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. 2024 Sep 27;19(1):6–16. doi: 10.1097/CU9.0000000000000257

Holmium laser enucleation of the prostate versus transurethral resection of the prostate in treatment of benign prostatic hyperplasia: A meta-analysis of 13 randomized control trials

Besut Daryanto a, Wisnu Syahputra Suryanullah b,∗, Probo Yudha Pratama Putra b
PMCID: PMC12042171  PMID: 40313420

Abstract

Background

The prevalence of benign prostatic hyperplasia (BPH) in older men increases with age, beginning at 40–45 years and reaching to 60% by 60 years and 80% by 80 years. Surgical procedures such as holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP) are the preferred treatments for BPH. Nevertheless, there is disagreement regarding the most efficient and safe treatment for BPH. The objective of this meta-analysis was to assess the efficacy and safety of HoLEP and TURP based on existing evidence.

Materials and methods

This meta-analysis was performed in accordance with the PRISMA guidelines. In February 2023, a literature review was conducted using PubMed, ScienceDirect, and the Cochrane Library, and the meta-analysis was performed using RevMan V.5.4.

Results

A total of 656 patients underwent HoLEP, and 653 patients underwent TURP. There was no statistically significant difference in the International Prostate Symptom Score at 1 month or at 3, 6, 18, 24, and 36 months; the HoLEP group showed a significant difference at 12 months. The pooled data from the maximum urinary flow rate at 1–12 months revealed no significant findings, but the TURP group showed significant results at 24 months. Meanwhile, the HoLEP group showed significant postvoid residual results. There was no significant difference in the quality of life between the groups. Patients who underwent HoLEP had shorter hospital stay and catheter usage period and had lower hemoglobin drop. The operating time was shorter in the TURP group. The difference in specimen weight between the 2 groups was not statistically significant. The overall complications were similar in both groups, but the HoLEP group received significantly fewer blood transfusions.

Conclusions

Holmium laser enucleation of the prostate demonstrated excellent efficacy and safety, with fewer hematological changes and complications; however, TURP had a shorter operating time.

Keywords: Benign prostatic hyperplasia, Holmium laser enucleation of the prostate, Transurethral resection of the prostate

1. Introduction

The prevalence of benign prostate hyperplasia (BPH) increases with age in older men, beginning at 40–45 years and reaching 60% by 60 years and 80% by 80 years.[1,2] Surgical procedures such as holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP) are the preferred treatments for BPH. Nevertheless, there is a disagreement regarding which treatment can be considered the gold standard for BPH in terms of efficacy and safety.[3–5]

Several decades of advancement have resulted in changes in the minimal treatment procedure for BPH, including the HoLEP. Holmium laser enucleation of the prostate is an efficient and safe procedure, particularly for large prostates, owing to its high evaporation capacity and coagulation properties. This method is expected to be promising for the treatment of BPH.[6–9] According to Barboza et al., TURP and HoLEP are comparable in terms of efficacy and application. Based on other studies, TURP remains the recommended procedure for treating small- to medium-sized prostate glands, accounting for most cases in urology practice.[10] In contrast, a recent study by Shvero et al. showed that HoLEP is more advanced in terms of safety and efficacy in treating BPH patients with various prostate sizes and has superseded the gold standard for BPH surgical intervention.[11]

Based on the aforementioned explanation and evidence from previous research, we aimed to assess the efficacy and safety of HoLEP and TURP and analyze their efficacy and safety using a randomized control trial (RCT) and to obtain evidence-based perspectives from clinical practice.

2. Materials and methods

2.1. Literature search

A literature search was conducted to identify articles published between 2004 and 2021 using the Cochrane Library, ScienceDirect, and PubMed,[11] and the search terms used were “HoLEP,” “holmium laser of the prostate,” “TURP,” “transurethral resection of the prostate,” “benign prostatic hyperplasia,” and “BPH.” There was no limitation on location or publication status, but the language was limited to English. Additionally, a manual search of the references from the identified clinical trials and review articles was performed. This meta-analysis was performed in accordance with the PRISMA guidelines and registered in PROSPRO platform (registry number: CRD42024544803).

2.2. Study selection

The inclusion criteria for the RCTs were the following: RCTs that compare both the efficacy and safety of TURP and HoLEP; those whose participants’ BPH was associated with lower urinary tract symptoms; those that included patients with an International Prostate Symptom Score (IPSS) ≥8; and those that included patients with a maximum urinary flow rate (Qmax) <15 mL/s. Studies whose patients had prostate cancer, neurogenic bladder, or a history of urethral and bladder surgeries were excluded.

