapt. This can manifest as an accumulation of residual urine, which can lead to recurrent urinary tract infections and the formation of bladder calculi. In severe cases, acute urinary retention can occur and obstructive nephropathy can develop if high voiding pressures are transmitted back to the kidneys.

BPH can be managed medically or surgically. The standard surgical treatment of BPH is transurethral resection of the prostate (TURP). However, relatively high morbidity associated with TURP has led to the development of a range of minimally invasive techniques, some of which use thermal energy. One such minimally invasive technique is the use of holmium: yttrium-aluminium-garnet (YAG) laser.

Holmium laser resection of the prostate (HoLRP) utilises the holmium laser as a precise cutting instrument to resect large pieces of prostate. Initially a bilateral bladder neck incision is made to define the margins of resection. The median and lateral lobes are then individually undermined and peeled off the prostate capsule in a retrograde direction until only a bridge of tissue remains at the bladder neck. 

HoLRP uses is performed with a modified continuous flow resectoscope that has a circular fibre guide in the tip of the scope. An end-firing laser fibre is used as a precise cutting instrument to resect large pieces of prostate. The laser is then used to cut the resected tissue into smaller pieces before their removal. 

A further evolution of the HoLRP procedure is holmium laser enucleation of the prostate (HoLEP) in which the intact prostatic lobes are removed with the holmium laser and then passed into the bladder where they are cut into smaller pieces before removal.

A primary advantage of HoLRP over other laser prostatectomy techniques is that it can rapidly create a large 'TURP-like' cavity by immediately removing obstructing tissue, rendering it suitable for large prostates of up to 100 grams. The coagulative ability of the holmium laser effectively seals tissue planes as the operation progresses, which makes HoLRP a relatively bloodless operation with a concomitant reduction in transfusion requirement, and also avoids the dangers of systemic fluid absorption.

Other postulated advantages include a reduced need for bladder irrigation, shorter postoperative catheterisation period and length of hospital stay, and the ability to retrieve tissue for histological examination. However, HoLRP is associated with high initial start up costs, a steep learning curve that requires the development of significant endoscopic skill and longer procedure times, particularly for larger prostates.

Coding recommendations

M65.4 Endoscopic resection of prostate using laser

Includes: Transurethral resection of prostate

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account, and specifically any special arrangements relating to the introduction of new interventional procedures. The guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer. 

All problems (adverse events) related to a medicine or medical device used for treatment or in a procedure should be reported to the Medicines and Healthcare products Regulatory Agency using the Yellow Card Scheme.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties. Providers should ensure that governance structures are in place to review, authorise and monitor the introduction of new devices and procedures.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.