High-power holmium laser versus thulium fibre laser for endoscopic enucleation of the prostate in patients with glands larger than 80 ml: Results from the PEEL study group

Endoscopic enucleation of the prostate (EEP) has gained acceptance as an equitable alternative to transurethral resection of the prostate for benign prostate hyperplasia (BPH). Our primary aim is to compare peri-operative outcomes of EEP using thulium fibre laser (TFL) against high-power holmium laser (HPHL) in hands of experienced surgeons for large prostates (≥80ml in volume). Secondary outcomes were assess complications within 1 year of follow up. We retrospectively reviewed patients with benign prostatic hyperplasia who underwent EEP with TFL or HPHL in 13 centers (January 2019-January 2023). Patients with prostate volume ≥80ml were included, while those with concomitant prostate cancer, previous prostate/urethral surgery, and pelvic radiotherapy were excluded. Of 1929 included patients, HPHL was utilized in 1459 and TFL in 470. After propensity score matching (PSM) for baseline characteristics, 247 patients from each group were analyzed. Overall operative time (90 [70, 120] vs 52.5 [39, 93] min, p< 0.001) and enucleation time (90 [70, 105] vs 38 [25, 70] min, p<0.001) were longer in the TFL group, with comparable morcellation time (13 [10, 19.5] vs 13 [10, 16.5] min, p=0.914). In terms of postoperative outcomes, there were no differences in 30-day complications such as acute urinary retention, urinary tract infection or sepsis. In the PSM cohort, univariable analyses showed that higher age, lower preoperative Qmax, higher preoperative PVRU, and longer operation time were associated with higher odds of postoperative incontinence, while 2-lobe enucleation had lower odds of incontinence compared to 3-lobe enucleation. This real-world study reaffirms that HPHL and TFL in large prostates are equally efficacious in terms of 30-day complications. TFL with the en-bloc technique has a shorter operative time which significantly improves short- and medium-term functional outcomes.