Anatomical Enucleation of the Prostate
Prostate enucleation is the anatomic BPH operation: the transition-zone adenoma is separated from the compressed peripheral / central-zone "surgical capsule" and removed as a shell-out procedure. HoLEP is the mature reference technique, but the same principle now includes thulium laser enucleation, thulium fiber laser enucleation, bipolar transurethral enucleation, and hybrid platform variants. The AUA BPH amendment lists HoLEP and ThuLEP as prostate-size-independent options for LUTS/BPH, and EAU guidance similarly places endoscopic enucleation as the size-independent alternative to open simple prostatectomy for large glands.[1][2]
On WARWIKI, this page is intentionally a general enucleation hub with HoLEP as the anchor. That prevents duplicate pages for every energy source while preserving the operative details that matter: capsule recognition, apical release, hemostasis, morcellation safety, continence protection, and the learning curve.
Where Enucleation Fits
| Scenario | Why enucleation fits | Main caution |
|---|---|---|
| Large prostate (>80-100 mL) | Removes the adenoma endoscopically with open-prostatectomy-level debulking and shorter hospitalization | Learning curve and morcellation logistics |
| Any-size gland with retention | Strong outlet relief and catheter-free outcomes, including very large glands | Chronic retention still needs detrusor-function counseling |
| Anticoagulated / high bleeding risk | Laser enucleation is more hemostatic than classic monopolar TURP and avoids glycine TUR syndrome | Antithrombotic continuation can still increase catheter time, hematuria, and readmission |
| Need tissue diagnosis | Retrieves transition-zone tissue for pathology, unlike vaporization or many MISTs | Incidental prostate cancer needs PSA-density and grade-group-based follow-up |
| Maximal durability priority | Lower retreatment than many MISTs and durable IPSS / Qmax / PVR gains | Retrograde ejaculation is common with standard techniques |
| Ejaculation-preservation priority | Modified two-lobe, mucosal-sparing, and bladder-neck-sparing variants may help | Evidence is less mature and deobstruction goals must remain primary |
Enucleation is a poor default if the patient primarily wants office therapy, rapid recovery with minimal catheter time, or ejaculation preservation above durability. In those cases, compare against Prostatic Urethral Lift, water vapor therapy, iTIND, Aquablation, or Optilume BPH from the BPH & Male LUTS database.
Equipment and Physics
| Item | Standard HoLEP setup | Notes |
|---|---|---|
| Energy source | Ho:YAG laser, 2,140 nm | Water-absorbed, shallow penetration around 0.4 mm, pulsed cutting with hemostasis[3][4] |
| Power range | 20-120 W | Functional outcomes appear similar across low-, medium-, and high-power systems; experience and technique matter more than peak wattage[5][6] |
| Fiber | 550 um or 1000 um | Larger fibers may feel faster / more stable; smaller fibers may improve visibility and deflection depending on bridge and scope |
| Scope | 26-28 Fr continuous-flow resectoscope with laser bridge | Miniaturized 22 Fr MiLEP aims to reduce urethral trauma[7] |
| Tissue retrieval | Mechanical morcellator through nephroscope | The morcellation phase carries the distinctive bladder-injury risk[8][9] |
| Irrigation | Saline | Avoids classic glycine-absorption TUR syndrome |
Representative laser settings
| Phase | Common low / medium setting | Common high-power setting | Practical note |
|---|---|---|---|
| Main enucleation | 1.5-2 J x 20-25 Hz (30-50 W) | 2 J x 40-50 Hz (80-100 W) | Low power can be fully effective; high power may speed large-gland dissection |
| Apical dissection | 1-2 J x 20-30 Hz | Reduced energy / long pulse near sphincter | Prioritize visibility and mucosal preservation over speed |
| Hemostasis | 1 J x 30 Hz or defocused coagulation | Defocused, reduced-energy pulses | Coagulate perforators on the capsular bed rather than painting the whole capsule |
The ESUT laser-use consensus reported expert preference for long pulse or pulse-shape-modified modes for the main gland, with lower-energy / more controlled delivery near the apex.[10]
Pulse modulation and platform variants
| Platform / mode | Proposed advantage | Evidence signal |
|---|---|---|
| MOSES HoLEP | Vapor-channel pulse sequence; less energy loss in irrigation | RCT and comparative data show shorter hemostasis / operative time in some series, with similar functional outcomes[11][12] |
| Quanta Virtual Basket / Magneto | Pulse modulation for cutting plus coagulation mode | Early comparative data suggest efficient hemostasis and morcellation with similar safety[13] |
| Thulium laser / thulium fiber enucleation | Continuous or highly adjustable water-absorbed cutting | Same anatomic operation with different energy delivery; outcomes depend heavily on surgeon experience |
| Bipolar enucleation | Uses familiar bipolar TUR equipment and saline | Useful when laser platform unavailable; still requires true capsular-plane enucleation skills |
Operative Sequence
The operation has two major phases: enucleation and morcellation.
Core landmarks
- Verumontanum: the distal safety landmark; apical work should stay proximal and respectful of sphincteric mucosa.
- Surgical capsule: white, fibrous, glistening, sometimes cobblestone-textured plane between adenoma and compressed peripheral / central zone.[14]
- Perforating vessels: perpendicular vessels from capsule into adenoma confirm correct depth but require selective hemostasis.
