Slim 22F vs Standard 26F Sheath Holmium Laser Enucleation of the Prostate in the Management of Benign Prostatic Hyperplasia: A Prospective, Randomized Controlled Trial

Background: To compare outcomes of ambulatory miniaturized holmium laser enucleation of the prostate (MiLEP) using a slim 22F sheath vs standard holmium laser enucleation of the prostate (HoLEP) with a 26F sheath. Methods: In this randomized controlled trial, 100 patients were randomized to 22F MiLEP or standard 26F HoLEP between April and November 2024. Intraoperative and perioperative outcomes, including admission and readmission rates, were recorded. International Prostate Symptom Score, quality of life, maximum urinary flow rate, and postvoid residual volume were assessed at 1, 3, 6, and 12 months. Prostate-specific antigen was measured at 3 months, and late complications, including urethral stricture and bladder neck contracture (BNC), were recorded during follow-up. Results: Fifty patients underwent 22F MiLEP, and 50 received 26F HoLEP. Preoperative characteristics were comparable between groups. While total operative, enucleation, morcellation, and hemostasis times, resected weight, and efficiencies did not differ, the 26F sheath demonstrated shorter postoperative hematuria duration, catheterization time, and hospital stay. Postoperative hematuria requiring admission was higher in the 22F group (26% vs 10%, p = 0.037). Patients treated with 26F HoLEP were more likely to achieve a successful same-day trial of void (TOV) than those treated with 22F MiLEP (86.7% vs 64.9%, respectively; p = 0.02). Postoperative functional outcomes and complication rates (stress urinary incontinence [SUI], BNC, and urethral stricture) were comparable between cohorts through 12 months. Conclusions: Both 22F and 26F sheaths provided satisfactory intraoperative and postoperative functional outcomes in endoscopic enucleation of the prostate. However, 26F HoLEP was associated with higher same-day TOV success and lower postoperative admission rates, with no statistically significant differences in postoperative SUI, BNC, or stricture rates.