2.3. Study quality

The Jadad score, which ranges from 0 to 5, was used to evaluate the quality of the methodology of the RCTs. An RCT was considered of good quality if the score was >4, moderate quality if the score was between 3 and 4, and low quality if the score was <3. The criteria of the Oxford Center for Evidence-based Medicine were used to assess the strength of the evidence for each study.[12–14]

2.4. Data extraction

For identification purposes, data extracted included the first author’s name and year of publication. The IPSS, Qmax, and quality of life (QoL) were assessed at 1 month and 3, 6, 12, 18, 24, and 36 months. Perioperative data such as blood loss, operating time, hospital stay, catheterization, weight of resected prostate tissue, and postoperative complications were also assessed.

2.5. Statistical analysis

RevMan V.5.4 (Cochrane Collaboration, Oxford, England) was used to conduct the meta-analysis. The summary statistics for the combined odds ratios were generated using dichotomous data. Continuous variables were used to determine the mean differences (MDs). Odds ratios and MDs were presented with 95% confidence intervals (CIs). In addition, to assess study heterogeneity, the Cochrane χ2 test and inconsistency (I2) were used; a p value <0.05 was considered heterogeneous, whereas I2 < 50% was considered to be of acceptable heterogeneity.

3. Results

The flowchart of the article search is shown in Figure 1. A total of 4262 articles were obtained from the search results with continuity or potentially related research. Of the 13 studies we included, 1309 eligible patients were considered; the research articles included had 656 patients who underwent HoLEP and 653 patients who underwent TURP. The cases were processed using a statistical meta-analysis based on previously specified selection criteria.

Figure 1.

Figure 1

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PRISMA flowchart of the article search.

3.1. Characteristics and quality of study

Table 1 shows the characteristics of the studies that met the inclusion criteria. The level of evidence in 6 research, comprising 13 RCTs, was 1b. The Jadad scale was used to evaluate the quality of the methodological evaluations in the RCT.

Table 1.

HoLEP versus TURP: Summary of comparative study.

Study Institution Intervention Study design LE Inclusion criteria Cases (n) Follow-up (mo) Jadad score
HoLEP TURP
Ahyai et al., 2007[15] Urology Department Aguste Viktoria Hospital (Berlin, Germany) HoLEP vs. TURP RCT 1b IPSS ≥12, Qmax ≤12 mL/s, PVR ≥50 mL, Schӓfer grade ≥II, TRUS <100 cm3 100 100 72 4
Bai et al., 2019[16] Department of Urology, The Second Affiliated Hospital of Zhejiang University School of Medicine (Hangzhou, China) HoLEP vs. TURP RCT 1b Severe lower urinary tract symptoms, refractory to medical therapy with alpha-blockers and/or 5-alpha reductase inhibitors, PVR >100 mL, and acute urinary retention 35 35 3
Basić et al., 2013[17] University of Niš, Faculty of Medicine of Niš (Niš, Serbia) HoLEP vs. TURP RCT 1b PVR 50 mL, TRUS up to 50 g, IPSS >19 20 20 12 3
Eltabey et al., 2010[18] Urology Department at King Fahd Specialist Hospital in Al Qassin (Buraidah, Saudi Arabia) HoLEP vs. TURP RCT 1b TRUS >30 and <100 g, IPSS ≥12, Qmax ≤12 mL/s 40 40 12 3
Gilling et al., 2012[19] Department of Urology, Tauranga Hospital (Tauranga, New Zealand) HoLEP vs. TURP RCT 1b TRUS 40–200 mL, Qmax ≤15 mL/s, AUA symptom score ≥8, PVR <400 mL, Schӓfer grade ≥2 30 31 92 4
Gupta et al., 2006[20] Department of Urology, All India Institute of Medical Sciences (New Delhi, India) HoLEP vs. TURP RCT 1b Prostate volume >40 g 50 50 12 3
Hamouda et al., 2013[21] Urology Department at Sherouk and Arab Contractor Medical Centers (Nasr City, Egypt) HoLEP vs. TURP RCT 1b TRUS >20–80 g, IPSS >12, Qmax <15 mL/s 30 30 12 3
Jhanwar et al., 2017[22] Department of Urology, King George’s Medical University (Lucknow, India) HoLEP vs. TURP RCT 1b Qmax <15 mL/s, TRUS 60 g, PVR >150 mL, and Schӓfer grade ≥II 72 72 24 3
Kuntz et al., 2004[23] Urology Department Aguste Viktoria Hospital Berlin (Berlin, Germany) HoLEP vs. TURP RCT 1b IPSS ≥12, Qmax ≤12 mL/s, PVR ≥50 mL, Schӓfer grade ≥II, TRUS <100 cm3 100 100 12 3
Mavuduru et al., 2019[24] Department of Urology, Postgraduate Institute of Medical Education and Research (Chandigarh, India) HoLEP vs. TURP RCT 1b Previous prostatic or urethral surgery and documented cases of prostrate carcinoma were excluded 15 15 9 3
Montorsi et al., 2004[25] Departments of Urology, University Vita-Salute (Milan, Italy) HoLEP vs. TURP RCT 1b Age <75 yr, Qmax <15 mL/s, TRUS 100 g, PVR >100 cm3, Schӓfer grade ≥II 52 48 12 3
Sayed et al., 2020[26] Department of Urology, Ain Shams University Hospitals (Cairo, Egypt) HoLEP vs. TURP RCT 1b Prostate volume <80 mL, IPSS >19 30 30 12 3
Sun et al., 2014[27] Department of Urology, Urology and Nephrology Center, First Hospital of Jilin University (Changchun, China) HoLEP vs. TURP RCT 1b Age <90 yr, Qmax <10 mL/s, PVR >50 mL, IPSS >8, TRUS 100 g 82 82 12 3
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AUA = American Urological Association; HoLEP = holmium laser enucleation of the prostate; IPSS = International Prostate Symptom Score; LE = level of evidence; PVR = postvoid residual; Qmax = maximum urinary flow rate; RCT = randomized controlled trials; TRUS = transrectal ultrasonography; TURP = transurethral resection of the prostate.

