Lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is one of the most common diseases affecting the aging man, with almost 80% of men greater than 70 affected. Historically, transurethral resection of the prostate (TURP) has been considered the historical gold standard in the treatment of LUTS due to BPH for many years, contemporary literature indicates that holmium laser enucleation of the prostate (HoLEP) has replaced TURP and open simple prostatectomy as surgical gold standard for BPH treatment. This study was to evaluate  the safety and efficiency of ‘En-bloc’ holmium laser enucleation of the prostate (HoLEP) in the treatment of small prostate (less than 25 mL) patients with lower urinary tract symptoms (LUTS).

716 consecutive patients who underwent HoLEP by a single surgeon using ‘Inverted omega-shaped En-bloc’ HoLEP technique to treat bladder outlet obstruction from 2014 to 2021 were retrospectively analyzed. Patients were divided into group 1 (<25 cc, mean 21.5 cc, n=105), group 2 (25-35 cc, mean 29.9 cc, n=156), group 3 (<35 cc, mean 59.2 cc, n=455). Perioperative parameters, safety and functional outcomes were assessed and analyzed.

Mean ages, body mass index, and comorbid disease of 3 groups were no significant difference but showed a significantly higher median PSA level in larger prostate sizes (p<0.01). Perioperative parameters, such as enucleation time (28.3±21.4 min), morcellation time (5.5±5.2 min), and catheterization duration (1.6±1.5 day) were significantly shorter in group 1 (p<0.01). The significant improvements of IPSS (total, voiding, storage, and quality of life), PVR, and Qmax were showed from 3 months after HoLEP, and continued during the 1-year follow-up period in all groups (p<0.01). Postoperative complications in the all patients were urethral stricture 11 (1.5%), bladder neck contracture 12 (1.7%), urinary incontinence 14 (2.0%), and bladder injury by morcellator 4 (0.6%). But urethral stricture and bladder injury by morcellation were not occurred in group 1. Postoperative surgical managements (Re-HoLEP) for bladder neck contracture were 6 (5.7%) in group 1, 5 (3.2%) in group 2, and 1 (0.2%) in group 3. And Re-HoLEP for regrowing adenoma were 2 (1.9%) in group 1, 3 (1.9%) in group 2, and 10 (2.2%) in group 3. Postoperative cholinergics medications for underactive bladder were 10 (9.5%) in group 1. Postoperative incidental prostate cancers were 34 (4.8%), but no one (0%) in group 1.

The significant improvements of IPSS (total, voiding, storage, and quality of life), PVR, and Qmax were showed in from 3 months after HoLEP, and continued during the 1-year follow-up period in samll sizef prostae group (<25mL) (p<0.01). Bladder neck contracture were relatively higher in small prostate group (<25 mL) and could be resolved with  Re-HoLEP.. But operation time, catheterization time, and other complication rates were significantly differed in favor of smaller prostate sizes (p<0.01).

‘Inverted omega-shaped En-bloc’ HoLEP technique is safe and effective for the treatment of bladder outlet obstruction in LUTS patients with small prostate (less than 25 mL).