ABSTRACT
Purpose
This study aims to investigate the effects of holmium laser enucleation of the prostate (HoLEP) with proactive preservation of one lateral lobe (PLL‐HoLEP) on urinary function and sexual function in patients with benign prostatic hyperplasia (BPH).
Methods
From April 2024 to April 2025, 71 patients who underwent PLL‐HoLEP (Group A) were studied based on inclusion and exclusion criteria. Meanwhile, 140 patients who underwent traditional HoLEP from September 2022 to March 2024 were selected as the control group (Group B). After propensity score matching (PSM) was performed, the baseline characteristics of the two groups were balanced. Subsequently, differences in clinical outcomes between the groups were compared. We compared preoperative and postoperative complications, international prostate symptom score (IPSS), quality of life (QoL), maximum urine flow rate (Q max), postvoid residual urine (PVR), International Index of Erectile Function (IIEF‐5), QMSHQ EjF, and QMSHQ EjS between the two groups, and conducted follow‐up evaluations of surgical outcomes and sexual function.
Results
Fifty‐four pairs of patients were successfully matched by PSM. Operative time, resected prostate weight, hemoglobin decrease, and incidence of transient incontinence and retrograde ejaculation in Group A were lower than those in Group B. There were significant differences in IPSS, QoL, Q max, and PVR between preoperative and 1 month postoperative periods in two groups (p < 0.05). However, there were no statistically significant differences in IPSS, QoL, Q max, and PVR between the two groups at one and 6 months postoperatively (p > 0.05). Significant differences in IIEF‐5, QMSHQ EjF, and QMSHQ EjS scores were observed between the two groups during the 6‐month postoperative follow‐up of sexual function (p < 0.05), with Group A showing better outcomes.
Conclusion
For patients who satisfy the inclusion and exclusion criteria, PLL‐HoLEP can reduce the incidence of transient urinary incontinence and retrograde ejaculation and more effectively preserve the sexual function of patients with BPH.
Keywords: benign prostatic hyperplasia, enucleation of the prostate, holmium laser, proactive preservation of one lateral lobe, sexual function
Abbreviations
- BPH
benign prostatic hyperplasia
- GreenLEP
greenlight laser enucleation of the prostate
- HoLEP
holmium laser enucleation of the prostate
- IIEF‐5
international index of erectile function‐5
- IPSS
international prostate symptom score
- LUTS
lower urinary tract symptoms
- PLL‐HoLEP
HoLEP with proactive preservation of one lateral lobe
- PSA
prostate‐specific antigen
- PSM
propensity score matching
- PVP
photovaporization of the prostate
- PVR
postoperative residual urine
- Q max
maximum urinary flow rate
- QMSHQ‐EjF
quality of male sexual health questionnaire ejaculatory function
- QMSHQ‐EjS
quality of male sexual health questionnaire ejaculatory satisfaction
- QoL
quality of life
- ThuLEP
thulium laser enucleation of the prostate
- TURP
transurethral resection of the prostate
1. Introduction
Benign prostatic hyperplasia (BPH) is a common disease among middle‐aged and elderly men. The incidence rate of BPH increases significantly with age: 50%–60% of men in their 60s and 80%–90% of men in their 70s and 80s are affected [1]. As more people worldwide live longer, BPH is expected to impose a substantial economic burden on the global healthcare system in the coming years [2]. BPH is caused by the proliferation of stromal and epithelial cells in the prostate transitional zone, as well as histopathological changes, leading to partial or complete obstruction of the urethra. As the disease progresses, the detrusor muscle of the bladder may become overactive or hypocontractile, resulting in lower urinary tract symptoms (LUTS) such as urinary frequency and urgency, increased nocturia, and difficulty urinating [3]. Transurethral surgery is the most commonly performed procedure for BPH and includes transurethral prostatectomy (TURP), holmium laser enucleation of the prostate (HoLEP), thulium laser enucleation of the prostate (ThuLEP), green light laser enucleation of the prostate (GreenLEP), and greenlight photovaporization of the prostate (PVP) [4]. Among these, HoLEP has demonstrated superiority over traditional transurethral prostatectomy in terms of efficacy and safety [5, 6]. Therefore, it is considered the most likely gold standard for treating BPH [7].
