Safety and Efficacy of Laser Enucleation of the Prostate in Elderly Patients - A Narrative Review

The Implementation of Trifecta Score to Assess the Quality of Holmium Laser Enucleation of the Prostate in Elderly Patients: An Analysis of Perioperative and Functional Outcomes and the Impact of Age

Background: The aim of this study was to assess the efficacy and safety of Holmium Laser Enucleation of the Prostate (HoLEP) in the treatment of symptomatic benign prostatic hyperplasia (BPH) in elderly patients using the Trifecta Score, based on a 1-year follow-up. Methods: We conducted a retrospective analysis of patients with BPH who underwent HoLEP at our institution between January 2016 and December 2022. The patients were divided into two groups: Group 1: patients aged ≥75 years, Group 2: patients aged below 74 years. The Trifecta Score achievement rates were then evaluated. Logistic regression analyses were performed to examine the impact of age on Trifecta parameters and to assess factors associated with urinary incontinence. Results: Overall, 981 participants were enrolled, with 490 in Group 1 and 491 in Group 2. Operative characteristics were similar between groups, though Group 1 had a longer time to catheter removal. At the 3-month follow-up, Group 1 had a higher IPSS and lower Qmax compared to Group 2, while there were no significant differences in functional outcomes by one year. In terms of postoperative morbidities, Group 1 exhibited a higher rate of blood transfusion. The Trifecta Score was similar between Groups 1 and 2 (63.5% vs. 68.8%, respectively, p = 0.08), and no parameter of that score exhibited a negative correlation with age. Conclusions: HoLEP demonstrates comparable functional outcomes to those observed in younger cohorts after one year. Overall, the Trifecta Score appears to be a valuable tool for this assessment. Nevertheless, incorporating an assessment of postoperative urinary continence and 1-year postoperative Qmax could enhance the system's validity.

Comparative study of HoLEP in elderly patients with indwelling catheters: a retrospective dual-center study

INTRODUCTION

This study aimed to evaluate the safety and efficacy of HoLEP in patients aged > 85 years with indwelling catheter (IDC).

METHODS

We retrospectively analyzed our bicentric HoLEP database to identify consecutive patients with IDC and trial without catheter (TWOC) failure who underwent surgery between June 2012 and April 2020. Our primary focus was on the population over 85 years of age; Patients under 70 years of age were used as controls. We evaluated the rate of postoperative spontaneous micturition, adverse events and mortality, as well as catheterization duration, hospital stay, and rate of urinary incontinence.

RESULTS

In total, 144 patients were included, with 71 (49.3%) and 73 (50.8%) in the ≥ 85 and control group, respectively. The median [IQR] prostatic volume and Charlson score was 90 [70-130] vs. 90 [65-120] mL and 6 [5-7] vs. 3 [2-4] in the ≥ 85 and control groups, respectively. Postoperatively, the rates of major complications (2% vs. 3%) and transfusion (11% vs. 9%) were not significantly different. The median length of stay (2 [1-3] vs. 1 [1-2]; p = 0.03) and rate of TWOC failure during hospitalization (24% vs. 5%, p < 0.001) were significantly higher in the ≥ 85 group. At 3 months and one year follow-up visits, 0 and 10 patients (14.1%) in the ≥ 85 group and 0 and 2 patients (3%) in the control group died, respectively. One year after surgery, 69 (97%) and 73 (100%) (p = 0.2) patients in the ≥ 85 and control groups, respectively, could void spontaneously.

CONCLUSION

HoLEP is a safe and effective procedure for elderly patients with indwelling catheters. At one year, 97% of patients achieved spontaneous voiding, while the urinary incontinence rate was 11%. The 1-year mortality rate was 14%, comparable to that of the general male population of the same age.

A Programmatic Approach to En Bloc Transurethral Enucleation of the Prostate with Bipolar System: A Single-Center Retrospective Report

INTRODUCTION

This study presents a systematic approach for en bloc transurethral enucleation of the prostate utilizing a bipolar system (TUEB), evaluating its effectiveness and safety. Furthermore, the research aims to pinpoint risk factors contributing to early stress urinary incontinence (SUI) after undergoing en bloc TUEB.

