Laser Enucleation of the Prostate (HoLEP and ThuLEP)

Anatomy and Physiology

The anatomy of the prostate was first described in detail by Andreas Vesalius in 1543, followed by more advanced studies, including McNeal's classification of prostate zones in 1968.[2] McNeal divided the prostate into 4 distinct zones—peripheral, anterior fibromuscular, central, and transitional zones. The transitional zone, which comprises approximately 10% to 15% of the prostate's total volume, is of primary interest when discussing benign prostatic hyperplasia (BPH), as it is the most commonly affected zone by hyperplasia.[1][2][13] Within the prostate, important structures include the internal sphincter muscle, the prostatic urethra, the capsule, and the ejaculatory ducts, which open into the urethra from the verumontanum.

Embryologically, the prostate originates from the urogenital sinus and develops just below the bladder under the influence of androgens secreted by the Leydig cells.[14][15] Androgens, particularly testosterone and its more potent derivative, dihydrotestosterone, play a central role in the development and maintenance of the prostate.

The primary blood supply to the prostate is derived from the inferior vesical artery, which branches into the prostatic artery, further dividing into capsular and urethral arteries. The urethral artery gives rise to Flock's branches at the 1 and 11 o'clock positions and Badenoch's branches at the 5 and 7 o'clock positions, which are critical anatomical landmarks during procedures such as HoLEP and ThuLEP.[15] 

The venous drainage of the prostate flows into the internal iliac veins, and the gland is innervated by sympathetic and parasympathetic fibers from the hypogastric and pelvic nerves, respectively.[13] Please see StatPearls' companion resource, "Anatomy, Abdomen and Pelvis, Prostate," for more information.

The pathophysiology of BPH is influenced by a balance between prostatic cell proliferation and apoptosis (programmed cell death). As men age, a decrease in apoptosis results in an overall increase in prostatic cell mass, contributing to the enlargement of the gland.[16] Dihydrotestosterone, which is synthesized from testosterone by intracellular 5-alpha-reductase, significantly affects prostatic development and growth, maintaining and promoting the hyperplastic process later in life.[17][18] There are 2 types of 5-alpha-reductase enzymes—type 1 and type 2—located in the liver, skin, scalp, and prostate.[19] The prostate predominantly contains 5-alpha-reductase type 2, which is mainly located in the stromal cells.[13][19] Please see StatPearls' companion resource, "Benign Prostatic Hyperplasia," for more information.

As the transitional zone expands, it compresses the prostatic urethra, leading to obstructive symptoms such as decreased urine flow and increased frequency of urination. The resulting symptoms are not solely dependent on the size of the prostate but rather on the degree of obstruction and the functional response of the bladder to increased outflow resistance.[1][13][16] Please see StatPearls' companion resource, "Benign Prostatic Hyperplasia," for more information.

Indications

Laser enucleation procedures are particularly advantageous for patients at an increased risk of bleeding or those on anticoagulation therapy, as the laser's coagulative properties can effectively manage hematuria during surgery, making it a safer alternative compared to conventional methods such as monopolar or bipolar TURP. For these patients, the option to continue anticoagulation during surgery may be considered. However, patients who can safely hold their anticoagulants are generally advised to do so based on the half-life of the specific medication, overall health, and specific bleeding risk.[20][21]  

For patients unable to temporarily discontinue anticoagulation due to underlying conditions, such as mechanical heart valves or recent thromboembolic events, laser enucleation provides a safer option compared to TURP, robotic simple prostatectomy, or open surgical removal of the prostate.[5][22]

Prostate volume assessment is critical for planning the intervention and determining the most appropriate surgical approach. This assessment can be estimated by prostatic imaging as follows:

• Transrectal ultrasound (TRUS) remains the standard for measuring prostate size, offering better detail compared to abdominal ultrasound.
• Magnetic resonance imaging provides the most precise volume measurement and excellent anatomical visualization, particularly valuable when prostate cancer is suspected, although it is less commonly used in BPH assessments.
• TRUS-based formulas, such as height × width × length × 0.52, are widely used to estimate the overall prostate volume and can be integrated into automated calculations on ultrasound machines.
• Unlike most other surgical treatments for BPH, HoLEP and ThuLEP are size-independent procedures suitable for prostates of any size.
• The inability of a patient to temporarily discontinue anticoagulation is not necessarily an absolute contraindication to the procedure, although it is recommended when possible.[16]
• Please see StatPearls' companion resource, "Prostate Imaging," for more information.

Laser enucleation of the prostate, encompassing HoLEP and ThuLEP, is primarily indicated for patients with larger prostate volumes (>80 cc) and for those whose symptoms have not responded to maximal tolerable medical therapy, as recommended by guidelines from the National Institute for Health and Care Excellence (NICE), American Urological Association (AUA), and European Association of Urology (EAU).[4][23][24][25][26] However, laser enucleation is technically suitable for prostates of any size, providing a highly effective option even for smaller glands if patient-specific factors, such as significant comorbidities, warrant a minimally invasive approach and the patient can safely tolerate the required anesthesia.

Laser enucleation is typically offered after medical management fails, particularly for larger prostates (>80 cc) or patients who cannot safely stop their anticoagulation.[3] Medical management involves an adequate clinical trial of maximally tolerable alpha-blocker therapy to relax the smooth muscle in the bladder neck and prostate, and 5-alpha reductase inhibitors for patients with prostates >40 cc and a prostate-specific antigen level >1.4 ng/mL.

The broader indications for surgical intervention include recurrent urinary tract infections, persistent hematuria, bladder stones, high-pressure chronic urinary retention, and recurrent episodes of acute urinary retention secondary to BPH, especially when medical therapy has failed. Laser enucleation offers a less invasive alternative to open or robotic prostatectomy in these scenarios, minimizing the risks associated with more invasive surgeries and providing long-term relief of obstructive symptoms.[3][27][28]

Preoperative evaluation is essential and should include urinalysis, flow rate study, post-void residual measurement, and completion of the International or AUA Prostate Symptom Score questionnaire. Flexible cystoscopy is typically performed for patients with severe symptoms or hematuria to allow direct visual assessment of the prostatic urethra and bladder anatomy.[3][11][29]

Contraindications

There are no absolute contraindications specific to HoLEP and ThuLEP other than those that prevent a patient from safely undergoing anesthesia. However, considerations for the patient's overall health and ability to tolerate a prolonged surgical procedure are critical, as laser enucleation typically requires 2 to 3 hours under general or spinal anesthesia. Patients with severe cardiopulmonary comorbidities or those classified as high anesthetic risk may be better suited to alternative treatments that require shorter operative times or staged procedures.[30]

For patients with a history of severe urethral stricture disease or bladder neck contractures, laser enucleation may be challenging due to difficulty in advancing the endoscopic instruments into the bladder and exacerbating any pre-existing strictures. Dealing with urethral strictures certainly extends the operative time for the surgery and the duration of the anesthesia required. These conditions should be thoroughly evaluated during preoperative planning, and alternative approaches should be considered when the risks outweigh the benefits of proceeding with laser enucleation.