Although HoLEP has shown good therapeutic effects in clinical applications, surgical complications remain an issue that cannot be ignored. HoLEP‐related complications include urinary incontinence, urethral stricture, erectile dysfunction, and ejaculation dysfunction, which not only affect patients' physical health but also negatively impact their psychological and social well‐being [8, 9, 10]. Therefore, effectively relieving urinary tract obstruction while reducing the incidence of complications has become a significant focus in clinical research.
To address this challenge, we propose a modified surgical strategy of HoLEP with proactive preservation of one lateral lobe (PLL‐HoLEP). Proactive preservation of one lateral lobe can effectively relieve urinary tract obstruction and reduce postoperative complications such as urinary incontinence and urethral stricture. In addition, PLL‐HoLEP has a protective effect on erectile and ejaculatory function. This study compared and analyzed the clinical outcomes of PLL‐HoLEP with traditional HoLEP. We used the PSM method to control for confounding variables and ensure the reliability of the results. The findings indicate that PLL‐HoLEP significantly improves urinary function, reduces postoperative complications, and protects functional integrity. This study provides novel surgical approaches and clinical evidence for the treatment of BPH, and we hope to promote its application in clinical practice, thereby further improving the quality of life (QoL) of patients.
2. Materials and Methods
2.1. Patients
From April 2024 to April 2025, 108 patients underwent HoLEP for BPH. Based on inclusion and exclusion criteria, 71 patients who received PLL‐HoLEP were selected as the study group (Group A). Separately, from September 2022 to March 2024, 174 patients received HoLEP. Among them, 140 patients who underwent traditional HoLEP were chosen as the control group (Group B), according to the same criteria. Inclusion criteria: (1) The patient retains the ability to achieve penile erection and engage in satisfactory sexual intercourse and hopes to maintain sexual function after surgery. (2) Patients meet the surgical indications according to the Chinese urological disease diagnosis and treatment guidelines on BPH (2022) [11]. Meanwhile, the surgery ensures postoperative patency of the prostatic urethra. Exclusion criteria: (1) Patients with a history of neurological disorders such as cerebral infarction and Parkinson's disease; Patients with urodynamic examination showing severe impairment of detrusor muscle function in the bladder, suggestive of neurogenic bladder; (2) Patients with indications for prostate biopsy; (3) Patients with a history of prostate surgery; (4) Patients with severe organ dysfunction, such as cardiovascular disease, cerebrovascular disease, or pulmonary dysfunction; (5) Patients whose postoperative pathological results suggest prostate cancer; and (6) Patients with a prostate volume exceeding 100 mL.
We performed PSM, resulting in 54 successfully matched pairs after adjusting for potential confounding factors, age, and IPSS between groups. The study design was approved by the Ethics Committee at Lu'an Hospital Affiliated to Anhui Medical University, and all patients provided written informed consent to participate. This study was conducted in accordance with the Declaration of Helsinki and standards of good clinical practice. Figure 1 presents a flowchart describing the selection of the study population.
Figure 1.
Flowchart of study population.
2.2. Equipment and Techniques
The 96 W‐SRM‐H3B Ho laser generator was used during the HoLEP surgery. It was equipped with a 550 µm fiber and a 26 Fr resectoscope sheath. The energy settings were 2 J at 40 Hz for cutting and 0.8 J at 40 Hz for coagulation. The surgeon performed morcellation using a YSB‐III morcellator. The surgical procedure for Group A patients is as follows. Taking BPH patients with bilateral lobe hyperplasia as an example. First, the surgeon makes an inverted U‐shaped laser incision in front of the seminal colliculus for marking. Then, the left lobe of the prostate is separated along the plane of the prostatic capsule. Second, laser cutting begins at the 6 o'clock position of the bladder neck, extending to the plane of the distal prostatic capsule. At the 12 o'clock position of the bladder neck, the urethral mucosa is incised, and the cut is extended to the 12 o'clock position at the top of the seminal colliculus. Laser cutting is performed on the urethral mucosal strip between the external sphincter and the left lobe. The left lobe is then separated and cut from top to bottom along the surgical sac plane. The laser enucleation continues until it reaches the neck muscle fibers of the bladder, completely removing the left lobe of the prostate and pushing it into the bladder cavity. Carefully examine the surgical wound of the prostatic fossa and perform thorough coagulation (Figure 2). Subsequently, morcellation within the bladder and extraction are performed by aspiration of the prostate tissue. After the surgery, a 20‐Fr, three‐lumen catheter is placed through the urethra, and the catheter balloon is filled with 30 ml of saline. When BPH mainly involves bilateral lobe hyperplasia, surgery generally aims to preserve the right lobe. The left lobe is preserved only if proliferation is more severe on the right than on the left. However, if mid‐lobe hyperplasia coexists, the mid‐lobe should be removed. All patients undergo continuous bladder irrigation after surgery. The surgical procedure for Group B patients includes removal of the right lobe of the prostate, while the rest of the procedures are the same as those for Group A. All operations were performed by the same surgeon.
