Pulsed Thulium:YAG laser enucleation versus open simple prostatectomy for large-gland benign prostatic hyperplasia: a retrospective comparative observational study

Introduction

Benign prostatic hyperplasia (BPH) is a highly prevalent condition among older men, frequently leading to lower urinary tract symptoms (LUTS) and impaired quality of life (1). While pharmacological therapy remains the first-line approach, surgical intervention is indicated in cases of medical treatment failure, intolerance, or complications such as recurrent urinary retention or bladder stones.

For decades, open simple prostatectomy (OSP) has been considered the reference technique for large prostates (>80 mL) due to its complete adenoma removal and durable functional outcomes. However, OSP entails substantial perioperative morbidity—including greater blood loss, transfusion requirements, and prolonged catheterization and hospitalization—that limits its use in patients with multiple comorbidities or those receiving anticoagulant therapy (1,2).

The development of anatomical endoscopic enucleation of the prostate has redefined BPH surgery by replicating the principles of OSP through a minimally invasive approach. Holmium:YAG laser enucleation of the prostate (HoLEP) is currently supported by level 1a evidence and international guidelines [European Association of Urology (EAU), American Urological Association (AUA)] as an effective and size-independent treatment. Comparative studies between Holmium:YAG and Thulium:YAG enucleation techniques have reported minor differences in enucleation efficiency and intraoperative blood loss, without clinically significant differences in overall perioperative outcomes (3-5).

The Thulium:YAG laser technology represents an evolution of the enucleation concept. Owing to its higher water absorption coefficient and shallower tissue penetration compared with Holmium:YAG, it provides smoother cutting, better intraoperative visibility, and more homogeneous coagulation, potentially improving hemostasis and reducing bleeding (6-9). The first available Thulium:YAG laser technology emitted laser light in continuous wave (cw) mode, while newer developments in Thulium:YAG technology enable pulsed laser emission, which combine the hemostatic properties of the cw-Thulium:YAG laser with the mechanical push and tear properties of Holmium:YAG technology (9,10). The most recent pulsed Thulium:YAG laser system (Dornier Thulio^®, Dornier MedTech, Germany) delivers peak powers up to 3.7 kW, theoretically combining precise anatomical dissection with improved safety. Early clinical series have reported favorable perioperative outcomes and high postoperative satisfaction, but current evidence remains limited—particularly in large prostates and in direct comparison with OSP (9,11).

We hypothesized that pulsed Thulium:YAG enucleation (p-ThuLEP) offers equivalent functional efficacy to OSP while significantly reducing perioperative morbidity and recovery time in patients with prostates larger than 80 mL.

The objective of this study was to compare perioperative, functional, and safety outcomes between p-ThuLEP and OSP in a contemporary cohort, thereby providing additional evidence on the clinical role of pulsed Thulium:YAG laser enucleation (p-ThuLEP) in the management of large-gland BPH. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0091/rc).

Methods

Study design

A retrospective, observational comparative study was conducted at the Department of Urology, San Cecilio University Clinical Hospital (Granada, Spain). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Clinical Research Ethics Committee of Granada (Spain) (No. FIB-NES-2024-11). The Clinical Research Ethics Committee of Granada serves as the central ethics board for clinical research conducted across public hospitals in the Granada Health Area, including San Cecilio University Clinical Hospital, in accordance with Spanish regulations on biomedical research (Law 14/2007). All patients who participated in the study provided written informed consent. All consecutive patients undergoing p-ThuLEP between January 2023 and May 2025 were included and compared with patients treated with OSP during the same period. Men with prostate volumes between 80 and 150 mL were eligible in both groups.

To achieve comparable group sizes, cases were selected in a 1:1 ratio until equal sample size was reached; no formal matching algorithm was applied. Given that the primary objective of the study was comparative perioperative safety rather than formal causal inference, standardized mean difference (SMD) values were used to inform covariate selection for multivariable modeling rather than as matching diagnostics. This approach aimed to balance methodological rigor with model parsimony, considering the limited number of outcome events.

Postoperative functional outcomes [prostate-specific antigen (PSA), International Prostate Symptom Score (IPSS), and maximum flow rate (Qmax)] were evaluated during routine outpatient follow-up visits according to standard clinical practice. Patients were discharged from urological follow-up once clinically stable and asymptomatic.