The inability of a patient to safely discontinue anticoagulation is not an absolute contraindication to laser enucleation of the prostate.[5] When anticoagulation can safely be paused, it is recommended to do so according to the specific pharmacokinetics of the anticoagulant medication, such as discontinuing direct oral anticoagulants 24- to 48 hours before the procedure, depending on renal function.

In addition to medical contraindications, patient preferences and goals should be considered, especially for those concerned about potential adverse effects, such as retrograde ejaculation or stress urinary incontinence. Retrograde ejaculation without erectile dysfunction or anorgasmia is common, but significant urinary incontinence is rare. As these outcomes are associated with most surgical treatments for BPH, thorough discussions about the risks and benefits of laser enucleation compared to other procedures are essential for shared decision-making and obtaining informed consent. 

Equipment

Laser technology has significantly advanced urological interventions, particularly in procedures such as HoLEP and ThuLEP. These procedures necessitate specialized equipment to enable precise tissue ablation, coagulation, and resection.[31][32]

Laser Generator

The laser generator is the primary component of the setup, which delivers high-energy laser beams for tissue ablation and coagulation.

• For HoLEP, a holmium laser operates at a wavelength of 2140 nm, producing pulsed energy with a pulse duration of approximately 350 μs.[31][32] This pulsed nature allows for rapid heating and controlled ablation, making it effective for cutting through prostatic tissue with minimal thermal spread to surrounding structures. The penetration depth of 0.4 mm ensures precise targeting, while the coagulation zone is limited to 0.5 to 1 mm, helping to maintain hemostasis during enucleation.[6][7] The typical energy settings for HoLEP are 40 or 50 Hz and 2 Joules for tissue resection, whereas hemostasis and apical dissection are optimally performed at 20 or 30 Hz and 2 Joules.[6][7]

• ThuLEP uses the thulium laser operating at a wavelength of 2013 nm, emitting energy as a continuous wave. This continuous emission enables consistent tissue vaporization, with a shorter wavelength resulting in a shallower penetration depth of around 0.25 mm, facilitating rapid vaporization and enhanced hemostasis.[6][7][33] The continuous-wave nature allows for smoother ablation and more consistent visibility during surgery, which is particularly advantageous for procedures requiring detailed visualization of tissue planes.[6][7] Surgeons may use power settings of up to 150 to 200 W in ThuLEP to accommodate different tissue types and prostate sizes.[6][7]

Both holmium and thulium lasers are delivered through end-firing laser fibers, typically with a diameter of 550 μm, designed to precisely direct laser energy while maintaining flexibility for maneuvering through the resectoscope.[7] For both HoLEP and ThuLEP, the laser fiber is integrated into a 26 to 28 French continuous flow resectoscope equipped with a laser bridge, providing stability and precision during enucleation. The resectoscope facilitates continuous irrigation, ensuring a clear operative field throughout the procedure.[6]

Advanced Morcellation Devices

Advanced morcellation devices are used to remove prostatic tissue from the bladder after enucleation. Morcellation devices quickly fragment and grind up the freed prostate tissue into smaller pieces for evacuation. Effective morcellation is critical for minimizing operative time and reducing the risk of postoperative retention due to retained tissue fragments.[6][7]

Modern morcellators are generally comparable in performance, each offering distinct features to enhance efficiency.[6][7] One such device is known for its ergonomic design and efficiency, using oscillating blades that produce microbursts of suction, aiding in the safe and efficient removal of tissue fragments.[7] This design helps minimize the risk of bladder wall injury, a potential complication during morcellation, especially in cases involving large tissue volumes.[6][7]

Maintaining a filled bladder during morcellation is essential for ensuring optimal visualization and preventing injury to the posterior bladder wall.[21] Gravity-assisted irrigation is commonly used during this phase to maintain a steady flow of saline, helping to clear blood and debris from the surgical field.[6]

Fluid Management

Effective fluid management is essential during HoLEP and ThuLEP, requiring continuous irrigation with normal saline (3-L bags) to maintain a clear operative field during both enucleation and morcellation.[6][7] Saline is preferred over hypotonic solutions used in traditional monopolar transurethral prostate resections because it reduces the risk of TURP syndrome, a potentially life-threatening condition of sudden, severe dilutional hyponatremia caused by the absorption of large volumes of hypotonic fluid.[6][7] The isotonic nature of saline helps maintain the patient's electrolyte balance throughout the procedure.[6][7]

Continuous Flow Resectoscope

The continuous flow resectoscope is designed with separate inflow and outflow ports to manage irrigation. The inflow port is connected to the saline reservoir, whereas the outflow relies on gravity or controlled suction to ensure a constant fluid turnover. This system allows the surgeon to adjust the flow rate as needed, depending on visibility and the extent of bleeding encountered during the procedure.[7]

The choice of resectoscope sheath size varies depending on prostate size; the 28 French sheath size offers better irrigation and visibility but is more traumatic to the urethra and is typically reserved for larger prostates (>150 to 200 grams), depending on the surgeon's preference. In a prospective, randomized trial, there was no clear advantage in operative time, procedure time, morcellation efficiency, or 3-month outcomes between the different resectoscope sheath sizes (28 French versus 24 French) for prostates up to 200 grams.[34] However, patients treated with a 28-French sheath were slightly more likely to pass a same-day voiding trial and had a shorter length of stay compared to those treated with a smaller, 24-French resectoscope.[34] The same-day discharge rates were comparable.[34] 

The smaller 24-French sheath is ideal for patients with a history of urethral stricture disease, a penile prosthesis, or very small prostates. However, morcellation is more difficult as the irrigation inflow is insufficient to keep up with the fluid loss through the morcellator. In such cases, surgeons must periodically stop and refill the bladder to avoid posterior bladder wall injury.

Supporting Surgical Instruments

Supporting surgical instruments are necessary for successful laser enucleation. Van Buren sounds are used for initial dilation of the urethra, facilitating the smooth insertion of the resectoscope.[7] An Ellik evacuator or Toomey syringe may be used to remove small tissue fragments not effectively captured by the morcellator.[6][7] These instruments provide additional options for clearing the operative field and ensuring the bladder is free of residual debris.

Catheterization

Catheterization is typically performed using a 20-, 22-, or 24-French, 2-way Foley catheter with a 30-cc balloon, inserted postoperatively to ensure bladder drainage and tamponade of the prostatic fossa to control bleeding. This catheter helps prevent clot retention by allowing continuous outflow of urine, minimizing the risk of acute urinary retention immediately after surgery.[6][7] In cases with more than average bleeding requiring more aggressive bladder irrigation to prevent clot formation, a 3-way Foley catheter may be used, allowing simultaneous irrigation and drainage.[6]

Laser Physics

A solid understanding of specialized laser physics is crucial for evaluating the different clinical applications of laser technology. Laser light is characterized by monochromatic (single wavelength), collimated (parallel waves), and coherent (waves in phase) properties.[6][7] These properties ensure precise energy delivery to the target tissue, making laser energy ideal for ablation with minimal damage to surrounding structures.[6]

The absorption of laser energy by water molecules in the tissue is key to the function of both holmium and thulium lasers.