- Anterior apex: the most treacherous area because the plane is less distinct and close to the external sphincter.
- Bladder neck: defines proximal release and median-lobe orientation; bladder-neck preservation trades off against deobstruction in selected ejaculation-sparing strategies.
Classic three-lobe HoLEP
The original Gilling-style operation separates the median and lateral lobes before morcellation:[3][15]
- Create bladder-neck incisions at 5 and 7 o'clock down to capsule.
- Enucleate the median lobe retrograde from apex toward bladder.
- Develop each lateral-lobe plane along the capsule.
- Release the lobes into the bladder.
- Obtain capsular hemostasis.
- Morcellate the free adenoma under direct vision.
En-bloc and early-apical-release approaches
En-bloc HoLEP identifies the capsule once and removes the adenoma as a single horseshoe-shaped unit. Early apical release detaches adenoma from sphincteric mucosa at the beginning rather than at the end of the case. These modifications aim to improve efficiency and continence recovery by avoiding repeated apical re-entry and late traction on sphincteric tissue.[16][17][18]
| Technique | Intended advantage | Caveat |
|---|---|---|
| Three-lobe | Standardized anatomy, widely taught, reliable for varied gland shapes | More incisions and more repeated plane-finding |
| Two-lobe | Faster than three-lobe in some series; may reduce ejaculatory dysfunction when modified | Evidence is smaller and technique-specific |
| En-bloc | Less energy, shorter enucleation time, fewer adverse events in some matched / randomized data | Requires comfort with circumferential plane development |
| En-bloc with early apical release | Protects apical mucosa and sphincter by releasing the apex early | Multicenter data are mixed; hematuria / transfusion can increase if hemostasis lags |
| Top-down | Bladder-neck-to-apex dissection may simplify apical orientation for learners | Less universal than three-lobe / en-bloc |
| Urethral mucosal preservation | Improves early continence and may preserve ejaculation in selected patients | Must not leave obstructing adenoma behind |
The ESUT Delphi consensus emphasized early sphincter detachment, apical mucosal preservation between 11 and 1 o'clock, gentle apical disruption, and avoidance of excess energy near the apical mucosa.[18]
Morcellation Safety
Morcellation is where a technically successful enucleation can still become dangerous. Safe morcellation is a separate skill, not an afterthought.[8][9]
| Rule | Rationale |
|---|---|
| Keep the bladder distended | Creates distance between morcellator and bladder wall |
| Keep the blade in the center of the bladder | Avoids dome, lateral-wall, and trigonal injury |
| Never activate without tissue in view | Prevents blind suction of bladder mucosa |
| Keep tissue between lens and blade | Maintains a visual backstop |
| Pause for bleeding or poor visibility | Blind morcellation is the mechanism of major injury |
| Use transabdominal ultrasound guidance when difficult | Helps localize blade and tissue in very large glands, poor visibility, or residual chips |
Superficial mucosal injuries can often be catheter-managed; true perforation requires immediate recognition, bladder drainage strategy, and selective operative repair depending on location and depth.
Outcomes
HoLEP produces durable improvement in voiding symptoms and objective emptying measures across small, medium, large, and very large glands. Long-term series report large IPSS reductions, Qmax increases, PVR reductions, and PSA reductions reflecting transition-zone debulking.[19][20][21]
| Outcome domain | Typical direction after HoLEP | Practical interpretation |
|---|---|---|
| IPSS / QoL | Large sustained decrease | Symptom relief is durable beyond the early recovery phase |
| Qmax | Large increase | Objective deobstruction is the main advantage over many MISTs |
| PVR / retention | Large decrease; high catheter-free rates | Counsel chronic retention patients that detrusor underactivity may persist |
| PSA | Often falls 65-80% | New PSA baseline should be established after healing |
| Medication use | Usually decreases substantially | Persistent storage symptoms may still need OAB therapy |
| Retreatment | Low, often lower than TURP in database studies | Durability is a major reason to choose enucleation |
Compared with TURP
HoLEP generally provides equivalent or superior functional outcomes, removes more adenoma, shortens catheterization / hospitalization, and lowers transfusion and hyponatremia risk. The trade-off is longer operative time during the learning curve, early dysuria in some series, frequent retrograde ejaculation, and a procedure-specific need for morcellation.[22][23][24]
Compared with open or robotic simple prostatectomy
For large glands, HoLEP offers simple-prostatectomy-level debulking with less blood loss, shorter hospitalization, and shorter catheter duration. Robotic simple prostatectomy remains attractive when the surgeon can preserve antegrade ejaculation in selected patients, when concomitant bladder pathology requires open / robotic access, or when enucleation expertise is not available.[25][26][27]
Energy-source variants — ThuLEP, ThuFLEP, and bipolar enucleation
The emerging consensus across the EAU ESUT, AUA, and contemporary AEEP literature is that enucleation is a technique rather than an energy-dependent procedure — outcomes are driven primarily by the completeness of adenoma removal along the surgical capsule, not by the energy source.[42][43] The HoLEP page is the canonical AEEP reference; ThuLEP, ThuFLEP, and BipolEP are variant energy platforms applying the same anatomical operation.
