Challenging the Gold Standard Transurethral Resection of the Prostate with Holmium Laser Enucleation in the Treatment of Benign Prostatic Hyperplasia: Paradigm Shift in Northern Cyprus

Abstract

Benign prostatic hyperplasia (BPH) is a common condition among men over the age of 50, which can significantly impact their quality of life. Transurethral Resection of the Prostate (TURP) has long been considered the gold standard for the surgical treatment of BPH because of its effectiveness and integration into urology training. However, in recent years, Holmium Laser Enucleation of the Prostate (HoLEP) has gained popularity owing to reduced bleeding, shorter hospitalization, and faster recovery times. This study aimed to evaluate the transition from TURP to HoLEP among urologists at Burhan Nalbantoğlu State Hospital by analyzing learning curves, complication rates, and patient outcomes. The study results suggest that HoLEP offers several advantages over TURP, including shorter hospital stay and lower postoperative complications, although it requires significant training and investment. Overall, this study supports HoLEP as a promising alternative to TURP, reflecting a shift in the paradigm of BPH management.

1. Introduction

Benign prostatic hyperplasia (BPH) is a prevalent condition among the elderly male population that can cause lower urinary tract symptoms (LUTS) by impeding urine flow. This can have a substantial influence on the patients’ quality of life. Epidemiological studies have shown that approximately 50% of men in their 50s and up to 90% of men in their 80s are affected by BPH [1]. In the past, traditional surgical procedures such as Transurethral Resection of the Prostate (TURP) and open prostatectomy for significant prostates have been favored for BPH treatment. However, advancements in surgical techniques and technological progress have led to the emergence of less-invasive methods, the most noteworthy of which is Holmium Laser Enucleation (HoLEP) [2, 3].

For several years, the Transurethral Resection of the Prostate (TURP) has been widely regarded as the gold standard treatment for Benign Prostatic Hyperplasia (BPH). TURP was first introduced in the early twentieth century and has since made significant advances. Initially, the removal of prostate tissue using a resectoscope was refined over the years with improvements in devices and techniques [4]. This procedure, which involves the removal of prostate tissue using a resectoscope inserted through the urethra, has undergone significant advancements since its inception in the early twentieth century. Several factors have contributed to TURP being considered the gold standard. Efficacy is one reason for this. Rapid regression of symptoms and improvement in patients’ quality of life following prostate tissue removal are among the benefits of this procedure. The widespread acceptance of TURP is due to the experience gained over many years, which has increased the confidence in the method. The experience and reliability of the method have contributed to its success. Numerous studies have documented the long-term effectiveness of TURP [5, 6, 7]. Transurethral Resection of the Prostate (TURP) is widely regarded as a fundamental aspect of urological education, and as such, it is both accessible and widely available. Moreover, when considering the investment required for equipment and devices, TURP is a more cost-effective option than other more recent methods (Table 1).

Reason	Explanation
Efficiency	Transurethral Resection of the Prostate (TURP) is a highly effective procedure that removes prostate tissue to enhance urine flow and alleviate symptoms, such as difficulty urinating.
Experience and reliability	It has decades of clinical use with a proven track record, giving doctors confidence.
Long-term outcomes	Long-term relief from symptoms associated with benign prostatic hyperplasia (BPH) has been demonstrated to be durably provided by transurethral resection of the prostate (TURP), as per findings from studies.
Standardized training	TURP is a crucial component of urological training and is widely performed and accessible.
Cost effectiveness	TURP is often the more economical choice in various areas because of lower equipment costs compared to other treatments.

Table 1.

Reasons for considering TURP as the gold standard in BPH treatment.