Holmium lasers: These lasers absorb most of their energy in the superficial, thin tissue layers. This energy is converted to heat, which causes the vaporization of the target tissue. This controlled process is beneficial for the simultaneous coagulation of small and medium blood vessels, providing effective hemostasis during tissue cutting.[6] The thermal energy generated helps limit the depth of thermal injury, preserving surrounding structures during the enucleation process.[21][30]

Thulium lasers: These lasers, with their continuous-wave emission, provide a smoother energy delivery, ensuring consistent tissue vaporization and enhanced visualization throughout the procedure. Their shorter wavelength allows for more efficient water absorption, which is advantageous when maintaining a consistent enucleation plane.[6]

Surgical Proficiency

Achieving surgical proficiency in HoLEP and ThuLEP requires a prolonged learning curve, particularly for HoLEP. Studies indicate that inexperienced surgeons must perform approximately 50 cases to reach a level of competence characterized by decreased operative time and improved morcellation efficiency.[6] However, it has been suggested that true mastery only comes after completing 100 cases. For ThuLEP, the learning curve may be shorter, with studies suggesting that experienced endourologists can become proficient after performing approximately 30 cases, especially with prior simulator training.[6] Regular practice in high-volume centers is essential for maintaining surgical skills, reducing operative time, and ensuring optimal outcomes in this procedure.[6]

Essential Equipment for Laser Enucleation of the Prostate

Performing laser enucleation of the prostate (HoLEP or ThuLEP) requires a range of specialized tools to ensure precision, efficiency, and patient safety. Below is a comprehensive list of the necessary tools and devices: [6][7][35][36]

• Video and imaging equipment:
  • Video tower and camera: Provides high-definition visualization during the procedure.
  • A pendulum camera is recommended to maintain orientation during scope rotation.

• 30° cystoscope lens: Provides a wide-angle view of the prostate and surrounding tissues.

• Laser and associated tools:
  • Holmium/thulium generator laser unit: A holmium laser requires at least 80 to 100 W of maximum power for effective tissue ablation, whereas thulium typically requires 150 to 200 W.
  • 550-μm laser fiber: Delivers the laser energy to the prostate tissue.
  • 550-μm laser fiber stripper: Prepares the laser fiber for use.

• Resectoscope and stabilizing instruments:
  • 24-, 26-, or 28-French continuous flow resectoscope sheath: With a modified inner sheath containing a laser fiber stabilizing bridge. Larger resectoscopes are suggested for bigger prostates, as they provide greater irrigation flow and better visualization.
  • Stabilizing bridge for the laser: Ensures the laser fiber remains stable, preventing movement during the procedure.
  • 7-French laser fiber stabilizing catheter: Ensures the laser fiber remains stable during the procedure.

• Supportive surgical instruments:
  • Van Buren sounds: Used for initial urethral dilation.
  • Ellik evacuator: Used for the removal of tissue fragments.

• Morcellation equipment:
  • Offset rigid nephroscope: Facilitates the visualization and removal of the enucleated prostatic tissue mass.
  • Morcellator: Fragments and removes the enucleated prostate tissue.

• Irrigation and catheterization supplies:
  • Normal saline for irrigation (3-L bags): Maintains clear visualization and flushes out debris. Heated irrigation is recommended.
  • 20-, 22-, or 24-French, 2- or 3-way Foley catheter (30-cc balloon): Used immediately postoperatively to facilitate urine drainage, prevent clot retention, and tamponade the prostatic fossa to minimize bleeding.
  • A common choice is initially the 20- or 22-French 3-way Foley catheter (30-cc balloon) with continuous irrigation. Unless the bleeding is excessive, a 24-French catheter is typically not needed.
  • Catheter guide: Assists with the placement of the Foley catheter.
  • Lubricant for transurethral instruments, dilators, and the Foley catheter.

Effective use of this equipment is critical for achieving optimal outcomes in HoLEP and ThuLEP procedures. Clinicians must demonstrate proficiency in equipment selection, surgical enucleation techniques, morcellation, and troubleshooting to ensure the safe, efficient, and effective treatment of patients with BPH.

Technique or Treatment

The general steps involved in HoLEP and ThuLEP procedures provide the foundational approach to enucleating the prostate using laser technology, which is largely shared between the 2 treatment modalities, as summarized in Table 1.[6][7][35][36] A Top-Down approach to enucleation, where the laser incision starts anteriorly, has also been described.[37] Outcomes are comparable to the standard technique described below.[37][38]

Basic Steps in Standard Laser Prostate Enucleation

Preoperative preparation:

• Anesthesia: Both HoLEP and ThuLEP can be performed under general or spinal anesthesia, depending on patient preferences and medical history. General anesthesia is preferable.[39]
• Same-day discharge: To facilitate same-day discharge, anesthesia considerations include using laryngeal mask anesthesia and avoiding the use of intraoperative muscle relaxants and narcotics. 
• Equipment setup: High-powered lasers are used—100 to 120 W for HoLEP and 150 to 200 W for ThuLEP.
  • An end-firing 550-μm laser fiber is typically used for precision, and a continuous-flow resectoscope with a laser bridge is used for visualization and tissue removal.
  • A common laser setting is 2 Joules at 40 or 50 Hz for standard cutting, 2 Joules at 20 Hz for enhanced coagulation, and tight areas, such as the prostatic apex.

Patient positioning:

• The patient is placed in the dorsal lithotomy position.
• Pressure points are suitably padded, and sequential compression devices are placed.
• The patient should be in the optimal position at the end of the table to allow the resectoscope maximum unrestricted movement.

Fluid management:

• Continuous saline irrigation is essential to maintain visibility during the procedure.
• Gravity or pumps provide the inflow, as large volumes of saline may be required due to the need for substantial fluid irrigation for visualization during tissue resection and morcellation.

Insertion of the resectoscope:

• Urethral dilation is typically performed immediately before the insertion of the resectoscope.
• Dilation to one French size larger than the resectoscope is recommended. Greater dilation may be required if there is difficulty inserting the resectoscope.
• Complete dilation into the bladder is unnecessary, especially in cases of very large prostates. Dilation to the level of the external sphincter is typically adequate.
• The resectoscope is inserted into the urethra and advanced to the level of the prostate. This device allows the surgeon to visualize the obstructive prostatic tissue and access the area for laser enucleation.
• A 30° cystoscope lens is typically used to perform an inspection. This inspection is crucial for identifying anatomical landmarks, including the ureteral orifices and the precise extent of the prostatic anatomy, aiding in planning the dissection.

Capsular plane identification:

• The key to successful enucleation is identifying and staying within the capsular plane.
• The laser creates initial incisions in the urethral mucosa deep enough to expose the plane between the prostate tissue and the capsule.
• Multiple laser passes are often required to delineate the correct plane.
• Rotating the instrument starting from the initial incisions can help incise the lateral lobe mucosa to visualize the correct dissecting plane better. This technique also avoids mucosal pulling on the lateral lobe tissue later.
• These incisions can be extended by laser cutting and blunt pressure from the resectoscope.

