A comparative study of thulium fiber laser and holmium:YAG laser for prostate enucleation: a systematic review and meta-analysis

Introduction: Laser enucleation has become a preferred surgical treatment for benign prostatic hyperplasia (BPH), especially for large prostates and patients unable to discontinue anticoagulation. This systematic review and meta-analysis compared the efficacy and safety of Thulium Fiber Laser Enucleation of the Prostate (ThuFLEP) and Holmium Laser Enucleation of the Prostate (HoLEP). Methods: We searched PubMed, Scopus, Embase, and the Cochrane Library for studies published up to February 2025. We included randomized controlled trials and observational studies comparing ThuFLEP and HoLEP in adult males with BPH. Outcomes included symptom scores (IPSS), urinary flow (Qmax), quality of life (QoL), post-void residual (PVR), enucleation time, operative time, enucleation efficiency, and complications. Risk of bias was assessed using the Cochrane RoB 2.0 tool for RCTs and the Newcastle-Ottawa Scale for cohort studies. Data were synthesized using random-effects meta-analysis models. Results: Eleven studies were included. IPSS, QoL, PVR, total operative time, and complications showed no significant differences between groups. HoLEP showed a significantly greater Qmax improvement at 3 months (mean difference -1.25 mL/s; 95% CI -1.847 to -0.653) and shorter enucleation time (mean difference 7.654 min; 95% CI 0.362 to 14.947), though the clinical relevance was limited. No significant differences were observed in enucleation efficiency or urinary incontinence rates. Study limitations included heterogeneity in laser settings and surgical technique, limited RCTs, and a lack of long-term follow-up. Conclusion: ThuFLEP and HoLEP are comparable in efficacy and safety for prostate enucleation in BPH patients. While HoLEP showed modest advantages in specific operative metrics, the clinical impact appears minimal. TFL represents a viable alternative in the surgical management of BPH.