Laser enucleation of the prostate has become the dominant size-independent guideline-approved surgical option for benign prostatic hyperplasia. Holmium laser enucleation (HoLEP), long established in 1996, is the benchmark for anatomical endoscopic enucleation of prostate (AEEP). Over the last decade, there is ample literature to support that, compared with transurethral resection of the prostate (TURP), AEEP provides a greater and long-lasting improvement in International Prostate Symptom Score (IPSS), post-void residual urine (PVR), and maximum flow rate (Qmax).¹ More prostate tissue is removed with a lower drop in hemoglobin, shorter catheterization time, and shorter length of hospitalization. AEEP also provides comparable functional outcomes to open prostatectomy. This is indeed the new standard for the surgical management of benign prostatic hyperplasia. The question now is, do we still agree that “enucleation is enucleation is enucleation…,” irrespective of the energy source used?

The non–holmium laser options for AEEP are thulium-based lasers—the continuous wave thulium laser, pulsed thulium laser, or thulium fiber laser (TFL). Other lasers like diode and GreenLight are also being used for AEEP. Would these lasers, with their differing tissue interactions and physics (Table) and quality of first-pass hemostasis, have a variable impact on intraoperative visibility, ease of learning, surgical procedure time, catheterization time, safety, and ability to perform the procedure as a day case?²

Table. Comparison of Laser Physical Characteristics

HoLEP has stood the test of time. This is because holmium laser, due to its cavitation bubble and plasma dissection, provides complete adenoma enucleation while maintaining clear capsule identification. HoLEP is a size-independent treatment option that provides shorter hospital stay and catheterization time, less blood loss and fewer transfusions, and more tissue for histopathologic assessment.^3,4 This procedure is safe in patients receiving anticoagulants and in patients with a prior history of prostate surgery and a need for retreatment.

In contrast, the thulium laser has poor plasma dissection but a better cutting and coagulation capability. It works as a contact laser and has significant charring and hence suboptimal tissue identification. AEEP by thulium laser provides equivalent results to HoLEP. TFL has emerged as an attractive alternative with the purported benefits of smoother cutting, improved hemostasis, greater precision, and a potentially shorter learning curve. However, whether these newer technologies offer clinically meaningful advantages over HoLEP remains a matter of ongoing investigation.

Thulium fiber laser enucleation of prostate (ThuFLEP) has demonstrated promising results across multiple clinical settings, including medium to large glands. In a retrospective comparative study,⁵ ThuFLEP achieved postoperative improvements in IPSS and Qmax comparable to TURP in prostates above 80 g. Notably, quality-of-life improvement was superior in the ThuFLEP cohort, although operative time was significantly longer, and overall complication rates were higher. Early incontinence was more frequent after ThuFLEP, although differences leveled out by 3 months. These findings highlight that, while ThuFLEP matches standard outcomes, its perioperative profile may be influenced by surgeon expertise and early learning-curve effects.

Larger comparative datasets offer broader perspective. A comprehensive network meta-analysis across 5 enucleation technologies,⁶ HoLEP, thulium laser enucleation of the prostate (ThuLEP), plasmakinetic enucleation of the prostate, diode laser enucleation of the prostate, and ThuFLEP, found no significant differences in operative safety, complication profiles, or long-term outcomes. While HoLEP and ThuLEP tended to have shorter operative and enucleation times, ThuFLEP showed advantages in quality of life (QoL) and PVR reduction at 12 months. The analysis suggests that, despite theoretical differences in energy behavior, clinical differences remain small.

A prospective randomized controlled trial comparing MOSES-HoLEP with ThuFLEP⁷ demonstrated significantly faster enucleation and hemostasis times, shorter catheterization and hospitalization, and markedly reduced early hematuria with MOSES-HoLEP. Functional outcomes, however, were equivalent at 6 months. A similar retrospective series comparing MOSES and TFL⁸ reaffirmed these findings: ThuFLEP showed longer enucleation, hemostasis, and morcellation times, largely attributed to visibility challenges intrinsic to the fiber’s vapor-dominant effect. Yet postoperative IPSS, QoL, Qmax, and PVR remained indistinguishable between the 2 modalities.

A unique strength of TFL technology recognized across several studies is its potential for a gentler learning curve. Its superficial penetration depth, reduced fiber degradation, and greater cutting and coagulation precision may help early adopters transition more easily to enucleation. This was highlighted by Bulut et al,⁹ who observed that operative time plateaued after 20 cases in a new enucleation surgeon’s first 60 ThuFLEP cases.

Across all available evidence, a unifying theme emerges: functional outcomes between HoLEP, ThuFLEP, and ThuLEP are consistently comparable, with improvements in IPSS, Qmax, PVR, and QoL that match or exceed historical TURP standards. Differences lie primarily in ergonomics, visibility, enucleation efficiency, hemostasis, and early perioperative events, many of which are influenced by surgeon experience and laser platform optimization rather than inherent energy superiority.

Is there a clear winner? Based on current evidence, no laser modality demonstrates categorical superiority in clinical outcomes. The literature hints at the following.

• HoLEP remains the size-independent gold standard due to its long track record, reproducibility, and well-established training pathways.
• For large adenomas (>80 g), HoLEP should be the first-choice laser. A pulsed thulium laser would also be acceptable. Although TFL can also be used, it would have a disadvantage due to longer procedure time. The PSA drop after AEEP would be > 80% with holmium and thulium but low with GreenLight and TFL.
• For smaller adenomas (<30 g), GreenLight laser vaporization may have an advantage, but all lasers can be used.
• For patients on antiplatelet and anticoagulant medications, photoselective vaporization of the prostate would probably be the safest. TFL would have an advantage due to brilliant hemostasis. Thulium and holmium can also be used.
• For older patients, the type of laser would not make a difference.
• With regard to sexual function, all AEEP would lead to retrograde ejaculation without compromising the erections.
• Day case AEEP is possible with all lasers, but TFL may have an advantage due to its better hemostasis.

So how does one choose the laser for AEEP? HoLEP is difficult to learn but can be used for all prostate sizes and for other urological indications. Thulium laser enucleation is an easy procedure and may avoid morcellation but will need holmium for lithotripsy. TFL is good for moderate-sized adenomas (<80 g) and in patients with bleeding risk; it also has a smoother learning curve.

Whatever the energy source used, it is important that we switch to AEEP!