 Enucleation:

• The laser is used for cutting, and its coagulative properties are critical for minimizing intraoperative and postoperative bleeding.
• The entire instrument is used and moved as a unit to manipulate the laser for the enucleation.
• Dissection is typically performed with an early release of the ventral urothelium, using apical mucosal-sparing incisions to minimize postoperative incontinence. This technique also serves as a useful landmark.
• The enlarged portions of the prostate (adenoma) are enucleated, either lobe by lobe or in one piece (en bloc), depending on the selected technique and the anatomical characteristics of the prostate. 
  • En bloc resections can be considered in smaller prostates, whereas 2-lobe and 3-lobe enucleations work better for larger glands.
  • For bilateral lateral lobe enlargement, a single inferior incision from the bladder neck to the verumontanum can be used initially.
  • For a small-to-moderate–sized median lobe, the initial inferior incision can be made just lateral (offset) to the median lobe, as it can be removed with its associated lateral lobe.
  • For a large median lobe, the initial incision is on either side of the median lobe, which is enucleated separately.

• These initial incisions are made antegrade from the bladder neck to the verumontanum. All other incisions and resections are generally performed retrograde, from the apex towards the bladder neck.
• Connect the 2  inferior incisions, or the 2 apical sparing incisions, just proximal to the verumontanum.
• An incision is made at the distal edge of each lateral lobe to create a pocket in the plane of dissection.
• The scope is then placed under this pocket between the adenoma and capsule.
• Fluffy tissue is adenoma. Capsular tissue is slicker and shiny with blood vessels. The optimal plane for dissection is between these 2 tissues.
• Beginners may face challenges identifying the correct plane, especially in very large prostates.
• Typically, the lateral lobes are separated from the prostatic capsule in a sweeping motion by rotating the instrument, one lobe at a time, in a retrograde manner from the prostatic apex to the bladder neck.
• Connecting the various planes, such as anterior, inferior, and lateral, separates the prostatic adenoma from the capsule.
• The verumontanum should be preserved.
• Mucosal strips are cut as needed to reduce tension on the sphincter and adenoma.
• Bleeding should be controlled before proceeding to morcellation to improve visualization and minimize blood loss.

• Enucleation tips:
  • The laser should be pointed towards the capsule rather than the adenoma.
  • The urothelium should be cut with the laser if it gets bunched up or tethers the adenoma.
  • A lower coagulation laser setting, such as 2 Joules at 20 Hz, can increase the effectiveness of the coagulative function. This setting is particularly useful in tight quarters, such as the apical region, and at the end of the case during the final inspection for bleeding sources.
  • The anterior plane is often higher than expected. Start with whichever side is more easily demonstrated. As the anterior plane is released, the prostate drops down into the prostatic fossa.
  • The proper anterior plane demonstrates straight vertical fibers of the internal sphincter muscle.
  • Dividing the anterior commissure separates the lateral lobes, which is generally recommended for larger prostates. If the prostate is relatively small and the intention is to remove the gland en bloc, this step can be omitted.
  • The anterior portion of the external sphincter is more proximal than the posterior end.
  • Early incision of mucosal strips reduces tethering of the adenoma and sphincter. This approach also helps minimize postoperative incontinence by protecting the external sphincter muscle.
  • If the tissue being cut is fluffy, it is probably the adenoma.
  • Bleeding should be controlled on the capsular side, as it is encountered to maximize visualization and minimize overall blood loss.
  • Using a laser for dissection instead of traditional blunt dissection helps reduce bleeding.
  • Extra bleeding may be encountered as the laser dissection approaches the bladder neck.
  • There is no need to use standard resectoscopic electrocautery to control bleeding, as the laser works better at cauterizing bleeding sites.
  • When approaching the bladder neck, the irrigation outflow should be shut off or restricted to partially fill the bladder and move the posterior wall away from the area of active resection to avoid inadvertent injury. Overfilling the bladder should be avoided.
  • If orientation is lost, landmarks such as the verumontanum, bladder neck, and ureteral orifices should rechecked. Regular landmark checks are advised throughout the procedure.
  • Enucleating one lobe first provides more room to enucleate the other lobe. 
  • Maximal hemostasis should be achieved before switching to the morcellator and after completing the procedure.
  • If the patient has had a previous Urolift, the laser easily cuts, vaporizes, or releases the staples and sutures.
  • Patients with severe urgency, overactive bladder, or urge incontinence may benefit from limited simultaneous botulinum toxin bladder wall injections at the time of their enucleation procedure with the expectation that their voiding normalizes by the time the Botox wears off.
    • In a series of 82 patients with BPH and severe urgency undergoing HoLEP, half received intraoperative botulinum toxin. There was no difference in outcomes at 3 months, but the patients who received the botulinum toxin had significantly fewer urgency symptoms postoperatively, and none developed urinary retention (Unpublished data.)

Morcellation:

• Once the prostate tissue is enucleated, it is pushed into the bladder. A morcellator, a device that fragments the tissue, is then used to suction the tissue out of the bladder, ensuring complete adenoma removal.
• Morcellation is performed using an extended-length nephroscope or similar instrument along with the morcellator.
• The morcellator relies on strong suction, so all other ports should be configured to maximize inflow.

• Tips and troubleshooting:
  • The morcellator blade should not be set fully open in the aperture, as this creates too many large fragments that can clog the sheath and tubing. Generally, about one-third of the blade should be visible in the aperture when setting up the morcellating device before use. This proportion may vary depending on the individual equipment selected.
  • The suction valve switch on the morcellator should be firmly engaged to maintain full suction. The morcellator provides the only outflow required, as it has substantial suction.
  • All other ports except the morcellator blade attachment should be set to inflow for optimal function of the morcellator and to avoid inadvertent bladder wall injury, which means changing the usual outflow port on the resectoscope to inflow.
  • There should be at least 2 open inflows while morcellation is being performed, as the instrument's suction otherwise empties the bladder quickly, which risks bladder wall injury.
  • Achieving hemostasis before morcellation improves visualization during this portion of the procedure.
  • Suction is used to engage the prostatic tissue mass into the aperture of the morcellator, where the blade can then slice it.
  • Ensure the bladder is sufficiently filled to avoid injury to the bladder wall during morcellation but avoid bladder overdistension. Maximizing the inflow of irrigation can typically accomplish this.
  • If problems develop, make sure the device has been properly primed, the on/off suction valve is sealed and on, and the tubing is not clogged. A small piece of tubing can be used to flush the instrument, connecting to the end of the morcellator blade instrument on one end and a catheter tip syringe on the other.
  • If the morcellator is not engaging the tissue, ensure the suction works and reduce the blade rotations (RPM) from 1500 to 800 to help stabilize the tissue.
  • Once the enucleated prostatic tissue has been partially reduced in size, it can be repositioned in the prostatic fossa to stabilize it further, if necessary.