Men were included if diagnosed with BPH and prostate volumes between 80–150 mL after medical treatment failure [persistent moderate-to-severe LUTS despite α-blockers and/or 5-alpha reductase inhibitor (5-ARI), or recurrent urinary retention]. Excluded were patients treated with other surgical techniques, outside the volume range, or with incomplete clinical data or insufficient follow-up.

Variables collected

Clinical, laboratory, perioperative, and follow-up data were retrospectively obtained from electronic medical records and institutional surgical databases.

• Demographics and comorbidities: age, body mass index (BMI), Charlson score, ASA classification;
• Clinical and functional: serum PSA, prostate volume, IPSS, Qmax, post-void residual, presence of median lobe, bladder stones, catheter use;
• Previous medical treatment: alpha-blockers, 5-alpha-reductase inhibitors, anticholinergics, anticoagulants;
• Surgical and perioperative: procedure type (p-ThuLEP or OSP), operative time, hemoglobin change, transfusion need, hospital stay, catheter days;
• Complications: classified by Clavien-Dindo;
• Postoperative course: readmissions, emergency room (ER) visits, urinary infections, hematuria (visible bleeding requiring bladder irrigation or medical intervention), acute urinary retention.

The primary outcome was bleeding-related complications (transfusion and postoperative hematuria). Secondary outcomes included perioperative parameters and early functional results.

Prostate volume measurement

Volume was assessed using available imaging: transrectal ultrasound, multiparametric magnetic resonance imaging (MRI), abdominal ultrasound, or computed tomography (CT). This reflects routine clinical practice and was considered in statistical analysis.

Surgical technique

All p-ThuLEP procedures were performed by a single surgeon who had completed more than 50 prostate enucleations prior to the study period in a different institution, thus being beyond the initial learning curve at the time of cohort inclusion.

Procedures were carried out using a continuous-flow resectoscope system. A 22-Fr resectoscope was used in 47.9% patients and a 26-Fr catheter in 52.1% patients.

A standardized two-lobe enucleation technique with early apical mucosal release was employed. After identification of the external urinary sphincter and ureteral orifices, bilateral mucosal incisions were made proximal to the sphincter and connected at 12 o’clock to facilitate early apical release. A posterior incision at 6 o’clock was extended from the bladder neck to the verumontanum, allowing development of the anatomical plane. The adenoma was progressively dissected along posterior, lateral, and anterior planes and enucleated into the bladder. Hemostasis was achieved under direct vision, followed by intravesical morcellation. An 18–20 Ch Foley catheter was placed at the end of the procedure.

Energy settings and morcellation

All procedures were performed using a pulsed solid-state Tm:YAG laser (Thulio^®, Dornier MedTech Systems GmbH, Weßling, Germany).

Anatomical dissection was carried out in short-pulse mode (1,500–2,000 mJ, 50 Hz; 75–100 W), with most cases performed at 75 W and selective increase to 100 W when required. Hemostasis was achieved using the same parameters or, when necessary, long-pulse mode (2,000 mJ, 50 Hz; 40 W).

Morcellation was performed using a HAWK^® morcellator (YSB-III, Hangzhou HAWK Optical Electronic Instruments Co., Ltd.) at a maximum rotational speed of 1,200 rpm.

OSP was performed by different surgeons according to standard institutional practice prior to the introduction of laser enucleation. Both transvesical (Freyer) and retropubic (Millin) approaches were used during the study period; however, the specific approach was not systematically recorded. Historically, OSP represented the standard surgical treatment for large prostates in our institution before the implementation of laser enucleation.

Statistical analysis

SPSS v26.0 was used. Continuous variables were summarized as mean ± standard deviation or median (interquartile range), according to data distribution. Continuous variables were analyzed as such without arbitrary categorization, applying parametric or non-parametric tests according to distribution. Categorical variables were reported as number (percentage). Group comparisons were performed using Student’s t-test or Mann-Whitney U test for continuous variables, and Chi-squared or Fisher’s exact test for categorical variables, as appropriate.

For primary perioperative comparisons (hospital stay and catheterization time), mean differences with 95% confidence intervals (CIs) were estimated using bootstrap resampling (1,000 samples; bias-corrected and accelerated method) to provide robust effect size estimates independent of distributional assumptions.