Figure 2.
Surgical steps of PLL‐HoLEP (HoLEP with proactive preservation of one lateral lobe). (A) Perform an inverted U‐shaped laser incision anterior to the seminal colliculus. (B) Separate the left lobe of the prostate along the plane of the prostatic capsule. (C) Perform a laser incision starting from the 6 o'clock position of the bladder neck and extending to the plane of the prostatic capsule. (D) At the 12 o'clock position of the bladder neck, incise the urethral mucosa and extend the incision to the apex of the prostate gland. (E) Next, separate the left lobe of the prostate gland clockwise along the surgical capsule from 12 o'clock until 3 o'clock. (F) Then, perform a laser incision on the urethral mucosal strip between the external sphincter and the left lobe. Subsequently, separate the left lobe from top to bottom along the surgical capsule plane. (G) Perform a laser incision of the bladder neck muscle fibers and completely remove the left lobe of the prostate through the bladder cavity. (H) View of the prostate gland fossa wound after surgery. [Color figure can be viewed at wileyonlinelibrary.com]
2.3. Observation Indicator
The preoperative baseline data, operation time, hemoglobin decrease, capsule perforation, catheterization time, and hospital stay of the patients were compared between the two groups. Within 1 month after the surgery, the urine retention and gross hematuria, hemorrhage, temporary urinary incontinence, urinary tract infection, testicular epididymitis, and other complications of the patients between the two groups were monitored. One month and 6 months after the surgery, different parameters, including international prostate symptom score (IPSS), QoL, maximum urine flow rate (Q max), postvoid residual urine (PVR), international index of erectile function‐5 (IIEF‐5), quality of male sexual health questionnaire ejaculatory function (QMSHQ‐EjF) and quality of male sexual health questionnaire ejaculatory satisfaction (QMSHQ‐EjS) were compared between the two groups. Temporary urinary incontinence is defined as stress or urge incontinence reported within 3 months following catheter removal in post‐surgical patients, with resolution occurring during a 3‐month follow‐up period.
2.4. Statistical Analysis
The statistical analysis was performed using SPSS 25 (IBM Corp, Armonk, NY, USA). PSM was implemented using the PSM extension procedure in IBM SPSS. The nearest neighbor algorithm was used as the matching method, with the caliper value set to 0.02 and the ratio set to 1:1. Before matching, for the data with a normal distribution, independent‐samples t‐tests were used, and for the data with an abnormal distribution, Mann–Whitney U‐tests were used. Chi‐square tests were used to compare the categorical variables. After matching, normally distributed variable data are analyzed with a paired‐sample t‐test. For data with a nonnormally distributed variable, Wilcoxon–Mann–Whitney tests were used, and categorical variable data were analyzed with the McNemar test. p < 0.05 was considered statistically significant. All of the experimental data are displayed as the average value ± standard deviation.
3. Results
The primary difference was in the baseline characteristics between the two groups before matching (Table 1). We performed PSM for a total of 54 pairs that were matched successfully. The age of patients in Group A and Group B was 71.2 ± 6.7 and 71.3 ± 6.6 years, respectively. Preoperative baseline characteristics such as age, disease duration, anticoagulants, alpha blockers, urogenital complications, prostate volume, PSA, IPSS, QoL, Q max, PVR, IIEF‐5, and QMSHQ‐EjF were not statistically significant between the two groups (p > 0.05, Table 2). The operation time of patients in Group A and Group B was 56.7 ± 11.6 and 83.2 ± 14.9 min, respectively; the resected prostate volume was 30.8 ± 12.8 and 51.9 ± 11.8 cm3, and hemoglobin decrease was 6.3 ± 3.1 and 12.9 ± 7.1 g/dL, which were statistically significant (p < 0.001). The incidence of transient incontinence and retrograde ejaculation in Group A patients was significantly lower than that in Group B (p < 0.05). There was no significant difference in other indicators between the two groups, such as capsular perforation, catheterization time, hospital stay, urine retention, gross hematuria, hemorrhage, urinary tract infection, testicular epididymitis, and urethral stricture (p > 0.05, Table 3). Before and 1 month after the surgery, there were statistically significant differences in IPSS, QoL, Q max, and PVR in the two groups (p < 0.05, Table 4). At 1 month and 6 months after the surgery, there were no statistically significant differences in IPSS, QoL, Q max, and PVR between the two groups. However, in terms of IIEF‐5, QMSHQ‐EjF and QMSHQ‐EjS, patients in group A were significantly better than those in group B (p > 0.05, Table 5).