Thulium laser enucleation (ThuLEP)
Thulium lasers operate at 1940–2013 nm near the water-absorption peak. Penetration depth is ~ 0.2 mm — about 4× shallower than holmium (0.4 mm) — enabling smooth, precise incisions with rapid vaporization and excellent hemostasis while minimizing thermal injury.[44][45]
| Platform | Wavelength | Mode | Power | Notes |
|---|---|---|---|---|
| Tm:YAG continuous-wave | 2013 nm | CW | 100–200 W | Original thulium platform; smooth cutting, excellent hemostasis[45] |
| Thulium fiber laser (TFL / ThuFLEP) | 1940 nm | CW or pulsed | 50–200 W | Compact, portable, lower cost; even shallower penetration[46] |
| Pulsed solid-state Tm:YAG | 2013 nm | Pulsed (high peak power) | 100 W | Newest platform; shorter OR time and less postop pain vs HoLEP in multivariable analysis[47] |
An ESUT / T.R.U.S.T.-Group expert survey found Ho:YAG no longer the mainstay of EEP — TFL is now used by 50% of experts, Ho:YAG by 73%, continuous-wave Tm:YAG by 23%, pulsed Tm:YAG by 14%.[48]
ThuLEP vs HoLEP — the head-to-head data
| Trial / cohort | n | Key finding |
|---|---|---|
| Bozzini 2021 RCT (multicenter)[49] | 236 | No difference IPSS / QoL / Qmax / PVR / PSA at 3 and 12 mo. Hb decrease 0.45 vs 2.77 g/dL (p = 0.005) — significantly less blood loss with ThuLEP. HoLEP had higher rates of postop urinary retention and stress incontinence. |
| Shoma 2023 BJU 3-arm RCT (≥ 80 mL)[42] | 155 | No significant difference in Qmax / IPSS / QoL / PVR at 6 or 12 mo across HoLEP / ThuLEP / B-TUEP. For > 120 mL prostates: HoLEP and ThuLEP showed significantly better IPSS than B-TUEP (p = 0.01). |
| ThuFLEP (Petov 2022)[50] | 1,328 | 3-yr outcomes: IPSS 20.3 → 5.4; Qmax 7.8 → 21.8 mL/s; SUI 1.2%, stricture 1.1%, BNC 0.9%. |
| Network meta-analysis (Huang 2019 BMJ)[51] | 109 RCTs / 13,676 patients | Enucleation methods better Qmax / IPSS than resection / vaporization. Top three for Qmax at 12 mo vs monopolar TURP: bipolar enucleation +2.42, diode laser enucleation +1.86, holmium laser enucleation +1.07 mL/s. |
| EEP vs TURP meta (Vo 2025)[52] | 28 RCTs / 3,085 patients | EEP improved IPSS / Qmax / PVR; shorter catheter / LOS; lower transfusion (RR 0.22), strictures (RR 0.55), and reoperation for recurrent BPH (RR 0.32). |
Ejaculation-sparing ThuLEP (ES-ThuLEP)
Standard ThuLEP retrograde-ejaculation rates are similar to TURP (~ 60–70%).[53] ES-ThuLEP preserves the paracollicular and supracollicular tissue proximal to the verumontanum:
- Bozzini 2021 large cohort (n = 283): ejaculation preserved in 71.7% at 3 mo / 77.4% at 6 mo with no compromise in IPSS or erectile function.[54]
- Trama 2022 prospective (n = 53): 88.6% / 92.4% / 94.3% preservation at 3 / 6 / 12 mo.[55]
- Perri 2025 ES-ThuLEP using Tm:YAG vs TFL: 81% antegrade preservation in both groups, with significantly higher rates in prostates ≥ 80 mL.[56]
- Guldibi 2023 SR of laser AEEP: pooled retrograde-ejaculation rate 62.1% standard / 71.3% standard techniques / 27.2% with ejaculation-preserving modifications (p < 0.05).[53]
- One direct ThuLEP-vs-TURP comparison reported ED 17% (ThuLEP) vs 44% (TURP).[1][57]
ThuLEP learning curve
- Single-surgeon study: ~ 20 cases with significant improvements in morcellation / enucleation efficiencies.[58]
- Detailed single-surgeon analysis: ~ 60 cases with a well-trained mentor present.[59]
- ThuFLEP for laser-EEP-naïve surgeon with limited mentoring: ~ 60 cases, complications low throughout training.[60]
- Enikeev 2018 RCT comparing HoLEP / ThuFLEP / monopolar enucleation learning curves with structured mentoring: EEP can be safely adopted within 30 surgeries; laser EEP shows quicker adaptation than monopolar.[61]
Bipolar enucleation (BipolEP / B-TUEP / B-TUERP)
Bipolar enucleation uses bipolar electrocautery in saline delivered through a standard resectoscope loop or button electrode, applied to the same anatomical operation. The key advantage is that it uses existing bipolar TURP equipment already in most ORs — eliminating the laser-generator capital cost.[62][63] Bipolar in saline eliminates the TUR-syndrome risk of monopolar resection.
Multiple electrode and generator systems are available: Olympus TURis bipolar loop, Gyrus PK plasma button (large surface for simultaneous vaporization and coagulation), Karl Storz bipolar resectoscope. Typical settings: cutting 200–280 W, coagulation 80–120 W in saline.