Transurethral Resection of the Prostate (TURP) is a minimally invasive surgical procedure rooted in urologists’ efforts to minimize surgical invasiveness. In 2018, a study by MJ Young et al. examined the advancements in TURP techniques and traced the historical development of this treatment approach from its origins to the present day [4]. Transurethral Resection of the Prostate (TURP) has exhibited substantial advancements in both safety and efficacy; however, the procedure still presents certain challenges and intricacies. Although Transurethral Resection of the Prostate (TURP) has been established as a safe and effective therapy for Benign Prostatic Hyperplasia (BPH), a proficient surgeon must prevent potential complications and attain optimal results. Transurethral Resection of the Prostate (TURP) has gained considerable popularity in the mid-twentieth century as a treatment for benign prostatic hyperplasia (BPH). Technological advancements, including the development of modern instruments such as the Stern-McCarthy resectoscope in the 1930s, which improved optics and irrigation systems to enable better visualization and operational capabilities within the prostate, have contributed to the enhanced effectiveness of TURP [8]. A study conducted by CE Hawtrey and RD Williams in 2008 provided a comprehensive account of the evolution of TURP at the University of Iowa. This study documented the historical development of the procedure and its applications throughout various time periods, which facilitated a deeper understanding of TURP’s role of TURP in the field of surgical urology [9].

Holmium Laser Enucleation of the Prostate (HoLEP) was initially performed by Dr. Peter Gilling in New Zealand in 1997. This procedure is a minimally invasive technique that aims to alleviate bladder obstruction by removing the inner prostate tissue. HoLEP has emerged as an effective treatment option, particularly for large prostates, and offers several advantages over conventional methods such as transurethral resection of the prostate (TURP) [10].

In 1999, Dr. James Lingeman introduced Holmium Laser Enucleation of the Prostate (HoLEP) to the United States, which has since become the gold standard treatment for benign prostatic hyperplasia (BPH). HoLEP is recognized as the only surgical intervention that can be performed regardless of the size of the prostate. This characteristic of HoLEP makes it a highly appealing option for patients with larger prostates, who may not be suitable candidates for other surgical procedures.

Recently, the emergence of alternative treatment options, particularly laser therapy and medications, has called into question the traditional role of TURP in BPH management. Nevertheless, TURP continues to be a widely performed surgical procedure and has been continually refined through advancements in surgical techniques and equipment. Despite the development of minimally invasive procedures, TURP remains a popular surgical intervention because of its well-established effectiveness and versatility in the treatment of various urological conditions.

The history of Transurethral Resection of the Prostate (TURP) embodies the continuous evolution of medicine and the pursuit of more effective, safer, and minimally invasive treatments for benign prostatic hyperplasia (BPH). This journey exemplifies the progress made in medical technology and transformation of patient care. Nevertheless, it is crucial to acknowledge that these technological advancements have engendered new impediments pertaining to healthcare accessibility and affordability for numerous individuals.

1.1 The situation in the TRNC and the change of methodology

In the TRNC, there has been an important paradigm shift in the treatment of BPH, especially in health institutions, such as Burhan Nalbantoğlu State Hospital. The transition from traditional TURP and open prostatectomy to HoLEP surgery has led to significant improvements in both hospital practices and patient outcomes. These advancements have reduced perioperative complications, shortened recovery times, and improved patient satisfaction. Additionally, HoLEP allows for a more precise and minimally invasive approach, further enhancing the benefits of this procedure over traditional methods. Implementing this modification has resulted in a decrease in the duration of hospital stay, a decline in the incidence of complications, and an increase in patient satisfaction and confidence levels in surgical procedures [2].