To address potential sources of selection bias, all consecutive eligible patients were included, in a 1:1 ratio to obtain comparable group sizes; no formal matching procedure was performed. Baseline balance was subsequently assessed using SMDs, independently of sample size. Although lower SMD thresholds (e.g., 0.10–0.20) are often used to indicate minor imbalance, we considered SMD ≥0.30 as indicative of clinically meaningful imbalance. However, covariate inclusion in multivariable models was ultimately based on clinical relevance and outcome events to ensure model parsimony.

Multivariable logistic regression models were constructed to evaluate predictors of postoperative hematuria. Given the limited number of outcome events, the model was intentionally kept parsimonious to minimize overfitting. Covariates were pre-specified based on clinical relevance and baseline assessment and included type of surgery, prostate volume, anticoagulant use, and preoperative positive urine culture.

Given the limited number of outcome events (n=10), the number of covariates was restricted to clinically relevant variables to reduce overfitting risk.

Due to the limited number of transfusion events and the absence of events in the p-ThuLEP group, multivariable modeling for transfusion was not performed to avoid unstable estimates.

No formal variable selection procedures (e.g., stepwise methods) were applied.

The study size was determined by the number of consecutive eligible patients treated during the study period. No a priori sample size calculation was performed due to the retrospective and exploratory nature of the study.

Results

Population and baseline characteristics

A total of 98 patients were included: 49 underwent p-ThuLEP and 49 OSP. The clinical and surgical characteristics of the study population are summarised in Table 1.

No statistically significant differences were observed in age, comorbidities, PSA, IPSS, and urodynamic parameters. No clinically meaningful differences were observed in prostate volume, indwelling urinary catheter, median lobe presence, post-void residual, or bladder stones. Assessment of baseline balance using SMDs confirmed clinically meaningful imbalance (SMD ≥0.30) for body mass index and preoperative positive urine culture, whereas the remaining variables showed acceptable balance.

Prostate volume was assessed using different imaging modalities [transrectal ultrasound (TRUS), abdominal ultrasound, MRI, or CT] according to routine clinical practice. The distribution of imaging modalities was similar between groups (χ²=0.605, P=0.90), minimizing the likelihood of systematic measurement bias affecting volume-based case selection.

Medication use (alpha-blockers, 5-AR inhibitors, anticoagulants) was similar between groups.

No missing data were present for the variables included in the final analyses.

The median time to discharge from urological follow-up was 2.5 months (range, 1.5–27 months) in the p-ThuLEP group and 2 months (range, 2–14 months) in the OSP group, Table 2 and Figure 1.

Figure 1 Comparison of perioperative outcomes and hemorrhagic events between p-ThuLEP and OSP. (A) Expressed as mean ± standard deviation. (B) In proportions. The figures compare hospital stay, catheterization time, and hemorrhagic events between p-ThuLEP and OSP. p-ThuLEP was associated with less bleeding and faster recovery (all P<0.05). Source: Own data, San Cecilio University Clinical Hospital, 2025. OSP, open simple prostatectomy; p-ThuLEP, pulsed Thulium:YAG laser enucleation.

Perioperative outcomes

Operative times were comparable between groups. However, p-ThuLEP significantly reduced hospital stay by a mean of 3.04 days compared with OSP (95% CI: −4.09 to −2.16; P=0.002) and catheterization time by 6.42 days (95% CI: −7.85 to −4.73; P=0.001). Median hospital stay was 1.7 versus 4.8 days, and median catheter duration was 3.5 versus 10 days in the p-ThuLEP and OSP groups, respectively.

Transfusion rates were significantly lower in the p-ThuLEP group (0% vs. 12.2%, P=0.01). No significant differences were observed in rates of urinary infection, acute retention, emergency visits, or readmissions.

The few outliers observed in hospital stay and catheterization time were attributable to postoperative complications. In the OSP group, prolonged hospitalization (up to 20 days) was related to significant hematuria and infectious events. In the p-ThuLEP group, extended catheterization (up to 30 days) occurred in two patients due to morcellation-related technical issues, including one reintervention for morcellator malfunction and one case of residual adenoma fragment causing bladder outlet obstruction and urinary tract infection.

Functional outcomes

Both groups showed significant improvements in Qmax and IPSS postoperatively, with no intergroup differences. Postoperative PSA values (nadir) were comparable between groups, Table 2 and Figure 1.

No cases of persistent urinary incontinence were documented during follow-up. Transient irritative voiding symptoms occurred in 21% of patients in the early postoperative period and resolved with conservative management. No urethral strictures or bladder neck contractures were diagnosed during the available follow-up period.