METHODS

The en bloc TUEB procedure is visually demonstrated through images and videos. A retrospective analysis was conducted based on the data of 88 patients diagnosed with benign prostatic hyperplasia (BPH) who underwent en bloc TUEB between January 2018 and April 2023. Detailed perioperative and follow-up clinical data were collected and analyzed. Patients were categorized based on the occurrence of SUI, and their clinical characteristics were analyzed.

RESULTS

The mean surgical duration was 113.1 ± 50.0 min, resulting in an excised prostate gland weighing 58.0 ± 34.3 g and a hemoglobin drop of 14.3 ± 11.2 g/L. The average enucleation rate was 79.00 ± 11.01%, enucleation efficiency was 0.54 ± 0.26 g/min and prostate-specific antigen reduction rate was 42.08 ± 22.85%. There were no major complications during operation. Twenty-three patients (26.13%) developed early SUI after catheter removal, and 74% of them were in remission within 1 month. Importantly, no cases of persistent SUI were observed. Lower urinary tract symptoms (LUTSs) duration was significantly different between patients with and without postoperative SUI. Residual urine volume, International Prostate Symptom Score (IPSS), and Quality of Life (QoL) score were significantly improved in BPH patients after surgery (p < 0.05). Twelve months after surgery, only 2 patients (2.27%) had urethral stricture, although it recovered after transurethral dilation.

CONCLUSIONS

En bloc TUEB is proven to be effective, practical, efficient, and safe with minimal complications. This procedure could be standardized and widely adopted. LUTS duration can predict the risk of early SUI.

General anesthesia is associated with lower perioperative bleeding and better functional outcomes than spinal anesthesia for endoscopic enucleation of the prostate: a single-center experience

PURPOSE

Holmium laser enucleation of the prostate (HoLEP) and bipolar transurethral enucleation of the prostate (B-TUEP) are safe and effective treatment options for benign prostatic hyperplasia (BPH). Spinal anesthesia (SA) is widely used for endoscopic enucleation of the prostate (EEP) in place of general anesthesia (GA). We aimed to assess the impact of GA vs. SA on blood loss, postoperative course and functional outcomes after HoLEP and B-TUEP.

METHODS

After propensity score matching, we analyzed data from 148 patients treated with EEP in our centre for symptomatic BPH. We recorded patient's characteristics, procedural data, type of anesthesia (SA vs. GA). Postoperatively we evaluated hemoglobin drop, catheterization time (CT), and length of hospital stay (LOS). Functional outcomes were evaluated with the International Prostate Symptoms Score (IPSS) at baseline and 3 months after surgery. Descriptive statistics and linear regression models tested the association between anesthesia type and EEP outcomes.

RESULTS

After matching groups were comparable in terms of pre- and intra-operative variables. Of all, 111 (75%) patients were treated under SA. Haemoglobin drop was lower in GA compared to SA group (1 vs. 1.4 g/dL, p < 0.01). CT was shorter in the GA group (1 vs. 2 days, p = 0.01). Postoperative IPSS score was lower in GA group (4 vs. 8, p = 0.04). Multivariable linear regression models revealed that prostate volume (p = 0.01) and SA vs. GA (p = 0.01) were associated with higher haemoglobin drop, after accounting for age and use of anticoagulants/antiplatelets. Similarly, SA vs. GA (p = 0.02) and postoperative complications occurrence (p < 0.001) were associated with a longer LOS, after accounting for age, prostate volume and use of anticoagulants/antiplatelets.

CONCLUSION

EEP can be safely performed under both GA and SA. GA offers better outcomes in terms of perioperative bleeding and 3-month functional outcomes.

Predictors of Postoperative Urinary Incontinence After Holmium Laser Enucleation of the Prostate (HoLEP) for Surgeons Early in Their Experience

OBJECTIVES

To evaluate factors impacting continence recovery following holmium laser enucleation of the prostate (HoLEP) for surgeons early in their HoLEP experience.

METHODS

Predefined factors were evaluated from a prospectively maintained database for their impact on the recovery of continence after HoLEP. Both surgeons had performed fewer than 150 HoLEPs as attending physicians. Inclusion criteria were subjects with at least 6 months of incontinence data or documented recovery of continence. One or fewer pads per day was defined as continence. Statistical analyses were performed using R and Prism and included Spearman correlations, linear modeling, and Mantel-Cox log-rank testing as appropriate.