1.2 Literature review and current developments

According to a research conducted by Elmansy et al. in 2023, HoLEP has become widely recognized as a minimally invasive surgical option for the management of BPH. This study demonstrated that HoLEP is effective for prostate sizes ranging from small to large and offers several advantages over TURP, including a reduced risk of bleeding and a more rapid recovery time [2]. Furthermore, HoLEP is a minimally invasive procedure that utilizes a high-energy holmium laser to remove the prostate tissue, which results in precise and effective removal of the obstructive tissue, thereby improving the patient’s urinary symptoms. Additionally, HoLEP has been shown to be effective in treating patients with benign prostatic hyperplasia (BPH) and can be performed on an outpatient basis, making it a convenient option for many patients. Overall, the benefits of HoLEP make it a promising alternative to TURP and other traditional surgical procedures for BPH treatment. According to a study conducted by Elkoushy et al. in 2015, the necessity for reoperation following HoLEP is minimal and the long-term safety and efficacy of this method are evident [3]. Elkoushy et al. [3] emphasized the potential of HoLEP as a viable alternative to traditional surgical methods for the treatment of benign prostatic hyperplasia (BPH). This is attributed to its high success rate, low rate of complications, and minimal need for long-term reintervention. These findings have significant ramifications for the management of BPH and could potentially enhance the quality of life of patients with this condition.

1.3 Economic assessment

Although the HoLEP procedure has high initial costs, it improves the overall efficiency of patient care and saves costs for the healthcare system in the long run. Shorter hospital stays and lower complication rates allow for a more efficient use of hospital resources [2]. For instance, several studies found that patients who underwent a same-day surgery protocol had shorter hospital stays and lower complication rates than those who underwent traditional hospitalization procedures, demonstrating the potential benefits of more efficient use of hospital resources [11, 12].

The objective of this research was to thoroughly investigate the transition from traditional TURP to HoLEP in the management of BPH and to emphasize the progress, challenges, and consequences of this significant shift in paradigm. This chapter aims to deliver a comprehensive summary of the altering treatment landscape for BPH in North Cyprus by examining the clinical results and patient feedback linked to HoLEP, underlining the necessity of persistent innovation and education in urological practice.

2. Methodology

In the process of transitioning from traditional transurethral resection of the prostate (TURP) to holmium laser enucleation of the prostate (HoLEP), this study evaluated the conversion of experienced urologists. The learning curves and performance improvements of seven physicians who had access to the holmium laser device at Burhan Nalbantoğlu State Hospital were analyzed, as well as the patient series and treatment outcomes of seven physicians who began performing HoLEP at the hospital in 2022. The aforementioned urologists, A, B, C, D, E, F, and G, possess comparable qualifications in general urology, with each having a distinct focus on endourology based on their varying years of urology residency experience. Specifically, A has 16 years, B has 17 years, C has 27 years, D has 9 years, E has 2 years, F has 15 years, and G has 24 years of experience. A total of 216 surgical cases for benign prostatic hyperplasia (BPH) were included in the study. Information regarding physicians’ procedure preferences, order of procedures, procedure duration, complications, and recovery time was recorded. Time-series analysis was employed to evaluate changes in procedure duration, complication rates, and recovery times for physicians from the first to the last procedure. Similarly, learning curves are drawn to illustrate how physicians’ performance improves as their experience with the procedures increases. Changes in patients’ surgical preference requests following 6 months of adaptation and the first holmium laser enucleation of the prostate (HoLEP) cases will also be reflected in the paradigm results.

3. Exclusion criteria

Physicians who perform HoLEP are free to employ any technique they deem appropriate, regardless of whether it involves two-lobe or en bloc resection, regardless of the size of the prostate. Physicians are not bound by any specific guidelines or criteria when selecting patients for the HoLEP. The decision to perform HoLEP was entirely left up to the physician’s discretion and personal preferences. Two of the physicians had prior experience with HoLEP before 2022, but this was not considered an exclusion criterion during the transition from TURP to HoLEP. The patient can request a procedure for benign prostate enlargement; however, the final decision is made by the urologist responsible for the patient. Patients with neurogenic bladder and/or suspected neurogenic bladder were excluded from the study.