3.2. Perioperative outcomes

3.2.1. Operating time

Of the 12 articles included, 556 and 553 patients were included in the HoLEP and TURP groups, respectively (Fig. 2). The HoLEP group had a significantly longer duration of operating time (MD, 17.51; 95% CI, 11.87–23.14; p = 0.00001), with a reasonably high heterogeneity, as indicated by I2 = 90% in the χ2 test.

Figure 2.

Figure 2

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Comparison of operating time between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation; TURP = transurethral resection of the prostate.

3.2.2. Specimen weight

Of the 12 articles included, 556 and 553 patients were included in the HoLEP and TURP groups, respectively (Fig. 3). The HoLEP group had no different significance in the retrieval of prostate specimens (MD, 4.42 g; 95% CI, −3.89–12.72 g; p = 0.30), with high heterogeneity (I2, 99%).

Figure 3.

Figure 3

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Comparison of specimen weight between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation; TURP = transurethral resection of the prostate.

3.2.3. Hemoglobin drop

Eight studies reported a significant hemoglobin (Hb) drop (MD, −0.73 g/dL; 95% CI, −1.16–−0.29 g/dL; p = 0.001), indicating a lower Hb drop in HoLEP than in TURP, with high heterogeneity (I2, 80%) (Fig. 4).

Figure 4.

Figure 4

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Comparison of hemoglobin drop between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation; TURP = transurethral resection of the prostate.

3.3. Postoperative outcome

3.3.1. International prostate symptom score

A meta-analysis of 11 studies was conducted using the IPSS. Figure 5 shows the outcomes of data processing and subgrouping with follow-up at 1 month and 3, 6, 12, 24, and 36 months postoperatively. In addition, the HoLEP group showed significantly better IPSS at 12 months (MD, −0.97; 95% CI, −1.64–0.30; p < 0.00001) than the TURP group.

Figure 5.

Figure 5

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Comparison of the International Prostate Symptom Score between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation; TURP = transurethral resection of the prostate.

3.3.2. Maximum urinary flow rate

Ten articles showed the Qmax outcomes by comparing HoLEP and TURP (Fig. 6). The data were divided into subgroups of 1 month and 3, 6, 12, and 24 months. In general, neither group showed statistically significant results, but the TURP group at 24 months showed a better Qmax (MD, 1.18; 95% CI, 0.19–2.17; p = 0.02) than the HoLEP group.

Figure 6.

Figure 6

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Comparison of maximum urinary flow rate between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation; TURP = transurethral resection of the prostate.

