Early apical release versus conventional (non-early apical release) holmium laser enucleation of the prostate: a systematic review and meta-analysis of postoperative urinary incontinence and functional outcomes

Background Despite proven safety, efficacy, and durability of Holmium laser enucleation of the prostate (HoLEP), postoperative transient stress urine incontinence (SUI) was a concern for years. A technical modification of the original HoLEP, namely early apical release (EAR) has been suggested to reduce postoperative SUI. This study aimed to collate available evidence on the impact of EAR on the post HoLEP SUI and functional outcomes in comparison to conventional (non-EAR) HoLEP. Methods Following PRISMA guidelines, a comprehensive literature search was performed until February 2026. The Search focused on studies comparing EAR with conventional HoLEP. The primary outcome was the impact of each technique on SUI. Two reviewers independently screened studies, extracted data, and assessed quality using the Newcastle–Ottawa Scale and Cochrane Risk of Bias-2 tool. Pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were estimated using random-effects models. Analyses were performed using RevMan 5.3. Results Five studies with 2821 patients were analyzed. EAR showed a lower risk of early SUI at 4–6 weeks (RR0.47, 95%CI 0.37–0.60; I ² = 0.0%). At mid-term follow-up, 3–4 months, EAR was associated with lower risk of SUI (RR 0.44, 95%CI 0.28–0.69; I ² = 0%). At 6–12 months, there were no significant differences in urinary incontinence. EAR had fewer intraoperative and late postoperative complications. However, EAR showed more early postoperative complications, mainly Clavien–Dindo grade I–II. Despite this, hospital stay was similar between both groups. Functional outcomes, including IPSS, quality of life, Qmax, and PVR, were comparable between groups throughout follow-up. Lastly, Operative time, enucleation time, morcellation time, and catheter duration were also comparable. Conclusion EAR reduces early SUI while maintaining comparable functional outcomes compared to conventional HoLEP. These findings indicate EAR is an effective continence-optimizing modification during HoLEP.