Early apical release versus En-bloc no touch technique for holmium laser enucleation of the prostate: a high-volume single-surgeon cohort study

World J Urol. 2023 Jan;41(1):167-172. doi: 10.1007/s00345-022-04206-w. Epub 2022 Nov 10.


Purpose: To determine whether the early apical release (EAR) technique for holmium laser enucleation of the prostate (HOLEP) is associated with improved perioperative outcomes compared to the En-bloc no touch (EBNT) technique.

Methods: Consecutive men treated with HOLEP by a single surgeon from August 2018 to March 2021 were identified. Beginning in June 2021 all procedures were performed using the EAR technique, and these were compared to the preceding cases done with the EBNT technique. Intraoperative outcomes included operative time, need for open conversion, enucleation efficiency (tissue removed per minute of OR time), and enucleation ratio (tissue removed relative to preoperative gland size on imaging). Postoperative outcomes included catheter reinsertion, blood transfusion, and complications classified by the Clavien-Dindo scale.

Results: We identified 801 men, including 571 (71%) treated with EBNT and 230 (29%) with EAR. Median preoperative characteristics were similar between groups. The EAR approach was associated with significantly longer mean operating room time, 100.5 min versus 91.9 min, p = 0.003. However, EAR patients had a much lower rate of conversion to open cystotomy (0.43% versus 3.0%). There were no significant differences in rate of catheter reinsertion or perioperative complications between groups (p > 0.05).

Conclusion: EAR technique by an experienced HoLEP surgeon resulted in longer operative times, potentially reflecting an initial learning curve, but essentially eliminated the need for open cystotomy. Perioperative results including catheter reinsertion rate and bleeding complications were similar between the two cohorts. These data support continued use of the EAR technique for HOLEP to minimize risk of open conversion.

Keywords: Cystoscopy; Holmium; Lasers; Prostatic hyperplasia.

MeSH terms

  • Cohort Studies
  • Holmium
  • Humans
  • Laser Therapy* / methods
  • Lasers, Solid-State* / therapeutic use
  • Male
  • Prostate / surgery
  • Prostatic Hyperplasia* / complications
  • Prostatic Hyperplasia* / surgery
  • Surgeons*
  • Transurethral Resection of Prostate* / methods
  • Treatment Outcome


  • Holmium