• Dealing with a Beach Ball
  • A Beach Ball refers to a large, round, free-floating prostatic adenoma in the bladder, which is notoriously challenging to morcellate.
  • A flap of enucleated prostatic tissue should first be engaged, as this helps draw in the rest of the adenoma.
  • If engagement problems persist, the laser fiber should be used to incise the firmer outer tissue layers to reach the gland's softer inner parenchyma and partially disrupt the Beach Ball adenoma, which is now more easily engaged by the morcellator.
  • The laser can be used to cut the Beach Ball into two or more pieces, which is easier to morcellate.
  • In rare cases, if there is still a problem with morcellating the freed adenoma, a 3-way Foley should be placed overnight, and the patient should return to the operating room the next day. Having been de-vascularized, the tissue is much softer and easier to morcellate.

Residual adenoma and hemostasis:

• The surgical site should be thoroughly inspected to ensure no residual adenomatous tissue remains. Residual tissue may cause persistent urinary symptoms and may require repeat surgery.
• Both holmium and thulium lasers provide excellent hemostasis, allowing for real-time coagulation of blood vessels as the tissue is cut, which minimizes the risk of bleeding, even in patients on anticoagulants.
• The laser can be defocused to control bleeding vessels better and ensure hemostasis.
• High energy for only 2 to 3 seconds is generally sufficient to control bleeding.
• Coagulation is typically achieved by defocusing the laser, reducing the laser frequency, or backing the laser fiber away from the bleeding site for a few seconds.
• Slowing the irrigation inflow rate can help demonstrate additional bleeding sites.
• The use of warm irrigation fluid can help identify additional bleeding sites.
• Anything visually red is a potential bleeding site and should be laser-coagulated.
• The use of laser cutting produces less bleeding than blunt dissection.
• The prostatic fossa should be checked for bleeding control before switching to the morcellator and immediately afterward.
• Patients with a history of long-term Foley catheterization or prostatitis are likely to have more bleeding than average.
• A final inspection of the bladder and prostatic fossa should be performed before removing the instruments and placing the Foley catheter.

Post-procedure catheterization:

• A urinary catheter is typically inserted at the end of the procedure to facilitate postoperative drainage and monitor for any excessive bleeding.
• A 20- or 22-French Foley catheter with a 30-cc balloon (3-way irrigation is optional) is typically sufficient to control bleeding, which is primarily performed by the balloon.
• A 24-French catheter with continuous irrigation is reserved for cases with unusually heavy bleeding.
• The catheter is typically removed within 24 to 48 hours, depending on the patient's recovery speed and degree of hematuria.
• Minimizing the use of narcotics facilitates same-day discharge, and it is typically possible to remove the catheter the same day if the degree of hematuria is acceptable.[40][41][42][43]
  • In a prospective trial of 190 patients undergoing HoLEP, 90% could have their Foley catheters removed, voided on the same surgery day with acceptable levels of hematuria, and were discharged without a Foley.[43]

Thulium Laser Enucleation of the Prostate Techniques

Once the general steps are completed, specific variations in the ThuLEP procedure can be applied, depending on the surgeon's preference and the patient's prostate anatomy. The thulium laser provides precise cutting ability with superior coagulation, making it an ideal choice for laser enucleation.[44] However, compared to HoLEP, it can cause more charring, which may obscure visibility and complicate the development of tissue planes in some cases.

Classic three-lobe enucleation technique:

• Approach:
  • Create 2 mucosal incisions at the 5 o’clock and 7 o’clock positions to the surgical capsule, extending from the bladder neck to the verumontanum.
  • The urothelium is transected at the verumontanum.
  • The median lobe is enucleated first in a retrograde manner from the prostate apex to the bladder neck and then it is pushed into the bladder.
  • The lateral lobes are then enucleated separately by widening the incisions to free each lobe from the surgical capsule.

• Usage: The traditional three-lobe technique is commonly used in ThuLEP, providing a straightforward step-by-step approach, especially for less experienced surgeons.[45]

Two-lobe enucleation technique (Wolters’ Modification):

• Approach:
  • Enucleation starts with the left lateral lobe, which is removed first.
  • Later, the median and right lateral lobes are enucleated together as a single piece.

• Advantages: This method reduces the required number of incisions, which can shorten operative time.[46]

Median lobe first (Dallabella and Castellani Approach):

• Approach:
  • The enucleation begins with the removal of the median lobe.
  • This step allows for better visualization and easier access to the lateral lobes, which are then enucleated and joined anteriorly.

• Application: This technique improves exposure to the lateral lobes, making the procedure easier to complete.[47]

En Bloc enucleation technique (Kim et al):

• Approach:
  • A U-shaped incision is made above the verumontanum, followed by a circular incision at the prostate apex to define the distal boundary of enucleation.
  • The entire transitional zone is enucleated as one piece in a circumferential retrograde manner, working from the apex to the bladder neck.

• Advantages: The en bloc method improves efficiency by reducing tissue fragmentation, facilitating easier morcellation.[48]

Saredi's modification of the En Bloc technique:

• Approach:
  • An antegrade incision is made at the 5 o’clock position, starting from the bladder neck and extending to the prostate apex.
  • This incision serves as a landmark for maintaining the correct capsular plane.

• Benefits: This modification helps avoid discrepancies in the enucleation planes, ensuring consistent tissue removal while preventing damage to surrounding structures.[49]

Holmium Laser Enucleation of the Prostate Techniques

Several specific HoLEP techniques are available to enhance the effectiveness of prostate enucleation using a holmium laser. HoLEP is renowned for its precision in enucleating large prostates and delivering excellent long-term results.

Classic three-lobe enucleation technique:

• Approach:
  • Incisions are made at the 5 o’clock and 7 o’clock positions from the bladder neck to the verumontanum.
  • The median lobe is enucleated first, proceeding retrograde from the apex to the bladder neck.
  • A third incision at the 12 o’clock position separates the lateral lobes, which are then enucleated individually.

• Usage: This technique is commonly employed by surgeons with varying levels of experience and is ideal for large prostates.[50]

Two-lobe technique:

• Approach:
  • The median and lateral lobes are enucleated together as one unit, similar to the two-lobe technique in ThuLEP.

• Advantages: This technique reduces operative time by simplifying the number of cuts and lobes to be removed.

Antegrade enucleation:

• Approach:
  • Enucleation is started at the bladder neck and proceeds antegrade toward the apex of the prostate.

• Advantages: This technique offers better visualization of the prostate capsule, making it ideal for complex cases or very large prostates.

Midline incision technique:

• Approach:
  • A midline incision is made near the verumontanum, and the lateral lobes are enucleated individually.

• Application: This technique is helpful for surgeons who prefer more control over the enucleation process and is effective for dealing with larger prostates.

Several meta-analyses and systemic reviews showed minimal clinical differences between HoLEP and ThuLEP or between the various surgical enucleation techniques regarding outcomes or complications.[51][52][53][54][55]

Perineal urethrostomy: A perineal urethrostomy may be required in certain cases where the urethra is excessively long for easy access or to prevent urethral strictures. The procedure involves the following steps:

• A Van Buren sound is placed in the urethra to aid in identifying its location.
• A vertical incision is made over the perineum and the palpable sound.
• The bulbar urethra is incised over the sound, with the edges tagged with 3-0 absorbable sutures. Minimal cautery should be used on the urethral edges.
• When the procedure is completed, the urethra is closed, and the postoperative Foley catheter should be left for at least 1 week.

