Preserving the Endoscopic Promise of HoLEP: A Standardized Technique for Safe and Efficient Morcellation Across Prostate Sizes

Introduction: Holmium laser enucleation of the prostate (HoLEP) is an effective minimally invasive treatment for benign prostatic hyperplasia across a wide range of prostate sizes. However, concerns regarding morcellation efficiency and the need for open cystotomy in very large glands remain barriers to adoption. We evaluated morcellation characteristics across prostate sizes and identified predictors of prolonged morcellation time at a high-volume center. Methods: We performed a retrospective analysis of an institutional HoLEP registry from January 2021 to April 2026. Patients with preoperative prostate volume and documented morcellation time were included. Morcellation time and efficiency were analyzed by prostate size category. Multivariable linear regression was used to identify factors associated with prolonged morcellation. Results: A total of 2114 patients met inclusion criteria. The median prostate volume was 102 cc (IQR 65–150). The median morcellation time across all cases was 6 minutes and increased progressively with prostate size: <100 cc, 3 minutes; 100–199 cc, 10 minutes; 200–299 cc, 19.5 minutes; 300–399 cc, 29 minutes; and ≥400 cc, 39 minutes ( p < 0.001). Prostate size, age, prior benign prostatic hyperplasia surgery, and trilobar anatomy were associated with longer morcellation time. Intraoperative complication rates were low (2.8%) and not significantly associated with prostate size ( p = 0.292). Only one patient required open cystotomy for adenoma retrieval following attempted morcellation of a 547 cc prostate. Conclusions: Morcellation time increases with prostate size but remains efficient even in very large glands. Using a standardized technique, prostates up to 400 cc can be morcellated endoscopically with extremely low conversion rates.