B-TUEP vs B-TURP — RCTs and meta-analyses
| Trial / cohort | n | Key finding |
|---|---|---|
| Samir 2019 RCT (≥ 80 g)[64] | 240 | B-TUERP longer OR (105 vs 61 min) but more resected tissue, less Hb drop, shorter catheter / irrigation / LOS. At 24 mo: B-TUERP better IPSS (6 vs 7, p = 0.008), Qmax (24.9 vs 20.1 mL/s, p = 0.034), PVR (18.6 vs 24.7 mL, p = 0.001). |
| Arcaniolo 2020 ESUT cumulative[65] | meta | b-EEP higher resected tissue, Qmax improvement, lower transfusion than B-TURP. |
| Magistro 2021 matched-pair[66] | TURP / HoLEP / B-TUEP | HoLEP and B-TUEP superior to TURP in tissue retrieval (71.4% / 70% vs 50%, p < 0.05). |
| Bebi 2021 size-stratified[67] | mixed | No difference in functional outcomes / complications / sexual symptoms by prostate volume; enucleation efficacy higher in > 110 mL. Only comorbidity and anticoagulation predicted complications. |
B-TUEP long-term durability
- Filomena 2023 J Endourol 10-yr (n = 50): IPSS improvement sustained through 10 yr; Qmax +12 mL/s at 10 yr; ED improved early and maintained 5 yr; 0% required reoperation for persistent BOO at 10 yr.[68]
- Lombardo 2021 B-TUEP vs LSP, > 80 g, 3-yr (n = 296): durable results both arms; reintervention 5% B-TUEP vs 8% LSP; similar safety; 9% transfusion / no major complications.[69]
- Frendl 2021 claims-based real-world (n = 15,982, 7-yr): cumulative failure rates — TURP 15.3%, PVP 13.9%, endoscopic enucleation 6.7%; nonsignificant trend toward lower failure vs TURP (HR 0.67).[70]
B-TUEP technique — mushroom vs morcellation
A 234-pt B-TUEP comparison found morcellation had shorter OR time (60 vs 80 min, p < 0.001) vs the mushroom technique (resecting enucleated tissue into smaller pieces for evacuation through the resectoscope sheath).[71]
Head-to-head — when to choose which energy source
| Parameter | ThuLEP | BipolEP (B-TUEP) |
|---|---|---|
| Energy source | Thulium laser (1940–2013 nm) | Bipolar electrocautery in saline |
| Equipment cost | High (laser generator + fibers) | Low (standard bipolar resectoscope) |
| Prostate size | Size-independent (20–330+ mL) | Size-independent (30–110+ mL); > 120 mL — laser EEP slightly better IPSS |
| IPSS reduction | ~ 15 points | ~ 15 points |
| Qmax improvement | +14–22 mL/s | +15–25 mL/s |
| Blood loss (Hb drop) | 0.45 g/dL (Bozzini 2021 vs HoLEP) | 1.5 g/dL |
| Retreatment 3–10 yr | 1–3% | 0–5% |
| Ejaculation preservation (standard) | ~ 30–40% | Similar to TURP (~ 30%) |
| Ejaculation preservation (modified) | 81–94% (ES-ThuLEP) | Limited data |
| Learning curve | 20–60 cases | Steep but leverages TURP skills |
| Tissue for histology | Yes (morcellation) | Yes (morcellation or mushroom) |
The choice between ThuLEP, ThuFLEP, BipolEP, and HoLEP is primarily driven by equipment availability, cost, and surgeon expertise — not by clinical superiority of one energy source over another.[42][52]
Anticoagulation and High-Risk Patients
HoLEP is one of the best BPH operations for patients with antiplatelet / anticoagulant complexity because laser energy provides precise cutting and hemostasis in saline irrigation. However, "safe" does not mean "no extra friction."[28][29][30]
| Finding | Counseling point |
|---|---|
| AP / AC patients can undergo HoLEP effectively | Functional outcomes are generally preserved |
| Warfarin often behaves worse than DOACs | Expect more bleeding-related logistics in some series |
| Antithrombotics can prolong catheterization | Same-day catheter-free pathways may not apply |
| Minor hematuria / readmission risk can rise | Discuss clot retention, irrigation, and delayed bleeding |
| Major complications are not consistently increased | Center experience and protocol matter |
Anticoagulation decisions should still follow institutional perioperative-anticoagulation pathways, thrombotic risk, and anesthesia planning. See Antithrombotic Therapy and Anticoagulation Reversal for the medication framework.
