Abstract
Introduction
Holmium laser enucleation of the prostate (HoLEP) is a versatile treatment for benign prostatic hyperplasia (BPH), serving as an alternative to transurethral resection of the prostate (TURP) and open/robotic-assisted prostatectomy. Recent advancements have focused on evaluating the impact of smaller (22–24 Fr) vs larger (26–28 Fr) resectoscope sheaths on procedural outcomes.
The aim of this study was to assess and compare the safety, efficiency, and complication rates associated with smaller and larger resectoscope sheaths in HoLEP procedures through a meta-analysis.
Material and methods
A systematic review was conducted following PRISMA guidelines. Four studies (one RCT and three retrospective) comprising 633 patients (277 with small sheaths [SR] and 356 with large sheaths [LR]) met inclusion criteria. Outcomes assessed included operative time, enucleation/morcellation efficiency, complications (urethral strictures, transient incontinence), and recovery parameters.
Results
In terms of efficiency, no significant differences were observed in operative time, enucleation time, or enucleation efficiency. LR showed faster morcellation time (p = 0.03). As for complications, SR had significantly lower urethral dilation rates (8.0% vs 39.5%, p = 0.01). No significant differences in urethral stricture rates, catheterisation duration, complication rates or transfusion rates. In terms of recovery, similar hospital stay durations and incontinence rates were seen at 3 months postoperatively between groups, and SR might decrease incontinence rates at 1 month postoperatively.
Conclusions
Using smaller resectoscope sheaths in HoLEP reduces urethral dilation rates without compromising procedural efficiency or safety. Larger sheaths had shorter morcellation times. The choice of sheath size should be guided by patient anatomy, surgeon expertise, and procedural requirements. Further large-scale RCTs are needed to confirm long-term outcomes.
Keywords: benign prostatic hyperplasia, holmium laser enucleation of the prostate, resectoscope
INTRODUCTION
Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment option for benign prostatic hyperplasia (BPH). It serves as an alternative to traditional transurethral resection of prostate (TURP) for small to medium-sized prostates and to open or robotic-assisted simple prostatectomies (RASP) for larger prostates [1, 2].
HoLEP has been found to be superior to TURP in post-operative functional outcomes during both short and long-term follow-ups [3–5]. Compared to RASP, HoLEP has similar functional outcomes but offers advantages such as earlier recovery and a better safety profile with lower blood transfusion and moderate to significant complication rates [6].
Multiple recent studies have compared outcomes of HoLEP with miniaturised smaller resectoscope sheaths compared to the traditional larger sheaths [7–10]. It was hypothesised that smaller resectoscopes may lead to lower stricture rates compared to larger scopes, which have a stricture rate of 1.2–7.3%, due to decreased urethral trauma [11–15]. This was first hypothesised in an observational study comparing the outcomes of HoLEP with a 26 Fr vs 28 Fr resectoscope sheath, however, the rate of urethral strictures was not found to be statistically different at 3.5% vs 1.8% [16].
The objective of this meta-analysis is to consolidate current research comparing the operative outcomes of HoLEP with smaller and larger resectoscope sheaths, including the following: operative time, enucleation and morcellation efficiency, complications (urethral stricture, transient incontinence), and recovery parameters. This review aims to provide clarity regarding the impact of resectoscope size on procedural safety and efficiency, contributing to an informed choice of equipment and approach in clinical practice.
MATERIAL AND METHODS
In March 2024, with PROSPERO registration (CRD42024603851), a systematic search for a systematic review was performed following the PRISMA criteria (Figure 1). PubMed, EMBASE, and Cochrane library of systematic reviews were queried for the terms “(HoLEP) AND (resectoscope)”. No restrictions on publication date were applied; only English language articles were considered. Two independent (MZUA, MH) reviewers screened returned results for inclusion and data extraction. Data conciliation was performed through consensus. This study was exempt from review by the institutional review board, and informed consent was not required because data were publicly available.