Table 1.
Baseline criteria of the two groups before PSM.
| Group A | Group B | p | |
|---|---|---|---|
| Patients, n | 71 | 140 | |
| Age (year)a | 70.3 ± 6.8 | 73.0 ± 6.6 | 0.021 |
| Disease duration (year)a | 5.4 ± 2.3 | 6.2 ± 3.0 | 0.159 |
| Hypertensionb | 32 (45.1%) | 67 (47.9%) | 0.702 |
| Diabetesb | 12 (16.9%) | 23 (16.4%) | 0.930 |
| Anticoagulantsb | 15 (21.1%) | 32 (22.8%) | 0.775 |
| Alpha blockersb | 40 (56.3%) | 74 (52.9%) | 0.632 |
| 5ARIs alone or combined with alpha blockersb | 26 (36.6%) | 51 (36.4%) | 0.978 |
| Urogenital complications | |||
| With acute urinary retentionb | 20 (31%) | 40 (28.6%) | 0.951 |
| With gross hematuriab | 25 (35.2%) | 46 (32.8%) | 0.732 |
| With bladder stonesb | 14 (19.7%) | 26 (18.6%) | 0.841 |
| With bladder trabeculae or chambersb | 39 (53.2%) | 75 (54%) | 0.852 |
| Prostate volume (mL)a | 65.3 ± 16.6 | 62.6 ± 12.6 | 0. 403 |
| IPSSa | 24.7 ± 5.0 | 26.1 ± 4.4 | 0.034 |
| QoLa | 4.8 ± 0.8 | 4.7 ± 0.8 | 0.094 |
| Q max (mL/s)a | 6.6 ± 1.9 | 7.2 ± 2.3 | 0.108 |
| PVR (mL)a | 135.2 ± 121.1 | 123.2 ± 103.9 | 0.858 |
| PSA (ng/mL)a | 4.0 ± 2.4 | 4.1 ± 2.0 | 0.421 |
| IIEF‐5a | 17.2 ± 2.7 | 17.5 ± 2.4 | 0.383 |
| QMSHQ‐EjFa | 12.6 ± 1.9 | 12.8 ± 1.7 | 0.389 |
| QMSHQ‐EjSa | 1.1 ± 0.9 | 1.2 ± 0.9 | 0.874 |
Nonnormally distributed variable data analysed with the Mann–Whitney U‐test.
Categorical variable data analysed with the chi‐square test.
Table 2.
Baseline criteria of the two groups after PSM.
| Group A | Group B | p | |
|---|---|---|---|
| Patients, n | 54 | 54 | |
| Age (year)a | 71.2 ± 6.7 | 71.3 ± 6.6 | 0.827 |
| Disease duration (year)a | 5.6 ± 2.1 | 5.8 ± 2.8 | 0.774 |
| Hypertensionb | 24 (44.4%) | 25 (46.3%) | 0.847 |
| Diabetesb | 10 (18.5%) | 9 (16.7%) | 0.800 |
| Anticoagulantsc | 14 (25.9%) | 12 (22.2%) | 0.824 |
| Alpha blockersc | 27 (50%) | 29 (53.7%) | 0.832 |
| 5ARIs alone or combined with alpha blockersc | 21 (38.9%) | 23 (42.6%) | 0.855 |
| Urogenital complications | |||
| with acute urinary retentionc | 17 (31.5%) | 17 (31.5%) | 1.000 |
| with gross hematuriac | 19 (35.2%) | 19 (35.2%) | 1.000 |
| with bladder stonesc | 9 (16.7%) | 7 (12.9%) | 0.804 |
| with bladder trabeculae or chambersc | 30 (55.6%) | 34 (62.9%) | 0.523 |
| Prostate volume (mL)a | 63.0 ± 16.0 | 62.9 ± 11.2 | 0.845 |
| IPSSa | 25.4 ± 5.0 | 26.1 ± 4.2 | 0.481 |
| QoLa | 4.8 ± 0.8 | 4.8 ± 0.9 | 1.000 |
| Q max (mL/s)a | 6.9 ± 1.8 | 6.8 ± 1.9 | 0.906 |
| PVR (mL)a | 131.7 ± 121.8 | 139.3 ± 117.3 | 0.770 |
| PSA (ng/mL)d | 4.1 ± 2.6 | 4.1 ± 2.3 | 0.865 |
| IIEF‐5d | 17.5 ± 2.7 | 17.1 ± 2.4 | 0.444 |
| QMSHQ‐EjFd | 12.8 ± 1.9 | 12.6 ± 1.8 | 0.515 |
| QMSHQ‐EjSd | 1.0 ± 0.9 | 1.1 ± 0.8 | 0.157 |
Nonnormally distributed variable data analysed with the Wilcoxon‐Mann‐Whitney test.