RESULTS

From December 2020 to May 2023, 152 subjects met inclusion criteria with a median age of 70 (range: 51-93). The median case number was 56 (1-146). Within the study period, 144/152 (94.7%) recovered continence at a median of 1.6 months postoperatively. Linear modeling demonstrated that younger age (p = 0.01) and shorter enucleation time (p = 0.001) predicted recovery. Enucleation time less than 100 min predicted earlier continence recovery based on Mantel-Cox testing (p = 0.0004).

CONCLUSIONS

During the surgeons' HoLEP learning curve, age, and enucleation time were predictive of the recovery of continence. Enucleation time under 100 min predicted a faster rate of continence recovery. The relationship between enucleation time and continence recovery may be demonstrative of case difficulty or may be a result of pressure on the external urethral sphincter during enucleation. These findings further our understanding of HoLEP outcomes early in a surgeon's learning curve.

Emergency department visits following transurethral resection of prostate in the elderly: Does duration of postoperative catheterization count?

Background

Elderly patients with benign prostatic hyperplasia are increasingly having minimally invasive surgeries due to their safety. There is also a drive to minimize the duration of postoperative catheterization following transurethral resection of the prostate to reduce hospital stay and encourage early ambulation. These are desirable in the elderly to improve outcomes. Can early catheter removal be done safely in the geriatrics without an increase in presentation to the emergency department with complications? We compare the emergency presentation of elderly patients who had early and delayed catheter removal following transurethral resection of the prostate.

Materials and Methods

This was a retrospective review of transurethral resection of the prostate in the elderly (≥70 years) within 2 years in a single hospital. All the patients had monopolar transurethral resection of the prostate and were categorized based on the duration of postoperative catheterization as either early (third postoperative day) or delayed (> third postoperative day). The duration of catheterization was based on surgeon preference. Patients with intraoperative complications were excluded. Data on clinical presentation, comorbidities, and presentation at the emergency department were retrieved and analysed.

Results

Forty-one patients were studied with the mean age of patients being 76 ± 4 years. Twenty patients had early catheter removal and 21 had delayed catheter removal. A total of nine patients presented to the emergency department within the 30-day postoperative period with either bleeding urinary retention or incontinence requiring re-catheterization, six had early catheter removal, and three had delayed catheter removal. The catheter duration, preoperative ASA status prostate volume, and preoperative indwelling catheter were not statistically significant determinants of presentation to the emergency department in these elderly men. The presence of comorbidities assessed using the Charlson Comorbidity Index was a statistically significant variable to presentation at the emergency department after surgery P = 0.006.

Conclusion

Early catheter removal is safe in elderly patients following transurethral resection of the prostate, however, there is a risk of presentation to the emergency department with complications, especially in patients with comorbidities.

Construction of lncRNA- and circRNA-associated ceRNA networks in the prostatic urethra of rats after simulating transurethral laser prostatectomy (TULP)

Non-coding RNA appears to be involved in wound repair. Competing endogenous RNA (ceRNA) appears to be an important post-transcriptional mechanism, it means that long noncoding RNA (lncRNA) or circular RNA (circRNA) acts as a microRNA (miRNA) sponge to further regulate mRNA. However, ceRNA network related to wound repair after prostatectomy has yet been constructed. TULP is the main surgical method of prostatectomy, but there have been no reports of TULP rat models in the past. We simulated TULP on rats, and observed the whole process of wound injury and repair after operation through pathological examination of wound tissue. Next, we discovered 732 differentially expressed lncRNAs (DElncRNAs), 47 differentially expressed circRNAs (DEcircRNAs), 17 differentially expressed miRNAs (DEmiRNAs), and 1892 differentially expressed mRNAs (DEmRNAs) related to wound repair after TULP through full transcriptome microarray and bioinformatics methods, and confirmed the reliability of transcriptome data by quantitative Reverse Transcription PCR (qRT-PCR), and immunohistochemistry. Then, we constructed the lncRNA- and circRNA-associated ceRNA regulatory networks related to wound repair after TULP in rats. Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses showed that molecules in these networks were mainly involved in inflammatory infiltration, cell differentiation, and intercellular interactions and involved signal pathways such as the PI3K-Akt signaling pathway. Thus, this study successfully established the TULP model in rats, revealed potentially important biomarkers and ceRNA networks after prostatectomy in rats, and provided theoretical support for the repair of post-prostatectomy wound.