Figure 1.
PRISMA flowchart of article selection.
Inclusion criteria
Randomised controlled trials (RCTs) and observational studies comparing small resectoscope (SR) sheaths (22–24 Fr) to large resectoscope (LR) sheaths (26–28 Fr).
Exclusion criteria
Our exclusion criteria included conference abstracts and non-English articles.
Data extraction
Data were extracted independently by two reviewers. Data relevant to this meta-analysis besides authorship and year of publication were as follows: risk of bias assessment, cohort size, Anticholinergic use postoperatively, bladder neck contracture rates, catheterisation time, enucleation volume, enucleation time, hospitalisation duration, major complications (IIIb or higher as per Clavien Dindo classification system), morcellation efficiency, morcellation time, operative time, postoperative incontinence, total complications, transfusion rates, urethral dilation rates and urethral stenosis. Studies providing data in median and ranges were used to estimate mean and standard deviation using Wan’s method [17]. Bias was assessed using Cochrane’s Risk of Bias 2 tool for RCTs and the Newcastle-Ottawa Score, which is displayed in Tables 1 and 2.
Table 1.
Risk of bias 2 for Dean et al. 2023
| Domain | Risk of bias |
|---|---|
| 1. Bias arising from the randomization process | Low |
| 2. Bias due to deviations from intended interventions | Low |
| 3. Bias due to missing outcome data | Low |
| 4. Bias in measurement of the outcome | Some concerns |
| 5. Bias in selection of the reported result | Low |
| Overall Bias Assessment | Some concerns |
Table 2.
Newcastle Ottawa Score for non-randomised trials
| Study | Selection (Max 4) | Comparability (Max 2) | Outcome (Follow-up Adequacy Max 3) | Total Score (Max 9) | Limitations |
|---|---|---|---|---|---|
| Ibis et al. 2021 [10] | Representativeness: yes Non-exposed cohort: yes Exposure ascertainment: yes Baseline info: yes |
Controls for BMI and prostate size: partial | Short-term follow-up (4, 12, 24 weeks) | 7 | Short (90-day) follow-up |
| Taha et al. 2023 [9] | Representativeness: yes Non-exposed cohort: yes Exposure ascertainment: yes Baseline info: yes |
Propensity score matching: yes | Short-term follow-up (up to 3 months) | 8 | Short (24-week) follow-up and 26 Fr morcellator used following 22 Fr enucleation |
| Yildiz et al. 2022 [8] | Representativeness: yes Non-exposed cohort: yes Exposure ascertainment: no; Baseline info: no |
Controls for age, BMI, IPSS: partial | Long-term follow-up (12 months) | 6 | Single surgeon performing with different endoscopes at different periods (introducing experience bias). Various sizes of instruments were used |
Statistical analysis
Data analysis was performed in Review Manager V5.4 (Cochrane). Higgins’ 12% test was employed to test heterogeneity, using 50% as a cutoff value. Random-effects models were used in place of fixed-effects for heterogeneous variables. Continuous data are reported as mean difference with 95% confidence intervals (CI). Dichotomous data, such as complications, were reported using odds ratios (OR) with 95% CI. The resulting values with associated p-values <0.05 were considered significant. Funnel plots were plotted to look for small study bias in dichotomous data.
The data analysis was rerun, excluding non-PubMed-indexed (Yildiz et al. 2022) studies in outcomes, with three studies remaining after exclusion [8].
RESULTS
Four studies (one RCT and three retrospective studies) met the inclusion criteria and were analysed. This included 633 patients, 277 and 356 in the SR and LR groups, respectively. Overall characteristics of included studies are displayed in Table 3, baseline characteristics in Table 4, and outcomes analysed in each study in Table 5.
Table 3.
