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Anales de la Facultad de Ciencias Médicas (Asunción)
versión impresa ISSN 1816-8949
An. Fac. Cienc. Méd. (Asunción) vol.58 no.3 Asunción dic. 2025
https://doi.org/10.18004/anales/2025.058.03.35
ORIGINAL ARTICLE
Holmium laser enucleation of the prostate. Experience in a Urology Center in Paraguay.
1
http://orcid.org/0000-0002-5989-6572
1
http://orcid.org/0000-0003-2650-9377
1
http://orcid.org/0009-0002-0128-4714
1
http://orcid.org/0009-0004-8025-0954
1
http://orcid.org/0000-0002-1442-0079
1
http://orcid.org/0009-0005-9606-7895
1
http://orcid.org/0009-0000-3485-3675
1
http://orcid.org/0009-0001-5547-8613
1Centro Médico La Costa. Asunción, Paraguay.
Introduction:
Holmium Laser Enucleation of the Prostate (HoLEP) is an endoscopic surgical technique used to treat obstructive prostatic enlargement. Currently, the guidelines of the American Urological Association and the European Association of Urology consider HoLEP a surgical treatment alternative to TURP (Transurethral Resection of the Prostate) and open prostatectomy.
Materials and Methods:
An observational, descriptive, cross-sectional retrospective prevalence study was conducted from 2022 to 2024. Results: Data from 182 patients who underwent HoLEP at the La Costa Medical Center by the same surgical team were analyzed. The mean age of the operated patients was 66.59 years. The mean prostate size was 77.10. The average surgical time was 99.8 minutes. Regarding complications, there was a 2.7% rate of reintervention due to hematuria, 1% of patients required blood transfusion, and 1.6% of patients experienced episodes of acute urinary retention after catheter removal, resulting in an overall complication rate of 5.5%.
Conclusion:
Prostate gland enlargement is a natural event of male aging. Among the valid therapeutic alternatives, HoLEP is an option regardless of prostate size. It is currently considered the gold standard in the surgical management of the prostate gland. Our aim is to present the first cases described in our country with results comparable to those described in the global medical literature.
Keywords: Benign Prostatic Hyperplasia; Holmium Laser Enucleation of the Prostate; Lower Urinary Tract Symptoms; Prostate; Urologic Surgical Procedures.
Introducción:
La enucleación prostática por láser de Holmio (HOLEP por sus siglas en inglés) es una técnica quirúrgica endoscópica para tratar el crecimiento prostático obstructivo. Actualmente las guías de la Sociedad Americana de Urología y la Sociedad Europea de Urología consideran al HoLEP como alternativa de tratamiento quirúrgico a RTU-P y a la prostatectomía abierta.
Materiales y métodos:
Se realizó un estudio de tipo observacional, descriptivo de prevalencia de corte transversal retrospectivo del año 2022 al 2024.
Resultados:
Se analizaron los datos de 182 pacientes operados de HOLEP en el Centro Médico La Costa por un mismo equipo quirúrgico. Con respecto a la edad de los pacientes operados se encontró una media de 66,59 años. Sobre el tamaño prostático se encontró una media de 77,10. Como tiempo promedio de cirugía un valor de 99,8 minutos. Con respecto a complicaciones se tuvo un 2,7% de episodios de reintervención por hematuria, 1% de pacientes necesitaron transfusión sanguínea y 1,6% de los pacientes presentaron episodios de retención aguda de orina al retiro de la sonda, dando una tasa global de complicaciones de 5,5%.
Conclusión:
El agrandamiento de la glándula prostática es un evento natural del envejecimiento del varón, dentro de las alternativas terapéuticas validas indepedientes del tamaño se encuentra el HoLep. El mismo es considerado actualmente como el Gold Standard en el manejo quirúrgico de la glándula prostática, nuestra intención presentar los primeros casos descritos en nuestro país con resultados comparables a los descritos en la literatura médica mundial.
Palabras clave: Hiperplasia Prostática Benigna; Enucleación Prostática con Láser de Holmio; Síntomas del Tracto Urinario Inferior; Próstata; Procedimientos Quirúrgicos Urológicos.
INTRODUCTION Benign prostatic hyperplasia (BPH) is a common clinical condition that becomes clinically significant when it produces symptoms such as decreased urinary stream force and caliber, and increased nocturia, all of which are defined as lower urinary tract symptoms (LUTS). Prostatic enlargement is considered an event associated with male aging, influenced by hormonal factors, and it is estimated that it affects between 50% and 70% of men over 50 years of age, with up to 80% of men over 70 experiencing symptoms associated with BPH. Medical therapy is considered the first-line symptomatic management; when refractoriness occurs, surgical intervention remains the treatment of choice for both mild and severe symptoms 1.
The etiology of BPH is not yet fully understood; however, it is suggested to be influenced by factors such as age, family history, hormonal conditions, increased inflammation, and metabolic syndrome 2.