3.1 Surgical technique details

Patients were required to provide informed consent prior to surgery. During the procedure, a 26 F resectoscope sheath was used for both HoLEP and TURP procedures. HoLEP was performed through a combination of 2 and/or 3 lobe prostatectomy and en bloc, with the specific approach chosen based on factors such as the surgeon’s level of experience, prostate size, and education level. Initiating a procedure with an early apical release is a key consideration. Furthermore, it was not prohibited for certain urologists to conduct blunt dissection, while others chose to perform no-touch dissection or a combination of both. For TURP cases, monopolar energy was used for instances where the prostate size was 90 g or less.

3.2 Patient preferences and demands

Prior to the initiation of Holmium Laser Enucleation of the Prostate (HoLEP) surgery at the State Hospital, the first HoLEP procedure in the Turkish Republic of Northern Cyprus (TRNC) was performed at a private medical facility, leading to the formation of a patient group with extensive knowledge and surgical experience. Consequently, it was hypothesized that changes in patient preferences and demand for surgical options could be assessed by conducting HoLEP surgery at a public hospital. An analysis of modifications in patient preferences for surgical options during the six-month adjustment period following the initial HoLEP procedure was conducted to determine the acceptance of HoLEP and its impact on patient outcomes.

4. Analysis methods

4.1 Time series analysis and learning curves

Temporal changes in procedure duration, complication rates, and recovery times from the initial to the final procedure for each urologist were assessed using time series analysis. This analysis provides insights into the evolution of urologists’ performance over time. Learning curves were constructed to demonstrate the improvement in physician performance as the volume of procedures increased. These curves visually represent the improvement in procedure time and outcomes that can be achieved as physicians gain experience. The primary outcomes were the duration of surgery, intraoperative and postoperative complications, length of hospital stay, and patient recovery times. The secondary outcomes included patient satisfaction and reoperation rates. Statistical comparisons between the TURP and HoLEP groups were performed using independent t-tests for continuous variables and chi-squared tests for categorical variables.

5. Results

Between September 2022 and February 2024, 216 surgical interventions were performed for benign prostatic hyperplasia. The mean age of the patients who participated in the study was 69.4 ± 16.2 years. The allocation of patients seeking surgical or nonsurgical intervention at the time of admission was 64% HoLEP, 22% physician’s discretion, and 14% treatment with medication or alternative medicine. Specifically, 67 (31%) patients underwent transurethral resection of the prostate, 139 (64.3%) underwent holmium laser enucleation of the prostate, 7 (3.24%) underwent open prostatectomy, and 3 (1.38%) underwent laparoscopic urethra-sparing prostatectomy. Urologists were found to lack adequate experience in HoLEP and Laparoscopic urethro-sparing procedures. On the other hand, all physicians were proficient and skilled in performing open prostatectomy and TURP. Of the seven urologists who performed active prostate surgeries, only five performed the HoLEP procedure. The distribution of surgeries conducted according to urologist codes is shown inTable 2.

	Urologist codes
	A	B	C	D	E	F	G	Total
TURP*	2	4	28	16	3	3	11	67
HoLEP**	47	31	22	23	16	0	0	139
Open***	0	0	4	2	0	0	1	7
Laparoscopic****	3	0	0	0	0	0	0	3
Total	52	35	54	41	19	3	12	216

Table 2.

Distribution of surgeries conducted according to urologist codes.

^*

Transuretral resection of the prostate.

^**

Holmium laser enucleation of prostate.

^***

Open prostatectomy.

^****

Laparoscopic urethral sparing prostatectomy.

Based on the initial procedures of the five physicians (A, B, C, D, and E) who performed the Holep procedures, it was observed that operative times gradually decreased in a sequential manner. There was a positive correlation between the training curve and time series analysis. As shown in Figure 1, each physician’s operative time changed as they gained experience with the Holep procedure. The curve, constructed using a linear regression model, represents the overall reduction in operating times for each physician. According to the equation on the curve, the duration of surgery decreased as the order of the procedure increased. An R² value of 0.311 accounted for 31.1% of the model’s data points.

Figure 1.

Learning curves of urologists in the Transition from Transurethral Resection (TURP) to Holmium Laser Enucleation (HoLEP).