Complications
| Complication | Typical range / pattern | Prevention / management |
|---|---|---|
| Transient stress incontinence | Common early; falls sharply by 3-12 months | Apical mucosal preservation, early apical release, pelvic-floor therapy, patience |
| Persistent SUI requiring surgery | Rare, generally well below 1% in large series | Treat like post-BPH sphincteric incontinence; sling or AUS after stability |
| Urgency / urge incontinence | Often improves, but may persist with detrusor overactivity | Rule out UTI, BNC, stricture, residual obstruction; treat OAB phenotype |
| Bleeding / clot retention | Lower than TURP but not zero | Capsular perforator hemostasis, catheter traction / irrigation when needed |
| Bladder neck contracture | Around 1-2% in many series | Avoid excessive bladder-neck thermal injury; treat with incision / resection if it occurs |
| Urethral stricture | Around 1-2% | Minimize instrumentation trauma; consider smaller-scope approaches in selected patients |
| Capsular perforation | Usually catheter-managed if extraperitoneal / limited | Stay in plane; recognize fat, venous sinus, or sudden loss of resistance |
| Morcellation injury | Rare but distinctive | Stop when visibility is poor; maintain bladder distension; ultrasound when difficult |
Transient SUI risk factors
Risk factors reported across series include older age, higher BMI, diabetes, larger adenoma weight, pre-existing incontinence, shorter membranous urethral length, high detrusor voiding pressure, and early surgeon learning curve.[31][32][33]
Sexual Function
Erectile function is usually preserved after HoLEP, although men with strong baseline erections may notice small declines and very large glands may carry higher risk in some cohorts. Ejaculatory function is the predictable trade-off: standard HoLEP commonly causes retrograde ejaculation or markedly reduced ejaculatory volume.[34][35]
| Goal | Enucleation counseling |
|---|---|
| Preserve erections | Reasonable expectation, but assess baseline SHIM and vascular risk |
| Preserve antegrade ejaculation | Standard HoLEP is poor for this goal; consider modified techniques or non-enucleative alternatives |
| Maximize durability | HoLEP / enucleation is often the stronger choice than ejaculation-preserving MISTs |
| Avoid bothersome dry orgasm | Discuss before surgery; many patients are not bothered, but some strongly are |
Incidental Prostate Cancer
Enucleation retrieves a transition-zone specimen, so incidental prostate cancer is not rare. Reported rates vary widely with preoperative PSA / MRI / biopsy intensity, but many detected cancers are Grade Group 1 and suitable for active surveillance.[36][37]
Practical pathway:
- Establish a new PSA nadir after healing.
- Interpret PSA density against residual peripheral-zone volume when imaging is available.
- Use grade group, percent involvement, MRI findings, and life expectancy to choose surveillance vs definitive therapy.
- Radical prostatectomy after HoLEP is feasible, but bladder-neck reconstruction and operative complexity may increase.[38]
Learning Curve
The learning curve is the main barrier to HoLEP adoption. Basic efficiency may improve after 25-50 cases, but continence, complication control, morcellation comfort, and large-gland speed continue to improve beyond that.[39][40]
High-yield training structure:
- Start with mentored cases and standardized three-lobe or en-bloc-with-apical-release anatomy.
- Avoid first cases with extreme gland size, severe bleeding risk, bladder stones, or distorted post-radiation anatomy.
- Separate metrics: enucleation efficiency, morcellation efficiency, conversion, capsular perforation, SUI at 1 / 3 / 12 months, and readmission.
- Review unedited video, especially apical release and anterior commissure joining.
- Build a plan for morcellation rescue before the first case: spare resectoscope loop, Ellik evacuation, open conversion threshold, and ultrasound availability.
The hardest steps for learners are usually apical dissection and joining anterior / posterior planes; the operation is learned by recognizing planes, not by memorizing laser settings.[40][41]
Operative Pearls
- Enucleation is a plane operation, not a laser operation. The energy source matters less than staying on the capsule.
- The apex decides continence. Slow down near the sphincter, preserve mucosa, and avoid thermal painting.
- Perforators confirm the plane. Coagulate selectively rather than stripping the capsule into a charred surface.
- Morcellation needs its own pause point. Reassess visibility, bladder distension, and chip size before activating the blade.
- Large PVR does not equal surgical failure risk by itself. Chronic retention may still do well, but detrusor underactivity changes counseling.
- Reset the PSA baseline. A post-HoLEP PSA that fails to fall or rises later deserves evaluation.
- Do not sell HoLEP as ejaculation-sparing. Modified techniques may improve rates, but standard counseling should assume dry or reduced ejaculation.
References
1. Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA guideline amendment 2023. J Urol. 2024;211(1):11-19. doi:10.1097/JU.0000000000003698
2. European Association of Urology. EAU Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms. 2026 update. EAU
3. Tan AH, Gilling PJ. Holmium laser prostatectomy: current techniques. Urology. 2002;60(1):152-156. doi:10.1016/S0090-4295(02)01648-5
4. Xu H, Wan X, Gu M, et al. Surgical treatment for benign prostatic hyperplasia: holmium laser enucleation of the prostate (HoLEP). J Vis Exp. 2018;(133):56683. doi:10.3791/56683
5. Chen L, Chen C, Li C, et al. Low-power versus high-power laser for holmium laser enucleation of prostate: systematic review and meta-analysis. World J Urol. 2025;43(1):228. doi:10.1007/s00345-025-05621-5
6. Elshal AM, El-Nahas AR, Ghazy M, et al. Low-power vs high-power holmium laser enucleation of the prostate: critical assessment through randomized trial. Urology. 2018;121:58-65. doi:10.1016/j.urology.2018.07.010
7. Alves BB, Gabrich P, Favorito LA. Prospective results of the minimally invasive laser enucleation of the prostate (MiLEP). Prostate. 2024;84(16):1501-1505. doi:10.1002/pros.24790
8. Rijo E, Misrai V, Aho T, Gomez-Sancha F. Recommendations for safe and efficient morcellation after endoscopic enucleation of the prostate. Urology. 2018;121:197. doi:10.1016/j.urology.2018.06.027
9. Tzou DT, Metzler IS, Tsai C, et al. Ultrasound-guided morcellation during difficult holmium laser enucleation of the prostate. Urology. 2020;135:171-172. doi:10.1016/j.urology.2019.09.027
10. Ortner G, Guven S, Somani BK, et al. Experts' recommendations in laser use for the endoscopic treatment of prostate hypertrophy: a comprehensive guide by ESUT and T.R.U.S.T. World J Urol. 2023;41(11):3277-3285. doi:10.1007/s00345-023-04565-y
11. Kavoussi NL, Nimmagadda N, Robles J, et al. MOSES technology for holmium laser enucleation of the prostate: a prospective double-blind randomized controlled trial. J Urol. 2021;206(1):104-108. doi:10.1097/JU.0000000000001693
12. Nottingham CU, Large T, Agarwal DK, Rivera ME, Krambeck AE. Comparison of newly optimized Moses technology standard holmium:YAG for endoscopic laser enucleation of the prostate. J Endourol. 2021;35(9):1393-1399. doi:10.1089/end.2020.0996
13. Perri D, Besana U, Mazzoleni F, et al. Holmium:YAG laser enucleation of the prostate using the new Cyber Ho generator with Magneto technology. World J Urol. 2025;43(1):161. doi:10.1007/s00345-025-05536-1
14. Oh SJ, Shitara T. Enucleation of the prostate: an anatomical perspective. Andrologia. 2020;52(8):e13744. doi:10.1111/and.13744
15. Fraundorfer MR, Gilling PJ. Holmium:YAG laser enucleation of the prostate combined with mechanical morcellation: preliminary results. Eur Urol. 1998;33(1):69-72. doi:10.1159/000019535
16. Scoffone CM, Cracco CM. The en-bloc no-touch holmium laser enucleation of the prostate (HoLEP) technique. World J Urol. 2016;34(8):1175-1181. doi:10.1007/s00345-015-1741-y
17. Tamalunas A, Schott M, Keller P, et al. Efficacy, efficiency, and safety of en-bloc vs three-lobe enucleation of the prostate. Urology. 2023;175:48-55. doi:10.1016/j.urology.2023.02.014
18. Tunc L, Herrmann T, Guven S, et al. A Delphi consensus to standardize the technique of anatomical endoscopic enucleation of prostate. World J Urol. 2023;41(9):2303-2309. doi:10.1007/s00345-023-04496-8
19. Ibrahim A, Alharbi M, Elhilali MM, Aube M, Carrier S. 18 years of holmium laser enucleation of the prostate: a single center experience. J Urol. 2019;202(4):795-800. doi:10.1097/JU.0000000000000280
20. Krambeck AE, Handa SE, Lingeman JE. Experience with more than 1,000 holmium laser prostate enucleations for benign prostatic hyperplasia. J Urol. 2013;189(1 Suppl):S141-S145. doi:10.1016/j.juro.2012.11.027
21. Elmansy HM, Kotb A, Elhilali MM. Holmium laser enucleation of the prostate: long-term durability of clinical outcomes and complication rates during 10 years of followup. J Urol. 2011;186(5):1972-1976. doi:10.1016/j.juro.2011.06.065
22. Chen F, Chen Y, Zou Y, et al. Comparison of holmium laser enucleation and transurethral resection of prostate in benign prostatic hyperplasia: a systematic review and meta-analysis. J Int Med Res. 2023;51(8):3000605231190763. doi:10.1177/03000605231190763
23. Li S, Zeng XT, Ruan XL, et al. Holmium laser enucleation versus transurethral resection in patients with benign prostate hyperplasia: updated systematic review and meta-analysis. PLoS One. 2014;9(7):e101615. doi:10.1371/journal.pone.0101615
24. Magistro G, Schott M, Keller P, et al. Enucleation vs resection: a matched-pair analysis of TURP, HoLEP and bipolar TUEP in medium-sized prostates. Urology. 2021;154:221-226. doi:10.1016/j.urology.2021.04.004
25. Lee MS, Assmus MA, Ganesh M, et al. Outcomes comparison between HoLEP, open simple prostatectomy, and robotic simple prostatectomy for large gland BPH. Urology. 2023;173:180-186. doi:10.1016/j.urology.2022.12.018
26. Benzouak T, Addar A, Prudencio-Brunello MA, et al. Comparative analysis of HoLEP and robotic-assisted simple prostatectomy in BPH management: systematic review and meta-analysis. J Urol. 2025;213(2):150-161. doi:10.1097/JU.0000000000004297