Evaluation of Current Surgical BPH Interventions for Young and Elderly Men

PURPOSE OF REVIEW

Benign prostatic hyperplasia affects the quality of life of a significant number of men, especially as they age. There are continuous innovations in the surgical management of benign prostatic hyperplasia, but many of these innovations are studied in the core population of men 50-70 years of age. This review focuses on the outliers of men aged 18-50 and 70 and older.

RECENT FINDINGS

Older populations have more comorbidities, higher rates of antithrombotic medications, and advanced symptoms. Properly selected older men can safely have significant objective and subjective improvement in their symptoms. The literature was scarce when evaluating younger men; however, ejaculatory preserving techniques are promising providing improvement in symptoms and preserving ejaculation. This review demonstrates that in properly selected elderly patients, improvements in quality of life while also providing safe surgical interventions can be achieved. Ejaculatory preservation techniques demonstrate promising results, but further studies are required to elucidate true outcomes.

Results from a global multicenter registry of 6193 patients to refine endoscopic anatomical enucleation of the prostate (REAP) by evaluating trends and outcomes and nuances of prostate enucleation in a real-world setting

PURPOSE

To collect a multicentric, global database to assess current preferences and outcomes for endoscopic enucleation of the prostate (EEP).

METHODS

Endourologists experienced in EEP from across the globe were invited to participate in the creation of this retrospective registry. Surgical procedures were performed between January 2020 and August 2022.

INCLUSION CRITERIA

lower urinary tract symptoms not responding to or worsening despite medical therapy and absolute indication for surgery.

EXCLUSION CRITERIA

prostate cancer, concomitant lower urinary tract surgery, previous prostate/urethral surgery, pelvic radiotherapy.

RESULTS

Ten centers from 7 countries, involving 13 surgeons enrolled 6193 patients. Median age was 68 [62-74] years. 2326 (37.8%) patients had large prostates (> 80 cc). The most popular energy modality was the Holmium laser. The most common technique used for enucleation was the 2-lobe (48.8%). 86.2% of the procedures were performed under spinal anesthesia. Median operation time was 67 [50-95] minutes. Median postoperative catheter time was 2 [1, 3] days. Urinary tract infections were the most reported complications (4.7%) followed by acute urinary retention (4.1%). Post-operative bleeding needing additional intervention was reported in 0.9% of cases. 3 and 12-month follow-up visits showed improvement in symptoms and micturition parameters. Only 8 patients (1.4%) required redo surgery for residual adenoma. Stress urinary incontinence was reported in 53.9% of patients and after 3 months was found to persist in 16.2% of the cohort.

CONCLUSION

Our database contributes real-world data to support EEP as a truly well-established global, safe minimally invasive intervention and provides insights for further research.

Perioperative care based on roy adaptation model in elderly patients with benign prostatic hyperplasia: impact on psychological well-being, pain, and quality of life

PURPOSE

This study aimed to assess the impact of perioperative care based on the Roy Adaptation Model (RAM) on psychological well-being, postoperative pain, and health-related quality of life (HRQoL) in elderly patients with benign prostatic hyperplasia (BPH) undergoing transurethral resection of the prostate (TURP).

METHODS

A total of 160 elderly patients diagnosed with BPH between June 2021 and June 2022 and scheduled for TURP were randomly assigned to either the routine care group (n = 80) or the RAM group (n = 80). The RAM group received standard care supplemented with interventions based on the RAM model. Negative emotions measured by the Hospital Anxiety and Depression Scale (HADS), pain intensity by the Visual Analog Scale (VAS), and HRQoL by the 36-Item Short Form Health Survey (SF-36) were measured at the preoperative visit (T0), at 30 days (T1), and at 3 months of (T2) follow‑up.

RESULTS

Repeated measures ANOVA revealed significant differences in psychological well-being, postoperative pain intensity, and HRQoL within both the routine care and RAM groups across the three time points. Holm-Sidak's multiple comparisons test confirmed significant differences between each time point for both groups. The RAM intervention led to significant reductions in anxiety and depression levels, alleviation of postoperative pain intensity, and improvements in various domains of HRQoL at T1 and T2 compared to routine care.

CONCLUSION

Incorporating the RAM model into perioperative care for elderly patients undergoing TURP for BPH has shown promising results in improving psychological well-being, reducing postoperative pain intensity, and enhancing HRQoL.

