A Randomized Controlled Trial Comparing En-bloc vs Lobe-by-Lobe HoLEP: Surgical Efficiency and Early Continence Outcomes

A Randomized Controlled Trial Comparing En-bloc vs Lobe-by-Lobe HoLEP: Surgical Efficiency and Early Continence Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article A Randomized Controlled Trial Comparing En-bloc vs Lobe-by-Lobe HoLEP: Surgical Efficiency and Early Continence Outcomes Mahmoud Laymon, Yahya Elmorsy, Ahmed Elshal, Ahmed El-Nahas, Ahmed EL-Assmy, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7068506/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Nov, 2025 Read the published version in Prostate Cancer and Prostatic Diseases → Version 1 posted 11 You are reading this latest preprint version Abstract Objective: To compare en-bloc HoLEP with conventional lobe-by-lobe (LBL) HoLEP technique in terms of surgical efficiency, perioperative outcomes, and early continence recovery through a randomized controlled trial. Patients and Methods: This single-center randomized controlled trial included patients with prostate volumes > 80 mL undergoing HoLEP for bladder outlet obstruction secondary to benign prostatic hyperplasia. Eligible patients were randomized to either en-bloc or LBL HoLEP. All procedures incorporated early apical release and sphincteric mucosal preservation. Assessments were performed preoperatively and at 1, 3, and 6 months postoperatively. primary outcome was enucleation efficiency (resected weight/enucleation time). Secondary outcomes included operative efficiency, laser energy use, blood loss, hospital stay, complications, and functional outcomes (IPSS, QoL, Qmax, PVR, and transient stress urinary incontinence [SUI]). Results: A total of 123 patients were randomized (en-bloc: 60; LBL: 63). En-bloc HoLEP was associated with shorter enucleation time (62.5 vs. 74.3 min, P = 0.02), operative time (78.6 vs. 94.9 min, P = 0.0007), and lower laser energy use (135 vs. 154 KJ, P = 0.014). Enucleation efficiency was comparable (1.25 ± 0.49 vs. 1.17 ± 0.62 g/min; P = 0.42). Both techniques resulted in significant postoperative improvements in IPSS, QoL, Qmax, and PVR (all P < 0.0001). Complication rates were similar (14.6% vs. 14%; P = 0.8). At 3 months, transient SUI rates were low and comparable (3.8% en-bloc vs. 4% LBL; P = 0.3). Conclusion: En-bloc HoLEP reduces enucleation time, operative time, and laser energy consumption compared to LBL HoLEP, while maintaining comparable safety, efficacy, and early continence outcomes when performed with modern technical refinements. Health sciences/Diseases/Urogenital diseases/Prostatic diseases Health sciences/Medical research/Outcomes research Figures Figure 1 Figure 2 Introduction Since its introduction in 1998 ( 1 ), and through numerous level 1a evidence studies, Holmium Laser Enucleation of Prostate (HoLEP) has become size-independent gold standard for management of bladder outlet obstruction (BOO) secondary to benign prostatic hyperplasia (BPH) ( 2 – 5 ). Alongside minimally invasive simple prostatectomy, HoLEP is widely accepted as preferred alternative to open simple prostatectomy for prostates larger than 80 mL ( 6 , 7 ). Despite being most thoroughly investigated laser technique, HoLEP adoption remains limited to relatively few centers. This is largely due to a long and flat learning curve and absence of structured mentorship programs ( 8 – 10 ). Additionally, prevalence of stress urinary incontinence following HoLEP has been reported to range between 3.3% and 26% ( 11 ). To improve the learning curve and optimize surgical outcomes, several modifications of the original three-lobe HoLEP technique have been proposed ( 12 ). One notable advancement is the en-bloc enucleation approach incorporating early apical release (EAR), first introduced by Sancha et al. in 2015 using the GreenLight laser. Their technique emphasized early demarcation of the apex with preservation of the mucosal covering of the external urethral sphincter (EUS), aiming to reduce postoperative stress incontinence and improve functional outcomes ( 13 ). These principles of EAR and sphincteric mucosal preservation have since been adapted to the lobe-by-lobe (LBL) technique as well ( 14 ). Although the benefits of EAR and sphincteric mucosal preservation on continence recovery are increasingly recognized, few studies have directly compared en-bloc and lobe-by-lobe HoLEP while consistently applying these refinements. This study aimed to provide high-level evidence on efficacy of en-bloc HoLEP, focusing specifically on its impact on enucleation efficiency, enucleation time, operative time, and early recovery of continence compared to conventional lobe-by-lobe approach. Patients and Methods Study Design : This prospective randomized controlled trial (RCT) was approved by local institutional review board (IRB No.: MS.21.07.1561) and registered on clinicaltrials.gov (Registration ID: NCT07014969) Inclusion criteria were age ≥ 40 years and prostate volume between 80–200 mL, measured via transrectal ultrasound (TRUS). Surgical indications included refractory lower urinary tract symptoms (LUTS) or complications related to BPH, such as recurrent acute urinary retention, gross hematuria, bladder stones, recurrent infections, or upper urinary tract deterioration. Exclusion criteria included: known neurological conditions affecting bladder function, prostate or bladder cancer, coagulopathy (INR > 1.5 or platelet count 3. All eligible patients provided informed consent in accordance with Good Clinical Practice and Declaration of Helsinki. Sample Size Calculation : Based on Saita et al. ( 15 ), en-bloc enucleation was associated with a 23% reduction in mean operative effeciency compared to three-lobe technique described by Gilling et al. ( 1 ). Assuming a type I error < 5% and power of 80%, and considering a reported enucleation efficiency of 1.4 ± 0.6 g/min ( 16 ), a total sample size of 120 patients was calculated to account for a 10% dropout rate ( 17 ). Randomization: Once HoLEP was indicated, patients were randomized in a 1:1 ratio using computer-generated random tables. Allocation was performed independently from outcome assessor to minimize bias. Preoperative Workup : All patients underwent comprehensive clinical evaluation, including medical history, physical examination, International Prostate Symptom Score (IPSS), quality of life (QoL) score, uroflowmetry, post-void residual (PVR) urine measurement, PSA testing, urine analysis, culture, and TRUS. Patients with positive urine cultures received appropriate antibiotics and were included only after a sterile culture was confirmed. Interventions: Both en-bloc and LBL HoLEP procedures were performed using EAR while preserving mucosa overlying EUS, as previously described ( 18 , 14 , 15 ). Four experienced HoLEP surgeons performed all procedures. Equipment included a 26F continuous flow resectoscope (Karl Storz, Tuttlingen, Germany) with rotating inner sheath and Kuntz working element, a 30° optics lens, and a 100W Sphinx laser system (Lisa Laser, Katlenburg-Lindau, Germany), set at 2 J and 30 Hz (short pulse). Tissue morcellation was performed via a 26F rigid nephroscope (Karl Storz) using PIRANHA morcellator system (Richard Wolf, Knittlingen, Germany). Primary outcome was enucleation efficiency, defined as resected weight divided by enucleation time (g/min), from laser fiber insertion to completion of enucleation. Secondary outcomes included operative efficiency (g/min): resected weight / total operative time, percentage of gland removed: resected weight / total prostate volume, Laser energy density (kJ/g): laser energy used / resected weight, continence recovery, evaluated subjectively via ICIQ-UI SF ( 19 ) and objectively using the one-hour pad test. Urinary continence was defined as a negative one-hour pad test and an ICIQ-UI SF score of ≤ 2. Urinary incontinence was categorized as stress, urge, or mixed, and graded as mild, moderate, or severe based on pad weight ( 20 ). Other variables that were also compared were hemoglobin drop, hospital stay, catheterization time, Clavien-Dindo classified complications. Functional outcomes included IPSS, QoL, Qmax, PVR, and PSA reduction (change from baseline to 6 months post-op, expressed as a percentage). Statistical Analysis: Data were analyzed using SPSS version 20 (IBM Corp., Armonk, NY, USA). Categorical variables were compared using chi-square tests. Kolmogorov–Smirnov test assessed normality. Continuous variables were analyzed using Student's t-test (for normally distributed data) or Mann–Whitney U and Wilcoxon signed-rank tests (for non-normal data). Statistical significance was set at p < 0.05. Results Between October 2022 and October 2024, a total of 123 eligible patients were randomly assigned to undergo either en-bloc HoLEP technique (60 patients) or LBL-HoLEP technique (63 patients). patient flow through study is depicted in Fig. 1 . Baseline demographic characteristics were similar between two groups (Table 1 ). Table 1 Baseline Characteristics of Study Population. Variable Lobe-by-lobe En-bloc P value Age : (years): mean ± SD 67.1 ± 7.6 67.2 ± 6.1 0.9* Presentation : N (%) 0.59 & LUTS 47 (74.7) 49 (81.7) Indwelling urethral catheter 12 ( 19 ) 9 ( 15 ) Haematuria 4 (6.3) 2 (3.3) BMI (kg/m 2 ): mean ± SD 29.3 ± 5.1 29.8 ± 5.2 0.59* Diabetes: N (%) 14 (22.2) 17 (28.3) 0.44 & Antiplatelet or anticoagulant use: N (%) 17 (26.9) 9 ( 15 ) 0.27 & ASA Score: N (%) 0.67 & I or II 50 (79.4) 45 (75) III 13 (20.6) 15 ( 25 ) PVR in ml: median (range) 32 (0-575) 20 (0-300) 0.18 # PSA in ng/ml: median (range) 7.1 (1.2–28.4) 6.3 (1.1–23.3) 0.25 # Preoperative biopsy: N (%) 22 (34.9) 21 (35) 0.9 & Total prostate volume in ml: mean ± SD 135.2 ± 35.1 127.6 ± 34.2 0.23* Baseline Urine flow parameters for non-catheterized patients : IPSS: median (range) 29 (22–35) 26 (21–35) 0.19 # QoL: median (range) 6 ( 4 – 6 ) 5 ( 3 – 6 ) 0.34 # Q max: ml/sec mean ± SD 8.6 ± 3.8 8.9 ± 3.2 0.64* & : Chi-square test *: Independent sample t-test # : Mann-Whitney test Operative and Perioperative Parameters Enbloc was associated with shorter enucleation time (62.5 vs 74.3 