Included studies characteristics
| Study | Study type | Journal (Impact factor) | HoLEP Technique | Resectoscope sheath sizes | Morcellator Used |
|---|---|---|---|---|---|
| Ibis et al. 2021 [10] | Observational (retrospective) | LUTS: Lower Urinary Tract Symptoms (1.5) | En-bloc HoLEP with early apical release | 22F and 26F | 26F nephroscope with VersaCut tissue morcellator (Lumenis) |
| Taha et al. 2023 [9] | Observational (prospective, propensity score-matched) | World Journal of Urology (2.8) | Mini-HoLEP (MiLEP) compared with standard HoLEP | 22F (MiLEP) and 26F (HoLEP) | Wolf® Piranha |
| Yildiz et al. 2022 [8] | Observational (retrospective) | Haseki Medical Bulletin (0.2) | Standard three-lobe HoLEP | 24F and 26F | Jena Surgical Multicut |
| Dean et al. 2023 [7] | Randomized controlled trial | Journal of Endourology (2.9) | Standard three-lobe/two-lobe HoLEP with early apical release | 24F and 28F | 24F and 28F morcellator |
Table 4.
Baseline characteristics of the included studies
| Study | Baseline finding | Smaller resectoscope group | Larger resectoscope group | p |
|---|---|---|---|---|
| Ibis et al. 2022 [10] | Mean age [years] | 66.3 | 67.1 | 0.575 |
| Prostate volume [ml] | 63.9 | 66.0 | 0.213 | |
| Preoperative IPSS | 22.3 | 23.5 | 0.149 | |
| Preoperative PSA | 4.8 | 5.7 | 0.228 | |
| BMI | 29 | 30.7 | 0.195 | |
| Taha et al. 2023 [9] | Mean age [years] | 74 | 74 | 0.200 |
| Prostate volume [ml] | 100 | 100 | 0.940 | |
| Chronic retention [%] | 33 | 31 | 1.000 | |
| ASA score | 2 | 2 | 0.310 | |
| Indwelling catheter use [%] | 38 | 33 | 0.800 | |
| Yildiz et al. 2022 [8] | Mean age [years] | 69.1 | 68.5 | 0.608 |
| Prostate volume [ml] | 108.6 | 112.8 | 0.395 | |
| Preoperative IPSS | 26.5 | 27.3 | 0.102 | |
| BMI | 23.6 | 23.8 | 0.427 | |
| Post void residual | 151.1 | 150.9 | 0.983 | |
| Dean et al. 2023 [7] | Mean age [years] | 68.6 | 70.1 | 0.218 |
| Prostate volume [cm3] | 92.3 | 100.2 | 0.355 | |
| Preoperative AUASS | 20.6 | 20 | 0.732 | |
| ASA score | 2.3 | 2.3 | 0.288 | |
| Indwelling catheter use [%] | 22 | 26 | 0.574 |
ASA – American Society of Anesthesiologists; AUASS – American Urological Association symptom score; BMI – body mass index; IPSS – International Prostate Symptom Score; PSA – prostate-specific antigen
Table 5.
Outcomes analysed
| Outcomes | Findings | |||
|---|---|---|---|---|
| Ibis et al. 2021 [10] | Taha et al. [9] 2023 | Yildiz et al. 2022 [8] | Dean et al. 2023 [7] | |
| Operative time | NR | NSD | NSD | NSD |
| Enucleation time | NSD | NR | NSD | NSD |
| Enucleation efficiency | NSD | NR | NSD | NSD |
| Morcellation time | NSD | NR | Lower in smaller resectoscope group | NSD |
| Morcellation efficiency | NSD | NR | Lower in smaller resectoscope group | NSD |
| Specimen weight | NSD | NR | NSD | NSD |
| Urethral dilation rates | NSD | Lower in smaller resectoscope group | Lower in smaller resectoscope group | NSD |
| Catheterisation duration | NSD | NR | NSD | NR, (Higher same day successful trial of void in larger resectoscope group) |
| Transfusion rates | NR | NR | NSD | NSD |
| Hospitalisation duration | NR | NSD | NSD | Lower in larger resectoscope group |
| Complication rates | NR | NSD | NSD | NSD |
| Urethral stricture rates | NR | NR | NSD | NSD |
| Bladder neck contracture | NR | NR | NSD | NSD |
| Urinary incontinence at one month | Lower incontinence in the smaller resectoscope group | Lower incontinence in the smaller resectoscope group | NSD | NSD |
| Urinary incontinence at three months | NSD | NSD | NR | NSD |
NSD – no statistical difference; NR – not reported
Operative time
Operative time was described in 3 studies, totalling 533 patients (237 and 296 in the SR and LR, respectively). Analysis revealed no differences between groups, with a mean difference of –0.5 minutes [–3.88, 2.87], p = 0.77, suggesting equivalent operative time with both methods. This finding is displayed in Figure 2.
