Ten HoLEPs in Two Days with Colleagues from Brazil

This week we had the pleasure of welcoming a group of urologists from Brazil to ICUA.

Two full days. Ten prostatic enucleations. And plenty of conversations worth having.

There is no better way to learn HoLEP than watching it live, case after case, with time to ask questions, pause, and discuss what just happened in the operating room. Books and videos have their place — but surgery is learned next to someone who does it every day.

What I enjoy most about these visits is not just teaching the technique. It is the exchange. Every colleague brings their own experience, their own doubts, their own patients in mind. And that always enriches the way I operate and think.

Brazil has an outstanding urological community and a growing interest in prostatic enucleation. Seeing that enthusiasm in person is always deeply rewarding.

Thank you for coming. I hope what you observed will be useful when you return to your patients.

Not All LISTs for BPH Are Trying to Solve the Same Problem

ICUA Viewpoint · BPH & prostate surgery

Minimally invasive treatments for benign prostatic hyperplasia are often discussed as if they belonged to one coherent family. In reality, some are designed to preserve function and reduce treatment burden, while others aim to deliver more durable deobstruction. Treating them as equivalents creates more confusion than clarity.

Over the past few years, the treatment landscape for benign prostatic hyperplasia has become increasingly crowded with acronyms, devices, and promises. UroLift, Rezūm, iTIND, Aquablation, PAE, TPLA, Optilume… These procedures are often grouped under a single umbrella: MISTs or LISTs, meaning minimally or least invasive surgical treatments.

The problem is that once everything is placed under the same label, a misleading idea quickly follows: that all of these options are competing in the same therapeutic space and differ only in technology. That is not true.

The reality is more uncomfortable, but also more clinically useful: these procedures are not trying to solve the same clinical problem.

The problem with the umbrella label

When we talk about LISTs for BPH, we often mix procedures with very different goals.

Some are primarily designed to offer lower burden, less impact on ejaculation, a more acceptable patient experience, and faster recovery. Others aim to go further and deliver stronger and more durable deobstruction, coming much closer to what we expect from effective surgery. And some are still trying to define their true role.

This is the central weakness of the current field: the phrase “minimally invasive” has become too broad and too comfortable. It may help marketing, but it does not always help explanation.

The right question is not “which technique is best”

The right question is this:

What problem is each technique actually trying to solve, and what functional or therapeutic price does it ask the patient to pay in return?

Because in BPH treatment there is always a trade-off. No technique gives everything to everyone.

In general, the less invasive a treatment is, the more likely it is to depend on favorable anatomy, to sacrifice some deobstructive power, and to make durability and retreatment more important.

In other words, many of these techniques do not truly compete with enucleation. They compete with something else: fear of surgery, the desire to preserve ejaculation, the wish to avoid anesthesia or hospitalization, or the search for symptom relief that is “good enough” without committing to definitive surgery.

That is not a flaw. It is a different clinical proposition.

Functional compromise procedures

This group clearly includes techniques such as UroLift and iTIND.

Their main attraction is not maximal deobstruction. It is a combination of low procedural burden, better ejaculatory preservation, and relatively fast recovery.

They do have a real niche, especially in carefully selected patients with small or moderate prostates, favorable anatomy, and a very strong priority to preserve sexual function or avoid a more ablative treatment.

But that is precisely why we should be honest: these procedures do not appear to be designed to compete with prostate enucleation in terms of deobstructive strength and long-term durability.

They are not meant to solve every form of BPH. They are meant to solve a specific form of BPH in a specific kind of patient.

The intermediate space: Rezūm

Rezūm probably occupies the most interesting niche in the current LIST field.

It is not just a compromise treatment like an implant or a mechanical remodeling device. But neither is it a high-powered deobstructive procedure on the level of enucleation. It sits somewhere in between.

That is why it generates so much interest. It offers a compelling proposition: real tissue treatment, a lower-burden narrative, reasonably attractive functional outcomes, and good patient and physician acceptance.

The problem is not its original niche. The problem appears when the technique is pushed beyond that niche.

Over the past few years, there has been a clear movement toward larger prostates. That is precisely where caution matters most. A procedure may be feasible in expert hands without having established a convincing comparative role against more powerful options.

Rezūm has a place. But that place should be defined by honest comparison, not by enthusiasm alone.