min, p = 0.02), operative time (78.6 vs 94.9 min, p = 0.0007), less total laser energy (135 vs 154 KJ, p = 0.014). However, enucleation and operative efficiency was comparable between both groups (Table 2 ). Additionally, there were no statistically significant differences in median hospital stay, time to catheter removal, or perioperative blood loss (Table 2 ). Table 2 Perioperative Efficacy and Safety Outcomes: Variables Lobe-by-lobe En-bloc P value Intraoperative Measures Prostate Morphology 0.15 & Bilobar (kissing lobes) 28 (44.4%) 35 (58.3%) Trilobar (median lobe) 35 (55.6%) 25 (41.7%) Concomitant Cystolithotripsy 13 (20.6%) 15 (25%) 0.36 & Total LASER Energy (KJ) 154.14 ± 42 135 ± 42.7 0.014 * Operative Time (min) mean ± SD median(range) 94.9 ± 33.2 90 (42–180) 78.6 ± 33.1 72.5 (33–160) 0.007 * Enucleation Time (min) mean ± SD median(range) 74.3 ± 28 70 (13–150) 62.5 ± 27.3 55 (25–140) 0.019 * Morcellation Time (min) mean ± SD median(range) 16.3 ± 12.2 13 (2–60) 13.9 ± 9.5 10 (3–46) 0.216 # Enucleated Weight (gm) mean ± SD median(range) 76.5 ± 26.5 71 (40–142) 70.5 ± 24.41 68(27–130) 0.192 * Enucleation Efficiency (gm/min): mean ± SD 1.17 ± 0.62 1.25 ± 0.49 0.105* Operative Efficiency (gm/min): mean ± SD 0.86 ± 0.31 0.98 ± 0.35 0.053* Laser density (KJ/gm): mean ± SD 2.17 ± 0.75 2.02 ± 0.68 0.228* Percentage of enucleated weight / total prostate size 57% ± 15.9% 56% ± 16.7% 0.81* Percent of PSA reduction at 6 months: mean ± SD 81.8% ± 13.7% 86.2% ± 11% 0.46* Intraoperative Safety Measures Capsular Violation: N. (%) 2 (3.2) 3 ( 5 ) 0.68 & Bladder Injury: N. (%) 4 (6.3) 0 0.12 & Urethral False Passage: N. (%) 1 (1.5) 0 1 & Need of electrocautery for hemostasis: N. (%) 3 (4.7) 1 (1.6) 0.62 & Auxiliary TURP for residual tissues: N. (%) 1 (1.5) 1 (1.6) 1 & Postoperative measures Haemoglobin deficit: (gm/dl) median (range) 1.1 (1.2–3.4) 0.7 (1-3.5) 0.098 # Catheterization Time (days): median (range) 2 ( 1 – 7 ) 2 ( 1 – 3 ) 0.117 # Hospital stays (days): median (range) 3 ( 2 – 5 ) 3 ( 2 – 5 ) 0.93 # 30-day postoperative complications Clavien grade Failed 1st trial without catheter: N. (%) GI 1 (1.5) 1 (1.8) 1 & Need for blood transfusion: N. (%) 1 (1.5) 2 (3.3) 0.53 & Haematuria: N. (%) GII 1 (1.5) 4 ( 6 ) 0.2 & Epididymo-orchitis: N.(%) GII 0 1 (1.8) 0.5 & & : Chi-square test *: Independent sample t test # : Mann-Whitney U test Functional Outcomes Both techniques resulted in significant improvements in the International Prostate Symptom Score (IPSS), Quality of Life (QoL), Post-Void Residual (PVR) volume, and maximum urinary flow rate (Qmax) at two weeks, three months, and six months postoperatively when compared to baseline values (P < 0.05). No significant differences were observed between two groups at any follow-up visit (Fig. 2 ). mean postoperative reduction in prostate-specific antigen (PSA) was comparable between groups. Continence Outcomes The mean ICIQ-UI (International Consultation on Incontinence Questionnaire – Urinary Incontinence) scores among patients who experienced incontinence were comparable between the two groups at both two weeks and three months postoperatively (Table 3 ). Table 3 Postoperative Stress and Urge Urinary Incontinence: 1 st follow up visit (2 weeks) LBL En-bloc P value Patient-reported Stress incontinence: N. (%) 3 (5.3) 4 (7.1) 0.11 & GI: Mild (≤ 10 ml) 3 (5.3) 3 (5.3) GII: Moderate (11–50 ml) 0 1 (1.8) GIII: Severe (> 50 ml) 0 0 ICIQ-UI score median (range) 5( 4 – 7 ) 5( 4 – 14 ) 1 # Patient-reported Urge incontinence: N. (%) 8 (14.2) 12 (22.2) 0.32 & GI: Mild (≤ 10 ml) 7 (12.5) 8 (14.8) 0.52 & GII: Moderate (11–50 ml) 1 (1.7) 3 (5.6) GIII: Severe (> 50 ml) 0 1 (1.8) ICIQ-UI score median (range) 6( 4 – 10 ) 7 ( 5 – 17 ) 0.32 # 2 nd follow up visit (3 months) LBL En-bloc P value Patient-reported Stress incontinence: N. (%) 2 ( 4 ) 2 (3.8) 0.31 & GI: Mild (≤ 10 ml) 2 ( 4 ) 1 (1.9) GII: Moderate (11–50 ml) 0 1 (1.9) GIII: Severe (> 50 ml) 0 0 ICIQ-UI score median (range) 7( 7 – 8 ) 8 ( 8 – 9 ) 1 # Patient-reported Urge incontinence: N. (%) 5 ( 10 ) 7 (13.6) 0.96 & G0: (negative pad test) 4 ( 8 ) 1 (1.9) 0.67 & GI: Mild (≤ 10 ml) 1 ( 2 ) 5 (9.8) GII: Moderate (11–50 ml) 0 1 (1.9) GIII: Severe (> 50 ml) 0 0 ICIQ-UI score median(range) 5( 5 – 8 ) 8( 5 – 10 ) 0.24 # & Chi square test # Mann-Whitney test Transient urge urinary incontinence (UUI) was observed in 8 patients (14.2%) in the LBL group and 12 patients (22.2%) in the en-bloc group at two weeks. By three months, the incidence had decreased to 5 patients (10%) and 7 patients (13.6%) in the LBL and en-bloc groups, respectively. The differences in UUI incidence and severity between the two groups were not statistically significant. At six months, only two patients in the en-bloc group had persistent UUI, both with mild leakage (pad test weight of 5 g) and ICIQ-UI scores of 11 and 14. These cases were successfully managed with anticholinergic therapy. Transient stress urinary incontinence (SUI) occurred in 3 patients (5%) in the LBL group and 4 patients (7%) in the en-bloc group at two weeks. At three months, this declined to 2 patients (4%) and 2 patients (3.8%), respectively. Again, no significant differences were noted between the two groups in terms of SUI incidence or severity. By six months, persistent SUI was observed in only one patient from each group, with ICIQ-UI scores of 8 (LBL) and 12 (en-bloc). Notably, no patients in either group developed severe SUI (≥ Grade III). Complications The incidence of intraoperative complications, including capsular violation, bladder injury, and urethral false passage, was comparable between the two groups (Table 2 , P = 0.12). The rates and severity of 30-day postoperative complications were also similar. One patient in each group experienced a failed first trial to void, both of which were managed with re-catheterization for one week, followed by successful voiding. Hematuria requiring catheter prolongation or continuous bladder irrigation (CBI) occurred in 4 patients (6%) in the en-bloc group and in 1 patient (1.5%) in the LBL group. One patient in the en-bloc group developed a urethral stricture, and another developed bladder neck contracture, at three and six months, respectively. Both complications were managed with endoscopic dilatation and bladder neck incision, respectively. Discussion The classical three-lobe technique for HoLEP offers the theoretical advantage of a step-by-step enucleation. It divides the procedure into smaller, more manageable steps, while providing clear reference points, borders, and landmarks. This method provides clear anatomical reference points and is particularly useful in prostates with a prominent middle lobe. However, it also has notable limitations. First, it requires three separate incisions, which may increase the risk of leaving residual adenomatous tissue due to inconsistent dissection planes. Additionally, the traditional approach lacks EAR, which increases the risk of mucosal trauma to the EUS. This typically occurs due to downward levering of the scope during the 12 o’clock incision, potentially leading to transient stress urinary incontinence (SUI). The reported incidence of transient SUI after classic HoLEP can reach up to 30% even in the hands of experienced surgeons ( 21 ). To address these issues, en-bloc enucleation with EAR, developed first by Sancha et al. in 2015 using the Green Light Laser ( 13 ) and later validated by Ferrari et al. ( 22 ). The potential advantages of this technique include: 1) preserving the integrity of the mucosal covering of the EUS by early demarcation of the ‘white line,’ between the prostatic apex and EUS, 2) dissecting the anterior zone from the sides, lowering the adenoma and eliminating the need for downward levering of the scope, thus avoiding the splitting of the sphincter that can result from the traditional 12 o’clock incision; 3) improved visibility, as irrigation fluid is restricted to a narrower area; and 4) reduced operative time, as the adenoma is dissected apically from the EUS, enabling a circumferential line of dissection that speeds up the procedure because a single plane of dissection is followed throughout the procedure. In 2019, Saita et al. replicated these principles using HoLEP and reported shorter overall operative time compared to other methods, with a lower incidence of SUI (1.5% at three months)( 15 ). Some authors have applied the principles of EAR and urethral sphincter mucosal preservation to the lobe-by-lobe technique, reporting improved outcomes, particularly in terms of a reduced incidence of early urinary incontinence.( 18 , 14 ) In this study we compared both en-bloc vs lobe by lobe HoLEP while ensuring that both techniques incorporated EAR and careful sphincteric mucosal preservation. This allowed us to isolate the impact of the enucleation strategy itself on perioperative and functional outcomes. We identified several key findings. First, the en-bloc technique was associated with significantly shorter enucleation and operative times and required less laser energy compared to the LBL approach, despite comparable enucleated tissue weights. The observed intraoperative advantages of en-bloc HoLEP may be attributed to maintaining a consistent dissection plane and avoiding repeated lobe repositioning. While enucleation and operative efficiency were numerically higher in the en-bloc group, these differences did not reach statistical significance. This finding is likely explained by the comparable resected prostate weights between groups, which narrowed the absolute difference in efficiency values. Additionally, variability in operative performance across individual cases—reflected in the relatively wide standard deviations for enucleation time and tissue weight—may have limited the statistical power to detect a significant difference in this derived metric. Our findings were consistent with previously published data. In a RCT comparing en-bloc vs 2-lobe vs 3 lobe HoLEP, Rucker et al ( 23 ) reported a significantly higher operative efficiency for en-bloc and two-lobe compared to three-lobe (1.82, 1.76 and 1.67 gm/min, respectively P = 0.006) with no significant difference between en-bloc and two-lobe techniques. Similarly, Tuccio et al ( 24 ), in a retrospective analysis, found that enucleation time, operative times and laser energy were significantly lower in the en-bloc compared to three-lobe technique. It is however worth noting that the mean prostate volume in the current study was notably larger than in the previous studies. Second, we evaluated postoperative continence using a robust approach that combined objective measurement via the pad test and subjective assessment with the ICIQ-SF questionnaire, enabling a more accurate comparison between the en-bloc and lobe-by-lobe HoLEP techniques. At three months, the incidence of stress urinary incontinence (SUI) was 3.8% in the en-bloc group and 4% in the LBL group, without significant difference. These rates are notably lower than the historically reported incidence of SUI following conventional HoLEP techniques, where transient SUI rates reached up to 30%. Our findings aline with previous studies that implemented similar technical modifications. For example, Saitta et al. ( 15 ) reported a 1.5% SUI rate at three months in 137 patients undergoing en-bloc HoLEP. Similarly, Tuccio et al.