Histologically, BPH is characterized by proliferation of glandular elements, smooth muscle, and connective tissue in the transitional zone of the prostate. This progresses to benign prostatic enlargement, which may extend outward from or compress the prostatic urethra, ultimately causing lower urinary tract obstruction. This, combined with prostatic inflammation, is considered the main cause of LUTS 3-5.
Transurethral resection of the prostate (TURP) was historically considered the standard treatment for BPH with prostate volume under 80 g, with its indication limited by prostate size. For prostates larger than 80 g, open surgery (Millin or Freyer) was traditionally used 6. Subsequently, various techniques were developed to treat large prostate volumes with improved outcomes. Bipolar transurethral resection of the prostate (B-TURP) and bipolar transurethral enucleation of the prostate (BPEP) demonstrated lower perioperative morbidity and favorable medium- and long-term efficacy. The emergence of laser-based techniques, especially Holmium-YAG, allowed procedures to be performed independently of prostate size, offering greater safety and relatively fewer complications compared to TURP 4.
HoLEP, an acronym for Holmium Laser Enucleation of the Prostate, is an endoscopic surgical technique for treating obstructive prostatic enlargement. It was first introduced in 1998 by Drs. Frank Rücker and Gilling, with the trilobar technique being the most studied type of endoscopic prostate surgery, noted for its safety, efficiency, and speed 5.
Currently, both the American Urological Association (AUA) and the European Association of Urology (EAU) guidelines consider HoLEP a surgical alternative to TURP and open prostatectomy. The AUA states that it is independent of prostate size, while the EAU emphasizes its efficacy and safety 6.
HoLEP has been shown to be more effective than TURP, with advantages including improved hemostasis, greater short-term improvements in urinary parameters, shorter transurethral catheterization times, and reduced hospital stay 7-11.
The objective of this study is to present the recent introduction of HoLEP in Paraguay, describe the first cases performed, and highlight its clinical relevance as an internationally endorsed procedure with the potential to establish itself as the new gold standard in the surgical management of benign prostatic hyperplasia.
OBJECTIVES
GENERAL OBJECTIVE
To describe the initial experience with holmium laser enucleation of the prostate (HoLEP) in a urology service in Paraguay during the period 2022-2024.
SPECIFIC OBJECTIVES
To characterize the treated population by describing its demographic distribution (age).
To quantify the baseline characteristics of the disease, including prostate size and pre-procedure PSA values.
To determine the surgical parameters of the procedure, such as average operative time.
To analyze the frequency and types of postoperative complications observed in the series.
(Optional but recommended to close the cycle) To compare the obtained results with those reported in the international literature to contextualize their clinical relevance.
MATERIALS AND METHODS
Study design: An observational, descriptive, cross-sectional retrospective prevalence study was conducted from 2022 to 2024.
Equipment used for the procedures: Laser from the Italian company Quanta System©, Cyber Ho 100-watt model. Endoscopic equipment from Karl Storz©, including laser resectoscope and morcelloscope. Morcellators from Lumenis, VersaCuT™ model, and Karl Storz, DrillCut-X® II model.
POPULATION
Target population: Patients undergoing laser prostate enucleation with holmium laser during the period 2022 to 2024.
Accessible population: Patients undergoing laser prostate enucleation with holmium laser during the period 2022 to 2024 at La Costa Medical Center and performed by the same surgical team.
Inclusion criteria: Patients undergoing laser prostate enucleation with holmium laser at La Costa Medical Center during the period 2022 to 2024, performed by the same surgical team, and with complete data available for statistical analysis.
Exclusion criteria: Patients undergoing laser prostate enucleation with holmium laser performed by another surgical team, with incomplete statistical data, or outside the study period.
Sampling: Non-probabilistic consecutive case sampling.
DATA ANALYSIS
A database was generated from Google.doc using a survey system and subsequently processed using Microsoft Excel 2021®. The presentation of the study was prepared using the Microsoft Word Office LTSC Professional Plus 2021® word processor.
RESULTS
Data from 182 patients who underwent HoLEP at La Costa Medical Center from 2022 to 2024 by the same surgical team were analyzed; incomplete records or cases performed by another operator were excluded.
Regarding patient age, the youngest patients were 47 years old (3 patients) and the oldest were 87 years old (2 cases), yielding a mean age of 66.59 years.
Considering prostate size, a mean of 77.10 was found, with the smallest prostate measuring 20 grams and the largest 230 grams, as measured by ultrasound.
The pre-procedure PSA value had a mean of 3.84, with the lowest value being 0.06 and the highest 57.
The average surgical time was 99.8 minutes.
Regarding complications, there were 5 episodes of reintervention due to hematuria, two patients required blood transfusions, and three patients experienced episodes of acute urinary retention after catheter removal.
