Benign prostatic hyperplasia (BPH) is the most common urological condition, often associated with lower urinary tract symptoms impacting quality of life. It is estimated to affect approximately 50% of men over the age of 50 and more than 85% of men in their 80s. Currently, we have a growing arsenal of surgical treatment options, ranging from minimally invasive surgical therapies to enucleation techniques. This wide availability allows us to address the needs of each patient in an individualized manner, providing increasingly personalized treatments. The first description of endoscopic enucleation of prostate (EEP) dates back to 1983, when Hiraoka¹ published data on his technique in Japan. However, it was only after 1998, with the development of the first morcellators associated with the use of the holmium laser by Fraundorfer and Gilling,² that holmium laser enucleation of the prostate (HoLEP) gained widespread popularity, marking the beginning of the modern era of EEP.

In the last 25 years, interest in endoscopic enucleation has been growing around the world, with many different energy sources being used. HoLEP is now included in the guidelines as the only surgical treatment for BPH that is independent of prostate size, with proven objective and subjective benefits in terms of effectiveness, low morbidity, and durability.³ Some of these features are of utmost importance in an increasingly aging population worldwide, with potential future saturation of financial and human resources.

One of the major barriers to the universal adoption of HoLEP is its long learning curve, combined with its potential complication profile and costs of accessing high-power lasers. These issues often discourage endourologists during their initial training phase when facing challenges and difficulties, frustrating the incorporation of the method into their centers. It is estimated that approximately 30 to 50 cases are required to perform the procedure safely and with good outcomes. During this period, the guidance of a mentor/proctor facilitates the acquisition of the skills and confidence necessary to handle increasingly complex cases (large prostates, anticoagulant use, postradiotherapy, chronic prostatitis). This support possibly makes the adoption of the method smoother and leads to a higher success rate.

HoLEP, like other surgeries, is a procedure in constant evolution. Transient urinary incontinence (TUI) is an inconvenient and relatively common complication in the early descriptions of HoLEP, resolving in the vast majority of patients over time.⁴ Through the years, surgical technique improvements and technological developments have been incorporated to improve efficiency and reduce complication rates, many of them addressing the distressing symptom of TUI. Originally, the described technique was the 3-lobe approach, where incisions at 5 and 7 o’clock were made, with initial enucleation of the middle lobe followed by enucleation of the lateral lobes, with late release of the junction between the prostatic apex and the urinary sphincter. Over time, different modifications were introduced to facilitate learning curves and aiming to achieve better outcomes. Initially, prostatic incisions were suppressed, and the 2-lobe technique was described, followed more recently by the en bloc approach with early apical release of the adenoma from the sphincter. The aim is to maintain mucosal coverage of the entire urinary sphincter since the beginning of the procedure, protecting it from excessive traction and trauma during retrograde enucleation (Figure 1). Other potential advantages of the en bloc technique with early apical release include easier identification of the capsular plane, maintaining a closed irrigation system that facilitates visualization of proper planes during surgery (Figure 2), enabling a faster procedure, which reduces urethral trauma and its potential consequences.⁵ Through this gentle manipulation of the sphincter, avoiding traction, contemporary studies report TUI rates as low as 5% at 30 days postoperatively and less than 1% at 6 months postoperatively (Figure 3).^6,7

Just as there have been modifications in the way we perform HoLEP, we have also observed technological advancements that have allowed us to perform the surgery more efficiently and safely. Nowadays, we have highly efficient and safe morcellators available, enabling the removal of large amounts of tissue in short periods of time. Similarly, new generations of holmium lasers are capable of producing pulse modulation, an effect that possibly improves first-pass hemostasis and accelerates the surgical procedure. This has allowed many centers to perform the surgery on an outpatient basis, with catheter removal on the same day of surgery in a growing number of patients.⁸ This significantly increases patient satisfaction and safety, delivering some of the benefits that minimally invasive techniques provide, while reducing costs associated with prolonged surgeries and hospital stays. Additionally, we have seen the incorporation of many laser sources for EEP, with different properties, expanding our surgical arsenal in the treatment of BPH. These new devices, especially the thulium fiber laser and the pulsed thulium:YAG laser, have some peculiar and distinct features when compared with holmium laser. For instance, they offer less tissue penetration and potentially more effective hemostasis (as their wavelength is closer to water’s absorption peak compared with the holmium laser). However, this comes at the cost of a lower energy peak, which may make it more challenging to maintain the surgical plane between the capsule and the adenoma, and possible longer surgical times.

In summary, contemporary outcomes of HoLEP establish it as a mature and highly effective technique, delivering excellent functional results with high intraoperative safety and low complication rates. Despite the inherent challenges of the learning curve, its adoption should be encouraged as an excellent tool in any BPH treatment center, as it is the most durable endoscopic therapeutic modality for managing BPH.