Comparison of three-lobe and en-bloc techniques during the holmium laser enucleation of the prostate learning curve: a prospective, multicenter, cohort study

The aim of this study was to compare the safety and effectiveness of the three-lobe and en-bloc techniques during the learning curve of holmium laser enucleation of the prostate.

We conducted a prospective, parallel-group, multicenter study that included patients who underwent holmium laser enucleation of the prostate between February and December 2024 at two tertiary urology departments. Patients with prostate volumes ≥80 cm3 scheduled for holmium laser enucleation of the prostate were alternately assigned (1:1) to either the three-lobe or en-bloc technique. Exclusion criteria included use of anticoagulants, prostate biopsy within the previous month, diagnosis of prostate cancer, or a history of pelvic surgery or radiotherapy associated with overactive bladder symptoms. The study evaluated the performance of a single surgeon at each center using either the three-lobe or en-bloc technique during their holmium laser enucleation of the prostate learning curve. Primary outcomes were enucleation time/efficiency and complications. Secondary outcomes included postoperative incontinence and functional outcomes.

A total of 116 patients were enrolled in the study, with 60 in the three-lobe group and 56 in the en-bloc group. Patients in the en-bloc group were older than those in the three-lobe group (69.4 vs. 64.9 years, p=0.001). Body mass index and performance scores were comparable between groups. The mean prostate volume was 83.5 cm3 in the three-lobe group and 81.3 cm3 in the en-bloc group (p=0.732). No significant differences were observed in prostate volume or Prostate-Specific Antigen density. Short-term complication rates and postoperative urinary incontinence were similar between techniques. Operative and enucleation times were significantly shorter in the en-bloc group compared to the three-lobe group (86.1 vs. 107.4 min, p=0.042; 56.7 vs. 72.9 min, p=0.001, respectively). However, enucleation and morcellation efficiencies did not differ significantly. Other intraoperative parameters, as well as postoperative functional outcomes and uroflowmetry measurements, were comparable between the groups.

The en-bloc technique demonstrated comparable safety and functional outcomes to the three-lobe technique but offered significantly shorter operative and enucleation times during the holmium laser enucleation of the prostate learning curve.