Comparison of Immediate (In-Hospital) Outcomes of Holmium Laser Enucleation of the Prostate and Open Prostatectomy in the Surgical Treatment of Large-Sized Benign Prostatic Hyperplasia (Over 80 cm³)

Abstract

Benign prostatic hyperplasia (BPH) is one of the most common causes of lower urinary tract symptoms (both obstructive and irritative), as well as bladder outlet obstruction requiring surgical treatment. According to the European Association of Urology guidelines (EAU, 2025), in cases of large-volume BPH (greater than 80 mL), open prostatectomy remains the procedure of choice in the absence of equipment for laser enucleation of the prostate. However, open prostatectomy is a highly invasive intervention associated with a significant rate of intra- and postoperative bleeding, complications, and prolonged hospital stay. In order to reduce and prevent complications, holmium laser enucleation of the prostate (HoLEP) has been introduced into urological practice. Aim. To evaluate and compare the immediate (in-hospital) outcomes of simultaneous open transvesical prostatectomy and holmium laser enucleation of the prostate in the surgical treatment of large-volume BPH (greater than 80 cm³). Materials and Methods. At the Urology Department of Vinnytsia Regional Clinical Hospital named after M.I. Pirogov, from 2024 to 2025, 100 open transvesical prostatectomies and 100 holmium laser enucleations of the prostate (HoLEP) were performed. HoLEP procedures were carried out using a MultiPulse HoPlus 150 W holmium laser, a MultiCut morcellator, a 600 μm laser fiber (Jena Surgical, Germany), and a 26F Olympus resectoscope. Intraoperative blood loss during transvesical prostatectomy was measured using the gravimetric method, whereas during HoLEP it was assessed by a colorimetric method. Postoperative surgical complications were classified according to the Clavien–Dindo system. Urinary function before and after surgery was evaluated using uroflowmetry (“Potik-K”) with assessment of maximum urinary flow rate (Qmax). Statistical analysis was performed using methods of variation statistics. Results and Discussion. The mean age of patients who underwent HoLEP was 68.7 ± 7.4 years, with a mean prostate volume of 93.9 ± 39.5 cm³. The mean operative time (enucleation and morcellation) was 67.2 ± 17.4 minutes, mean intraoperative blood loss was 119.7 ± 37.2 mL, and the mean postoperative hospital stay was 6.2 ± 2.9 days. In the open transvesical prostatectomy group, the mean age was 67.7 ± 7.6 years, mean prostate volume was 94.2 ± 32.6 cm³, mean operative time was 68.3 ± 12.7 minutes, mean intraoperative blood loss was 252.7 ± 23.2 mL (p < 0.05), and mean hospital stay was 9.3 ± 1.9 days (p < 0.05). In the postoperative period, patients after open prostatectomy required an average of 2.4 ampoules of morphine per patient, whereas no opioid analgesics were required after HoLEP. Complications after HoLEP included postoperative bleeding in 1 case (1%), hyperthermia after urethral catheter removal in 1 case (1%), and urinary incontinence in 4 cases (4%); one patient required blood transfusion. In the open prostatectomy group, complications included postoperative bleeding requiring transfusion in 5 cases (5%), hyperthermia in 5 cases (5%), acute urinary retention in 1 case (1%), pneumonia in 1 case (1%), urinary incontinence in 2 cases (2%), acute epididymo-orchitis in 2 cases (2%), hypertensive crisis in 1 case (2%), postoperative anemia in 1 case (1%), urine leakage through the suprapubic wound in 1 case (1%), exacerbation of chronic pyelonephritis in 1 case (1%), and postoperative hypotension in 2 cases (2%). No mortality was observed in either group. The overall complication rate was 6% in the HoLEP group and 22% in the open prostatectomy group (p < 0.05). The mean Qmax increased from 7.3 ± 1.1 to 23.7 ± 2.6 mL/s after HoLEP and from 7.0 ± 1.5 to 24.0 ± 2.7 mL/s after open prostatectomy. Conclusions. Holmium laser enucleation of the prostate is associated with lower intraoperative blood loss, reduced postoperative pain, fewer early postoperative complications, and shorter hospital stay compared to open prostatectomy. Both techniques are effective surgical methods for restoring urinary function in patients with BPH, as confirmed by uroflowmetry data. Further studies are required to evaluate long-term outcomes of HoLEP compared to transvesical prostatectomy, as well as to assess urinary function in the late postoperative period.