Does Size Matter? Comparison of Miniaturized (22 Fr) versus Standard (26 Fr) Instruments in Pulsed Thulium:YAG Laser Enucleation of the Prostate

Purpose Anatomic enucleation of the prostate is increasingly performed worldwide. While 26Fr instruments are commonly used, miniaturized devices have been introduced to reduce complications and improve recovery without compromising efficiency. We compared 22Fr and 26Fr instruments in pulsed Thulium:YAG anatomic enucleation regarding intraoperative efficiency and postoperative outcomes. Methods A total of 150 patients who underwent pulsed Thulium:YAG laser enucleation of the prostate between December 2024 and July 2025 were prospectively enrolled. MiLEP was performed in 70 patients, while standard AEEP was performed in 80. The primary endpoint was intraoperative efficiency, and secondary endpoints were postoperative complications and functional recovery, comparing miniaturized with standard instruments. Results The MiLEP group had a smaller median prostate volume (50.5 vs. 88 mL, p < 0.001) and shorter enucleation time (19 vs. 25 min, p < 0.001), although enucleation efficiency was higher in the standard group (3.6 vs. 2.7 g/min, p < 0.001). Irrigation volume was lower (13.5 vs. 21 L, p < 0.001), and no intraoperative urethrotomy/meatotomy was required in the MiLEP group compared with 10 patients (12.5%) in the standard group (p = 0.002). At 1 month, urethral stricture was identified in 1 (1.4%) MiLEP and 3 (3.8%) standard patients (p = 0.379), whereas incontinence occurred in 3 (4.3%) and 4 (5.0%), respectively (p = 0.836). Conclusions MiLEP with pulsed Thulium:YAG laser represents an effective modality for anatomic enucleation of the prostate. It offers comparable intraoperative efficiency and favorable postoperative functional outcomes compared to standard resectoscope size. Our findings support the role of MiLEP for patients with low urethral compliance and smaller prostate size.