DISCUSSION
Of the 182 patients who underwent HoLEP at La Costa Medical Center between 2022 and 2024, the mean age was 66.6 years (SD = 8.9; 95% CI ≈ ±1.3), with a range of 47 to 87 years and a median of 67 years. The first quartile was 60, the third quartile 72.25, and the coefficient of variation was 13.3%, indicating a relatively homogeneous population in terms of age. The distribution was approximately symmetrical (skewness = -0.05) with slight platykurtosis (kurtosis = -0.53). These values are consistent with those reported in the literature, such as the study by Blanco Fernández et al., where the average age of treated patients was 65.1 years, which is expected since this age range corresponds to the period of highest incidence of obstructive lower urinary tract symptoms that lead to surgical indication for prostatic enlargement 1,8.
The average prostate size was 77.1 ± 37.6 g (range: 20-230 g), with a median of 70 g. The distribution was skewed toward higher values (skewness = 0.95), reflecting the presence of large glands. These results are consistent with series such as that of Gild et al., which report an average of 80 g, and confirm the applicability of HoLEP in prostates of various sizes, including those larger than 80 g.
The box plot shows the distribution of ultrasound-measured prostate weight as a function of age, evidencing a wide variation in gland volume across all analyzed decades and confirming that HoLEP was applied to prostates of different sizes regardless of patient age.
Figure 1: Box plots of age and ultrasound-measured prostate weight in the 182 patients undergoing HoLEP. The median and quartiles show the central distribution of each variable, while extreme values reflect the variability of the studied population. The wide dispersion of prostate size demonstrates the applicability of the procedure in glands of different volumes
The pre-procedure PSA value showed a mean of 3.84 ng/mL (SD = 3.67; standard error = 0.27), with a median of 2.74 ng/mL and a wide range between 0.06 and 24.93 ng/mL, evidencing the clinical heterogeneity of the sample. The first quartile was 1.41 ng/mL and the third quartile 4.87 ng/mL, with a high coefficient of variation (95.4%), positive skewness (2.41), and high kurtosis (8.07), indicating the presence of extreme values. This parameter is relevant both for initial prostate cancer screening and for postoperative follow-up, as studies such as that by Bâcle et al. have demonstrated a significant reduction in PSA after prostate enucleation 13.
The average operative time was 99.8 minutes for the 182 included cases, a value lower than that reported in other series, such as that of Gürlen et al., who described 178.7 minutes for 200 procedures 14. This result is clinically relevant, as operative times under 100 minutes have been associated with faster recovery of urinary continence, as reported by Doersch and colleagues.
Regarding complications, there was a 2.7% rate of reintervention due to hematuria (five patients), 1% of patients required blood transfusion (two patients), and 1.6% of patients experienced episodes of acute urinary retention after catheter removal (three patients), resulting in an overall complication rate of 5.5%.
Figure 2 presents the joint distribution of age and prostate weight in patients without postoperative complications. The graph shows that the absence of adverse events was consistently maintained across different age ranges and gland volumes, suggesting that in our series neither advanced age nor larger prostate size was evidently associated with a higher risk of complications.
CONCLUSION
Holmium laser enucleation of the prostate (HoLEP) was successfully implemented in our center, constituting the first documented experience in Paraguay. In this initial series of 182 patients, the procedure proved to be safe and effective, with competitive surgical times, a low complication rate (5.5%), and results comparable to those reported in the international literature. These findings support the applicability of HoLEP in prostates of different volumes and consolidate its role as a valid surgical alternative independent of gland size.
Considering the obtained results, HoLEP represents a high-value option for the management of benign prostatic hyperplasia in our setting and is projected as the reference standard for the surgical treatment of the disease. The expansion of this technique in Paraguay will strengthen local urological practice, reduce morbidity associated with conventional procedures, and align with the recommendations of major international societies.
REFERENCES
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12. Bâcle C, de Mazancourt ES, Abid N, Ruffion A, Rouvière O, Colombel M, et al. Impact of holmium laser enucleation of the prostate on active surveillance for prostate cancer in patients with lower urinary tract symptoms. Prostate. 2025;85(6):399-406. doi: 10.1002/pros.24906. [ Links ]
13. Gürlen G, Karkin K, Ünal U, Aksay B, Aydamirov M, Vuruşkan E. Comparison of modified single-incision two-loop technique and classical three-lobe technique in holmium laser enucleation of the prostate (HoLEP): experience of 200 cases of a single surgeon. J Cukurova Anesth Surg Sci. 2023;6(3):508-511. doi: 10.36516/jocass.1401431. [ Links ]
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Responsible Editor: Prof. Dr. Hassel Jimmy Jiménez, https://orcid.org/0000-0003-4078-5853; Dra. Lourdes Talavera, https://orcid.org/0000-0001-9671-3037.
Received: June 25, 2025; Accepted: December 09, 2025
Este es un artículo publicado en acceso abierto bajo una licencia Creative Commons