Table 1. A Comparison Between Holmium Laser Enucleation of the Prostate and Thulium Laser Enucleation of the Prostate

Several meta-analyses and systemic reviews showed minimal clinical differences between HoLEP and ThuLEP or between the various surgical enucleation techniques regarding outcomes or complications.[51][52][53][54][55]

Instructional surgical videos and additional educational material on HoLEP and ThuLEP are available at the Endourological Society and the American Urological Association. Videos such as Surgical Guide to En-block Holmium Laser Enucleation of the Prostate from the University of Miami and Tips & Tricks of Morcellation from Baylor are available at www.auanet.org or university.auanet.org/core/BPH/surgical-bph.

In addition, Amy Krambeck, MD, from Northwestern University has uploaded several excellent instructional videos for HoLEP on YouTube at www.youtube.com/watch?v=4Bk_uWuvBzc&t=603s and www.youtube.com/watch?v=uT9_lOEDWt0. Numerous other instructional videos from various institutions are also available online.

Complications

Proper identification and maintenance of the capsular plane are crucial for achieving complete enucleation. For beginners, the classic three-lobe technique offers clear anatomical guidance, reducing the risk of moving out of the correct plane. Careful attention during distal dissection is critical to avoid damage to the external urinary sphincter, which could result in postoperative stress incontinence. A circumferential inverted U incision at the verumontanum, a circular incision at the apex, and the early cutting of mucosal tethers help preserve external sphincter integrity. Both holmium and thulium lasers provide excellent hemostasis due to the inherent properties of the lasers. 

General Complications

General complications associated with HoLEP and ThuLEP include anesthetic and cardiovascular risks commonly associated with any procedure requiring a general anesthetic of similar duration. These procedures, like many other surgeries, can lead to complications such as chest infections, pulmonary embolism, stroke, deep vein thrombosis, heart attack, and, in rare cases, death. Such complications emphasize the importance of a thorough preoperative assessment and close intraoperative monitoring, particularly in patients with pre-existing medical conditions. Intensive care may be necessary for patients who develop severe cardiovascular or respiratory issues during or immediately after surgery.

Acute Postoperative Urinary Retention

Acute postoperative urinary retention or residual obstructive symptoms are less common complications of laser enucleation of the prostate. In a study involving 50 patients, retention occurred in 2% of ThuLEP cases and 0% in HoLEP. Another larger study involving 246 patients showed postoperative urinary retention in only 1.2% of cases.[57]

Bleeding (Severe Hemorrhage or Hematuria)

Bleeding (severe hemorrhage or hematuria) is one of the most notable and potentially serious complications.  A study by Chang et al showed that 3.2% of patients undergoing HoLEP and 4.34% of patients with ThuLEP required blood transfusions.[58] Hemorrhage can be diagnosed either intraoperatively or postoperatively when the urine color fails to clear. When this happens, the surgeon can reinsert the resectoscope to perform additional coagulation, either with the laser or the rollerball of the resectoscope. Unlike TURP, dutasteride and finasteride have minimal effects on bleeding after laser enucleation surgery. However, they may shorten morcellation time, reduce postoperative complications, and lower the postoperative prostate-specific antigen.[59][60][61]

• If significant bleeding occurs in the recovery room, it can be managed with a bladder washout and gentle traction on the catheter against the bladder neck, although traction should not be applied for too long to avoid ischemia and potential bladder neck stenosis. Blood tests and close monitoring of hemoglobin levels and vital signs are essential during this time.
• In rare cases where these measures do not control the bleeding, the patient may need to return to the operating room for further hemostasis. Studies suggest that ThuLEP is associated with less hemoglobin reduction compared to HoLEP, although the data are heterogeneous.

Laser enucleation can also be used in urgent situations to manage intractable hematuria in BPH patients with very large prostates. The outcomes are equivalent to those of other laser enucleation patients.

Bladder Wall Injury

Bladder wall injury is another potential intraoperative complication, typically caused during the morcellation phase when the enucleated prostate tissue is being fragmented and suctioned out. The bladder mucosa can be trapped in the morcellator, leading to hematuria or injury to the bladder wall, which can be identified by endoscopic visualization. Such injuries almost always occur due to insufficient irrigation inflow, as the morcellator's suction quickly empties the bladder, allowing the posterior bladder wall to engage with the morcellator blades. For example, an untrained operating room nurse entering the room may think that too many irrigation bags are running and shut some off without the surgeon's knowledge.

• In these cases, achieving hemostasis and leaving the Foley catheter in place longer may be necessary to aid healing. Most injuries are superficial and can be treated with a longer duration of the Foley catheter or hemostatic treatment using the laser. If the issue is identified promptly, gently disengaging the morcellator suction and carefully disassembling the instrument externally can help minimize further damage, which is why good visualization is critically necessary during morcellation.
• Pulling on the morcellator with the bladder wall still entrapped may turn a minor superficial injury into a major perforation.
• Significant bladder wall injury has been reported in up to 4% of cases, especially with inexperienced surgeons.
• Extraperitoneal perforations are treated with prolonged Foley catheterization, whereas intraperitoneal leaks or large remaining prostatic adenomas require an open repair.

Capsular Perforation

Capsular perforation can occur during the procedure and is typically identified by the appearance of a fat plane. When this happens, the surgeon should immediately stop the procedure, achieve hemostasis, place a Foley, and postpone further intervention until the patient is stabilized. If the procedure's results are unsatisfactory, the patient may require additional treatment after thorough counseling.

Some experts have suggested that if the perforation is small, the surgery may be safely continued, but the postoperative Foley may need to remain in place longer than usual depending on the severity of the tear.

Infection and Fever

Infection and fever are notable risks in the immediate postoperative period. A 2023 study reported that 12.4% of patients developed a fever following HoLEP, which led to early clinic visits or emergency department admissions in 7.4% of cases.[62] Positive postoperative urine cultures were recorded in 13.5% of patients. Studies comparing HoLEP and ThuLEP showed that the incidence of urinary tract infections is comparable, with urinary tract infection rates of 11.5% in HoLEP and 13.5% in ThuLEP.

Injury to Ureteral Orifices

Injury to one or both ureteral orifices is another possible complication. Surgeons must also take special care around the ureteric orifices during enucleation. The dissection should stay distal to the ureteral orifices to avoid injury. Standard practice includes inspecting the ureteral orifices before and after the procedure to ensure they are unharmed. If the ureteral orifices cannot be identified, the anesthetist may administer diuretics or dye to encourage urine efflux and help locate the orifices. In cases where injury is suspected, postoperative monitoring of renal function through ultrasound is required, and nephrostomy or antegrade stenting may be necessary if hydronephrosis develops.

Temporary Urinary Incontinence

Temporary urinary incontinence is another complication, typically affecting about 30% of patients following laser enucleation, with symptoms lasting 6 weeks to 3 months and, in some cases, up to 6 months.[63] This incidence is similar to that observed in TURP. Urodynamic studies are typically recommended preoperatively for patients with significant overactive or neurogenic bladders.