Predictors of early catheter replacement after HoLEP. Results from a high-volume laser center

INTRODUCTION

The aim of the study was to investigate clinical and surgical factors associated with early catheter replacement in patients treated with Holmium Laser Enucleation of the Prostate (HoLEP).

MATERIALS AND METHODS

Data of patients treated with HoLEP at our Institution by a single surgeon from March 2017 to January 2021 were collected. Preoperative variables, including non-invasive uroflowmetry and abdominal ultrasonography (US), were recorded. Bladder wall modifications (BWM) at preoperative US were defined as the presence of single or multiple bladder diverticula or bladder wall thickening 5 mm. Clinical symptoms were assessed using validated questionnaires. Only events occurred within the first week after catheter removal were considered.

RESULTS

Overall, 305 patients were included, of which 46 (15.1%) experienced early catheter replacement. Maintenance of anticoagulants/antiplatelets (AC/AP) therapy at surgery (p=0.001), indwelling urinary catheter (p=0.02) and the presence of BWM (p=0.001) were more frequently reported in patients needing postoperative re-catheterization. Intraoperative complications (p=0.02) and median lasing time (p=0.02) were significantly higher in this group. At univariate analysis, indwelling urinary catheter (p=0.02), BWM (p=0.01), ongoing AC/AP therapy (p=0.01) and intraoperative complications (p=0.01) were significantly associated with early catheter replacement. At multivariate analysis, indwelling urinary catheter (OR: 1.28; p=0.02), BWM (OR: 2.87; p=0.001), and AC/AP therapy (OR: 2.21; p=0.01) were confirmed as independent predictors of catheter replacement.

CONCLUSIONS

In our experience the presence of indwelling urinary catheter before surgery, BWM and the maintenance of AC/AP therapy were shown to be independent predictors of early catheter replacement after HoLEP.

En bloc holmium laser enucleation of prostate in octogenarians and nonagenarians: clinical characteristics and outcome

Extended longevity leads to greater numbers of elderly patients with benign prostatic hyperplasia (BPH) who seek surgical solutions. We assessed the clinical characteristics and outcomes of octogenarians and nonagenarians with BPH who underwent en bloc holmium laser enucleation of prostate (HoLEP). Retrospective cohort of all consecutive HoLEP patients treated in our medical center between January 2020 and January 2023. Cohort was divided into group aged < 80 years (n = 290) and group aged ≥ 80 years (n = 77). Their demographics, presentations, indications, and outcomes were compared. Octogenarians and nonagenarians had higher rates of indwelling catheters (p = 0.00001), chronic retention (p = 0.00006), larger prostates (p = 0.03), higher American Anesthesiology Association scores (p = 0.000001), and more antiplatelet medications (p = 0.0003) at presentation. They had longer operations (median 115 vs 90 min, respectively, p = 0.0008), longer hospital stay (median 2 vs 1 day, p = 0.01E-7), a higher complication rate (17% vs 7%, p = 0.02), and a higher transitory urinary incontinence (TUI) rate (54% vs 9%, p = 0.00001). TUI was more prevalent in the older group with indwelling catheters (61% vs, 13%, p = 0.00001). The functional outcome was similar for both age groups, and all patients could void spontaneously after the procedure. En-bloc HoLEP improves urinary symptoms and quality of life in patients ≥ 80 years of age despite larger prostates, more comorbidities, and higher complications rate, compared to younger men. HoLEP bestows a significant improvement in urologic quality of life regardless of age.

Efficacy and Safety of 1470 nm Diode Laser Enucleation of the Prostate in Elderly Benign Prostatic Hyperplasia Patients

