Does miniaturisation improve holmium laser enucleation of prostate outcomes? A meta-analysis of comparative studies

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.

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.

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.

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.