# Assessing the Surgical Efficiency of Instrument Miniaturization: Comparison of Holmium Laser Enucleation of the Prostate (HoLEP) and Minimally Invasive Laser Enucleation of the Prostate (MiLEP)

## TL;DR

This study compares two prostate surgery techniques, HoLEP and MiLEP, to see if smaller surgical tools improve efficiency and safety.

## Contribution

The study evaluates the impact of instrument miniaturization on surgical efficiency in prostate enucleation procedures.

## Key findings

- MiLEP had shorter surgical time compared to HoLEP.
- No differences were found in tissue weight or morcellation efficiency between the two techniques.
- MiLEP showed a trend toward shorter hemostasis time, though not statistically significant.

## Abstract

Introduction: Benign prostatic hyperplasia is one of the most common medical problems. It can be treated with holmium laser enucleation of the prostate (HoLEP), which provides efficacy with few complications and a short hospitalization. A more recent evolution of this technique is minimally invasive laser enucleation of the prostate (MiLEP), using smaller sheaths, which aims to further reduce urethral trauma while maintaining surgical efficiency.

Objective: This study set out to compare HoLEP and MiLEP interventions in prostate enucleation to assess the impact of instrument miniaturization on surgical efficiency.

Methods: In this observational study, we analyzed patients undergoing prostate enucleation in the Minimally Invasive Urology Service at Hospital Angeles del Carmen. Patients were recruited from March 1 to July 31, 2025. We included patients with a prostate volume ≤ 80 cc, International Prostate Symptom Score (IPSS) value >8, and an American Society of Anesthesiologists (ASA) Staging of I or II, and excluded those with a history of bladder pathology, prior urinary catheterization, or urolithiasis. Epidemiological and clinical variables and surgical intervention were evaluated. Statistical analysis was descriptive, and medians were compared with the Mann-Whitney U test.

Results: A total of 40 patients were included, and the HoLEP and MiLEP techniques were compared. The median age was 68 years, IPSS 21, and prostate tissue 24 gr. Enucleation time was longer in the subgroup of HoLEP (p=0.01). Surgical time was shorter in the subgroup of MiLEP (p=0.01). No differences were observed in morcellation time, enucleated tissue weight, enucleation efficiency, and morcellation efficiency. A trend toward shorter hemostasis time was observed in MiLEP, though this trend did not achieve statistical significance.

Conclusion: Miniaturized instrumentation using a 22 Fr sheath in MiLEP is comparable to the standard 26 Fr sheath in HoLEP in terms of surgical efficiency and safety. The smaller sheath may provide additional advantages. Further studies with longer follow-up are needed to evaluate the long-term functional outcomes.