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Thulium Fiber Laser Versus Holmium MOSES™ Laser Enucleation of the Prostate for the Treatment of Benign Prostatic Hyperplasia: A Randomized Prospective Clinical Study - Beyond the Abstract

The evolution of laser technologies has significantly enhanced the utility of anatomical endoscopic enucleation of the prostate (AEEP) for treating benign prostatic hyperplasia (BPH). While the energy source used during AEEP is often debated, current evidence indicates that the favorable outcomes of this technique are largely attributed to the completeness of adenoma removal rather than the specific laser applied.

In this prospective, randomized, controlled trial, we compared two widely used laser systems: the superpulsed thulium fiber laser (ThuFLEP) and the holmium laser with MOSES™ pulse modulation (M-HoLEP). Holmium with MOSES™ (Boston Scientific, Marlborough, USA) enhances energy delivery by facilitating tissue separation, optimizing dissection along the surgical plane, and improving hemostasis.1 Conversely, the thulium fiber laser operates at a 1940 nm wavelength with higher water absorption, prolonged pulse duration, and a shallower penetration depth, offering different tissue interactions.2

Our study enrolled 104 patients with follow-up extending to 12 months. While both techniques achieved comparable long-term functional outcomes, notable perioperative differences were observed. Enucleation efficiency significantly favored M-HoLEP (1.97 vs. 1.49 g/min, p < 0.001), with shorter enucleation times and superior hemostatic performance. Postoperative metrics such as hemoglobin drop, continuous bladder irrigation (CBI) duration, and hematuria severity were all significantly improved in the M-HoLEP group.

Furthermore, same-day discharge was more feasible with M-HoLEP. Only 7.7% of patients required postoperative admission compared to 30.8% in the ThuFLEP group (p = 0.003), primarily due to prolonged hematuria necessitating overnight CBI. Hospital stay was also significantly longer in the ThuFLEP cohort (p = 0.016).

While both lasers are safe and effective, their differing physical properties affect tissue interaction and clinical workflow. Skilled surgeons can achieve excellent outcomes with either platform,3 but familiarity with a specific wavelength enables better handling of tissue response, dissection precision, and hemostasis quality. These factors may ultimately influence the feasibility of ambulatory care and patient satisfaction.

To our knowledge, this is the first RCT to report same-day trial of voiding (TOV) outcomes for ThuFLEP. Looking forward, future comparative trials, particularly those involving the pulsed solid-state Thulium: YAG laser, will be crucial in guiding laser selection and refining AEEP strategies.

In summary, both M-HoLEP and ThuFLEP are viable options, and the decision should center around surgeon expertise, safety considerations, and local clinical infrastructure.

Written by: Hazem Elmansy, MD, MSc, FRCSC, Urologist, Chief, Division of Endourology and Stone Disease, Houston Methodist Hospital, Houston, TX
 
References:

  1. Kavoussi NL, Nimmagadda N, Robles J, et al. MOSES™ technology for holmium laser enucleation of the prostate: a prospective double-blind randomized controlled trial. J Urol. 2021;206:104–108.
  2. Dalton DC, Shelton TM, Rivera M. Laser technology advancements in the treatment of benign prostatic hypertrophy. Curr Urol Rep. 2024;25:71–78.
  3. Socarras MR, Del Alamo JF, Sancha FG. Long Live Holmium! Eur Urol Open Sci. 2023;48:28–30.
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