Figure 2.
Forest plot for operative time.
Enucleation time
Enucleation time was described in 3 studies, totalling 553 patients (237 and 316 in the SR and LR, respectively). Analysis revealed no differences between groups, with a mean difference of –0.88 minutes [–3.53, 1.77], p = 0.52, suggesting equivalent enucleation time with both methods. This finding is displayed in Figure 3.
Figure 3.
Forest plot for enucleation time.
Enucleation efficiency
Enucleation efficiency was described in 3 studies, totalling 553 patients (237 and 316 in the SR and LR, respectively). Analysis revealed no differences between groups, with a mean difference of –0.07 g/min [–0.16, 0.02], p = 0.11, suggesting equivalent enucleation efficiency with both methods. This finding is displayed in Figure 4.
Figure 4.
Forest plot for enucleation efficiency.
Morcellation time
Morcellation time was described in 3 studies, totalling 553 patients (237 and 316 in the SR and LR, respectively). Analysis revealed statistically significant differences between groups with a mean difference of 0.97 minutes [0.11, 1.83], p = 0.03 in favour of LR. This suggests faster morcellation time with LR. This finding is displayed in Figure 5.
Figure 5.
Forest plot for morcellation time.
Morcellation efficiency
Morcellation efficiency was described in 3 studies, totalling 553 patients (237 and 316 in the SR and LR, respectively). Analysis revealed differences between groups with a mean difference of –0.71 g/min [–1.43, 0.02], p = 0.06, in favour of LR. However, this finding was not statistically significant. This finding is displayed in Figure 6.
Figure 6.
Forest plot for morcellation efficiency.
Specimen weight
Specimen weight was described in 3 studies, totalling 533 patients (237 and 296 in the SR and LR, respectively). Analysis revealed no differences between groups with a mean difference of –1.43 g [–3.60, 0.74], p = 0.20, suggestive of equivalent enucleation volume with both methods. This finding is displayed in Figure 7.
Figure 7.
Forest plot for specimen weight.
Urethral dilation rates
Urethral dilation rates were described in 3 studies, totalling 533 patients (237 and 296 in the SR and LR groups, respectively). Urethral dilation rates for patients in the SR group were 8.0% as compared with 39.5% for LR. This finding was statistically significant with an associated OR of 0.17 [0.04, 0.69], p = 0.01. The funnel plot is included in the supplemental material. This finding is displayed in Figure 8.
Figure 8.
Forest plot for urethral dilation rates.
Catheterisation duration
Catheterisation duration was described in 2 studies, totalling 401 patients (161 and 240 in the SR and LR, respectively). Analysis revealed no differences between groups, with a mean difference of 0.93 hours [–0.49, 2.35], p = 0.20, suggesting of equivalent catheterisation duration with both methods. This finding is displayed in Figure 9.
Figure 9.
Forest plot for catheterisation duration.
Transfusion rates
Transfusion rates were described in 2 studies, totalling 453 patients (197 and 256 patients in the SR and LR groups, respectively). Of these, SR reported 0 (0%) transfusions and LR 1 (0.4%) transfusion. This difference was not statistically significant OR = 0.49 [0.02, 12.19], p = 0.67. The funnel plot is included in the supplemental material (suppl. Figures 1–8). This finding is displayed in Figure 10.