( 24 ) compared en-bloc HoLEP with EAR to the lobe-by-lobe technique and found a significantly lower incidence of SUI at one month in favor of the en-bloc (4.5% vs. 13.5%, P < 0.05). In a large multicenter study involving over 5,000 patients, the incidence of SUI was significantly higher in the LBL group compared to the en-bloc group. Furthermore, the absence of EAR was identified as an independent predictor of SUI on multivariate analysis.( 25 ) Interestingly, Rucker et al. ( 23 )found no statistically significant difference in SUI incidence among en-bloc, two-lobe, and three-lobe techniques within the first three months (5%, 4%, and 5.5%, respectively; P = 0.8), though they used a binary (yes/no) question to assess SUI. The slightly higher SUI rates observed in our study could be attributed to the use of more sensitive assessment methods, including the pad test, which likely captured milder degrees of incontinence. Third, we found that both the en-bloc and lobe-by-lobe HoLEP techniques yielded comparable functional outcomes, as reflected by significant and sustained improvements in IPSS, QoL, PVR, and Q max at all follow-up time points. This confirms both techniques effectively relieve obstruction and improve function. Additionally, no significant differences in intraoperative or 30-day postoperative complications were found, suggesting comparable safety profiles when performed by experienced surgeons. Thus, technique selection can depend on surgeon experience without compromising outcomes. Finally, our study offers several strengths., it is the first RCT comparing en-bloc and lobe-by-lobe HoLEP incorporating EAR and EUS mucosal preservation. It was adequately powered and used standardized dual-modality continence assessment: objective (pad test) and subjective (ICIQ-SF), ensuring a comprehensive evaluation. minimizing the risk of type I and type II statistical errors. However, there are some limitations. First, sexual function was not assessed, as a large proportion of patients were not sexually active preoperatively. Second, the study was conducted at a single high-volume center, and all procedures were performed by experienced endourologists, limiting the generalizability of our findings. Third, although the follow-up period was sufficient to capture early and intermediate outcomes, a longer follow-up is needed. Finally, the study was not powered to detect small differences in early urinary incontinence rates between both techniques. Further multicenter, prospective studies are warranted to assess the learning curve and long-term functional outcomes of different HoLEP techniques. Conclusions This randomized controlled trial demonstrates that both en-bloc and lobe by lobe HoLEP techniques offer comparable functional and safety outcomes. The en-bloc approach, however, confers advantages in operative time and laser energy usage. These findings support the flexibility of surgical technique choice in HoLEP based on surgeon experience, with en-bloc HoLEP representing a streamlined, anatomically guided alternative. Declarations Conflict of interest: Nothing to disclose. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. ACKNOWLEDGEMENTS The authors are grateful for the patients for participating in this study, as well as the staff of our department for supporting this study. AUTHOR CONTRIBUTIONS First author: Yahya H. Elmorsy: contributed in conception and design of the study, acquisition and analysis of data and writing the manuscript. Second author: Ahmed M. Elshal : contributed in the design of the study, statistical analysis and revision of the manuscript. Third author: Ahmed R. EL-Nahas: participated in supervision and revision of the manuscript for important intellectual content. Fourth author: Ahmed M. EL-Assmy supervision and revision of the manuscript. Last author: Mahmoud Laymon: study concept and design, statistical analysis, interpretation of data and writing of the manuscript. COMPETING INTERESTS The authors declare no competing interests References Fraundorfer MR, Gilling PJ. Holmium:YAG laser enucleation of the prostate combined with mechanical morcellation: preliminary results. Eur Urol. 1998;33(1):69-72. Elterman D, Aubé-Peterkin M, Evans H, Elmansy H, Meskawi M, Zorn KC, et al. UPDATE – 2022 Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH). Canadian Urological Association Journal. 2022;16(8):245-256. 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Stress urinary incontinence after holmium laser enucleation of prostate:incidence and risk factors. 2022;18(1). Oh SJ. Current surgical techniques of enucleation in holmium laser enucleation of the prostate. Investig Clin Urol. 2019;60(5):333-342. Gomez Sancha F, Rivera VC, Georgiev G, Botsevski A, Kotsev J, Herrmann T. Common trend: move to enucleation-Is there a case for GreenLight enucleation? Development and description of the technique. World J Urol. 2015;33(4):539-547. Oh SJ, Shitara T. Enucleation of the prostate: An anatomical perspective. Andrologia. 2020;52(8):e13744. Saitta G, Becerra JEA, Del Álamo JF, González LL, Elbers JR, Suardi N, et al. 'En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol. 2019;37(11):2451-2458. Elshal AM, El-Nahas AR, Ghazy M, Nabeeh H, Laymon M, Soltan M, et al. Low-Power Vs High-Power Holmium Laser Enucleation of the Prostate: Critical Assessment through Randomized Trial. Urology. 2018;121:58-65. Kane S. Sample Size Calculator. ClinCalc: https://clincalc.com/stats/samplesize.aspx. Updated July 24, 2019. Accessed February 19, 2021 [ Elshal AM, Ghazy M, Ghobrial FK. Enhancing continence post holmium laser enucleation of the prostate: assessment of novel technique through randomized clinical trial. Minerva Urol Nephrol. 2024;76(2):210-220. Avery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn. 2004;23(4):322-330. O'Sullivan R, Karantanis E, Stevermuer TL, Allen W, Moore KH. Definition of mild, moderate and severe incontinence on the 24-hour pad test. BJOG: An International Journal of Obstetrics & Gynaecology. 2004;111(8):859-862. Capogrosso P, Ventimiglia E, Fallara G, Schifano N, Costa A, Candela L, et al. Holmium Laser Enucleation of the Prostate Is Associated with Complications and Sequelae Even in the Hands of an Experienced Surgeon Following Completion of the Learning Curve. Eur Urol Focus. 2023;9(5):813-821. Ferrari G, Rabito S, Gatti L, Ntep NN, Vitelli FD, Marchioni M, et al. Green light laser enucleation of the prostate with early apical release is safe and effective: single center experience and revision of the literature. Minerva Urol Nephrol. 2022;74(4):467-474. Rücker F, Lehrich K, Böhme A, Zacharias M, Ahyai SA, Hansen J. A call for HoLEP: en-bloc vs. two-lobe vs. three-lobe. World J Urol. 2021;39(7):2337-2345. Tuccio A, Grosso AA, Salvi M, Sessa F, Tellini R, Viola L, et al. En-bloc’ HoLEP with early apical release: are we ready for a new paradigm? European Urology Open Science. 2020;20:S89. Castellani D, Gauhar V, Fong KY, Sofer M, Socarrás MR, Tursunkulov AN, et al. Incidence of urinary incontinence following endoscopic laser enucleation of the prostate by en-bloc and non- en-bloc techniques: a multicenter, real-world experience of 5068 patients. Asian J Androl. 2024;26(3):233-238. Additional Declarations There is NO conflict of interest to disclose. Cite Share Download PDF Status: Published Journal Publication published 06 Nov, 2025 Read the published version in Prostate Cancer and Prostatic Diseases → Version 1 posted Editorial decision: revise 29 Jul, 2025 Review # 3 received at journal 22 Jul, 2025 Review # 1 received at journal 18 Jul, 2025 Review # 2 received at journal 17 Jul, 2025 Reviewer # 3 agreed at journal 15 Jul, 2025 Reviewer # 2 agreed at journal 13 Jul, 2025 Reviewer # 1 agreed at journal 13 Jul, 2025 Reviewers invited by journal 13 Jul, 2025 Editor assigned by journal 11 Jul, 2025 Submission checks completed at journal 10 Jul, 2025 First submitted to journal 07 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7068506","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":484670228,"identity":"26ff8d41-bf0c-4a8f-81a4-eade48fd6632","order_by":0,"name":"Mahmoud Laymon","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABJUlEQVRIiWNgGAWjYDCCA0DM2ABiJYNJBn6oBEQQv5ZEiBrJBpK1GBwgoIXv9gHWDT93bJMzOJ7Y+Jk3xybP+NrhZw9/MNjIbjjAfPgFFi2S5xLYbvaeuW1scOZhszTvtrRis9tp5sY8DGnGGw6wpVlg0WJwhoHtBm/b7cQNNxIbgFoOJ267nWAmzcBwOHHDAR4zAxxabv6FaGn+DdKyeXb6N8kfDP+BWvi/4dJyG2pLG9iWDdI5ZhI8DAdAtjA/wOYXkBbZttvGkmcetlnO3ZaWOON2Tpk0j0Gy8czDbGZYQwzksLdtt+X4jicfvvF2m01i/+z0bZI/Kuxk+443P/6ANZj5EcJMPAgHAzEzA5sEVi1IgPEHmgAzdltGwSgYBaNghAEArY11ESTxGOcAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-7929-0407","institution":"Urology and nephrology center","correspondingAuthor":true,"prefix":"","firstName":"Mahmoud","middleName":"","lastName":"Laymon","suffix":""},{"id":484670229,"identity":"0a08adc3-9fd7-4a4b-a62a-6b06c0b8583a","order_by":1,"name":"Yahya Elmorsy","email":"","orcid":"","institution":"Urology