Erectile and ejaculatory outcomes after holmium laser enucleation of the prostate: A comprehensive narrative review

ABSTRACT Holmium laser enucleation of the prostate (HoLEP) has emerged as a widely adopted surgical technique for the management of benign prostatic hyperplasia (BPH), regardless of prostate size; however, its impact on male sexual function—particularly in terms of erectile and ejaculatory outcomes—remains a subject of ongoing debate. The aim of this study is to critically evaluate the effects of HoLEP on male sexual function (SF), with emphasis on erectile and ejaculatory outcomes, intraoperative considerations, and comparative effectiveness versus other surgical treatments for BPH. The narrative review was conducted using PubMed, Web of Science, and Google Scholar to identify English‐language clinical studies, cohort trials, randomized controlled trials, and meta‐analyses published between January 2000 and May 2025. Included studies evaluated SF before and after HoLEP using validated tools such as the International Index of Erectile Function (IIEF) and the Male Sexual Health Questionnaire‐Ejaculatory Dysfunction (MSHQ‐EjD). The literature indicates that HoLEP has a neutral to modestly favorable effect on erectile function (EF). Transient declines may occur in the early postoperative period, with most patients returning to baseline by three to six months. In contrast, retrograde ejaculation is a frequent and expected outcome, with incidence rates typically ranging from 74% to 78%. While various surgical modifications—such as modified enucleation techniques and partial apical preservation—have demonstrated potential in preserving ejaculatory function, outcomes remain inconsistent and poorly standardized. HoLEP is an effective and durable treatment for BPH with a stable EF profile but a high likelihood of ejaculatory dysfunction. Although promising ejaculation‐sparing techniques exist, robust evidence supporting their routine use is lacking. Future research should focus on standardized intraoperative strategies, validated patient‐reported outcome measures, and personalized approaches to optimize both urinary and sexual outcomes.