The important exception: Aquablation

If there is one technique that breaks the conceptual umbrella of LISTs, it is Aquablation.

It is often presented alongside other minimally invasive therapies, but clinically it behaves very differently. It is not simply a friendlier or more function-preserving option. It is a procedure with much stronger deobstructive potential, and medium-term data place it closer to effective surgery than to compromise treatments.

That is why discussing Aquablation on the same plane as UroLift or iTIND creates confusion.

Not because it does not share the ambition of reducing morbidity, but because its therapeutic proposition is different: not merely to ease symptoms, but to deliver substantial deobstruction while trying to preserve a more favorable functional profile than some traditional surgeries.

The main driver of the market: sexual function

A large part of the success of this field cannot be explained by flow rates or IPSS scores alone. It is explained by something far more human and far more powerful: the preservation of sexual function, especially ejaculation.

And that matters. Greatly.

The mistake would be to treat this endpoint as a minor detail. It is not. For many patients, preserving ejaculation is not a luxury. It is a central priority.

But the opposite mistake is just as common: talking about sexual outcomes as if they could be separated from all the other outcomes.

The key question is not “which technique best preserves ejaculation?”. The key question is: what is the patient willing to trade in order to preserve it?

Because the price may be lower deobstructive power, more retreatment, greater dependence on favorable anatomy, or less robust outcomes when obstruction is significant.

Anatomical selection: where honesty is won or lost

This is one of the most important points in the entire debate.

LISTs should not be discussed as if they were interchangeable options chosen by taste. In practice, success depends heavily on prostate size, the presence of a median lobe, the severity of obstruction, bladder function, and patient priorities.

The more this is simplified in commercial messaging, the further the conversation drifts from real medicine.

A procedure can be excellent in one patient and unconvincing in another without saying anything negative about the procedure itself. It simply means that not everything is suitable for everyone.

So what is the real role of LISTs versus HoLEP?

Our view is that most LISTs do not truly compete with HoLEP in complete and durable deobstruction.

They compete in another arena: acceptability, lower perioperative burden, ejaculatory preservation, and lower perceived aggressiveness.

That is their value. And that value is legitimate.

But precisely because it is legitimate, it does not need to be exaggerated or presented as if it were equivalent to enucleation.

The partial exception is Aquablation, which enters much more clearly into the territory of strong deobstructive efficacy. The rest, in different ways, mostly inhabit the space of balance and functional compromise.

Conclusion

The modern discussion of LISTs for BPH should not begin with technology. It should begin with a simple clinical question:

What is the patient willing to give up in exchange for lower treatment burden?

In some cases, the answer will be durability. In others, deobstructive power. In others, ejaculation. And in others, the desire to avoid a more invasive surgical pathway.

Understanding that does not weaken the role of LISTs. On the contrary, it gives them a more honest and more useful place.

Because the future of this field will not depend only on how much technology it accumulates, but on how clearly it explains the real trade-off it offers the patient.

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ICUA take-home message
Most LISTs are not “small HoLEPs”. They are different tools for different patients, with real benefits, real limitations, and a role that only becomes clear when their trade-offs are discussed honestly.

Suggested reading

• Sandhu JS et al. Benign Prostatic Hyperplasia (BPH) Guideline. AUA Guidelines
• EAU Guidelines on Non-neurogenic Male LUTS (2024). EAU Guidelines
• Selecting Minimally Invasive Surgical Treatments for BPH. Eur Urol Focus 2025. PMID 40348622
• Ablative minimally invasive surgical therapies for BPH. Prostate Cancer Prostatic Dis 2023. PMID 37081044
• Impact of minimally invasive surgical therapies on sexual function in BPH. PMID 40891476
• Aquablation versus TURP: 5-year outcomes (WATER study). PMID 37838991
• Aquablation Therapy in Large Prostates (80-150 mL): 5-year outcomes. PMID 37115632
• Mechanical and Ablative Minimally Invasive Techniques for Male LUTS due to BPH. PMID 33849045

The Next Wave of LISTs for BPH: How Much Is Innovation, How Much Is Hype

ICUA Viewpoint · Innovation & BPH

The second generation of LISTs is no longer selling only “less invasiveness”. It is selling anatomy-tailored care, better functional preservation, and a friendlier overall treatment experience. The real question is how much of that promise will translate into meaningful patient benefit and how much is simply a better narrative.