Postoperatively, 2% of HoLEP patients require antimuscarinic medications, compared to 0% of ThuLEP patients. In addition, 3.9% of HoLEP patients were advised to perform pelvic floor muscle exercises to manage incontinence, compared to 0% of ThuLEP patients.[64] Patients with preoperative urinary incontinence, frailty, obesity, and larger prostates are generally more likely to develop short-term postoperative incontinence.[65]

In a large study involving 2512 patients from 14 centers who underwent laser enucleation for large prostates at least 80 cc in volume, age was the only identified risk factor for postoperative urinary incontinence, and preoperative prostatic volume appeared to have no influence.[66]

Persistent or Chronic Stress Urinary Incontinence

Persistent or chronic stress urinary incontinence is a late but serious postoperative complication. This incontinence is a relatively common complication following most bladder outlet obstruction surgeries, as these procedures can disrupt the mechanisms that maintain urinary continence. Stress urinary incontinence is involuntary urine leakage during activities that increase intra-abdominal pressure, such as coughing or lifting. In most cases, symptoms improve over weeks or months, and the risk of permanent postoperative urinary stress incontinence is about 1% to 1.5%.[67][68]

If the incontinence persists and significantly affects the patient's quality of life, options such as adjustable implantable dual periurethral continence balloons or artificial urinary sphincters may be considered. Please see StatPearls' companion resource, "Artificial Urinary Sphincters and Adjustable Dual-Balloon Continence Therapy in Men," for more information.

Reoperation Rates

In general, reoperation rates for laser enucleations are relatively low, with good long-term outcomes. In a comprehensive 2023 study of reoperation rates, 130,106 patients from 119 studies were compared.[69] The 5-year reoperation rates for each procedure studied were reported as follows: 

• HoLEP: 6.6%
• Laser vaporization of the prostate 7.1%
• Open prostatectomy: 4.4%
• Prostatic artery embolization: 23.8%
• ThuLEP: 8.4%
• Transurethral incision of the prostate: 13.4%
• Transurethral microwave thermotherapy: 31.2%
• TURP: 7.7% [69]

This rate is slightly higher than the findings of several other large studies, which report a 5-year reoperation incidence for laser enucleation patients ranging from 1% to 5.9%.[6][70][71][72]

Retrograde Ejaculation

Retrograde ejaculation is a well-known and common adverse effect of laser enucleation procedures, affecting up to 75% of patients. Both HoLEP and ThuLEP have been associated with high rates of retrograde ejaculation, reaching up to 92%.[73] However, only 26% of patients reported this adverse effect as bothersome, and only 10% considered it severely distressing.[73] In addition, moderate erectile dysfunction was reported in about 19% of patients.[74] As retrograde ejaculation is difficult to preserve during laser enucleation, it is important to counsel patients about this expected outcome before surgery.

Urethral Strictures

Urethral strictures may also develop, requiring surgical treatment in the long term.[46] The risk can be minimized by extensive use of lubricant and adequate urethral dilation before placing the resectoscope. The reoperation rate for urethral strictures is about the same as for TURP at around 5% over 5 years, highlighting the importance of long-term patient follow-up.[69] The risk of urethral stricture disease or bladder neck contracture is generally higher after laser enucleation in patients who have had prior prostate surgical procedures. Please see StatPearls' companion resource, "Urethral Strictures," for more information.

Clinical Significance

The clinical significance of HoLEP and ThuLEP lies in their role as highly effective, minimally invasive surgical techniques for treating BPH, particularly for larger prostates and patients who cannot safely stop their anticoagulation.

Symptomatic benign prostatic hypertrophy is a prevalent condition among aging men, characterized by prostate gland enlargement that leads to lower urinary tract symptoms. Both HoLEP and ThuLEP offer several significant clinical benefits that enhance patient outcomes and quality of life. Please see StatPearls' companion resource, "Benign Prostatic Hyperplasia," for more information.

Since 1996, over 500 papers have compared laser enucleation to other prostatic surgeries, including TURP, Greenlight vaporization, open prostatectomy, and simple robotic prostatectomy. Laser enucleation is superior to all of these in terms of shorter hospital lengths of stay, less postoperative Foley catheter time required, blood loss, and long-term improvement in BPH symptomatology.[75][76][77][78][79] Some recent studies indicate that laser enucleation with more modern instruments is quicker compared to TURP and similar surgeries when performed by experienced surgeons.[80] Prostate-specific antigen levels are typically lowered by about two-thirds by laser enucleation.[79] 

Laser enucleation of the prostate is now the recommended first-line surgical therapy for symptomatic larger prostates (>80 grams) that have failed medical treatment.[3][4][6][25]

Anticoagulant Use

Laser enucleation of the prostate is one of the only surgical procedures for BPH that can be reasonably used in patients on active anticoagulation.[3][5][22][81][82][83]

Applicability to Various Prostate Sizes

Unlike some surgical approaches that are less effective for larger prostates, HoLEP and ThuLEP are versatile and can be applied to prostates of all sizes, including large glands (>80 cc).[3][4] This adaptability makes these techniques suitable for a broader range of patients, including those with very large prostates, where traditional methods may be less effective or technically challenging.[3][6][7] Laser enucleation can also be safely performed in patients who have previously undergone TURP, laser vaporization, microwave ablation, urethral lift procedures, or any other failed prostatic surgery for BPH.

Cost-effectiveness

Laser enucleation is roughly equivalent in initial cost to TURP and heated prostatic thermotherapy (Rezum) but becomes much more cost-effective over time due to its exceptionally long-duration benefits compared to other minimally invasive procedures. Cost-effectiveness is increased if patients can be discharged on the same day, as demonstrated in studies from several high-volume centers.[41][42][84] Urethral lift procedures (Urolift) can optimally be used only in selected patients (optimal prostate size without a large median lobe), are relatively costly, have a fairly high failure rate, and often require additional procedures later. Overall, laser enucleation of the prostate is the most cost-effective solution for symptomatic BPH.

Durability

Long-term studies have shown that both HoLEP and ThuLEP provide durable outcomes, with sustained improvements in urinary flow and symptom relief over time. The low retreatment rates observed in these procedures reinforce their efficacy as definitive treatments for BPH.[6][7] Both techniques offer long-lasting results, ensuring that patients benefit from fewer complications or the need for additional interventions in the years following the procedure.[6]

Efficacy

Numerous studies have demonstrated that both HoLEP and ThuLEP provide superior or comparable results to traditional BPH treatments, such as TURP, in terms of symptom relief, urinary flow improvement, and reduction in prostate volume. These procedures effectively address lower urinary tract symptoms caused by BPH and are associated with sustained improvements in patient's quality of life. Long-term data support their effectiveness, with a low incidence of retreatment (1%) and durable symptom relief over time.[6][7][35]

Based on several meta-analyses, the 2023 European Association of Urology Guidelines have concluded that compared to other surgical options, laser enucleation of the prostate generally has shorter inpatient stays, reduced need for lengthy Foley catheterization, typically less than 24 to 48 hours; less blood loss, and fewer recurrences. Still, it needs specialized equipment, has a steep learning curve for surgeons requiring about 50 monitored cases, and tends to require longer anesthesia/operative time until proficiency is achieved.[3][11][85][86][87][88][89][90]

