Smaller scopes, bigger impact: retrospective outcomes of minimally invasive holmium enucleation of the prostate (MILEP)

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) is a size-independent and durable treatment, traditionally performed using 26-28 Fr resectoscopes. While larger scopes offer improved visualization and irrigation, they may increase the risk of urethral trauma and strictures. A 22 Fr HoLEP system has recently been introduced, aiming to minimize morbidity without compromising surgical efficiency. This study evaluates perioperative outcomes, safety, and early functional results using the 22 Fr HoLEP system for Minimally Invasive Laser Enucleation of the Prostate (MiLEP). METHODS: We conducted a retrospective review of a database of patients who underwent MiLEP between January 2022 and September 2024. Inclusion criteria were age ≥ 40, prostate volume ≥ 35 cm³, and moderate-to-severe lower urinary tract symptoms (LUTS). Preoperative, intraoperative, and postoperative data were analyzed, including IPSS, PSA, uroflowmetry (Qmax), post-void residual (PVR), complications, and need for urethral or meatal dilation. All procedures utilized the 22 Fr resectoscope with a 100 W holmium laser using an en bloc technique. RESULTS: All cases were successfully completed using the MiLEP system without scope upsizing or conversion. Mean prostate volume was 84.5 ± 36.3 cm³, operative time was 76.1 ± 21.6 min, and morcellation time was 20.7 ± 6.8 min. Meatal dilation was required in 4% of cases; no patients required urethral dilation. Capsular perforation occurred in 7%, and 1% experienced non-perforating bladder injury during morcellation. No blood transfusions or intraoperative conversions were required. At 3 months, IPSS improved from 24.4 ± 3.7 to 6.7 ± 1.4 (p < 0.001), Qmax increased from 9.0 ± 2.8 to 21.1 ± 6.3 mL/s (p < 0.001), and PSA decreased from 5.7 ± 3.7 to 0.48 ± 0.3 ng/mL (p < 0.001). De novo stress urinary incontinence was reported in 3% of patients. No urethral strictures or bladder neck contractures were observed. CONCLUSIONS: MiLEP using the 22 Fr system is a feasible and effective technique for BPH treatment, offering significant improvements in LUTS and urinary flow with minimal morbidity. This approach may reduce the risk of urethral trauma and postoperative complications while maintaining surgical efficiency.