Objective: The aim of this study was to evaluate efficacy and safety of 1470 nm diode laser enucleation of the prostate (DiLEP) and plasmakinetic resection of the prostate (PKRP) in elderly benign prostatic hyperplasia (BPH) patients with lower urinary tract symptoms. Methods: A total of 123 elderly patients with BPH were randomized to undergo either 1470 nm DiLEP or PKRP by means of a random number table from September 2020 to April 2022. The perioperative and postoperative data were studied during a 3- and 6-month follow-up. Results: The patients treated with 1470 nm DiLEP had significantly decreased operation time (74.6 ± 17.0 vs 98.8 ± 18.9 minutes, p < 0.001), hemoglobin loss (1.06 ± 0.49 vs 1.59 ± 0.60 g/dL, p < 0.001), bladder irrigation time (22.1 ± 8.1 vs 33.9 ± 10.0 hours, p < 0.001), catheter duration (3.2 ± 1.3 vs 5.8 ± 1.0 days, p < 0.001), and hospital stay (7.6 ± 1.4 vs 9.6 ± 1.3 days, p < 0.001) compared with the PKRP group. Besides, International Index of Erectile Function-5 score of 1470 nm DiLEP group at postoperative 3- and 6-month follow-up was significantly higher than PKRP group. No differences achieving statistical significance were identified in total prostate-specific antigen, maximum urinary flow rate, International Prostate Symptom Score, quality-of-life score, and the postvoid residual urine volume, transient incontinence, urethral stricture, bladder neck contracture, and retrograde ejaculation at 3- and 6-month follow-up. Conclusions: 1470 nm DiLEP is safer than PKRP, with a smaller effect on sexual function, and it is comparable with the efficacy of PKRP, thus making it more suitable for elderly BPH patients. Clinical Trial Registration number: S2021-463-01.

Age-specific effect of transurethral holmium laser enucleation of the prostate on overactive bladder in men with benign prostatic hyperplasia: An investigation using an overactive bladder symptom score

OBJECTIVES

To investigate the age-specific effect of transurethral holmium laser enucleation of the prostate (HoLEP) on overactive bladder (OAB).

METHODS

A total of 186 consecutive patients who underwent HoLEP were included. They were divided into three groups: patients aged less than 65 years, between 65 and 74, and 75 or older. The OAB symptom score as well as other relevant variables of lower urinary tract symptoms and function were assessed before and 1, 3, 6, and 12 months after surgery. Age-specific prevalence of OAB, the proportion of resolution of OAB, and de novo OAB were evaluated.

RESULTS

The mean age of patients was 70.7 years, and the mean total prostate volume was 75.8 ml. The mean OAB symptom scores before surgery of patients aged less than 65 years, between 65 and 74, and 75 or older were 6.0, 5.2, and 5.7, respectively. At 12 months after surgery, the scores for the respective groups had significantly decreased to 2.1, 2.5, and 3.5. The prevalence of OAB based on the score in the respective groups was 45.8%, 56.9%, and 54.0% (p = .6391) preoperatively and 9.1%, 11.3%, and 15.8% at 12 months after the surgery (p = .7613). Of those with preoperative OAB, 75.0%, 79.2%, and 75.0% of the respective groups showed resolution of OAB at 12 months postoperatively (p = .9427).

CONCLUSIONS

In candidates for surgical deobstruction of benign prostatic hyperplasia, HoLEP has potential to improve OAB symptoms regardless of age.

B-TURP versus HoLEP: Peri-Operative Outcomes and Complications in Frail Elderly (>75 y.o.) Patients: A Prospective Randomized Study

Background: The aim of this study was to compare the peri-operative and functional results between trans-urethral resection of the prostate (TURP) and holmium laser enucleation of the prostate (HoLEP) in the treatment of benign prostatic hyperplasia (BPH) associated with lower urinary tract symptoms (LUTS) in middle-old patients. Materials and Methods: This prospective single-center study included patients over 75 years old treated with B-TURP or HoLEP for BPH associated with LUTS with prostate volume (PV) <100 mL. Primary endpoints were the intra-operative blood loss, percentage of loss of hemoglobin, blood transfusion, complications, and the comparison of functional outcomes. All patients were evaluated at 1, 3, 6, and 12 months of follow-up. Results: Overall, 96 patients undergoing HoLEP and 104 B-TURP were eligible and enrolled for the study. Post-operative results showed statistically significant differences between the two groups, all in favor of HoLEP group, specifically in terms of removed prostate tissue, PV reduction rate, hemoglobin values at 24 h, hemoglobin loss, operative time, length of hospitalization, days of catheterization, and urinary flow rates. There was no significant difference in terms of postvoid residual urine volume, perioperative complication, blood transfusion, International Prostate Symptom Score (IPSS), and IPSS quality of life scores. Conclusions: In middle-old patients, the HoLEP technique represents a prostate size-independent treatment option with a more favorable safety profile defined by less bleeding, lower blood transfusions, and a significantly lower hemoglobin drop than B-TURP.