Low Reoperation Rates

The reoperation rates for HoLEP and ThuLEP are significantly lower compared to other BPH treatment options. Long-term studies report reoperation rates of no more than 5% over a 5-year period (1%-1.5% in experienced centers), making these procedures reliable long-term solutions for BPH management.[6]

Minimal Blood Loss

The precision of laser technology used in HoLEP and ThuLEP allows for exact tissue removal while minimizing blood loss due to the laser's excellent coagulative ability. This precision significantly reduces the need for blood transfusions, which is particularly beneficial for patients with bleeding disorders, on anticoagulants, or those at risk of excessive bleeding.[3][5][6][7] Such precision improves intraoperative control and, together with the laser's natural anticoagulative properties, makes these procedures ideal for patients with coagulopathies or obligatory anticoagulation.[3][6][81][82][83]

Preservation of Sexual Function

One of the key clinical advantages of HoLEP and ThuLEP is their ability to minimize the risk of erectile dysfunction; however, many patients experience retrograde ejaculation. Studies have shown that these procedures can preserve ejaculatory function in up to 46% of cases.[6] Long-term assessments indicate that HoLEP has a better outcome in maintaining erectile function compared to TURP, as measured by the International Index of Erectile Function-5 (IIEF-5) questionnaire.[6] Several studies also suggest that ThuLEP may be more favorable compared to TURP in preserving erectile function, further highlighting the sexual health benefits of these techniques.[6][7]

A systematic review comparing ejaculation-preserving to standard techniques of laser enucleation surgeries has demonstrated that modified surgeries are generally superior for preserving ejaculation, with decreasing rates of dysfunction over time while maintaining effective control of BPH symptoms.[91] Such modified surgeries may be reasonably considered in patients who have significant concerns regarding postoperative retrograde ejaculation following laser enucleation procedures.

Safety

HoLEP and ThuLEP have been associated with lower intraoperative and postoperative complication rates compared to TURP, including a reduced risk of bleeding, fluid absorption issues, and sexual dysfunction.[6] These advantages make these laser-based techniques a safer alternative for patients with comorbidities or those on anticoagulant therapy.[6][7] Furthermore, studies have shown a lower incidence of urethral strictures following HoLEP and ThuLEP compared to bipolar TURP, with rates of 2.6% versus 4.4%, respectively, and lower infection rates, particularly in larger European studies.[6][47]

Shorter Hospital Stay and Recovery

One of the significant advantages of HoLEP and ThuLEP is the shorter hospital stay and quicker recovery compared to open surgical approaches. These procedures can often be performed on an outpatient basis or with a short hospital stay, reducing the burden on healthcare resources and treatment costs.[6] There is minimal time required with a Foley catheter postoperatively, as it can often be removed the same day after surgery, and most patients void well immediately with acceptable hematuria.[40][41][92][93][94][95] Faster recovery allows patients to return to their daily activities more quickly, usually only 1 to 2 weeks, further enhancing the overall appeal of these techniques.[6][7]

Tissue Available for Pathological Evaluation

Unlike other types of laser prostate surgeries, laser prostate enucleation procedures provide abundant tissue for histological examination for prostate cancer. About 8% of these patients have been found to have prostate cancer.

Summary

The clinical significance of HoLEP and ThuLEP lies in their ability to provide safe, effective, and durable treatment for BPH, even in patients with otherwise prohibitively large prostates and obligatory anticoagulation, while minimizing the risk of complications such as bleeding, postoperative urinary retention, and prostatic regrowth.[3]

These enucleation procedures represent important advancements in urological surgery, significantly benefiting patients with symptomatic BPH from very large prostates (>80 grams) and improving their quality of life.

No other prostatic surgical procedure offers the same level of safety and effectiveness for large prostates (>80 grams), even with patients on full anticoagulation therapy.[3][81][82][83] 

Enhancing Healthcare Team Outcomes

HoLEP and ThuLEP represent advanced surgical techniques for treating BPH, offering the potential to significantly improve healthcare outcomes. Success in these procedures requires a well-coordinated interprofessional healthcare team consisting of surgeons, advanced practitioners, anesthesiologists, pharmacists, primary care physicians, and allied health professionals. This team ensures a patient-centered approach, optimizing both outcomes and patient safety throughout the perioperative process.

Healthcare professionals involved in HoLEP and ThuLEP must possess specialized expertise. Surgeons require precise surgical skills to effectively enucleate obstructive prostate tissue while preserving surrounding structures. Anesthesiologists are responsible for the safe administration of anesthesia, taking into account each patient's unique medical requirements, especially in cases with significant comorbidities. Nurses play a critical role in preoperative, intraoperative, and postoperative monitoring, ensuring early detection of complications and providing essential patient care. Pharmacists contribute by managing medications, ensuring compatibility, and supporting perioperative pain management and anticoagulant protocols. Primary care practitioners refer patients appropriately and help monitor postoperative outcomes.

A strategic approach to HoLEP and ThuLEP is essential for optimizing outcomes and minimizing complications. Evidence-based treatment plans are collaboratively developed, integrating feedback from the surgical team, nursing staff, pharmacists, and advanced practitioners. These plans focus on delivering individualized care that respects the patient's autonomy and ensures informed consent is obtained prior to surgery. Tailoring each procedure to the patient's specific requirements while also adhering to ethical standards is critical for enhancing treatment success.

Each healthcare team member has defined responsibilities in the care of patients undergoing HoLEP and ThuLEP. Surgeons lead the operative team, select appropriate patients for the procedure, and oversee its technical execution. Nurses ensure thorough preoperative preparation, assist in intraoperative care, and provide postoperative monitoring and patient education. Pharmacists ensure proper medication management, particularly for patients on anticoagulants or those requiring pain management. Advanced practitioners, such as physician assistants or nurse practitioners, contribute to patient assessments, develop preoperative plans, and facilitate postoperative care, ensuring that the overall care delivery is comprehensive and seamless.

Effective communication among team members is key to facilitating smooth patient care and achieving successful outcomes. Regular interprofessional meetings allow team members to discuss patient progress, share observations, and collaborate on decision-making, ensuring that the treatment plan is continuously refined and aligned with the patient's care goals. Clear communication channels, such as electronic medical records and verbal briefings, ensure that all healthcare professionals are fully informed and able to contribute to the patient's care plan.

Care coordination plays a pivotal role in ensuring that all aspects of the patient's journey, from preoperative assessments to postoperative follow-up, are well-managed. This collaboration minimizes the risk of errors, enhances patient safety, and supports optimal recovery. Patient education is also a vital part of care coordination. Engaging patients in their own treatment decisions and educating them on self-management strategies postoperatively empower them to take an active role in their recovery, thus improving long-term outcomes.

By leveraging collective expertise, strategic planning, ethical considerations, effective communication, and care coordination among the interprofessional team, HoLEP and ThuLEP procedures can provide high-quality, patient-centered care. This approach not only enhances patient outcomes but also improves the healthcare team's overall performance in managing BPH. Through these collaborative efforts, patients can benefit from reduced complications, faster recoveries, and improved quality of life following surgery.