En bloc HoLEP with vesical mucosal release: a technical refinement for safety and operative efficiency.

OBJECTIVES: To describe a vesical mucosal release modification of the en bloc holmium laser enucleation of the prostate (HoLEP) technique and report its perioperative outcomes, and to compare the operative efficiency of this modification when performed with high-power (100 W) versus low-power (50 W) holmium laser. METHODS: This is a retrospective study of 194 consecutive patients who underwent en bloc HoLEP with vesical mucosal release between January 2024 and October 2025 for benign prostatic obstruction (BPO). Laser assignment was guided by operating room logistics and prostate volume feasibility, with the 50 W system limited to glands < 120 mL. Perioperative outcomes were compared between laser groups. Multivariable regression was used to assess the independent association between laser power and enucleation time, adjusting for tissue workload. RESULTS: Median prostate volume was 80.0 mL (IQR 60.0–101.5) and median enucleated tissue weight was 37.0 g (IQR 20.7–60.9). Median total operative time was 83.0 min (IQR 59.0–109.8). Vesical mucosal release was successfully performed in all patients. Overall complications occurred in 3 patients (1.5%). Ureteric orifice injury occurred in 1 patient (0.5%). Transient stress urinary incontinence at 1 month was observed in 4 patients (2.0%), with no cases at 3 months. After adjustment for tissue workload, laser power was not independently associated with enucleation time (p = 0.059), though this borderline result warrants cautious interpretation given the non-randomised design. CONCLUSIONS: The vesical mucosal release modification of en bloc HoLEP demonstrated a favourable safety profile with low complication rates and preserved early continence across different laser power settings. Prospective comparative studies are needed to establish the relative benefit of this technical modification.