and nephrology center","correspondingAuthor":false,"prefix":"","firstName":"Yahya","middleName":"","lastName":"Elmorsy","suffix":""},{"id":484670230,"identity":"9c81ef5b-825d-4333-a016-f1de26217028","order_by":2,"name":"Ahmed Elshal","email":"","orcid":"https://orcid.org/0000-0003-0938-0161","institution":"Urology \u0026 Nephrology Center, Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Elshal","suffix":""},{"id":484670231,"identity":"e2120b31-ce05-40c9-8d04-dd5f6ae9558c","order_by":3,"name":"Ahmed El-Nahas","email":"","orcid":"","institution":"Urology \u0026 Nephrology Center, Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"El-Nahas","suffix":""},{"id":484670232,"identity":"107439b3-8a35-4ef2-8aa6-f7e98ac7a2d9","order_by":4,"name":"Ahmed EL-Assmy","email":"","orcid":"","institution":"Urology and nephrology center","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"EL-Assmy","suffix":""},{"id":484670233,"identity":"248123f0-106d-41ee-bb16-64cbcd65a219","order_by":5,"name":"Mahmoud Laymon","email":"","orcid":"","institution":"Urology and nephrology center","correspondingAuthor":false,"prefix":"","firstName":"Mahmoud","middleName":"","lastName":"Laymon","suffix":""}],"badges":[],"createdAt":"2025-07-07 19:55:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7068506/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7068506/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41391-025-01040-0","type":"published","date":"2025-11-06T05:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":87032965,"identity":"37304901-babe-40d8-8aae-ee07c91a1475","added_by":"auto","created_at":"2025-07-18 13:03:02","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":62186,"visible":true,"origin":"","legend":"\u003cp\u003eCONSORT Flow Chart of the Study\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7068506/v1/6dcaef2233b3cbc3c29ea03c.jpg"},{"id":87032971,"identity":"333d5805-780d-4297-9a3b-e22d52dc8bf6","added_by":"auto","created_at":"2025-07-18 13:03:02","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":139153,"visible":true,"origin":"","legend":"\u003cp\u003eUrinary outcomes among the study groups: a) IPSS, b) QoL, c) PVR and d) Q-Max\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7068506/v1/c885f0406e8e5aed993f80cc.jpg"},{"id":95363660,"identity":"7aabb5fb-1903-4617-beaa-d4c151ed0ed9","added_by":"auto","created_at":"2025-11-07 08:09:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1224408,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7068506/v1/075f596e-1638-46a2-996c-d611613a51ba.pdf"}],"financialInterests":"There is \u003cb\u003eNO\u003c/b\u003e conflict of interest to disclose.","formattedTitle":"A Randomized Controlled Trial Comparing En-bloc vs Lobe-by-Lobe HoLEP: Surgical Efficiency and Early Continence Outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSince its introduction in 1998 (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), and through numerous level 1a evidence studies, Holmium Laser Enucleation of Prostate (HoLEP) has become size-independent gold standard for management of bladder outlet obstruction (BOO) secondary to benign prostatic hyperplasia (BPH) (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Alongside minimally invasive simple prostatectomy, HoLEP is widely accepted as preferred alternative to open simple prostatectomy for prostates larger than 80 mL (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite being most thoroughly investigated laser technique, HoLEP adoption remains limited to relatively few centers. This is largely due to a long and flat learning curve and absence of structured mentorship programs (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Additionally, prevalence of stress urinary incontinence following HoLEP has been reported to range between 3.3% and 26% (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo improve the learning curve and optimize surgical outcomes, several modifications of the original three-lobe HoLEP technique have been proposed (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). One notable advancement is the en-bloc enucleation approach incorporating early apical release (EAR), first introduced by Sancha et al. in 2015 using the GreenLight laser. Their technique emphasized early demarcation of the apex with preservation of the mucosal covering of the external urethral sphincter (EUS), aiming to reduce postoperative stress incontinence and improve functional outcomes (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These principles of EAR and sphincteric mucosal preservation have since been adapted to the lobe-by-lobe (LBL) technique as well (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlthough the benefits of EAR and sphincteric mucosal preservation on continence recovery are increasingly recognized, few studies have directly compared en-bloc and lobe-by-lobe HoLEP while consistently applying these refinements. This study aimed to provide high-level evidence on efficacy of en-bloc HoLEP, focusing specifically on its impact on enucleation efficiency, enucleation time, operative time, and early recovery of continence compared to conventional lobe-by-lobe approach.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003e\u003cb\u003eStudy Design\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eThis prospective randomized controlled trial (RCT) was approved by local institutional review board (IRB No.: MS.21.07.1561) and registered on clinicaltrials.gov (Registration ID: NCT07014969)\u003c/p\u003e\u003cp\u003eInclusion criteria were age ≥ 40 years and prostate volume between 80–200 mL, measured via transrectal ultrasound (TRUS). Surgical indications included refractory lower urinary tract symptoms (LUTS) or complications related to BPH, such as recurrent acute urinary retention, gross hematuria, bladder stones, recurrent infections, or upper urinary tract deterioration. Exclusion criteria included: known neurological conditions affecting bladder function, prostate or bladder cancer, coagulopathy (INR \u0026gt; 1.5 or platelet count \u0026lt; 90,000/mL), and ASA score \u0026gt; 3. All eligible patients provided informed consent in accordance with Good Clinical Practice and Declaration of Helsinki.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSample Size Calculation\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eBased on Saita et al. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), en-bloc enucleation was associated with a 23% reduction in mean operative effeciency compared to three-lobe technique described by Gilling et al. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Assuming a type I error \u0026lt; 5% and power of 80%, and considering a reported enucleation efficiency of 1.4 ± 0.6 g/min (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), a total sample size of 120 patients was calculated to account for a 10% dropout rate (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRandomization: Once HoLEP was indicated, patients were randomized in a 1:1 ratio using computer-generated random tables. Allocation was performed independently from outcome assessor to minimize bias.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePreoperative Workup\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eAll patients underwent comprehensive clinical evaluation, including medical history, physical examination, International Prostate Symptom Score (IPSS), quality of life (QoL) score, uroflowmetry, post-void residual (PVR) urine measurement, PSA testing, urine analysis, culture, and TRUS. Patients with positive urine cultures received appropriate antibiotics and were included only after a sterile culture was confirmed.\u003c/p\u003e\u003cp\u003eInterventions: Both en-bloc and LBL HoLEP procedures were performed using EAR while preserving mucosa overlying EUS, as previously described (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Four experienced HoLEP surgeons performed all procedures. Equipment included a 26F continuous flow resectoscope (Karl Storz, Tuttlingen, Germany) with rotating inner sheath and Kuntz working element, a 30° optics lens, and a 100W Sphinx laser system (Lisa Laser, Katlenburg-Lindau, Germany), set at 2 J and 30 Hz (short pulse). Tissue morcellation was performed via a 26F rigid nephroscope (Karl Storz) using PIRANHA morcellator system (Richard Wolf, Knittlingen, Germany).\u003c/p\u003e\u003cp\u003ePrimary outcome was enucleation efficiency, defined as resected weight divided by enucleation time (g/min), from laser fiber insertion to completion of enucleation.\u003c/p\u003e\u003cp\u003eSecondary outcomes included operative efficiency (g/min): resected weight / total operative time, percentage of gland removed: resected weight / total prostate volume, Laser energy density (kJ/g): laser energy used / resected weight, continence recovery, evaluated subjectively via ICIQ-UI SF (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and objectively using the one-hour pad test. Urinary continence was defined as a negative one-hour pad test and an ICIQ-UI SF score of ≤ 2. Urinary incontinence was categorized as stress, urge, or mixed, and graded as mild, moderate, or severe based on pad weight (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOther variables that were also compared were hemoglobin drop, hospital stay, catheterization time, Clavien-Dindo classified complications.\u003c/p\u003e\u003cp\u003eFunctional outcomes included IPSS, QoL, Qmax, PVR, and PSA reduction (change from baseline to 6 months post-op, expressed as a percentage).\u003c/p\u003e\u003ch2\u003eStatistical Analysis:\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS version 20 (IBM Corp., Armonk, NY, USA). Categorical variables were compared using chi-square tests. Kolmogorov–Smirnov test assessed normality. Continuous variables were analyzed using Student's t-test (for normally distributed data) or Mann–Whitney U and Wilcoxon signed-rank tests (for non-normal data). Statistical significance was set at p \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween October 2022 and October 2024, a total of 123 eligible patients were randomly assigned to undergo either en-bloc HoLEP technique (60 patients) or LBL-HoLEP technique (63 patients). patient flow through study is depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Baseline demographic characteristics were similar between two groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline Characteristics of Study Population.