Optimizing Laser Settings for Holmium Laser Enucleation of the Prostate: A Randomized Controlled Trial

Introduction: Studies validating the optimal high-power laser energy settings for holmium laser enucleation of the prostate (HoLEP) are lacking. The goal of our study is to determine if different laser settings during HoLEP influence operative time primarily and postoperative symptoms and complications secondarily. Methods: From March 2024 to April 2025, patients undergoing HoLEP with prostate measurements <200 mL were randomized 1:1:1 to laser energy settings of 2 Joules and 40, 50, or 60 Hertz (Hz) (NCT06531473). A high-power 120-watt holmium laser with pulse modulation was used for all patients. Patients were followed for 3 months postoperatively with daily surveys until day 14, surveys every third day until day 30, and then monthly thereafter until day 90. Postoperative outcomes were manually charted. Results: Out of 341 patients screened, 319 consented for the study, and 76 (23.8%) did not complete their daily surveys. There were no significant differences in baseline characteristics. Surgery duration was similar in all groups, but energy usage was significantly higher with increased frequency settings ( p < 0.001). Laser settings were changed from 40 Hz to 60 Hz in five cases and from 50 Hz to 60 Hz in one case due to inadequate coagulation effect. Patient-reported time to resolution of dysuria, difficult urination, incontinence, hematuria, and resumption of normal activity did not differ between cohorts ( p > 0.05). There were no differences in emergency room visits related to HoLEP ( p = 0.8). There was no difference in the change of IPSS or Michigan Incontinence Symptom Index scores between groups. Conclusion: Overall, there is no significant difference in the operative times and postoperative complications with the 2 J 40 Hz, 2 J 50 Hz, and 2 J 60 Hz laser settings for HoLEP, affirming the broad safety and efficacy of the procedure across diverse energy configurations.