3.3.3. Postvoid residual

Data obtained from 8 studies showed significant postvoid residual (PVR) results in the HoLEP group (Fig. 7). Postvoid residual was divided into 5 subgroups: 1 month and 3, 6, 12, and 24 months. The data showed significant PVR results in the HoLEP group at 6 (MD, −8.60 mL; 95% CI, −14.11–−3.10; p = 0.0002) and 12 months (MD, −10.27 mL; 95% CI, −16.38–−4.15; p = 0.001), implying better PVR progress in the HoLEP group than in the TURP group.

Figure 7.

Figure 7

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Comparison of postvoid residual between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation; TURP = transurethral resection of the prostate.

3.3.4. Quality of life

Four sets of data were obtained to show the differences in Qmax between HoLEP and TURP, which were divided into 3 subgroups: 1 month and 6 and 12 months (Fig. 8). In general, there were no significant differences between the 2 groups. However, in 2 studies, one by Basić et al. and the another by Gilling et al., the HoLEP group showed better QoL results than the TURP group.[17,19]

Figure 8.

Figure 8

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Comparison of quality of life between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation TURP = transurethral resection of the prostate.

3.3.5. Catheterization time

Figure 9 shows that in 8 studies, the HoLEP group had significant catheterization time results (MD, −19.54 hours; 95% CI, −25.28–−13.80; p < 0.00001). Furthermore, the HoLEP group had a shorter catheterization time than the TURP group.

Figure 9.

Figure 9

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Comparison of catheterization time (hours) between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation; TURP = transurethral resection of the prostate.

The results obtained from 4 studies (Fig. 10) regarding catheterization time in days did not differ from those shown in Figure 9. The HoLEP group had shorter periods in days of catheter use than the TURP group (MD, −1.13 days; 95% CI, −2.07–−0.18; p = 0.020).

Figure 10.

Figure 10

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Comparison of catheterization time (days) between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation; TURP = transurethral resection of the prostate.

3.3.6. Hospital stay

Figure 11 presents 5 studies with 284 and 281 patients in the HoLEP and TURP groups, respectively. Data obtained regarding hospital stay (hours) showed a significant result (MD, −27.54 hours; 95% CI, −36.17–−18.90; p < 0.0001), with the HoLEP group having a shorter hospital stay (hours) than the TURP group. From 5 other studies on hospital stay in days (Fig. 12), a better outcome was also observed in the HoLEP group (MD, −1.14 days; 95% CI, −1.51–−0.76; p < 0.0001) than that in the TURP group.

Figure 11.

Figure 11

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Comparison of hospital stay (hours) between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation; TURP = transurethral resection of the prostate.

Figure 12.

Figure 12

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Comparison of hospital stay (days) between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; IV = inverse variance; SD = standard deviation. TURP = transurethral resection of the prostate.

3.3.7. Adverse events

For the adverse events, Figure 13 presents the complications that occurred postoperatively. The researchers found 5 postoperative complications in which the rate of blood transfusion was lower in HoLEP and the number of bladder mucosal injury was lower in TURP. Neither procedure showed significant results in terms of bladder neck contractures, urethral strictures, or incontinence.

Figure 13.

Figure 13

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Comparison of adverse events between the HoLEP and TURP groups. CI = confidence interval; HoLEP = holmium laser enucleation of the prostate; TURP = transurethral resection of the prostate.

4. Discussion

When medical treatment for BPH is unsuccessful, surgical alternatives, including TURP and HoLEP, are performed.[15–26] In this meta-analysis, we evaluated the efficacy and safety of HoLEP and TURP, the 2 surgical interventions for BPH. The researchers divided the efficacy and safety outcomes into perioperative and postoperative outcomes, with a total of 10 subgroups: operating time, specimen weight, Hb drop, IPSS, Qmax, PVR, QoL, hospital stay, catheterization, and adverse events.

