Ejaculation-preserving holmium laser enucleation of the prostate: a systematic review of techniques, functional outcomes, and safety

Holmium laser enucleation of the prostate (HoLEP) is a guideline-endorsed, size-independent surgical standard for benign prostatic hyperplasia (BPH). However, conventional HoLEP is frequently associated with loss of antegrade ejaculation (AE), an outcome of increasing importance for sexually active patients. Anatomically informed modifications aimed at preserving peri-ejaculatory structures have been proposed, yet the evidence supporting antegrade ejaculation-preserving HoLEP (EP-HoLEP) remains fragmented. To systematically review and synthesize the contemporary evidence on ejaculation-preserving HoLEP techniques, focusing on ejaculatory outcomes, urinary function, and surgical safety. A systematic literature search of PubMed and Embase was conducted in accordance with the PRISMA 2020 guidelines to identify studies evaluating EP-HoLEP techniques published through December 2025. Randomized controlled trials, prospective comparative studies, and retrospective cohorts reporting ejaculatory outcomes were eligible. Risk of bias was assessed using RoB 2, ROBINS-I, and MINORS tools as appropriate. Ten studies encompassing 1,675 patients were included, comprising three randomized controlled trials, four non-randomized comparative studies, and three single-arm case series. EP-HoLEP techniques were categorized as ejaculatory hood–sparing, mucosal and sphincter-sparing (including modified two-lobe and Double-n techniques), and selective median-lobe enucleation. Hood-sparing approaches alone demonstrated limited efficacy in preserving AE. In contrast, techniques that preserved peri-verumontanum tissue, anterior urethral mucosa, and bladder-neck fibers consistently achieved higher AE preservation rates, reaching 70–85% in selected cohorts. Selective median-lobe enucleation yielded the highest AE preservation in anatomically favourable patients but was associated with less pronounced symptom relief in some series. Across studies, improvements in International Prostate Symptom Score and maximum urinary flow rate were comparable to standard HoLEP, with no consistent increase in perioperative complications, although some techniques required longer operative times. Overall methodological quality was moderate, with residual confounding and heterogeneity limiting direct comparison. EP-HoLEP techniques can substantially improve rates of antegrade ejaculation without compromising short-term urinary outcomes in appropriately selected patients. Effective preservation appears to depend on anatomically informed modification of the enucleation plane rather than superficial tissue sparing alone. EP-HoLEP represents a spectrum of techniques rather than a single standardized approach, and potential trade-offs related to operative complexity and durability should be discussed during patient counselling. High-quality, standardized prospective studies are needed to define optimal techniques and long-term outcomes. Modified HoLEP techniques that preserve key anatomical structures involved in ejaculation may help sexually active men maintain normal ejaculation while still achieving effective relief of urinary symptoms from prostate enlargement.