Holmium Laser Enucleation of the Prostate Efficiency by Prostate Gland Size: Is There a Sweet Spot?

Holmium laser enucleation of the prostate (HoLEP) is one of only two AUA guideline-recommended prostate size-independent surgeries for benign prostate hyperplasia (BPH). The significant variation in gland size treated results in a wide range of enucleation and morcellation times. We sought to understand the effect of prostate size on HoLEP efficiency to better educate patients and improve operative room utilization. After IRB approval, we identified patients from 1 July 2016 to 1 January 2020 who underwent HoLEP by two endourologists. Our primary objectives were to assess the effects of increasing increments (25 g) of mean enucleated prostate tissue weight on enucleation and morcellation efficiency (g/min). One-way Kruskal–Wallis ANOVA with Dunn’s post hoc test was used, with significant p < 0.05. We included 675 HoLEPs with all comers mean tissue weight resected of 72.1 g (Range 1–448 g), energy used 110.00 kJ (10.73–340 kJ), enucleation time 48.6 min (5–151 min), and morcellation time 10.1 min (0.5–113 min). Average enucleation efficiency increased with increasing prostate size categories (e.g., <25 g–0.48 g/min, >325 g–3.91 g/min) (K-W ANOVA p = 0.004, Dunn’s post hoc p = 0.004). The combined average enucleation and morcellation efficiency was ≥5 g/min between 55 and 271 g. Inefficiency for cases <55 g was driven by enucleation, while >271 g case inefficiency was driven by morcellation. Increasing tissue weight at the time of HoLEP is associated with a linear relationship of increasing enucleation and decreasing morcellation efficiencies.