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLobe-by-lobe\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEn-bloc\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e: (years): mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.9*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePresentation\u003c/b\u003e: N (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.59\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLUTS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (74.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49 (81.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndwelling urethral catheter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaematuria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (6.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e): mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.59*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDiabetes: N (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (28.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.44\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAntiplatelet or anticoagulant use: N (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (26.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.27\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eASA Score: N (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.67\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eI or II\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (79.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIII\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (20.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePVR in ml: median (range)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32 (0-575)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (0-300)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.18 \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePSA in ng/ml: median (range)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.1 (1.2\u0026ndash;28.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.3 (1.1\u0026ndash;23.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.25 \u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePreoperative biopsy: N (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (34.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.9\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal prostate volume in ml: mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e135.2\u0026thinsp;\u0026plusmn;\u0026thinsp;35.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e127.6\u0026thinsp;\u0026plusmn;\u0026thinsp;34.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.23*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBaseline Urine flow parameters for non-catheterized patients\u003c/b\u003e:\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIPSS: median (range)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (22\u0026ndash;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (21\u0026ndash;35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.19\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eQoL: median (range)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.34\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eQ max: ml/sec mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.64*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e\u0026amp;\u003c/sup\u003e: Chi-square test\u003c/p\u003e\u003cp\u003e*: Independent sample t-test\u003c/p\u003e\u003cp\u003e\u003csup\u003e#\u003c/sup\u003e: Mann-Whitney test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldUnderline\" class=\"BoldUnderline\" name=\"Emphasis\"\u003eOperative and Perioperative Parameters\u003c/span\u003e\u003c/p\u003e\u003cp\u003eEnbloc was associated with shorter enucleation time (62.5 vs 74.3 min, p\u0026thinsp;=\u0026thinsp;0.02), operative time (78.6 vs 94.9 min, p\u0026thinsp;=\u0026thinsp;0.0007), less total laser energy (135 vs 154 KJ, p\u0026thinsp;=\u0026thinsp;0.014). However, enucleation and operative efficiency was comparable between both groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Additionally, there were no statistically significant differences in median hospital stay, time to catheter removal, or perioperative blood loss (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePerioperative Efficacy and Safety Outcomes:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eVariables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLobe-by-lobe\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEn-bloc\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eIntraoperative Measures\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eProstate Morphology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.15\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBilobar (kissing lobes)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (44.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35 (58.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTrilobar (median lobe)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (55.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (41.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eConcomitant Cystolithotripsy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (20.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.36\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTotal LASER Energy (KJ)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e154.14\u0026thinsp;\u0026plusmn;\u0026thinsp;42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e135\u0026thinsp;\u0026plusmn;\u0026thinsp;42.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.014\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOperative Time (min) mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003cp\u003emedian(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e94.9\u0026thinsp;\u0026plusmn;\u0026thinsp;33.2 90 (42\u0026ndash;180)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e78.6\u0026thinsp;\u0026plusmn;\u0026thinsp;33.1 72.5 (33\u0026ndash;160)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.007\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eEnucleation Time (min) mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003cp\u003emedian(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.3\u0026thinsp;\u0026plusmn;\u0026thinsp;28 70 (13\u0026ndash;150)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62.5\u0026thinsp;\u0026plusmn;\u0026thinsp;27.3 55 (25\u0026ndash;140)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.019\u003c/b\u003e\u003csup\u003e\u003cb\u003e*\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMorcellation Time (min) mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003cp\u003emedian(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.2 13 (2\u0026ndash;60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5 10 (3\u0026ndash;46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.216\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eEnucleated Weight (gm) mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003cp\u003emedian(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76.5\u0026thinsp;\u0026plusmn;\u0026thinsp;26.5 71 (40\u0026ndash;142)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70.5\u0026thinsp;\u0026plusmn;\u0026thinsp;24.41 68(27\u0026ndash;130)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.192\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eEnucleation Efficiency (gm/min): mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.105*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eOperative Efficiency (gm/min): mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.98\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.053*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eLaser density (KJ/gm): mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.02\u0026thinsp;\u0026plusmn;\u0026thinsp;0.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.228*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePercentage of enucleated weight / total prostate size\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e57% \u0026plusmn; 15.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e56% \u0026plusmn; 16.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.81*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003ePercent of PSA reduction at 6 months: mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81.8% \u0026plusmn; 13.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86.2% \u0026plusmn; 11%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.46*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntraoperative Safety Measures\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCapsular Violation: N. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (3.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.68\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBladder Injury: N. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (6.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.12\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eUrethral False Passage: N. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eNeed of electrocautery for hemostasis: N. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (4.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.62\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAuxiliary TURP for residual tissues: N. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePostoperative measures\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHaemoglobin deficit: (gm/dl) median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.1 (1.2\u0026ndash;3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7 (1-3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.098\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCatheterization Time (days): median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.117\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eHospital stays (days): median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.93\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003e30-day postoperative complications\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eClavien grade\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFailed 1st trial without catheter: N. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeed for blood transfusion: N. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.53\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHaematuria: N. (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.2\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEpididymo-orchitis: N.(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e\u0026amp;\u003c/sup\u003e: Chi-square test\u003c/p\u003e\u003cp\u003e*: Independent sample t test\u003c/p\u003e\u003cp\u003e\u003csup\u003e#\u003c/sup\u003e: Mann-Whitney U test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldItalicUnderline\" class=\"BoldItalicUnderline\" name=\"Emphasis\"\u003eFunctional Outcomes\u003c/span\u003e\u003c/p\u003e\u003cp\u003eBoth techniques resulted in significant improvements in the International Prostate Symptom Score (IPSS), Quality of Life (QoL), Post-Void Residual (PVR) volume, and maximum urinary flow rate (Qmax) at two weeks, three months, and six months postoperatively when compared to baseline values (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No significant differences were observed between two groups at any follow-up visit (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). mean postoperative reduction in prostate-specific antigen (PSA) was comparable between groups.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cspan type=\"BoldItalicUnderline\" class=\"BoldItalicUnderline\" name=\"Emphasis\"\u003eContinence Outcomes\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThe mean ICIQ-UI (International Consultation on Incontinence Questionnaire \u0026ndash; Urinary Incontinence) scores among patients who experienced incontinence were comparable between the two groups at both two weeks and three months postoperatively (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostoperative Stress and Urge Urinary Incontinence:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e1\u003csup\u003est\u003c/sup\u003e follow up visit (2 weeks)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLBL\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEn-bloc\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient-reported Stress incontinence: N. (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (5.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (7.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.11\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGI: Mild (\u0026le;\u0026thinsp;10 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (5.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (5.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGII: Moderate (11\u0026ndash;50 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGIII: Severe (\u0026gt;\u0026thinsp;50 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICIQ-UI score median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5(\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient-reported Urge incontinence: N. (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (14.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.32\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGI: Mild (\u0026le;\u0026thinsp;10 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (14.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.52\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGII: Moderate (11\u0026ndash;50 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (5.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGIII: Severe (\u0026gt;\u0026thinsp;50 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICIQ-UI score median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6(\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10 CR11 CR12 CR13 CR14 CR15 CR16\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.32\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e2\u003csup\u003end\u003c/sup\u003e follow up visit (3 months)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eLBL\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003eEn-bloc\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient-reported Stress incontinence: N. (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (3.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.31\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGI: Mild (\u0026le;\u0026thinsp;10 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGII: Moderate (11\u0026ndash;50 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGIII: Severe (\u0026gt;\u0026thinsp;50 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICIQ-UI score median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePatient-reported Urge incontinence: N. (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (13.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.96\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eG0: (negative pad test)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.67\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGI: Mild (\u0026le;\u0026thinsp;10 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (9.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGII: Moderate (11\u0026ndash;50 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGIII: Severe (\u0026gt;\u0026thinsp;50 ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICIQ-UI score median(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8(\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.24\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003csup\u003e\u0026amp;\u003c/sup\u003e Chi square test \u003csup\u003e#\u003c/sup\u003eMann-Whitney test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTransient urge urinary incontinence (UUI)\u003c/b\u003e was observed in 8 patients (14.2%) in the LBL group and 12 patients (22.2%) in the en-bloc group at two weeks. By three months, the incidence had decreased to 5 patients (10%) and 7 patients (13.6%) in the LBL and en-bloc groups, respectively. The differences in UUI incidence and severity between the two groups were not statistically significant. At six months, only two patients in the en-bloc group had persistent UUI, both with mild leakage (pad test weight of 5 g) and ICIQ-UI scores of 11 and 14. These cases were successfully managed with anticholinergic therapy.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTransient stress urinary incontinence (SUI)\u003c/b\u003e occurred in 3 patients (5%) in the LBL group and 4 patients (7%) in the en-bloc group at two weeks. At three months, this declined to 2 patients (4%) and 2 patients (3.8%), respectively. Again, no significant differences were noted between the two groups in terms of SUI incidence or severity. By six months, persistent SUI was observed in only one patient from each group, with ICIQ-UI scores of 8 (LBL) and 12 (en-bloc). Notably, no patients in either group developed severe SUI (\u0026ge;\u0026thinsp;Grade III).\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eComplications\u003c/span\u003e\u003c/p\u003e\u003cp\u003eThe incidence of intraoperative complications, including capsular violation, bladder injury, and urethral false passage, was comparable between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, P\u0026thinsp;=\u0026thinsp;0.12). The rates and severity of 30-day postoperative complications were also similar. One patient in each group experienced a failed first trial to void, both of which were managed with re-catheterization for one week, followed by successful voiding. Hematuria requiring catheter prolongation or continuous bladder irrigation (CBI) occurred in 4 patients (6%) in the en-bloc group and in 1 patient (1.5%) in the LBL group.\u003c/p\u003e\u003cp\u003eOne patient in the en-bloc group developed a urethral stricture, and another developed bladder neck contracture, at three and six months, respectively. Both complications were managed with endoscopic dilatation and bladder neck incision, respectively.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe classical three-lobe technique for HoLEP offers the theoretical advantage of a step-by-step enucleation. It divides the procedure into smaller, more manageable steps, while providing clear reference points, borders, and landmarks. This method provides clear anatomical reference points and is particularly useful in prostates with a prominent middle lobe. However, it also has notable limitations. First, it requires three separate incisions, which may increase the risk of leaving residual adenomatous tissue due to inconsistent dissection planes. Additionally, the traditional approach lacks EAR, which increases the risk of mucosal trauma to the EUS. This typically occurs due to downward levering of the scope during the 12 o\u0026rsquo;clock incision, potentially leading to transient stress urinary incontinence (SUI). The reported incidence of transient SUI after classic HoLEP can reach up to 30% even in the hands of experienced surgeons (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTo address these issues, en-bloc enucleation with EAR, developed first by Sancha et al. in 2015 using the Green Light Laser (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and later validated by Ferrari et al. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The potential advantages of this technique include: 1) preserving the integrity of the mucosal covering of the EUS by early demarcation of the \u0026lsquo;white line,\u0026rsquo; between the prostatic apex and EUS, 2) dissecting the anterior zone from the sides, lowering the adenoma and eliminating the need for downward levering of the scope, thus avoiding the splitting of the sphincter that can result from the traditional 12 o\u0026rsquo;clock incision; 3) improved visibility, as irrigation fluid is restricted to a narrower area; and 4) reduced operative time, as the adenoma is dissected apically from the EUS, enabling a circumferential line of dissection that speeds up the procedure because a single plane of dissection is followed throughout the procedure. In 2019, Saita et al. replicated these principles using HoLEP and reported shorter overall operative time compared to other methods, with a lower incidence of SUI (1.5% at three months)(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSome authors have applied the principles of EAR and urethral sphincter mucosal preservation to the lobe-by-lobe technique, reporting improved outcomes, particularly in terms of a reduced incidence of early urinary incontinence.(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) In this study we compared both en-bloc vs lobe by lobe HoLEP while ensuring that both techniques incorporated EAR and careful sphincteric mucosal preservation. This allowed us to isolate the impact of the enucleation strategy itself on perioperative and functional outcomes.\u003c/p\u003e\u003cp\u003eWe identified several key findings. First, the en-bloc technique was associated with significantly shorter enucleation and operative times and required less laser energy compared to the LBL approach, despite comparable enucleated tissue weights. The observed intraoperative advantages of en-bloc HoLEP may be attributed to maintaining a consistent dissection plane and avoiding repeated lobe repositioning. While enucleation and operative efficiency were numerically higher in the en-bloc group, these differences did not reach statistical significance. This finding is likely explained by the comparable resected prostate weights between groups, which narrowed the absolute difference in efficiency values. Additionally, variability in operative performance across individual cases\u0026mdash;reflected in the relatively wide standard deviations for enucleation time and tissue weight\u0026mdash;may have limited the statistical power to detect a significant difference in this derived metric.\u003c/p\u003e\u003cp\u003eOur findings were consistent with previously published data. In a RCT comparing en-bloc vs 2-lobe vs 3 lobe HoLEP, Rucker et al (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) reported a significantly higher operative efficiency for en-bloc and two-lobe compared to three-lobe (1.82, 1.76 and 1.67 gm/min, respectively P\u0026thinsp;=\u0026thinsp;0.006) with no significant difference between en-bloc and two-lobe techniques. Similarly, Tuccio et al (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), in a retrospective analysis, found that enucleation time, operative times and laser energy were significantly lower in the en-bloc compared to three-lobe technique. It is however worth noting that the mean prostate volume in the current study was notably larger than in the previous studies.\u003c/p\u003e\u003cp\u003eSecond, we evaluated postoperative continence using a robust approach that combined objective measurement via the pad test and subjective assessment with the ICIQ-SF questionnaire, enabling a more accurate comparison between the en-bloc and lobe-by-lobe HoLEP techniques. At three months, the incidence of stress urinary incontinence (SUI) was 3.8% in the en-bloc group and 4% in the LBL group, without significant difference. These rates are notably lower than the historically reported incidence of SUI following conventional HoLEP techniques, where transient SUI rates reached up to 30%. Our findings aline with previous studies that implemented similar technical modifications. For example, Saitta et al. (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) reported a 1.5% SUI rate at three months in 137 patients undergoing en-bloc HoLEP. Similarly, Tuccio et al.(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) compared en-bloc HoLEP with EAR to the lobe-by-lobe technique and found a significantly lower incidence of SUI at one month in favor of the en-bloc (4.5% vs. 13.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eIn a large multicenter study involving over 5,000 patients, the incidence of SUI was significantly higher in the LBL group compared to the en-bloc group. Furthermore, the absence of EAR was identified as an independent predictor of SUI on multivariate analysis.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) Interestingly, Rucker et al. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)found no statistically significant difference in SUI incidence among en-bloc, two-lobe, and three-lobe techniques within the first three months (5%, 4%, and 5.5%, respectively; P\u0026thinsp;=\u0026thinsp;0.8), though they used a binary (yes/no) question to assess SUI. The slightly higher SUI rates observed in our study could be attributed to the use of more sensitive assessment methods, including the pad test, which likely captured milder degrees of incontinence.\u003c/p\u003e\u003cp\u003eThird, we found that both the en-bloc and lobe-by-lobe HoLEP techniques yielded comparable functional outcomes, as reflected by significant and sustained improvements in IPSS, QoL, PVR, and Q max at all follow-up time points. This confirms both techniques effectively relieve obstruction and improve function.\u003c/p\u003e\u003cp\u003eAdditionally, no significant differences in intraoperative or 30-day postoperative complications were found, suggesting comparable safety profiles when performed by experienced surgeons. Thus, technique selection can depend on surgeon experience without compromising outcomes.\u003c/p\u003e\u003cp\u003eFinally, our study offers several strengths., it is the first RCT comparing en-bloc and lobe-by-lobe HoLEP incorporating EAR and EUS mucosal preservation. It was adequately powered and used standardized dual-modality continence assessment: objective (pad test) and subjective (ICIQ-SF), ensuring a comprehensive evaluation.\u003c/p\u003e\u003cp\u003eminimizing the risk of type I and type II statistical errors.\u003c/p\u003e\u003cp\u003eHowever, there are some limitations. First, sexual function was not assessed, as a large proportion of patients were not sexually active preoperatively. Second, the study was conducted at a single high-volume center, and all procedures were performed by experienced endourologists, limiting the generalizability of our findings. Third, although the follow-up period was sufficient to capture early and intermediate outcomes, a longer follow-up is needed. Finally, the study was not powered to detect small differences in early urinary incontinence rates between both techniques. Further multicenter, prospective studies are warranted to assess the learning curve and long-term functional outcomes of different HoLEP techniques.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis randomized controlled trial demonstrates that both en-bloc and lobe by lobe HoLEP techniques offer comparable functional and safety outcomes. The en-bloc approach, however, confers advantages in operative time and laser energy usage. These findings support the flexibility of surgical technique choice in HoLEP based on surgeon experience, with en-bloc HoLEP representing a streamlined, anatomically guided alternative.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e Nothing to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACKNOWLEDGEMENTS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful for the patients for participating in this study, as well as the staff of our department for supporting this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst author: Yahya H. Elmorsy: contributed in conception and design of the study, acquisition and analysis of data and writing the manuscript. Second author: Ahmed M. Elshal\u003csup\u003e:\u0026nbsp;\u003c/sup\u003econtributed in the design of the study, statistical analysis and revision of the manuscript. Third author: Ahmed R. EL-Nahas: participated in supervision and revision of the manuscript for important intellectual content. Fourth author: Ahmed M. EL-Assmy supervision and revision of the manuscript. Last author: Mahmoud Laymon:\u0026nbsp; study concept and design, statistical analysis, interpretation of data and writing of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOMPETING INTERESTS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFraundorfer MR, Gilling PJ. Holmium:YAG laser enucleation of the prostate combined with mechanical morcellation: preliminary results. Eur Urol. 1998;33(1):69-72.\u003c/li\u003e\n\u003cli\u003eElterman D, Aub\u0026eacute;-Peterkin M, Evans H, Elmansy H, Meskawi M, Zorn KC, et al. UPDATE \u0026ndash; 2022 Canadian Urological Association guideline on male lower urinary tract symptoms/benign prostatic hyperplasia (MLUTS/BPH). Canadian Urological Association Journal. 2022;16(8):245-256.\u003c/li\u003e\n\u003cli\u003eGravas S, Gacci M, Gratzke C, Herrmann TRW, Karavitakis M, Kyriazis I, et al. Summary Paper on the 2023 European Association of Urology Guidelines on the Management of Non-neurogenic Male Lower Urinary Tract Symptoms. Eur Urol. 2023.\u003c/li\u003e\n\u003cli\u003eSandhu Jaspreet S, Bixler Brooke R, Dahm P, Goueli R, Kirkby E, Stoffel John T, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia (BPH): AUA Guideline Amendment 2023. Journal of Urology. 2023;0(0):10.1097/JU.0000000000003698.\u003c/li\u003e\n\u003cli\u003evan Rij S, Gilling PJ. In 2013, Holmium Laser Enucleation of the Prostate (HoLEP) May Be the New \u0026lsquo;Gold Standard\u0026rsquo;. Current Urology Reports. 2012;13(6):427-432.\u003c/li\u003e\n\u003cli\u003eFuschi A, Al Salhi Y, Velotti G, Capone L, Martoccia A, Suraci PP, et al. Holmium laser enucleation of prostate versus minimally invasive simple prostatectomy for large volume (\u0026ge;120 mL) prostate glands: a prospective multicenter randomized study. Minerva Urol Nephrol. 2021;73(5):638-648.