Comparative Outcomes of MOSES ™ 1.0 Versus 2.0 in Holmium Laser Enucleation of the Prostate Is There Really a Difference?

Introduction: Holmium laser enucleation of the prostate (HoLEP) is a size-independent treatment for benign prostatic hyperplasia (BPH) that has emerged as the gold standard. Pulse-modulated energy delivery, MOSES™ laser technology, optimizes the delivery of energy by reducing energy loss between the laser fiber and tissue. This study aims to compare the operative parameters of HoLEP using MOSES™ 1.0 vs 2.0. Materials and Methods: We prospectively enlisted patients undergoing HoLEP at two sites in a single institution. Patients were assigned to MOSES™ 1.0 or 2.0 by site and remained blinded to laser settings. Primary outcomes were differences in postoperative hemoglobin and enucleation, morcellation and hemostasis times. Secondary outcomes were improvement in International Prostate Symptom Score, maximum urinary flow rate, proportion of prostate enucleated and enucleation efficiency. Results: Among 236 patients (median age 73 (46–90), 67 (28%) were assigned to the 1.0 group and 169 (72%) to the 2.0 group. Baseline demographics were similar, except higher rates of active anticoagulation in the 2.0 cohort (0 vs 8%, p < 0.03). The 2.0 group had significantly higher hemoglobin on postoperative day 1 (POD1) (1.0: 12.5 vs 2.0: 13.0, p < 0.05). Enucleation (51.0 vs 46.5 minutes) and morcellation (6.0 vs 7.0) were comparable. Hemostasis was 33% faster with the 2.0 (15.0 vs 10.0 minutes, p < 0.001), even when adjusted for prostate volume ( p < 0.0001) and anticoagulation status ( p = 0.001). Although not statistically different, the 1.0 cohort had higher rate of urinary tract infection (11.9% vs 6.0%), while the 2.0 cohort had more Clavien-Dindo IV complications (0% vs 1.2%) and clot retention (0% vs 1.2%). Conclusions: Compared with the 1.0, the MOSES™ 2.0 laser demonstrated significantly improved intraoperative hemostasis while maintaining comparable enucleation efficiency. Although POD1 hemoglobin values were higher with the 2.0 system, the difference was small and unlikely clinically meaningful. Secondary postoperative outcomes were also similar between groups. Our findings suggest that the primary advantage of the updated technology lies in enhanced hemostatic performance rather than procedural efficiency.