Low-power versus high-power laser for holmium laser enucleation of prostate: systematic review and meta-analysis

Holmium laser enucleation of the prostate (HoLEP) has emerged as a minimally invasive alternative to transurethral resection of the prostate (TURP), offering benefits such as reduced bleeding and faster recovery. While high-power (HP, 80-100 W) is widely used, low-power (LP, 20-50 W) has gained attention for its cost-effectiveness and versatility. This study presents the first meta-analysis of randomized controlled trials (RCTs) comparing the outcomes of low-power (LP) and high-power (HP) HoLEPin patients with benign prostatic hyperplasia (BPH).

RCTs were retrieved from PubMed, Embase, Web of Science, and the Cochrane Library up to February 28, 2025. Primary outcomes included the International Prostate Symptom Score (IPSS) at three months and intraoperative enucleation efficiency (EE). Secondary outcomes encompassed IPSS, maximum urinary flow rate (Qmax), post-void residual urine volume (PVR), quality of life (QoL) at three and six months, as well as complication incidence and hemoglobin decrease. Statistical analysis was performed using RevMan 5.3.

Five studies involving 488 patients (242 in the LP group and 246 in the HP group) were included, with low heterogeneity. LP- and HP-HoLEP demonstrated comparable outcomes in IPSS (MD: 0.45 points, p = 0.35), Qmax (MD: 0.30 mL/s, p = 0.49), PVR (MD: -2.92 mL, p = 0.53), and QoL (MD: 0.16 points, p = 0.46) at three months, with similar results observed at six months. LP-HoLEP showed lower EE (MD: -0.17 g/min, p < 0.00001) but no differences in hemoglobin decrease (MD: 0.00 g/dL, p = 0.95) or complication rates (RR: 0.85, p = 0.37).

Although LP-HoLEP may be associated with lower EE, it demonstrates comparable efficacy and safety. Further high-quality studies are necessary to strengthen the evidence base and promote broader clinical adoption of LP-HoLEP.