Complications

Overall complications are summarized in Table 3. Rates were similar between groups (P=0.83), and most events were low-grade (Clavien-Dindo I–II). One Clavien-Dindo grade IIIb complication occurred in the OSP group, and no grade IV–V events were observed. Transfusion requirement was significantly higher in the OSP group (12.2% vs. 0%, P=0.01), and minor hematuria was less frequent after p-ThuLEP (4.1% vs. 16.3%, P=0.045).

No differences were found in urinary infection, acute retention, ER visits, or readmissions.

The absence of difference in overall complication rates should be interpreted cautiously given the limited sample size.

Multivariate analysis

In multivariable logistic regression analysis (Table 4), adjusting for prostate volume, anticoagulant use, and positive urine culture, anticoagulation emerged as an independent predictor of hematuria [odds ratio (OR) 9.39; 95% CI: 1.56–56.45; P=0.01]. Surgical approach showed a strong association that did not reach statistical significance after adjustment (OR 5.84; 95% CI: 0.95–35.92; P=0.057). Prostate volume was not independently associated with bleeding events within the studied volume range.

Multivariable analysis was not performed for transfusion due to the low number of events and absence of events in the p-ThuLEP group.

Discussion

This study provides real-world comparative data on p-ThuLEP versus OSP in men with large prostates (>80 mL). Our findings show that p-ThuLEP significantly reduced perioperative morbidity while no significant differences in short-term functional outcomes were detected. These results reinforce the growing evidence of the pulsed Tm:YAG-based enucleation as a feasible minimally invasive alternative to open surgery for large glands (12-14).

Consistent with previous randomized trials and meta-analyses comparing HoLEP with OSP (15,16), anatomical endoscopic enucleation of the prostate, has been shown to markedly reduce catheterization and hospitalization times, blood loss, and transfusion rates while maintaining equivalent functional efficacy (17,18). Historically, OSP has been associated with transfusion rates of 10–25% and hospital stays exceeding 1 week (18-21).

Recent data indicate that p-ThuLEP achieves perioperative and functional outcomes comparable to those of HoLEP (9,22). In our series, p-ThuLEP reproduced these advantages over OSP, showing significantly shorter catheterization (3.5 vs. 10 days) and hospitalization times (1.7 vs. 4.8 days), together with a lower transfusion rate. These findings are unlikely to be explained by baseline imbalances, as groups were largely comparable and adjustment for clinically relevant imbalances did not modify the observed associations.

Comparative studies have found no significant differences in efficacy or safety between Thulium:YAG and Holmium:YAG lasers, although Thulium may offer better visibility and energy predictability (9).

It is important to distinguish between different thulium-based laser platforms currently used for prostate enucleation. Continuous-wave Thulium:YAG systems, Thulium fiber lasers (ThuFLEP), and pulsed solid-state Thulium:YAG platforms differ in their physical properties, energy delivery mechanisms, and peak power characteristics. Much of the available literature refers to fiber-based or continuous-wave systems, which are not technically identical to the high-peak-power pulsed Tm:YAG system evaluated in the present study.

Therefore, although previous reports on Thulium-based enucleation provide valuable clinical context, direct extrapolation to pulsed solid-state systems should be made cautiously. The present study contributes specific real-world data for this newer pulsed platform.

Functional recovery, assessed by IPSS, Qmax, and PSA reduction, was comparable between techniques, confirming that pulsed Thulium:YAG enucleation achieves complete anatomical deobstruction. The absence of significant differences in operative time may reflect growing surgical experience, suggesting that once beyond the learning curve, p-ThuLEP can match OSP in procedural efficiency. Literature supports a notable decline in operative time after approximately 30–50 cases, highlighting the importance of institutional expertise (20,22).

Importantly, the evidence base for pulsed Thulium:YAG laser technology remains very limited. Only a few clinical series, including that of von Bargen et al. [2025], have specifically assessed this novel high-peak-power solid-state laser. The pulsed Thulium:YAG system differs substantially from both continuous-wave Thulium:YAG and Thulium fiber lasers. While continuous systems primarily rely on thermal cutting or vaporization, the pulsed laser employs the bubble effect of high-energy pulses to separate tissue planes, mimicking the enucleation mechanism of HoLEP (9).