In this meta-analysis, HoLEP had a longer operating time than TURP, which could be due to the fact that HoLEP requires substantially more time for morcellation than standard TURP. Morcellation may prolong the procedure because of the limited field of view of the narrow scope, which may necessitate further transurethral resection coagulation in the event of an unanticipated injury. Because of the ability of morcellation technology to perform full-lobe enucleation, it was able to enucleate high-volume prostates that could have required a longer surgical time in HoLEP. Learning curves and surgeon’s skills also affect operating time.[17,21,28–30]

Although there was no significant difference in resected specimen weights between the 2 procedures, in other studies, the HoLEP group had more resected prostate tissue than that of the TURP group. The invention of an entirely new device, the transurethral mechanical tissue morcellator, enabled complete lobe enucleation, removal into the bladder, and fragmentation and exteriorization of the prostatic tissue. Consequently, high-volume prostate tissues may be enucleated. According to recent research, this technique is feasible and safe, even for prostate glands weighing more than 300 g.[17,21] The HoLEP technique clearly outperformed TURP in terms of Hb drop, which could be attributed to enhanced laser coagulation technology. Given that HoLEP results in better coagulation following enucleation than TURP, the Hb drop in the HoLEP group occurred at a lower rate than that in the TURP group. This also affected the rate of blood transfusion in both treatments.[18,25,28]

The current meta-analysis did not show statistically significant differences in the IPSS at 1 month and 3, 6, 24, and 36 months; however, the 12-month group showed a significant reduction in the IPSS after HoLEP. Moreover, other studies by Ahyai et al.,[15] Basić et al.,[17] and Sun et al.[27] determined that HoLEP had significant results, with better IPSS at 12 months than that of TURP. In the meta-analysis, the TURP group showed significant Qmax results at 24 months. However, in 2 articles by Hamouda et al.[21] and Sun et al.,[27] the HoLEP group had more significant Qmax improvement than the TURP group, especially in the long term. Furthermore, in this study, the 6- and 12-month groups showed better PVR progression in the HoLEP group. Moreover, other studies have reported better PVR results in the HoLEP group than those of the TURP group up to a year of follow-up.[17,18,27] In addition, QoL did not show significant results in either procedure, but 2 articles reported that QoL was better in the HoLEP group than that in the TURP group.[12,20]

Compared with TURP, HoLEP requires a shorter hospital stay and shorter catheterization time. The shorter period of catheter use in the HoLEP group could potentially be due to less postoperative bleeding, resulting in shorter hospital care and lower costs.[28,30,31] Adverse events such as bladder neck contracture, incontinence, and ureteral stricture did not show significant results with either procedure. Based on this meta-analysis, bladder mucosal injury was the most frequent complication of HoLEP. Gupta et al. and Montorsi et al. discovered that an unusual side effect of HoLEP was bladder mucosal injury caused by inadvertent suction of the mucosa into the morcellator blades.[20,25]

The choice between TURP and HoLEP depends on several factors such as the patient’s condition and the surgeon’s learning curve before surgery. If the surgeon prefers a shorter duration of operation on a prostate with a size <80 cm3 and has no hematological problems, then TURP can be an option. However, because HoLEP has excellent hemostatic properties in patients with BPH who are receiving anticoagulant therapy and have a bleeding disorder, HoLEP is the better choice and has been proven to be safe and effective for treating patients.[30,32]

Limitations

Our study has some limitations. Owing to the small number of included studies and the scarcity of long-term follow-up (>24 months), the difference between TURP and HoLEP could not be accurately analyzed. To further support our conclusion, we will focus on future publications of various surgical techniques. Further research is required to validate these findings.

5. Conclusions

Holmium laser enucleation of the prostate has greater efficacy and safety and fewer hematological abnormalities than TURP. Meanwhile, TURP has a shorter operating time than HoLEP. The HoLEP group had better IPSS and PVR and fewer postoperative complications than the TURP group.

Acknowledgments

None.

Statement of ethics

This meta-analysis was performed in accordance with the PRISMA guidelines and registered in PROSPRO platform (registry number: CRD42024544803).

Funding source

None.

Author contributions

BD: Conceived and designed the analysis, collected the data, contributed data or analysis tools, performed the analysis, wrote the paper;

WSS: Collected the data, contributed data or analysis tools, performed the analysis, rote the paper;

PYPP: Performed the analysis, wrote the paper.

Data Availability

The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

Footnotes

How to cite this article: Daryanto B, Suryannullah WS, Putra PYP. Holmium laser enucleation of the prostate versus transurethral resection of the prostate in treatment of benign prostatic hyperplasia: a meta-analysis of 13 randomized control trials. Curr Urol 2025;19(1):6–16. doi: 10.1097/CU9.0000000000000257

Contributor Information

Besut Daryanto, Email: urobes.fk@ub.ac.id.

Probo Yudha Pratama Putra, Email: wisnusyahputra20@gmail.com.

Conflict of interest statement

The authors declare no conflicts of interest.

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