AUA Summit - The History of Prostate Enucleation

The History of Prostate Enucleation

Endoscopic Enucleation of the Prostate (EEP) is a surgical intervention that is growing in popularity, but still represents only 5% of bladder outlet procedures done in the United States1. Despite existing for over 20 years, there are still residents graduating with no exposure to EEP. Today, there are an array of teaching and technique videos available to urologists and a few brave souls attempting self-directed surgical learning, but most urologists are dedicating significant clinical time to mastering the technique.

The history of EEP is rather interesting. A plethora of publications describe the emergence of EEP, the evolution in technique, the learning curve challenges, and the successes of EEP over the years. There is reference to the first descriptions of EEP from 1989, but most consider the origins of EEP to be in Tauranga, New Zealand. There, Drs. Peter Gilling and Mark Fraundorfer developed Holmium Laser Enucleation of the prostate (HoLEP) in 19982. That year, Dr. James Lingeman (Indianapolis, IN) visited New Zealand to observe HoLEP and returned home poised to launch HoLEP in the United States (US). The first article from the Indiana University Department of Urology, titled: Holmium Laser Enucleation of the Prostate With Tissue Morcellation: Initial United States Experience was published in 20003.

James Lingeman, MD

There have been over 100 subsequent publications on HoLEP from Indiana University, the most cited of which described the first 1000 cases4. Additionally, there are key publications validating that HoLEP can be completed on any size prostate5, in combination with lithotripsy or cystolithalopaxy6, in anticoagulated men7, and most recently as an outpatient procedure with immediate postoperative catheter removal8.

The faculty performing HoLEP at Indiana University has progressively expanded to include 5 surgeons. Under their guidance, this year’s graduating residents are the first class to have amassed more than 20 months of weekly exposure to HoLEP during their five years of training. They represent the first class of residents with equivalent proficiencies in Robotic Assisted Laparoscopic Prostatectomy (RALP) and HoLEP – two procedures that, over the years, have been heavily scrutinized for their steep learning curve. Twenty-three years on and EEP, now polyonymous with HoLEP, ThuLEP, BipolEP, MoLEP, SoLEP, and GreenLEP is considered the global gold standard treatment for bladder outlet obstruction due to benign prostate enlargement. In the US, it can be safely assumed that every surgeon performing EEP, directly or indirectly, learned EEP from training or observing HoLEP at Indiana University/Methodist Hospital. The continental propagation of HoLEP is attributed to the longstanding endourologic fellowship and the tireless work done to advance EEP at Indiana University. There is an inevitability that a novel intervention for BOO/BPH will emerge, but the significance of HoLEP and its IU roots will live forever.

  1. Anderson, B.B., et al., Trends and Perioperative Outcomes Across Major Benign Prostatic Hyperplasia Procedures from the ACS-NSQIP 2011-2015. J Endourol, 2019. 33(1): p. 62-68.
  2. Gilling, P. and M. Fraundorfer, Holmium laser enucleation of the larger prostate (HoLEP) combined with mechanical morcellation. Proceedings of the 4th International Consultation on Benign Prostatic Hyperplasia, 1997: p. 2-5.
  3. Moody, J.A.L., J. E., Holmium laser enucleation of the prostate with tissue morcellation: initial United States experience. 2000(0892-7790 (Print)).
  4. Krambeck, A.E., S.E. Handa, and J.E. Lingeman, Experience With More Than 1,000 Holmium Laser Prostate Enucleations for Benign Prostatic Hyperplasia. The Journal of Urology, 2010. 183(3): p. 1105-1109.
  5. Humphreys, M.R.M., N. L.; Handa, S. E.; Terry, C.; Munch, L. C.; Lingeman, J. E., Holmium laser enucleation of the prostate--outcomes independent of prostate size? J Urol, 2008. 180(6): p. 2431-5; discussion 2435.
  6. Kim, J.K.C., Min Chul; Son, Hwancheol; Ku, Ja Hyeon; Oh, Seung-June; Paick, Jae-Seung, Patient Perception of Ejaculatory Volume Reduction After Holmium Laser Enucleation of the Prostate (HoLEP). Urology, 2017. 99(Supplement C): p. 142-147.
  7. Agarwal, D.K., et al., Real World Experience Of Holmium Laser Enucleation Of The Prostate With Patients On Anticoagulation Therapy. Journal of Endourology, 2020(ja).
  8. Agarwal, D.K., et al., Same Day Discharge is a Successful Approach for the Majority of Patients Undergoing Holmium Laser Enucleation of the Prostate. European Urology Focus, 2020.


Tim Large, MD
Department of Urology
Indiana University