The graph shows the operation times of the five physicians (A, B, C, D, and E) who started to perform the HoLEP procedure in Burhan Nalbantoğlu State Hospital in 2022, in the order of procedure. A linear regression model was used to determine the overall decreasing trend in the operation times of each physician (R² = 0.311), and the duration of hospitalization and catheterization times were evaluated for TURP and HoLEP procedures. The mean length of stay was 3.49 ± 0.84 days for TURP and 2.41 ± 1.17 days for HoLEP. The results of the independent T test indicated a significant difference between the two procedures (p < 0.01). This suggests that, on average, patients stayed in the hospital for approximately 1.075 days less time after HoLEP procedures than after TURP procedures (95% confidence interval of the difference: 0.79292 to 1.35762 days). Cohen’s d effect size was 1.07 (95% confidence interval of the difference lower 0.690, upper 1.305).

No instances of permanent incontinence were documented in any patient or procedure. Transient stress incontinence occurred in 28% of HoLEP cases during the 3-week to 17-week postoperative period, 16.4% of TURP patients during the 1–3-week period, 42% of open prostatectomy patients during the 1–5-week period, and no cases were reported in laparoscopic urethra-sparing prostatectomy patients. In 14.9% of the TURP cases, postoperative bleeding necessitated extended irrigation and continuous monitoring. Among these patients, 30% were readmitted to the operating room, and bleeding control was established. Postoperative bleeding was identified in 4.31% (six patients) of the HoLEP cases, and only one (16.6%) of these patients received bleeding control during surgery. Only two patients in the TURP group required blood transfusions. No TUR syndrome requiring additional treatment or prolonged hospitalization was observed in any of the patients. Postoperative fever was observed in 12.2% (17 patients) in the HoLEP group. No postoperative fever was observed in the TURP group. During the procedure, 11.9% of patients who underwent transurethral resection of the prostate (TURP) experienced prostatic capsule injury, affecting a total of eight individuals. In contrast, 59.7% of patients who underwent holmium laser enucleation of the prostate (HoLEP) experienced this complication. In the HoLEP group, two patients required open surgery because of injury. A summary of general complications is presented in Table 3.

	Transurethral procedures
Complications	TURP (%)	HoLEP (%)
Transient incontinence	16.4	28
Bleeding	14.9	4.3
TUR syndrome	NIL	NIL
Postoperative fever	NIL	12.2
Injury of prostate capsule	11.9	59.7
Conversion to open surgery	NIL	1.4

Table 3.

A summary of general complications for transurethral procedures.

6. Discussion

Benign prostatic hyperplasia (BPH) is a prevalent condition among men, particularly those over the age of 50 years, and can adversely affect their quality of life. Although it is typically not a life-threatening condition, it can result in various complications if left untreated. In addition to medical therapies, surgical treatment options are also available for BPH. Among these surgical methods, Transurethral Resection of the Prostate (TURP) is widely regarded as the gold standard and an essential component of urology training programs. Consequently, most urologists acquired proficiency in TURP as part of their professional development. However, in the past decade, there has been a noticeable shift toward minimally invasive laser prostatectomy techniques, such as Holmium Laser Enucleation (HoLEP), which utilizes high-energy lasers [13]. Laser prostatectomies offer several benefits, including reduced bleeding, shorter duration of catheter and hospital stay, accelerated recovery, and early socialization [14]. Although these methods have certain advantages, they also have drawbacks. For instance, the training process can be quite challenging and expensive to undertake [15].

In terms of surgical techniques, TURP and HoLEP differ in their underlying principles. TURP begins at the bladder neck, extends to the apical lobes, and preserves the sphincter by removing parts of the prostatic urethra and capsule. In contrast, HoLEP and other laser prostatectomies preserve the apical sphincter and approach the bladder neck directly, creating a plan between the prostatic capsule and prostate adenoma [16]. From a urological perspective, the HoLEP procedure is regarded as a reverse approach for specialists who are experienced and skilled in performing TURP. According to our perspective, the primary challenge for novices arises from this detrimental approach. Additionally, initiating this procedure in clinics where there is insufficient utilization of a skilled urologist proficient in HoLEP presents another difficulty.