27. Grosso AA, Amparore D, Di Maida F, et al. Comparison of perioperative and short-term outcomes of en-bloc HoLEP and robot-assisted simple prostatectomy: propensity-score matching analysis. Prostate Cancer Prostatic Dis. 2024;27(3):478-484. doi:10.1038/s41391-023-00743-6
28. Agarwal DK, Large T, Stoughton CL, et al. Real-world experience of HoLEP with patients on anticoagulation therapy. J Endourol. 2021;35(7):1036-1041. doi:10.1089/end.2020.0886
29. Yuk HD, Oh SJ. Perioperative safety and efficacy of HoLEP in patients receiving antithrombotic therapy. Sci Rep. 2020;10(1):5308. doi:10.1038/s41598-020-61940-0
30. Romero-Otero J, Garcia-Gomez B, Garcia-Gonzalez L, et al. Critical analysis of a multicentric experience with HoLEP: outcomes and complications of 10 years of routine practice. BJU Int. 2020;126(1):177-182. doi:10.1111/bju.15028
31. Houssin V, Olivier J, Brenier M, et al. Predictive factors of urinary incontinence after HoLEP: a multicentric evaluation. World J Urol. 2021;39(1):143-148. doi:10.1007/s00345-020-03169-0
32. Cornwell LB, Smith GE, Paonessa JE. Predictors of postoperative urinary incontinence after HoLEP: 12 months follow-up. Urology. 2019;124:213-217. doi:10.1016/j.urology.2018.11.032
33. Lee N, Benzouak T, Nguyen DD, et al. Membranous urethral length as a predictor for urinary incontinence after holmium enucleation of the prostate. World J Urol. 2026;44(1):138. doi:10.1007/s00345-026-06232-4
34. Roper C, Slade A, Caras R, Shelton T, Rivera M. Ejaculatory and erectile function outcomes following HoLEP. Prostate. 2024;84(9):791-796. doi:10.1002/pros.24697
35. Deslandes M, Klein C, Marquette T, et al. Influence of HoLEP on erectile function: results of a multicentric analysis of 235 patients. World J Urol. 2022;40(11):2747-2754. doi:10.1007/s00345-022-04175-0
36. Han JH, Chung DH, Cho MC, et al. Natural history of incidentally diagnosed prostate cancer after HoLEP. PLoS One. 2023;18(2):e0278931. doi:10.1371/journal.pone.0278931
37. Sakai A, Borza T, Antar A, et al. Incidental prostate cancer diagnosis is common after HoLEP. Urology. 2024;183:170-175. doi:10.1016/j.urology.2023.11.014
38. Katsimperis S, Tzelves L, Markopoulos T, et al. Radical prostatectomy following HoLEP: systematic review of perioperative, oncological, and functional outcomes. Cancers (Basel). 2025;17(22):3685. doi:10.3390/cancers17223685
39. Kampantais S, Dimopoulos P, Tasleem A, et al. Assessing the learning curve of HoLEP: a systematic review. Urology. 2018;120:9-22. doi:10.1016/j.urology.2018.06.012
40. Elshal AM, Nabeeh H, Eldemerdash Y, et al. Prospective assessment of the learning curve of HoLEP using a multidimensional approach. J Urol. 2017;197(4):1099-1107. doi:10.1016/j.juro.2016.11.001
41. Chavali JSS, Rivera ME, Lingeman JE. HoLEP learning curve-resident perspective: survey of senior residents from a high-volume tertiary center. J Endourol. 2024;38(9):977-981. doi:10.1089/end.2024.0054
42. Shoma AM, Ghobrial FK, El-Tabey N, El-Hefnawy AS, El-Kappany HA. A randomized trial of holmium laser vs thulium laser vs bipolar enucleation of large prostate glands. BJU Int. 2023;132(6):686-695. doi:10.1111/bju.16174
43. Castellani D, Pirola GM, Pacchetti A, Saredi G, Dellabella M. State of the art of thulium laser enucleation and vapoenucleation of the prostate: a systematic review. Urology. 2020;136:19-34. doi:10.1016/j.urology.2019.10.022
44. Becker B, Netsch C, Bozzini G, et al. Reasons to go for thulium-based anatomical endoscopic enucleation of the prostate. World J Urol. 2021;39(7):2363-2374. doi:10.1007/s00345-021-03704-7
45. Netsch C, Gross AJ, Becker B. Thulium laser enucleation of the prostate. J Endourol. 2025;39(S1):S2-S7. doi:10.1089/end.2024.0617
46. Bozzini G, Berti L, Maltagliati M, et al. Thulium:YAG vs continuous-wave thulium fiber laser enucleation of the prostate: do potential advantages of thulium fiber lasers translate into relevant clinical differences? World J Urol. 2023;41(1):143-150. doi:10.1007/s00345-022-04201-1
47. von Bargen MF, Glienke M, Tonyali S, et al. Multivariable regression analysis of perioperative parameters for a novel pulsed solid-state thulium:YAG laser with high peak power versus holmium:YAG laser in prostate enucleation. World J Urol. 2025;43(1):459. doi:10.1007/s00345-025-05756-5
48. Ortner G, Güven S, Somani BK, et al. Experts' recommendations in laser use for the endoscopic treatment of prostate hypertrophy: a comprehensive guide by the European Section of Uro-Technology (ESUT) and Training-Research in Urological Surgery and Technology (T.R.U.S.T.)-Group. World J Urol. 2023;41(11):3277-3285. doi:10.1007/s00345-023-04565-y
49. Bozzini G, Berti L, Aydoğan TB, et al. A prospective multicenter randomized comparison between holmium laser enucleation of the prostate (HoLEP) and thulium laser enucleation of the prostate (ThuLEP). World J Urol. 2021;39(7):2375-2382. doi:10.1007/s00345-020-03468-6
50. Petov V, Babaevskaya D, Taratkin M, et al. Thulium fiber laser enucleation of the prostate: prospective study of mid- and long-term outcomes in 1,328 patients. J Endourol. 2022;36(9):1231-1236. doi:10.1089/end.2022.0029
