HoLEP for large and mega glands: real-world outcomes and evidence of size-enhanced efficiency

The term "mega gland" commonly refers to prostates > 200 mL on preoperative imaging. These glands are traditionally perceived as technically challenging for holmium laser enucleation of the prostate (HoLEP) due to increased vascularity, difficult dissection planes, and instrument length limitations. We evaluated perioperative outcomes and procedural efficiency of HoLEP for mega glands compared with large glands (120-200 mL).

We performed a single-center retrospective analysis of patients undergoing HoLEP for glands ≥ 120 mL between January 2021 and June 2025. Patients were categorized into large (120-200 mL) and mega (> 200 mL) gland groups. Baseline characteristics, intraoperative parameters, efficiency metrics, and postoperative outcomes were compared using Wilcoxon rank-sum, Pearson's Chi square, and Fisher's exact tests.

Among 602 HoLEPs performed, 243 patients met inclusion criteria, including 208 with large glands and 35 with mega glands. Baseline characteristics were similar, although mega glands had higher PSA values (9.9 vs 5.6 ng/mL, p = 0.001). Operative time was longer in mega glands (114 vs 96 min, p = 0.003). However, enucleation speed (2.8 vs 1.6 g/min, p < 0.001) and energy efficiency (0.8 vs 0.5 g/kJ, p < 0.001) were significantly higher despite similar enucleation times. Postoperative outcomes, including catheter duration, failed void trial, emergency department visits, readmissions, and 3-month PROMs, were similar between groups.

HoLEP for prostates > 200 mL showed higher enucleation speed and energy efficiency without worse short-term outcomes. These findings suggest HoLEP may be a size-enhanced procedure, not merely size-independent. Further work is needed to define this efficiency threshold more precisely and explore its clinical implications.