\u003c/li\u003e\n\u003cli\u003eLeonardo C, Lombardo R, Cindolo L, Antonelli A, Greco F, Porreca A, et al. What is the standard surgical approach to large volume BPE? Systematic review of existing randomized clinical trials. Minerva Urol Nefrol. 2020;72(1):22-29.\u003c/li\u003e\n\u003cli\u003eElshal AM, Nabeeh H, Eldemerdash Y, Mekkawy R, Laymon M, El-Assmy A, et al. Prospective Assessment of Learning Curve of Holmium Laser Enucleation of the Prostate for Treatment of Benign Prostatic Hyperplasia Using a Multidimensional Approach. J Urol. 2017;197(4):1099-1107.\u003c/li\u003e\n\u003cli\u003eGravas S, Bachmann A, Reich O, Roehrborn CG, Gilling PJ, De La Rosette J. Critical review of lasers in benign prostatic hyperplasia (BPH). BJU Int. 2011;107(7):1030-1043.\u003c/li\u003e\n\u003cli\u003eNaspro R, Gomez Sancha F, Manica M, Meneghini A, Ahyai S, Aho T, et al. From \u0026quot;gold standard\u0026quot; resection to reproducible \u0026quot;future standard\u0026quot; endoscopic enucleation of the prostate: what we know about anatomical enucleation. Minerva Urol Nefrol. 2017;69(5):446-458.\u003c/li\u003e\n\u003cli\u003eYe H, Codas R, Daily T, Badet L, Colombel M, Fassi-Fehri H. Stress urinary incontinence after holmium laser enucleation of prostate:incidence and risk factors. 2022;18(1).\u003c/li\u003e\n\u003cli\u003eOh SJ. Current surgical techniques of enucleation in holmium laser enucleation of the prostate. Investig Clin Urol. 2019;60(5):333-342.\u003c/li\u003e\n\u003cli\u003eGomez Sancha F, Rivera VC, Georgiev G, Botsevski A, Kotsev J, Herrmann T. Common trend: move to enucleation-Is there a case for GreenLight enucleation? Development and description of the technique. World J Urol. 2015;33(4):539-547.\u003c/li\u003e\n\u003cli\u003eOh SJ, Shitara T. Enucleation of the prostate: An anatomical perspective. Andrologia. 2020;52(8):e13744.\u003c/li\u003e\n\u003cli\u003eSaitta G, Becerra JEA, Del \u0026Aacute;lamo JF, Gonz\u0026aacute;lez LL, Elbers JR, Suardi N, et al. \u0026apos;En Bloc\u0026apos; HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol. 2019;37(11):2451-2458.\u003c/li\u003e\n\u003cli\u003eElshal AM, El-Nahas AR, Ghazy M, Nabeeh H, Laymon M, Soltan M, et al. Low-Power Vs High-Power Holmium Laser Enucleation of the Prostate: Critical Assessment through Randomized Trial. Urology. 2018;121:58-65.\u003c/li\u003e\n\u003cli\u003eKane S. Sample Size Calculator. ClinCalc: https://clincalc.com/stats/samplesize.aspx. Updated July 24, 2019. Accessed February 19, 2021 [\u003c/li\u003e\n\u003cli\u003eElshal AM, Ghazy M, Ghobrial FK. Enhancing continence post holmium laser enucleation of the prostate: assessment of novel technique through randomized clinical trial. Minerva Urol Nephrol. 2024;76(2):210-220.\u003c/li\u003e\n\u003cli\u003eAvery K, Donovan J, Peters TJ, Shaw C, Gotoh M, Abrams P. ICIQ: a brief and robust measure for evaluating the symptoms and impact of urinary incontinence. Neurourol Urodyn. 2004;23(4):322-330.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Sullivan R, Karantanis E, Stevermuer TL, Allen W, Moore KH. Definition of mild, moderate and severe incontinence on the 24-hour pad test. BJOG: An International Journal of Obstetrics \u0026amp; Gynaecology. 2004;111(8):859-862.\u003c/li\u003e\n\u003cli\u003eCapogrosso P, Ventimiglia E, Fallara G, Schifano N, Costa A, Candela L, et al. Holmium Laser Enucleation of the Prostate Is Associated with Complications and Sequelae Even in the Hands of an Experienced Surgeon Following Completion of the Learning Curve. Eur Urol Focus. 2023;9(5):813-821.\u003c/li\u003e\n\u003cli\u003eFerrari G, Rabito S, Gatti L, Ntep NN, Vitelli FD, Marchioni M, et al. Green light laser enucleation of the prostate with early apical release is safe and effective: single center experience and revision of the literature. Minerva Urol Nephrol. 2022;74(4):467-474.\u003c/li\u003e\n\u003cli\u003eR\u0026uuml;cker F, Lehrich K, B\u0026ouml;hme A, Zacharias M, Ahyai SA, Hansen J. A call for HoLEP: en-bloc vs. two-lobe vs. three-lobe. World J Urol. 2021;39(7):2337-2345.\u003c/li\u003e\n\u003cli\u003eTuccio A, Grosso AA, Salvi M, Sessa F, Tellini R, Viola L, et al. En-bloc\u0026rsquo; HoLEP with early apical release: are we ready for a new paradigm? European Urology Open Science. 2020;20:S89.\u003c/li\u003e\n\u003cli\u003eCastellani D, Gauhar V, Fong KY, Sofer M, Socarr\u0026aacute;s MR, Tursunkulov AN, et al. Incidence of urinary incontinence following endoscopic laser enucleation of the prostate by en-bloc and non- en-bloc techniques: a multicenter, real-world experience of 5068 patients. Asian J Androl. 2024;26(3):233-238.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"prostate-cancer-and-prostatic-diseases","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"pcan","sideBox":"Learn more about [Prostate Cancer and Prostatic Diseases](http://www.nature.com/pcan/)","snPcode":"41391","submissionUrl":"https://mts-pcan.nature.com/cgi-bin/main.plex","title":"Prostate Cancer and Prostatic Diseases","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7068506/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7068506/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective:\u003c/h2\u003e\u003cp\u003eTo compare en-bloc HoLEP with conventional lobe-by-lobe (LBL) HoLEP technique in terms of surgical efficiency, perioperative outcomes, and early continence recovery through a randomized controlled trial.\u003c/p\u003e\u003ch2\u003ePatients and Methods:\u003c/h2\u003e\u003cp\u003eThis single-center randomized controlled trial included patients with prostate volumes\u0026thinsp;\u0026gt;\u0026thinsp;80 mL undergoing HoLEP for bladder outlet obstruction secondary to benign prostatic hyperplasia. Eligible patients were randomized to either en-bloc or LBL HoLEP. All procedures incorporated early apical release and sphincteric mucosal preservation. Assessments were performed preoperatively and at 1, 3, and 6 months postoperatively. primary outcome was enucleation efficiency (resected weight/enucleation time). Secondary outcomes included operative efficiency, laser energy use, blood loss, hospital stay, complications, and functional outcomes (IPSS, QoL, Qmax, PVR, and transient stress urinary incontinence [SUI]).\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eA total of 123 patients were randomized (en-bloc: 60; LBL: 63). En-bloc HoLEP was associated with shorter enucleation time (62.5 vs. 74.3 min, P\u0026thinsp;=\u0026thinsp;0.02), operative time (78.6 vs. 94.9 min, P\u0026thinsp;=\u0026thinsp;0.0007), and lower laser energy use (135 vs. 154 KJ, P\u0026thinsp;=\u0026thinsp;0.014). Enucleation efficiency was comparable (1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49 vs. 1.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62 g/min; P\u0026thinsp;=\u0026thinsp;0.42). Both techniques resulted in significant postoperative improvements in IPSS, QoL, Qmax, and PVR (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Complication rates were similar (14.6% vs. 14%; P\u0026thinsp;=\u0026thinsp;0.8). At 3 months, transient SUI rates were low and comparable (3.8% en-bloc vs. 4% LBL; P\u0026thinsp;=\u0026thinsp;0.3).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eEn-bloc HoLEP reduces enucleation time, operative time, and laser energy consumption compared to LBL HoLEP, while maintaining comparable safety, efficacy, and early continence outcomes when performed with modern technical refinements.\u003c/p\u003e","manuscriptTitle":"A Randomized Controlled Trial Comparing En-bloc vs Lobe-by-Lobe HoLEP: Surgical Efficiency and Early Continence Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-18 13:02:57","doi":"10.21203/rs.3.rs-7068506/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"revise","date":"2025-07-29T15:58:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-07-22T09:41:57+00:00","index":3,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-07-18T15:43:13+00:00","index":1,"fulltext":"This content is not available."},{"type":"editorInvitedReview","content":"This content is not available.","date":"2025-07-17T05:22:17+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-07-15T17:23:44+00:00","index":3,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-07-13T22:10:11+00:00","index":2,"fulltext":"This content is not available."},{"type":"reviewerAgreed","content":"This content is not available.","date":"2025-07-13T13:28:26+00:00","index":1,"fulltext":"This content is not available."},{"type":"reviewersInvited","content":"","date":"2025-07-13T13:28:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-11T15:13:36+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-10T15:08:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"Prostate Cancer and Prostatic Diseases","date":"2025-07-07T19:50:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"prostate-cancer-and-prostatic-diseases","isNatureJournal":false,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"pcan","sideBox":"Learn more about [Prostate Cancer and Prostatic Diseases](http://www.nature.com/pcan/)","snPcode":"41391","submissionUrl":"https://mts-pcan.nature.com/cgi-bin/main.plex","title":"Prostate Cancer and Prostatic Diseases","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"42cd6ed4-01a0-469a-a795-a65bc7d9313f","owner":[],"postedDate":"July 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":51452900,"name":"Health sciences/Diseases/Urogenital diseases/Prostatic diseases"},{"id":51452901,"name":"Health sciences/Medical research/Outcomes research"}],"tags":[],"updatedAt":"2025-11-07T08:09:04+00:00","versionOfRecord":{"articleIdentity":"rs-7068506","link":"https://doi.org/10.1038/s41391-025-01040-0","journal":{"identity":"prostate-cancer-and-prostatic-diseases","isVorOnly":false,"title":"Prostate Cancer and Prostatic Diseases"},"publishedOn":"2025-11-06 05:00:00","publishedOnDateReadable":"November 6th, 2025"},"versionCreatedAt":"2025-07-18 13:02:57","video":"","vorDoi":"10.1038/s41391-025-01040-0","vorDoiUrl":"https://doi.org/10.1038/s41391-025-01040-0","workflowStages":[]},"version":"v1","identity":"rs-7068506","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7068506","identity":"rs-7068506","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}