HoLEP using a 21 Fr internal urethrotomy sheath, a feasible alternative to MiLEP in resource-limited settings

Holmium laser enucleation of the prostate (HoLEP) is an effective, size-independent surgical treatment for benign prostatic hyperplasia; however, the use of large-caliber resectoscope sheaths may increase urethral trauma. Dedicated minimally invasive laser enucleation of the prostate (MiLEP) systems aim to reduce this risk but are not universally available. This study aimed to evaluate whether a modified HoLEP technique using a 21 Fr internal urethrotomy sheath (mLC-HoLEP) technique performed with commonly available endourological instruments provides comparable short-term functional and safety outcomes to conventional HoLEP in settings without access to dedicated MiLEP systems.

This single-center retrospective cohort study included patients who underwent standard HoLEP (n = 48) or mLC-HoLEP (n = 47) between January 2021 and May 2023. The mLC-HoLEP technique utilized a 21 Fr internal urethrotomy sheath combined with passive bladder drainage via a 16 G suprapubic cannula, followed by standard morcellation with a 26 Fr morcelloscope. Groups were matched using propensity score matching. Perioperative parameters, functional outcomes (IPSS, Qmax, postvoid residual urine), irrigation volume, and early postoperative complications were compared.

Baseline demographic and preoperative characteristics were comparable between groups. Operative time, enucleation time, morcellation time, hemoglobin drop, and specimen weight showed no significant differences. Total irrigation volume was significantly lower in the mLC-HoLEP group (p < 0.001). Postoperative IPSS, Qmax, and residual urine volumes were similar between groups. Early postoperative complications and Clavien-Dindo complication grades did not differ significantly. No complications related to suprapubic drainage were observed.

Modified low-caliber HoLEP performed with commonly available endourological instruments offers comparable functional efficacy and safety to conventional HoLEP while significantly reducing irrigation volume, representing a feasible resource-adapted technical modification that eliminates the need for additional equipment acquisition, with potential practical advantages particularly in resource-limited settings.