Comparative efficacy and safety of low-power versus high-power holmium laser enucleation of the prostate for benign prostatic hyperplasia: an updated meta-analysis

Background: Holmium laser enucleation of the prostate (HoLEP) is the gold-standard surgical treatment for benign prostatic hyperplasia, irrespective of the prostate size. However, the optimal laser power setting remains uncertain. High-power systems (80–100 W) are commonly used in clinical practice, while emerging evidence suggests that low-power settings (24–50 W) may offer comparable efficacy with potential functional and safety advantages. Objective: To compare the perioperative, functional, and safety outcomes of low-power versus high-power HoLEP based on randomized controlled trials. Methods: We conducted a systematic review and meta-analysis of RCT comparing low-power (24–50 W) and high-power (80–100 W) HoLEP, searching four electronic databases from inception till April 2025. The data extracted on primary outcomes include International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), post-void residual volume (PVR), quality of life (QoL), and Clavien–Dindo-graded complications. Secondary outcomes included operative efficiency metrics. A random-effects model was used to calculate pooled effect sizes with 95% confidence intervals. Risk of bias was assessed using the Cochrane risk of bios (RoB 2) tool. Results: Four trials ( n = 394) were included. Low-power and high-power HoLEP showed similar IPSS improvement MD: −0.30 (95% CI: −1.00 to 0.41) and Qmax (0.30 ml/s, −0.42 to 1.01). Low-power HoLEP resulted in better QoL MD: 0.20 (95% CI: 0.10–0.31 and reduced PVR (–2.33 ml, −4.09 to −0.58). High-power HoLEP had shorter operative (–12.62 min) and enucleation times (–6.89 min). Safety outcomes revealed no significant differences. Conclusion: Low-power HoLEP is clinically non-inferior, providing comparable symptom relief and urinary flow improvement with better quality-of-life outcomes and more complete bladder emptying. Although operative times are modestly longer, the safety profile remains equivalent. These findings support low-power HoLEP as a viable surgical option.