Figure 10.
Forest plot for transfusion rates.
Hospitalisation duration
Hospitalisation duration was described in 3 studies, totalling 533 patients (237 and 296 in the SR and LR, respectively). Analysis revealed no differences between groups with a mean difference of 1.35 hours [–2.88, 5.59], p = 0.53, suggestive of equivalent hospitalisation duration with both methods. This finding is displayed in Figure 11.
Figure 11.
Forest plot for hospitalisation duration.
Complication rates
Complication rates were described in 3 studies, totalling 237 patients in the SR group and 296 in the LR group. Significant complications were defined as complications of Clavien-Dindo classification grade ≥IIIb. The overall complication rates for SR and LR were 24.05% vs 25.34% (p = 0.82), with a moderate/severe complication rate of 3.05% vs 4.3% (p = 0.60), respectively. Odds of total complications between groups were OR = 1.05 [0.70, 1.58], p = 0.82; the odds of moderate to significant complications were OR = 0.76 [0.28, 2.12], p = 0.60. Funnel plots are included in the supplemental material. This finding is displayed in Figures 12 and 13.
Figure 12.
Forest plot for total complications.
Figure 13.
Forest plot for major complications.
Urethral stricture rates
Urethral stricture rates were described in 3 studies, totalling 545 patients (233 and 312 patients in the SR and LR groups, respectively). Of these, SR and LR reported a stricture rate of 4 (1.72%) and 10 (3.21%), respectively. This difference was not statistically significant OR = 0.59 [0.18, 1.90], p = 0.37. The funnel plot is included in the supplemental material. This finding is displayed in Figure 14.
Figure 14.
Forest plot for urethral stricture.
Bladder neck contracture rates
Bladder neck contracture (BNC) rates were described in 2 studies, totalling 453 patients (197 and 256 patients in the SR and LR groups, respectively). Of these, SR reported 1 (0.51%) BNC and LR 2 (0.78%) BNC. This difference was not statistically significant, OR = 0.74 [0.07, 8.27], p = 0.81. The funnel plot is included in the supplemental material. This finding is displayed in Figure 15.
Figure 15.
Forest plot for bladder neck contracture.
Urinary incontinence at one month
Urinary incontinence at one-month (UI@1) rates were described in 4 studies, totalling 633 patients (277 and 356 patients in the SR and LR groups, respectively). Of these, SR reported 27 (9.75%) UI@1 and LR 56 (15.73%) UI@1. This difference was not statistically significant (OR = 0.53 [0.25, 1.11], p = 0.09). The funnel plot is included in the supplemental material. This finding is displayed in Figure 16A.
Figure 16.
A) Forest plot for urinary incontinence at one month. B) Forest plot for urinary incontinence at one month (excluding non-PubMed-indexed articles).
On exclusion of Yildiz et al. [8], urinary incontinence at one-month (UI@1) rates were described in three studies, totalling 332 patients (156 and 176 patients in the SR and LR groups, respectively). Of these, SR reported 19 (12.18%) UI@1 and LR 46 (26.14%) UI@1. This difference was statistically significant: OR = 0.40 [0.22, 0.72], p = 0.002. This is displayed in Figure 16B.
Urinary incontinence at three months
Urinary incontinence at 3-month (UI@3) rates were described in 3 studies, totalling 332 patients (156 and 176 patients in the SR and LR groups, respectively). Of these, SR reported 12 (7.69%) UI@3 and LR 18 (10.23%) UI@3. This difference was not statistically significant, OR = 0.75 [0.35, 1.62], p = 0.47. The funnel plot is included in the supplemental material. This finding is displayed in Figure 17.
Figure 17.
Forest plot for urinary incontinence at three months.
DISCUSSION
The findings of this meta-analysis, which included one RCT and three retrospective studies encompassing 633 patients, shed light on key aspects of using different resectoscope sheath sizes in HoLEP procedures and revealed several critical outcomes.