The Thulium:YAG laser’s superior hemostatic profile is related to its high water absorption and shallow tissue penetration, allowing precise coagulation with minimal thermal spread—particularly relevant in large glands (6,7,9).

In this context, our results contribute novel, real-world evidence on the clinical performance of the Dornier Thulio^® pulsed Tm:YAG laser in large prostates—a population scarcely represented in current publications. These technical advantages may be particularly relevant in large-gland BPH and in patients at increased bleeding risk.

Most complications in the present series were mild (Clavien-Dindo I–II) and transient. The lower incidence of hematuria in the p-ThuLEP group likely reflects superior hemostatic control and improved coagulation properties of the pulsed Thulium:YAG laser. Overall rates were comparable between groups and in line with multicenter data (20). In contrast, the few grade I events were mainly related to temporary irritative symptoms such as dysuria or frequency during the early postoperative period, which typically resolved with conservative management. These mild events are comparable to those reported in other Thulium:YAG laser series, where transient irritative symptoms have been described in 5.3 % to 18.5 % of patients (7,8), depending on energy settings and prostate size.

This study has several limitations inherent to its retrospective, single-center design, which may limit the generalizability of the findings. Functional outcomes were assessed during routine outpatient follow-up according to standard clinical practice, with a median time to discharge from urological follow-up of 2–2.5 months, although some patients were followed for longer periods (up to 27 months). Therefore, the present findings primarily reflect early and short-term perioperative and functional outcomes. Late complications such as urethral stricture, bladder neck contracture, late incontinence, or reoperation may not be fully captured and cannot be excluded.

In addition, key intraoperative parameters such as enucleation time, morcellation time, and total energy delivered were not separately recorded due to the retrospective data collection. These variables are standard reporting metrics in enucleation studies and their absence limits direct procedural comparison with other published Thulium:YAG series. Prostate volume was assessed using different imaging modalities, reflecting real-world clinical practice and potentially introducing minor measurement variability. Finally, the low number of bleeding-related events limited the precision of multivariable estimates, as reflected by wide CIs.

Continence outcomes and urethral stricture rates were not systematically assessed using validated instruments due to the retrospective design. Although no persistent incontinence or strictures were diagnosed during follow-up, subclinical or late functional events cannot be excluded.

Although robot-assisted simple prostatectomy (RASP) has gained popularity in selected centers, it was not included as a comparator in this study. The robotic platform was introduced in our institution only recently and has been primarily dedicated to radical prostatectomy and procedures without minimally invasive alternatives. Furthermore, in many real-world settings, laser enucleation is available whereas robotic platforms may not be routinely accessible for benign surgery. Importantly, recent propensity-matched analyses comparing Holmium laser enucleation of the prostate (HoLEP) and RASP in large prostates have demonstrated comparable short-term functional and continence outcomes, while endoscopic enucleation was associated with shorter hospital stay and catheterization time (23). These findings are particularly relevant in real-world settings where robotic platforms are not routinely available for benign surgery. Therefore, the comparison with OSP reflects a pragmatic and widely applicable clinical scenario during the implementation phase of laser enucleation in tertiary care institutions.

Nevertheless, long-term data and randomized comparisons with both HoLEP and robotic simple prostatectomy are required to determine whether these early perioperative benefits translate into sustained functional improvement and cost-effectiveness over time.

Conclusions

In conclusion, p-ThuLEP showed no significant differences in early functional outcomes compared with OSP, while significantly reducing hospitalization and transfusion rates. Given the retrospective design and relatively short follow-up, these findings primarily reflect early perioperative and short-term functional results. Within these limits, p-ThuLEP appears to be a safe minimally invasive alternative for large prostates when performed in experienced centers. Prospective studies with longer follow-up and formal comparative designs are required to confirm long-term durability and more precisely define its role among surgical options.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0091/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0091/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0091/prf

Funding: This study was supported by the Dornier MedTech. The sponsor had no role in study design, data analysis, interpretation of results, or manuscript preparation.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0091/coif). All authors report that Dornier MedTech provided financial support limited to the article processing charge upon the request of the authors. The sponsor had no involvement in the conception, patient selection, data acquisition, statistical analysis, interpretation of findings, manuscript drafting, or the decision to submit the manuscript. All scientific and editorial decisions were made independently by the authors. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Clinical Research Ethics Committee of Granada (Spain) (No. FIB-NES-2024-11). All patients who participated in the study provided written informed consent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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