Holmium laser enucleation of the prostate in the oldest-old: a comparative analysis across the extremes of age

Introduction Expansion of the “oldest-old” (≥85 years) has increased the prevalence of BPH and the need for surgery. Holmium laser enucleation of the prostate (HoLEP) is a size-independent alternative to TURP, yet age-specific outcomes remain understudied. We compared outcomes, complications, and recovery after HoLEP in men ≥85 years versus ≤55 years. Methods We conducted a retrospective analysis of a prospective database of HoLEP procedures performed by a single surgeon at a tertiary academic center (2017–2025). Men aged ≥85 years constituted the study cohort and were compared with men ≤55 years. Baseline demographics, frailty, perioperative variables, complications, and functional outcomes (IPSS, Qmax, PVR) were analyzed. Statistical comparisons used t -tests, Wilcoxon, chi-square, Fisher exact tests. Results Sixty-one patients were included (30 ≥ 85; 31 ≤ 55). The oldest-old exhibited significantly higher comorbidities and frailty, lower baseline hemoglobin, worse renal function, and more frequent catheter dependence, while younger men had higher BMI. Operative time, hemoglobin decline, and hospital stay were comparable. Catheterization was longer in the oldest-old. The elderly had significantly more minor complications and a nonsignificant increase in major complications. UTIs occurred only in the oldest-old. Incidental prostate cancer was more common in the ≥85 cohort. Both groups showed improvements in IPSS, Qmax, and PVR; however, younger men experienced significantly greater Qmax at 12 months. Conclusion HoLEP is safe and effective in the oldest-old, offering durable improvement despite increased frailty and risk of complications. Although younger patients exhibited greater improvements in urinary flow, it is uncertain whether this finding reflects a causal benefit of earlier intervention, underscoring the need for prospective validation. Advanced age alone should not preclude HoLEP candidacy.