HoLEP vs Open Simple Prostatectomy

Why very large glands are different

A prostate over 100 millilitres is large. Over 150 millilitres is very large. Over 300 millilitres is rare and challenging.

Traditional TURP becomes slow and riskier at these sizes. The time, fluid load, and bleeding all rise with volume.

For decades, the answer for very large glands was an open simple prostatectomy. A cut below the navel exposes the gland, and the adenoma is lifted out by hand.

Open simple prostatectomy in brief

Open simple prostatectomy is performed under general or spinal anaesthesia. The surgeon makes a small cut, opens the bladder or the outer capsule, and enucleates the adenoma.

The operation removes large amounts of tissue quickly. It is effective, and the evidence base is decades old.

The trade-offs are a visible cut, a longer hospital stay, more blood loss, and a longer time to full recovery.

Robotic simple prostatectomy in brief

A robotic version performs the same enucleation through keyhole ports. The robot provides wrist-like movements inside the body.

Blood loss is lower than open surgery. Hospital stay is a little shorter, though not as short as a pure endoscopic approach.

Robotic platforms are expensive and need trained teams. Availability varies by hospital.

Where HoLEP sits

HoLEP removes the same adenoma through the urethra. No cut on the outside. The same capsule plane exists at any prostate size.

A 2026 NSQIP-based analysis compared laser enucleation with robotic and open simple prostatectomy in men over eighty years of age[¹]. The analysis reported lower complication and transfusion rates with laser enucleation, with similar symptom relief.

For men whose glands are over 150 millilitres, HoLEP in experienced hands is a viable endoscopic alternative.

Where simple prostatectomy is still relevant

Some men have anatomy that rules out endoscopic enucleation — a bladder diverticulum that needs separate repair, or a bladder stone too large to morcellate.

In centres without a trained HoLEP surgeon, robotic or open simple prostatectomy remains a sensible option. The operation works, and the outcome is durable.

A cancer suspicion on scans can also tilt the plan toward an open approach, where additional tissue can be sampled in the same session.

What matters for you

Ask about your surgeon's experience with your gland size. A 120-millilitre gland is within the comfort zone for many trained HoLEP surgeons. A 300-millilitre gland is a specialist case.

Ask about expected hospital stay, expected catheter time, and expected return-to-work. Ask about transfusion risk.

Writing the answers down helps comparison at home.

Plain bottom line

HoLEP offers an endoscopic route for very large glands that used to require open surgery. Robotic and open simple prostatectomy remain valid options where endoscopic enucleation is not available or not a fit.

All three produce durable results in the right hands. The choice is made with you, not for you.