Both smaller (SR) and larger resectoscope sheath (LR) groups showed no significant differences in operative and enucleation times. This suggests that miniaturising the scope does not substantially impact the efficacy of the procedure, despite the reduced flow which is associated with a small scope. It could be argued that this might be due to relatively smaller prostate volume in included studies, as seen in Dean et al. [7], which excluded prostates above 200 ml. However, the average pre-operative prostate size was 90 ml or higher in three out of the four studies [7–10], which is similar to average pre-operative HoLEP prostate volumes as seen in the literature [14]. This indicates that surgeons can opt for either size based on comfort and institutional preference without compromising enucleation efficiency.
A significant finding was that the LR group demonstrated lower morcellation time. This may be attributed to the improved irrigation flow, which helps prevent bladder collapse and reduces the risk of bladder perforation requiring bladder repair. In a cohort of 1,476 patients, the rate of bladder injury during morcellation was 1.4% (20 patients), with 0.07% (1 patient) requiring open repair. Among the included studies, Dean et al. used 24 Fr and 28 Fr morcelloscopes. However, they switched the 24 Fr morcellator to a 28 Fr morcellator in 6 cases (8%) [7]. Alternatively, Yildiz et al. [8] and Ibis et al. [10] used a single-size Multicut morcellator system (Jena Surgical) and 26 F nephroscope with VersaCut tissue morcellator (Lumenis,) respectively, in all the cases. We believe this is currently the greatest challenge of miniaturised HoLEP. Using either a larger morcelloscope during morcellation or starting with a smaller scope but switching to the larger scope in cases of difficulties are acceptable strategies.
One of the most notable outcomes was the significantly lower urethral dilation rates observed in the SR group compared to LR (8.0% vs 39.5%, p = 0.01). This finding along with the hypothesis that smaller resectoscopes are associated with reduced urethral manipulation, potentially decreasing the risk of subsequent stricture formation might make SR HoLEP more attractive. However, in a RCT pre-operative dilation with Otis urethrotomy decreased the urethral stricture rates in patients undergoing HoLEP [11]. Thereby, it is possible to prevent the traditionally common complication associated with larger resectoscopes of urethral strictures by elective pre-operative dilation.
Although the rates of urethral strictures differed, it was not statistically significant at 1.7% with SR and 3.21% in LR, very similar rates were found in a retrospective cohort study of 502 patients undergoing HoLEP with urethral stricture rates of 1.8% vs 3.5% in 26 Fr and 28 Fr groups respectively (p = 0.405) [16]. Similarly, Gunes et al. [18], evaluating TURP resectoscope size, found a statistically significant increased urethral stricture rate with the larger resectoscope. Future adequately powered studies with a longer follow-up duration might show a statistically significant difference. This is likely the major advantage of miniaturised HoLEP.
The duration of catheterisation and hospitalization did not significantly differ between the SR and LR groups. Similarly, the total and significant complication rates, as well as transfusion rates, were comparable between the groups. These finding highlights that despite the reduced flow smaller sheath size had a similar safety profile as the large resectoscope.
The improved urinary incontinence on exclusion of non-PubMed-indexed studies, suggest that SR HoLEP might lead to early sphincteric recovery. Notably, the similar rates of urinary incontinence at three months postoperatively suggest that both techniques have eventual improvement of sphincteric dysfunction in a majority of patients. It is possible that the true benefit might be greater with complete SR HoLEP as some studies used larger morcelloscope’s during morcellation. Moreover, other techniques have been studied to decrease incontinence rates, including early apical release, pre-operative pelvic floor exercises and botulinum toxin administration during HoLEP, all of which have shown promising results [19–22].