51. Huang SW, Tsai CY, Tseng CS, et al. Comparative efficacy and safety of new surgical treatments for benign prostatic hyperplasia: systematic review and network meta-analysis. BMJ. 2019;367:l5919. doi:10.1136/bmj.l5919
52. Vo LT, Armany D, Chalasani V, et al. Endoscopic enucleation of the prostate versus transurethral resection of the prostate for benign prostatic hyperplasia: a systematic review and meta-analysis. Prostate Cancer Prostatic Dis. 2025. doi:10.1038/s41391-025-00970-z
53. Guldibi F, Altunhan A, Aydın A, et al. What is the effect of laser anatomical endoscopic enucleation of the prostate on the ejaculatory functions? A systematic review. World J Urol. 2023;41(12):3493-3501. doi:10.1007/s00345-023-04660-0
54. Bozzini G, Berti L, Maltagliati M, et al. Ejaculation-sparing thulium laser enucleation of the prostate (ES-ThuLEP): outcomes on a large cohort. World J Urol. 2021;39(6):2029-2035. doi:10.1007/s00345-020-03442-2
55. Trama F, Lauro GD, Illiano E, et al. Ejaculation sparing thulium laser enucleation of the prostate: an observational prospective study. J Clin Med. 2022;11(21):6365. doi:10.3390/jcm11216365
56. Perri D, Besana U, Mazzoleni F, et al. Ejaculation-sparing enucleation of the prostate with thulium:YAG laser (ES-ThuLEP) versus thulium fiber laser (ES-ThuFLEP): outcomes on sexual function. World J Urol. 2025;43(1):92. doi:10.1007/s00345-025-05483-x
57. Carmignani L, Bozzini G, Macchi A, et al. Sexual outcome of patients undergoing thulium laser enucleation of the prostate for benign prostatic hyperplasia. Asian J Androl. 2015;17(5):802-806. doi:10.4103/1008-682X.139255
58. Aydogan TB, Binbay M. Learning curve of ThuLEP (thulium laser enucleation of the prostate): single-centre experience on initial consecutive 60 patients. Andrologia. 2022;54(4):e14366. doi:10.1111/and.14366
59. Perri D, Pacchetti A, Morini E, et al. Evaluation of the learning curve for thulium laser enucleation of the prostate in a contemporary cohort. World J Urol. 2024;42(1):246. doi:10.1007/s00345-024-04958-7
60. Al Barajraji M, Moussa I, Soscia GL, et al. Evaluation of the learning curve for thulium fiber laser enucleation of prostate (ThuFLEP): retrospective study of a single-surgeon experience in real-world settings. World J Urol. 2024;42(1):444. doi:10.1007/s00345-024-05167-y
61. Enikeev D, Glybochko P, Rapoport L, et al. A randomized trial comparing the learning curve of 3 endoscopic enucleation techniques (HoLEP, ThuFLEP, and MEP) for BPH using mentoring approach — initial results. Urology. 2018;121:51-57. doi:10.1016/j.urology.2018.06.045
62. Ryang SH, Ly TH, Tran AV, Oh SJ, Cho SY. Bipolar enucleation of the prostate — step by step. Andrologia. 2020;52(8):e13631. doi:10.1111/and.13631
63. Giulianelli R, Gentile B, Albanesi L, Tariciotti P, Mirabile G. Bipolar button transurethral enucleation of prostate in benign prostate hypertrophy treatment: a new surgical technique. Urology. 2015;86(2):407-413. doi:10.1016/j.urology.2015.03.045
64. Samir M, Tawfick A, Mahmoud MA, et al. Two-year follow-up in bipolar transurethral enucleation and resection of the prostate in comparison with bipolar transurethral resection of the prostate in treatment of large prostates. Randomized controlled trial. Urology. 2019;133:192-198. doi:10.1016/j.urology.2019.07.029
65. Arcaniolo D, Manfredi C, Veccia A, et al. Bipolar endoscopic enucleation versus bipolar transurethral resection of the prostate: an ESUT systematic review and cumulative analysis. World J Urol. 2020;38(5):1177-1186. doi:10.1007/s00345-019-02890-9
66. Magistro G, Schott M, Keller P, et al. Enucleation vs. resection: a matched-pair analysis of TURP, HoLEP and bipolar TUEP in medium-sized prostates. Urology. 2021;154:221-226. doi:10.1016/j.urology.2021.04.004
67. Bebi C, Turetti M, Lievore E, et al. Bipolar transurethral enucleation of the prostate: is it a size-independent endoscopic treatment option for symptomatic benign prostatic hyperplasia? PLoS One. 2021;16(6):e0253083. doi:10.1371/journal.pone.0253083
68. Filomena GB, Gentile BC, Albanesi L, et al. Long-term outcomes following bipolar transurethral plasma enucleation of the prostate: 10-year follow-up. J Endourol. 2023;37(7):811-816. doi:10.1089/end.2022.0685
69. Lombardo R, Zarraonandia Andraca A, Plaza Alonso C, et al. Laparoscopic simple prostatectomy vs bipolar plasma enucleation of the prostate in large benign prostatic hyperplasia: a two-center 3-year comparison. World J Urol. 2021;39(7):2613-2619. doi:10.1007/s00345-020-03512-5
70. Frendl DM, Chen YW, Chang DC, Kim MM. A claims-based assessment of reoperation and acute urinary retention after ambulatory transurethral surgery for benign prostatic hyperplasia. J Urol. 2021;205(2):532-538. doi:10.1097/JU.0000000000001390
71. Kiss Z, Murányi M, Nagy A, Flaskó T. Effectiveness of the mushroom technique versus morcellation in en bloc bipolar prostate enucleation for prostates over 80 mL. PLoS One. 2025;20(9):e0331142. doi:10.1371/journal.pone.0331142