Categorical variable data analysed with the chi‐square test.
Categorical variable data analysed with the McNemar test.
Nonnormally distributed variable data analysed with the Mann–Whitney U test.
Table 3.
Intraoperative conditions and early postoperative complications in the two groups.
| Group A | Group B | p | |
|---|---|---|---|
| Operative time (min)a | 56.7 ± 11.6 | 83.2 ± 14.9 | < 0.001 |
| Resected prostate weight (mL)b | 30.8 ± 12.8 | 51.9 ± 11.8 | < 0.001 |
| Hemoglobin decrease (g/dL)b | 6.3 ± 3.1 | 12.9 ± 7.1 | < 0.001 |
| Capsular perforationc | 1 (1.8%) | 3 (5.5%) | 0.250 |
| Catheterization time (days)b | 2.9 ± 0.6 | 2.9 ± 0.5 | 0.866 |
| Hospital stay (days)b | 6.3 ± 0.7 | 6.4 ± 0.7 | 0.742 |
| Urinary retention (%)c | 3 (5.5%) | 1 (1.8%) | 0.250 |
| Postoperative hematuria (%)c | 2 (3.7%) | 3 (5.5%) | 1.000 |
| Hemorrhage (%)c | 2 (3.7%) | 1 (1.8%) | 1.000 |
| Transient incontinence (%)c | 5 (9.3%) | 14 (25.9%) | 0.022 |
| Urinary tract infections (%)c | 6 (11.1%) | 12 (22.2%) | 0.210 |
| Testicular epididymitis (%)c | 0 (0%) | 2 (3.7%) | 0.500 |
| Urethral stricture (%)c | 3 (5.5%) | 3 (5.5%) | 1.000 |
| Bladder neck strictures (%)c | 0 (0%) | 2 (3.7%) | 0.500 |
| Retrograde ejaculation (%)c | 3 (5.5%) | 11 (20.4%) | 0.021 |
Normally distributed variable data analysed with a paired‐sample t‐test.
Nonnormally distributed variable data analysed with the Wilcoxon–Mann–Whitney test.
Categorical variable data analysed with the McNemar test.
Table 4.
IPSS, QoL, Q max, and PVR in the two groups, preoperative and 1 month after surgery.
| Group A | Group B | |||||||
|---|---|---|---|---|---|---|---|---|
| IPSSa | QoLa | Q max (mL/s)a | PVR (mL)a | IPSSa | QoLa | Q max (mL/s)a | PVR (mL)a | |
| Pre | 25.4 ± 5.0 | 4.8 ± 0.8 | 6.9 ± 1.8 | 131.7 ± 121.8 | 26.1 ± 4.2 | 4.8 ± 0.9 | 6.8 ± 1.9 | 139.3 ± 117.3 |
| Post | 9.1 ± 4.1 | 1.9 ± 1.0 | 19.0 ± 4.6 | 8.8 ± 3.7 | 8.8 ± 3.8 | 1.8 ± 1.1 | 18.3 ± 4.1 | 6.9 ± 4.5 |
| p | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 |
Nonnormally distributed variable data analysed with the Wilcoxon–Mann–Whitney test.
Table 5.
