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

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.