Comparative efficacy and safety of low-power versus high-power holmium laser enucleation of the prostate for benign prostatic hyperplasia: an updated meta-analysis.

BACKGROUND

Holmium laser enucleation of the prostate (HoLEP) is the gold-standard surgical treatment for benign prostatic hyperplasia, irrespective of the prostate size. However, the optimal laser power setting remains uncertain. High-power systems (80-100 W) are commonly used in clinical practice, while emerging evidence suggests that low-power settings (24-50 W) may offer comparable efficacy with potential functional and safety advantages.

OBJECTIVE

To compare the perioperative, functional, and safety outcomes of low-power versus high-power HoLEP based on randomized controlled trials.

METHODS

We conducted a systematic review and meta-analysis of RCT comparing low-power (24-50 W) and high-power (80-100 W) HoLEP, searching four electronic databases from inception till April 2025. The data extracted on primary outcomes include International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), post-void residual volume (PVR), quality of life (QoL), and Clavien-Dindo-graded complications. Secondary outcomes included operative efficiency metrics. A random-effects model was used to calculate pooled effect sizes with 95% confidence intervals. Risk of bias was assessed using the Cochrane risk of bios (RoB 2) tool.

RESULTS

Four trials (n = 394) were included. Low-power and high-power HoLEP showed similar IPSS improvement [MD: -0.30 (95% CI: -1.00 to 0.41)] and Qmax (0.30 ml/s, -0.42 to 1.01). Low-power HoLEP resulted in better QoL [MD: 0.20 (95% CI: 0.10-0.31] and reduced PVR (-2.33 ml, -4.09 to -0.58). High-power HoLEP had shorter operative (-12.62 min) and enucleation times (-6.89 min). Safety outcomes revealed no significant differences.

CONCLUSION

Low-power HoLEP is clinically non-inferior, providing comparable symptom relief and urinary flow improvement with better quality-of-life outcomes and more complete bladder emptying. Although operative times are modestly longer, the safety profile remains equivalent. These findings support low-power HoLEP as a viable surgical option.