Comparison of Holmium Laser Enucleation vs. Transurethral Resection of the Prostate for Large Glands: A Meta-Analysis

Abstract

Introduction: Surgical management of large prostates (>80 mL) is challenging. Holmium laser enucleation of the prostate (HoLEP) offers a size-independent alternative to transurethral resection of the prostate (TURP). This meta-analysis compares perioperative and functional outcomes.

Methods: We searched CENTRAL, Embase, and clinicaltrials.gov (2000–2024) for randomized controlled trials (RCTs) comparing HoLEP vs. TURP for prostate volume ≥80 mL. Primary outcome: IPSS change at 12 months. Secondary outcomes: operation time, catheter duration, hospital stay, and complications (Clavien-Dindo). Random-effects models were used.

Results: Seven RCTs (n=812) were included. At 12 months, IPSS improvement was comparable (mean difference −0.4, p=0.32). HoLEP had longer operative time (mean +18 minutes, p<0.01) but shorter catheterization (−1.1 days, p<0.01) and hospital stay (−1.5 days, p<0.01). Blood transfusion risk was lower with HoLEP (RR 0.21, p<0.01). Postoperative dysuria was more frequent after HoLEP (RR 1.8, p=0.02).

Discussion: HoLEP provides equivalent functional outcomes with faster recovery and lower bleeding risk, at the expense of longer surgery and more dysuria. Heterogeneity in laser settings and surgeon experience may affect generalizability. Long-term reoperation rates remain understudied.

Conclusions: HoLEP is superior to TURP for large prostates in terms of safety and convalescence, though operative time is longer. Surgeon training in enucleation techniques should be emphasized.