Evaluation of the Transition from Holmium:YAG to Pulsed Thulium:YAG for Laser Endoscopic Enucleation of the Prostate and the Effect on Procedural Performance

TL;DR

Experienced surgeons can safely switch from holmium to thulium lasers for prostate surgery, improving efficiency and reducing complications.

Contribution

Demonstrates the feasibility and benefits of switching laser platforms in high-volume clinical settings without retraining.

Findings

ThuLEP showed higher enucleation efficiency compared to HoLEP.

ThuLEP reduced postoperative urinary retention and need for transurethral coagulation.

Complication rates remained stable after the laser transition.

Abstract

A transition from holmium laser to pulsed thulium laser for enucleation of the prostate is safe and feasible for experienced surgeons. Thulium:YAG laser improves the enucleation efficiency and hemostasis without increasing complication rates. These results support use of pulsed Tm:YAG laser as a viable alternative in high-volume clinical settings.

Endoscopic enucleation of the prostate (EEP) using holmium:YAG laser (HoLEP) is widely regarded as the surgical gold standard for surgical management of benign prostatic hyperplasia. EEP with a pulsed thulium:YAG laser (ThuLEP) has emerged as an alternative with distinct physical properties that may influence surgical performance. However, evidence on the real-world impact of switching between laser platforms remains limited.

In this retrospective single-center study, we analyzed 2688 consecutive EEP procedures performed between 2015 and 2025. Three high-volume surgeons transitioned from HoLEP (n = 1516) to ThuLEP (n = 1172) without retraining. Baseline characteristics, complication rates, and efficiency metrics were compared. Segmented regression analysis was used to evaluate temporal changes in performance across the laser transition.

Baseline parameters were comparable between the HoLEP and ThuLEP groups. ThuLEP was associated with significantly lower incidence of postoperative urinary retention (5.6% vs 9.3%; p = 0.0005) and a lower need for transurethral coagulation (3.0% vs 4.6%; p = 0.0471). EEP efficiency was higher with ThuLEP (0.93 ± 0.49 vs 1.64 ± 1.03 g/min; p < 0.001), accompanied by higher energy consumption (898.2 ± 692.1 vs 1,051.7 ± 1,003.3 J/g; p < 0.001). Segmented regression revealed an initial rise in efficiency after the transition, followed by mild performance fluctuations, which indicates a short adaptation phase.

A transition from HoLEP to ThuLEP with a pulsed thulium:YAG laser is safe and feasible in experienced hands. ThuLEP was associated with higher enucleation efficiency and a statistically significant improvement in hemostatic control, without an increase in complication rates. These findings highlight the procedural adaptability of laser EEP techniques and support the clinical viability of platform switching in high-volume settings.

We looked at outcomes in >2600 patients who underwent prostate surgery using two different laser systems. After switching from a holmium laser to a thulium laser, surgeons performed procedures more efficiently and with fewer cases of urinary retention and bleeding. This suggests that experienced surgeons can safely switch to newer laser systems without compromising patient care.

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