Follow‐up data on urinary control function, erection, and ejaculation after surgery in the two groups.
| Group A | Group B | p | |
|---|---|---|---|
| 1 month after surgery | |||
| IPSSa | 9.1 ± 4.1 | 8.8 ± 3.8 | 0.676 |
| QoLa | 1.9 ± 1.0 | 1.8 ± 1.1 | 0.603 |
| Q max (mL/s)a | 19.0 ± 4.6 | 18.3 ± 4.1 | 0.325 |
| PVR (mL)a | 8.8 ± 3.7 | 6.9 ± 4.5 | 0.657 |
| 6 months after surgery | |||
| IPSSa | 7.8 ± 3.3 | 7.8 ± 3.1 | 0.921 |
| QoLa | 1.1 ± 0.7 | 1.0 ± 0.8 | 0.739 |
| Q max (mL/s)b | 20.0 ± 4.2 | 19.2 ± 3.7 | 0.247 |
| PVR (mL)a | 6.5 ± 2.6 | 6.1 ± 3.3 | 0.510 |
| IIEF‐5a | 16.7 ± 2.5 | 15.1 ± 1.8 | < 0.001 |
| QMSHQ‐EjFa | 12.3 ± 1.7 | 10.9 ± 1.3 | < 0.001 |
| QMSHQ‐EjSa | 1.3 ± 0.8 | 2.3 ± 0.7 | < 0.001 |
Nonnormally distributed variable data analysed with the Wilcoxon test.
Normally distributed variable data analysed with a paired‐sample t‐test.
4. Discussion
This study compared several aspects between patients undergoing PLL‐HoLEP and those undergoing traditional HoLEP. These aspects included intraoperative status, early postoperative complications, sexual function, and follow‐up data. First, PSM was used to ensure that Group A and Group B had similar baseline characteristics before surgery. Second, when comparing the intraoperative conditions and early postoperative complications between the two groups, Group A demonstrated significant advantages in both the incidence of urinary incontinence and the number of cases of urethral stricture. This surgical method enhances safety and improves patient satisfaction after the procedure. Finally, follow‐up data at 1 and 6 months postoperatively showed no statistically significant differences in urinary function between the two groups. However, in terms of sexual function preservation, Group A had a greater advantage. These findings indicate that PLL‐HoLEP can better preserve the patient's erectile and ejaculatory function.
Rezūm, iTIND, UroLift, and Transperineal Laser Ablation of the Prostate (TPLA) demonstrate superior preservation of sexual function, notably regarding ejaculatory function, in patients with BPH after surgery [12, 13]. However, when compared to HoLEP, these procedures demonstrate less pronounced improvements in urinary function, and relative reoperation rates are higher [14, 15]. PLL‐HoLEP is a surgical concept rather than an innovative surgical technique. Prostate hyperplasia is benign, and surgery mainly aims to relieve urethral obstruction rather than completely remove prostate tissue. Currently, the theoretical basis of transurethral prostate surgery primarily involves removing some prostate tissue, as seen in procedures such as TURP, transurethral plasmakinetic resection of the prostate (TUPKRP), and HoLEP [4, 16, 17, 18]. To ensure effective surgery, the prostate volume of patients included in this study was less than 100 mL. PLLHoLEP should be avoided in patients with large prostate volumes because it may not fully relieve urethral obstruction. This study showed that urinary function indicators such as IPSS, QoL, Q max, and PVR were similar between the two groups, indicating that PLL‐HoLEP is feasible.
This study showed that the operative time, resected prostate volume, and hemoglobin decrease in Group A were lower than those in Group B. The improvement in this outcome is mainly attributed to the reduction in the number of surgical steps for unilateral lobectomy in Group A. PLL‐HoLEP is a surgical concept, not an innovative surgical method. BPH is benign, and the main purpose of surgery is to relieve urethral obstruction secondary to prostatic enlargement and improve LUTS, rather than the complete removal of prostate tissue [19]. Surgical approaches such as TURP and HoLEP also entail the partial resection of prostate tissue [20, 21]. To ensure surgical efficacy, the study included only patients with a prostate volume of less than 100 mL. For patients with a large prostate volume, PLL‐HoLEP should be avoided as it may not completely alleviate urethral obstruction.
