There is limited evidence comparing the holmium laser with MOSESTM technology and thulium fiber laser (TFL) in endoscopic enucleation of the prostate (EEP). Both MOSESTM holmium laser enucleation of the prostate (MoLEP) and thulium fiber laser enucleation of the prostate (ThuFLEP) are effective treatment options for benign prostatic obstruction (BPO). This video aims to describe our experience using MoLEP and ThuFLEP at our institution.

From December 2020 to October 2023, we prospectively recorded all EEP cases at our institution using MOSESTM technology and TFL after obtaining informed patient consent. A total of 316 procedures were performed by a single surgeon (H.E.), including 146 MoLEP cases with MOSESTM 1.0 and 50 MoLEP cases with MOSESTM 2.0 pulse-modulation systems (Lumenis, Yokneam, Israel), as well as 120 ThuFLEP cases (SoltiveTM Premium, Olympus, USA). We extracted video clips of the different energy sources employed during EEP from the original recordings.

The efficacy of EEP depends on several factors, including a comprehensive understanding of laser-tissue interactions, including wavelength, absorption coefficient, peak power, working distance and the surgeon’s expertise. The effect of TFL resembles a surgical blade or a hot knife, which cuts very well but does not particularly help in dissecting the anatomical plane. In contrast, MOSESTM technology functions in a manner similar to two scissor blades, opening the layer between the adenoma and surgical capsule, dissecting the virtual plane, and facilitating urologists in performing enucleation following the actual anatomical plane.

Our findings demonstrate that the favorable outcomes achieved with EEP can be attributed to the anatomical completeness of adenoma removal rather than the energy source utilized. Based on the early results of our institution’s randomized controlled trial (RCT), the new pulse-modulation holmium lasers demonstrate clinical advantages in intraoperative and perioperative outcomes. Larger comparative RCTS are warranted to consolidate our findings.