The limitations of this study include the inclusion of non-randomised retrospective studies; however, they did not differ in pre-operative characteristics as seen in Table 4. The means of certain variables were estimated from the median and ranges via the Wans method [17]. Outcomes such as BNC and urethral stricture might be inadequately assessed due to the limited follow-up duration in the studies. Further large-scale RCTs are warranted to strengthen the evidence base, particularly regarding long-term outcomes such as stricture formation and functional recovery. Functional outcomes such as post-operative International Prostate Symptom Score (IPSS) and uroflowmetry were not analysed due to heterogeneous reporting, and it is unlikely to be different based on the resectoscope sheath size. Moreover, there was no difference in the post-operative American Urological Association symptom score (AUASS), IPSS and uroflowmetry between the groups in the included studies [7–10].
CONCLUSIONS
This meta-analysis indicates that using a smaller resectoscope sheath (22–24 Fr) during HoLEP lower urethral dilation rates and may decrease early incontinence rates without compromising operative time, enucleation efficiency, or complication rates. While larger sheaths (26–28 Fr) showed faster morcellation times. The choice of sheath size should be tailored to the surgeon's expertise, patient anatomy, and desired outcomes.
Overall, this review demonstrates that smaller resectoscopes are safe and efficacious in HoLEP.
Funding Statement
FUNDING This research received no external funding.
CONFLICTS OF INTEREST
The authors declare no conflict of interest.
ETHICS APPROVAL STATEMENT
The ethical approval was not required.
SUPPLEMENTARY MATERIALS
Funnel plots
Suppl. Figure 1.
Total complications.
Suppl. Figure 2.
Major complications.
Suppl. Figure 3.
Urethral dilation.
Suppl. Figure 4.
Urethral stricture.
Suppl. Figure 5.
Bladder neck contracture.
Suppl. Figure 6.
Transfusions.
Suppl. Figure 7.
Post-operative incontinence at 1 month.
Suppl. Figure 8.
Post-operative incontinence at 3 months.
References
- 1.Sandhu JS, Bixler BR, Dahm P, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023. J Urol. 2024. Available at: https://www.auajournals.org/doi/10.1097/JU.0000000000003698 [DOI] [PubMed] [Google Scholar]
- 2.Management of Non-neurogenic Male LUTS - Uroweb [Internet]. Available at: https://uroweb.org/guidelines/management-of-non-neurogenic-male-luts/chapter/disease-management
- 3.Cornu JN, Ahyai S, Bachmann A, et al. A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update. Eur Urol. 2015; 67: 1066–1096. [DOI] [PubMed] [Google Scholar]
- 4.Zhang X, Shen P, He Q, et al. Different lasers in the treatment of benign prostatic hyperplasia: a network meta-analysis. Sci Rep. 2016; 6: 23503. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Zhang Y, Yuan P, Ma D, et al. Efficacy and safety of enucleation vs. resection of prostate for treatment of benign prostatic hyperplasia: a meta-analysis of randomized controlled trials. Prostate Cancer Prostatic Dis. 2019; 22: 493–508. [DOI] [PubMed] [Google Scholar]
- 6.Benzouak T, Addar A, Prudencio-Brunello MA, et al. Comparative Analysis of Holmium Laser Enucleation of the Prostate (HoLEP) and Robotic-Assisted Simple Prostatectomy (RASP) in BPH Management: A Systematic Review and Meta-Analysis. J Urol. 2024. Available at: https://www.auajournals.org/doi/10.1097/JU.0000000000004297 [DOI] [PubMed] [Google Scholar]
- 7.Dean NS, Lee MS, Assmus MA, et al. Does Resectoscope Sheath Size Influence Holmium Laser Enucleation of the Prostate Outcomes? A Prospective Randomized Controlled Trial. J Endourol. 2023; 37: 1261–1269. [DOI] [PubMed] [Google Scholar]