Research indicates that HoLEP has several benefits over TURP. In addition, according to Shvero et al. [13], HoLEP is the contemporary gold standard for surgical management of BPH and has an impressive efficacy and safety profile. Additionally, Frieben et al. [16] found that laser procedures, such as HoLEP, reduced postoperative sexual dysfunction compared with TURP.

Furthermore, Lokeshwar et al. [14] reported that laser-based treatments, including HoLEP, are preferred owing to their minimally invasive nature and low complication rates. Malaeb et al., examining surgical trends in the United States, reported an increased acceptance of laser treatments compared to TURP [17]. Similarly, Patel and Bariol examined BPH surgical treatment trends in Australia and showed that the shift to laser procedures reflects their increasing acceptance in clinical practice [15].

Our research focused on a limited time frame, thus precluding any meaningful assessment of the necessity for re-intervention. Nevertheless, it is widely accepted that HoLEP demonstrates a lower incidence of reoperation than TURP. Several investigations have indicated that the reoperation rate for HoLEP is less than 1%, while the rate for TURP is approximately 7.4% [18, 19]. HoLEP has been shown to be superior owing to its more comprehensive removal of prostate tissue, resulting in more effective relief of BPH symptoms. Additionally, HoLEP presents fewer risks of bleeding and shorter catheterization times as compared to other procedures. A consistent finding among studies is that HoLEP has lower long-term reoperation rates than TURP. Consequently, HoLEP is considered a preferable option, particularly in patients with larger prostates.

We assessed the learning curve in our study, which is common in many other studies, by evaluating the difficulty level. Experienced physicians who have undergone Transurethral Resection of the Prostate (TURP) for many years may be able to perform conscious and controlled enucleation in a certain number of patients. Moreover, 64% of patients who underwent surgery for benign prostatic hyperplasia (BPH) switched to holmium laser enucleation of the prostate (HoLEP), indicating a high level of confidence in the technique and a willingness to learn it. Notably, the number of urologists in our department who had no prior experience with laser prostatectomy and have since switched to this new method has been increasing over time. The low R2 in the time series analysis seems to be related to the size of the prostate, technical problems during surgery, other patient-related factors, and the skill of the urologists and their ability to improve this skill. Research on the assessment of the learning curve for Holmium Laser Enucleation of the Prostate (HoLEP) and Transurethral Resection (TURP) procedures is similar to our study. Although HoLEP has a long learning curve, it has been embraced by skilled surgeons. For instance, Dogan and Yildiz indicated that HoLEP was more effective in treating larger prostate glands and is regarded as an alternative to TURP by experienced practitioners [18]. In a study conducted by Eaton et al., the authors compared the learning curve between HoLEP and TURP procedures and highlighted that HoLEP demonstrates a lower complication rate despite facing technical challenges [19]. According to Shigemura et al., the learning curve of HoLEP demonstrates substantial progress in surgeons’ performance as experience accumulates, and it exhibits lower complication rates compared to TURP [20].

Over the past few years, our department has performed 70–100 prostate surgeries annually. However, since we began offering the HoLEP procedure, we have observed a substantial increase in demand by 64% and a corresponding decrease in the need for reoperation. Consequently, physicians are more likely to perform laser prostatectomy. In fact, we estimate that the number of patients undergoing surgery in public hospitals has risen by 30–45% annually. These findings suggest that HoLEP enhances both efficacy and patient satisfaction in the treatment of benign prostatic hyperplasia (BPH). According to Bright and Abrams’ study, HoLEP resulted in high patient satisfaction and low re-surgery rates [21].

