Efficacy, Efficiency, and Safety of En-bloc vs Three-lobe Enucleation of the Prostate: A Propensity Score-matched Analysis

Abstract

To assess efficacy, efficiency and safety in holmium laser enucleation of the prostate (HoLEP), we directly compared intraoperative performance, postoperative outcomes, and safety in the original three-lobe enucleation technique with the more recent en-bloc method. As HoLEP is widely accepted as a size-independent method for surgical treatment of patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO), detailed understanding of its benefits is mandatory. We conducted a retrospective, propensity score-matched analysis of 1,396 men who underwent HoLEP for LUTS/BPO between 2017 and 2020. We included 606 patients in the final analysis (en-bloc n=303; three-lobe n=303), who were matched for prostate size (50 cc), age, body mass index (BMI), and preoperative international prostate symptom score (IPSS). Patients were then stratified by technique, and groups were compared for perioperative parameters, safety, and short-term functional outcomes. While postoperative symptoms and urodynamic parameters improved irrespective of technique, we report significantly less adverse events (Clavien-Dindo classification ≥II vs <II) for patients receiving en-bloc enucleation. Additionally, en-bloc enucleation was more efficient i.e., less than half of total laser energy (kJ), twice shorter enucleation time, and surgical performance (g/kJ/min) significantly increased 4-fold with prostate volume, compared to three-lobe enucleation. While HoLEP in general is a safe and effective procedure, en-bloc enucleation techniques offer better surgical performance.