- 8.Yildiz SA. Comparison of Perioperative Outcomes and Urethral Complications Between Using 24-French and 26-French Resectoscope Sheaths in Holmium Laser Enucleation of the Prostate [Internet]. The Medical Bulletin of Haseki 2022. Available from: https://www.hasekidergisi.com/articles/comparison-of-perioperative-outcomes-and-urethral-complications-between-using-24-french-and-26-french-resectoscope-sheaths-in-holmium-laser-enucleation-of-the-prostate/doi/haseki.galenos.2022.8104
- 9.Taha T, Savin Z, Lifshitz K, et al. Mini-HoLEP (MILEP) vs HoLEP: a propensity score-matched analysis. World J Urol. 2023. Oct; 41: 2801–2807. [DOI] [PubMed] [Google Scholar]
- 10.Ibis MA, Tokatlı Z. Does the use of a small-size resectoscope during enucleation prevent transient urinary leakage and urethral stricture following holmium laser enucleation of the prostate? Low Urin Tract Symptoms. 2022; 14: 86–91. [DOI] [PubMed] [Google Scholar]
- 11.Park JK, Kim JY, You JH, et al. Effect of preoperative urethral dilatation on preventing urethral stricture after holmium laser enucleation of the prostate: A randomized, controlled study. Can Urol Assoc J. 2019; 13: E357–E360. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Naspro R, Suardi N, Salonia A, et al. Holmium laser enucleation of the prostate versus open prostatectomy for prostates >70 g: 24-month follow-up. Eur Urol. 2006; 50: 563–568. [DOI] [PubMed] [Google Scholar]
- 13.Shah HN, Mahajan AP, Hegde SS, Bansal MB. Peri-operative complications of holmium laser enucleation of the prostate: experience in the first 280 patients, and a review of literature. BJU Int. 2007; 100: 94–101. [DOI] [PubMed] [Google Scholar]
- 14.Ibrahim A, Alharbi M, Elhilali MM, Aubé M, Carrier S. 18 Years of Holmium Laser Enucleation of the Prostate: A Single Center Experience. J Urol. 2019; 202: 795–800. [DOI] [PubMed] [Google Scholar]
- 15.Elsaqa M, Risinger J, El Tayeb MM. Urethral Complications Post-Holmium Laser Enucleation of the Prostate: A Seven-Year Experience. J Endourol. 2022; 36: 1575–1579. [DOI] [PubMed] [Google Scholar]
- 16.Thai KH, Smith JC, Stutz J, Sung J, Shaver C, El Tayeb MM. Urethral Complications While Using 26F vs 28F Resectoscope Sheaths in Holmium Laser Enucleation of the Prostate: A Retrospective Observational Study. J Endourol. 2021; 35: 165–170. [DOI] [PubMed] [Google Scholar]
- 17.Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014; 14: 135. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Günes M, Keles MO, Kaya C, et al. Does resectoscope size play a role in formation of urethral stricture following transurethral prostate resection? Int Braz J Urol. 2015; 41: 744–749. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.de Figueiredo FCA, Cracco CM, de Marins RL, Scoffone CM. Holmium laser enucleation of the prostate: Problem-based evolution of the technique. Andrologia. 2020; 52: e13582. [DOI] [PubMed] [Google Scholar]
- 20.Huang MM, Dean NS, Assmus MA, Lee MS, Guo JN, Krambeck AE. Intradetrusor OnabotulinumtoxinA Injections at the Time of Holmium Laser Enucleation of the Prostate for Men with Severe Storage Symptoms. J Endourol. 2023; 37: 801–806. [DOI] [PubMed] [Google Scholar]
- 21.Anan G, Kaiho Y, Iwamura H, et al. Preoperative pelvic floor muscle exercise for early continence after holmium laser enucleation of the prostate: a randomized controlled study. BMC Urology. 2020; 20: 3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Heidenberg DJ, Choudry MM, Wymer K, et al. The Impact of Standard vs Early Apical Release Holmium Laser Enucleation of the Prostate Technique on Postoperative Incontinence and Quality of Life. Urology. 2024; 189: 101–107. [DOI] [PubMed] [Google Scholar]