One of the factors contributing to this increase is that HoLEP presents fewer complications and better long-term outcomes than TURP. Furthermore, although HoLEP has a steep learning curve, it is rapidly embraced by seasoned surgeons, and successful results are achieved, which amplifies its appeal. Although the learning curve for HoLEP is lengthy, its adoption by skilled surgeons in a timely manner and the attainment of positive results increase its demand. According to Shigemura et al., the learning curve for HoLEP significantly improves with greater experience and boasts lower complication rates than TURP [20]. Although this study employed a cross-sectional design, it is important to recognize its limitations. Future research incorporating additional data and more refined methods may yield a more comprehensive understanding of these issues.

HoLEP stands out compared to other surgical techniques for benign prostatic hyperplasia (BPH) owing to its reduced complication rates and faster recovery times. In our study, prostate capsule injury was more commonly reported among patients who underwent HoLEP than among those who underwent Transurethral Resection of the Prostate (TURP). However, the higher rate can be attributed to the surgeon’s level of experience. While the average time for urethral catheterization was slightly shorter for HoLEP patients, many studies have reported catheter-free discharge within 24 h after the procedure. The differences in perioperative capsule injury and catheterization time are expected to decrease as the number of cases and surgeon experience increases. In addition, Elkoushy et al., HoLEP resulted in significantly lower complication rates and faster recovery times than other surgical options [3]. Patients who underwent HoLEP could resume their social lives more quickly, and bleeding complications were significantly reduced. Another study by Gilling et al., reported that HoLEP provided a lower bleeding risk and shorter catheterization time than TURP [22]. These findings suggest that HoLEP is a safer and more effective BPH treatment option and that complication rates will continue to decrease as more experienced surgeons perform the procedure.

Holmium Laser Enucleation of the Prostate (HoLEP) surgery may have higher initial costs than Transurethral Resection of the Prostate (TURP), but its long-term benefits can be economically favorable due to the absence of residual tissue, early discharge, and rapid recovery. HoLEP is also effective in treating larger prostates, while traditional methods like open prostatectomy may require longer hospital stays and result in additional expenses, such as constant incontinence and erectile dysfunction. HoLEP does not impair sexual function, does not lead to permanent incontinence, and necessitates a shorter hospital stay, making it a superior option with numerous advantages. However, our study, with a short-term focus, is insufficient to report long-term outcomes. A cost-effective analysis conducted by Erman et al. found HoLEP to be economically advantageous in the long term due to fewer complications and a lower need for re-intervention [23]. Similarly, Lokeshwar et al. reported that HoLEP preserved sexual function and had lower complication rates compared to TURP [14]. HoLEP has been found to be especially effective in large prostates, with shorter hospitalization times and lower complication rates compared to conventional methods, increasing patient satisfaction, as reported by Gilling et al. [22]. From an economic point of view, although initial costs are high, HoLEP requires fewer reoperations and patients are discharged faster, saving the healthcare system costs in the long run [24]. Furthermore, HoLEP’s more complete removal of prostate tissue more effectively relieves benign prostatic hyperplasia (BPH) symptoms and contributes to lower long-term reoperation rates [20]. The long-term benefits of HoLEP offset the initial costs, making it a more economical option for the health system.

7. Conclusion

This research highlights a noteworthy change from Transurethral Resection of the Prostate (TURP) to Holmium Laser Enucleation of the Prostate (HoLEP) in the treatment of Benign Prostatic Hyperplasia (BPH) at Burhan Nalbantoğlu State Hospital in Northern Cyprus. Our results demonstrate that HoLEP offers various benefits over TURP, including shorter stays in the hospital, diminished postoperative complications, and more rapid recovery times. Although HoLEP involves a steep learning curve and extensive training, it is increasingly being recognized as the new gold standard in BPH treatment. Its superior patient outcomes and heightened satisfaction levels suggest its potential to replace TURP as the preferred surgical approach for BPH management. The shift to HoLEP represents a significant development in urological surgery, offering patients an improved quality of life.