PLL‐HoLEP offers several advantages. First, PLL‐HoLEP can preserve the urethral mucosa of one lateral lobe, avoiding damage and traction of the external and internal urethral sphincters on one lobe, reducing the incidence of postoperative urinary incontinence, and reducing the incidence of urethral stricture and bladder neck contracture. Previous studies have shown that the incidence of bladder neck stenosis (BNS) after HoLEP surgery is approximately 2% [22]. Second, preserving the urethral mucosa from the bladder neck to the prostate apex can significantly reduce the incidence of urinary incontinence after HoLEP [23]. In this study, the incidence of urinary incontinence in Group A was significantly lower than that in Group B. Previous studies have shown that HoLEP has a high incidence of retrograde ejaculation [24, 25]. However, methods preserving the bladder neck or urethral mucosa can reduce this incidence [23, 26]. Research has shown that among 32 patients with preoperative retrograde ejaculation, only four cases of new retrograde ejaculation occurred after holmium laser enucleation of the prostate with only the middle lobe removed [27]. This study showed that Group A had a significantly lower incidence of retrograde ejaculation than Group B, suggesting that PLL‐HoLEP has a protective effect on ejaculation function.
Previous studies have shown that postoperative erectile function in HoLEP patients does not decrease, but there is a significant decrease in ejaculation function [28, 29, 30]. Moreover, reduced ejaculation volume after HoLEP surgery has also been reported [31]. Kim et al. compared ejaculation‐preserving HoLEP with standard HoLEP and found no significant difference in IIEF‐5 scores or improvement in retrograde ejaculation [32]. However, another comparative study reported that while IIEF‐5 scores were similar, the Male Sexual Health Questionnaire‐Ejaculatory Dysfunction Short Form (MSHQ‐EjD‐SF) score at 6 months post‐surgery was significantly higher in the ejaculation‐preserving group [33]. This study showed that Group A had better IIEF‐5, QMSHQ‐EjF, and QMSHQ‐EjS scores than Group B.
PLL‐HoLEP is a consideration for the surgeon to weigh the pros and cons of resection and preservation. However, two precautions should be considered during surgery: (1) Retaining the urethral mucosa on the prostate surface may cause bleeding, requiring thorough hemostasis; (2) Before completing the surgery, inspect the prostatic fossa near the seminal colliculus to ensure the posterior urethra is unobstructed and urine flow is normal. Additionally, this study has several limitations. First, a potential selection bias exists wherein patients who wish to maintain sexual function are younger or possess better baseline sexual function. PSM can mitigate confounding factors such as prostate volume and sexual function between the two groups of patients, resulting in similar baseline characteristics before surgery. Nevertheless, the results may still be influenced by unmeasured or residual confounding factors. Second, the potential for increased reoperation rates resulting from unilateral prostate lobe preservation. The postoperative follow‐up period of only 6 months is relatively short, which limits the accurate assessment of long‐term effectiveness and reoperation rates. Therefore, extending the follow‐up period will further elucidate these outcomes. Third, this study represents the initial experience of individual surgeons, which may affect the reproducibility and universality of techniques and findings. Finally, this study is retrospective with a small sample size. Although PSM was employed, there is still potential bias in comparisons between patients at different stages. Therefore, prospective randomized large‐sample comparative studies with long‐term follow‐up are needed to validate our research findings.
5. Conclusion
For patients who satisfy the inclusion and exclusion criteria, PLL‐HoLEP can reduce the incidence of transient urinary incontinence and retrograde ejaculation and more effectively preserve the sexual function of patients with BPH.
Author Contributions
Protocol/project development, performance of operations, data collection, data analysis, and manuscript writing/editing: Yunwu Hao. Data collection: Qianjun Liang. Data analysis: Bin Liu. Manuscript editing: Yao Jiang. Protocol/project development and manuscript writing/editing: Degang Chen. All authors read and approved the final manuscript.
Ethics Statement
The study was approved by the Ethics Committee of Lu'an Hospital Affiliated to Anhui Medical University. All methods were performed following the relevant guidelines and regulations.
Consent
Informed consent was obtained from all the participants by completing the survey.
Conflicts of Interest
The authors declare no conflicts of interest.
Acknowledgments
The author would like to thank all the staff of the Department of Urology for their support in generating this manuscript. The author sincerely thanks the support of the Science and Technology Project Fund of Bengbu Medical University, Anhui Province.
Hao Y., Liang Q., Liu B., Jiang Y., and Chen D., “Holmium Laser Enucleation of the Prostate (HoLEP) With Proactive Preservation of One Lateral Lobe: A Technique for Benign Prostatic Hyperplasia to Preserve Sexual Function,” Prostate 86 (2026): 1307‐1315, 10.1002/pros.70209.
Yunwu Hao and Qianjun Liang contributed equally to this study.
Data Availability Statement
The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data sets used and/or analyzed during the current study are available from the corresponding author on reasonable request.