The field of minimally invasive treatment for BPH is entering a second phase.

The first phase was defined by the consolidation of recognizable names: UroLift, Rezūm, iTIND, PAE, Aquablation. Each had a relatively clear value proposition, a plausible niche, and a progressively identifiable evidence base.

The second phase is different.

New generations of devices and concepts are now appearing with a more ambitious promise: lower treatment burden, better anatomical adaptation, better sexual preservation, lower perioperative disruption, and an overall more acceptable patient experience.

That sounds appealing. And part of it may prove to be true.

But it is also exactly the kind of territory where real innovation and hype can begin to look uncomfortably similar.

What the new generation is promising

The new wave of LISTs no longer wants only to be “less invasive”. It wants to be more precise, more functional, more anatomically personalized, more acceptable to surgery-averse patients, and, ideally, durable enough to avoid becoming a temporary compromise.

That is a much stronger promise than the first wave offered.

Because it is no longer just selling a procedure. It is selling a vision of the future: better treatment with less penalty and more individualization.

In both market terms and clinical storytelling, that is a very powerful proposition.

Why this evolution makes sense

It would be unfair to dismiss it outright.

The BPH field still carries several unresolved tensions: how to achieve meaningful deobstruction without imposing so much sexual penalty, how to avoid overtreatment in patients who do not want high-powered surgery, how to individualize treatment better according to anatomy and patient priorities, and how to reduce the psychological and logistical burden of intervention.

In that sense, the emergence of new technologies is not arbitrary fashion. It responds to real unmet needs.

The question is not whether there is room for innovation. The question is how much of that innovation will be clinically meaningful and how much will mainly represent an improved narrative.

The new candidates

Among the names now entering the conversation are Optilume BPH, Zenflow Spring, Butterfly, ProVee, Urocross, and FloStent.

They all belong to a second-generation storyline: lower burden, more personalization, potentially more comfort, and a stronger promise of preserving function.

That makes them interesting. But for now, in most cases, they still matter more as a signal of where the field wants to go than as fully established additions to clinical practice.

Where there may be genuine innovation

1. Better anatomical matching

Many of the shortcomings of the first wave came from applying “minimally invasive” procedures to patients or anatomies for which they were never truly ideal.

If a new generation of LISTs can genuinely improve matching according to prostate size, median lobe configuration, bladder neck anatomy, and type of obstruction, that would represent meaningful progress.

2. A better balance between function and durability

This is the deeper promise of the field.

Until now, BPH innovation has largely lived with a fracture line: the more function is preserved, the greater the risk of sacrificing deobstructive power or durability.

If any new technology can materially shift that balance, it will deserve real attention.

But that threshold is high. It is not enough to look elegant. A procedure has to prove that it changes the equation in clinically meaningful terms.

3. Lower burden without drifting into undertreatment

The challenge is not simply to do less. It is to do less without doing too little.

That is one of the central uncertainties of the entire field.

Where hype is most likely

1. “Minimally invasive” as an emotional shortcut

The label has enormous psychological force. It suggests less pain, less risk, less regret, and less disruption.

But “less invasive” does not automatically mean “better” or even “enough”. Sometimes it simply means that the therapeutic cost is displaced elsewhere: more retreatment, lower efficacy, or greater dependence on ideal anatomy.

2. Sexual preservation as the dominant storyline

Ejaculatory preservation is one of the great engines of the LIST field, and rightly so.

But it is also an easy territory for overemphasis. When a technology foregrounds sexual function almost exclusively, we should ask: what happens to durability? what happens to deobstructive power? what happens in real-world outcomes? what happens when anatomy is less than ideal?

If those questions are not answered, then the result is not truly patient-centered care. It is selective storytelling.

3. High visibility with limited maturity

This is especially relevant for several of the newer remodeling or stent-like concepts.

The fact that a device appears in reviews, meetings, or “future of BPH” conversations does not mean it has already earned a stable role in practice.

In some cases, what grows first is not the evidence base, but the expectation.

4. Highly active adoption networks

Every innovation needs clinical leaders. That is normal and often beneficial.

But the more device-driven a field becomes, the more important it is to distinguish legitimate enthusiasm from early adoption and from independent validation.

A technology may look very promising within an adoption network and still not have demonstrated a sufficiently robust, independent benefit.

The case of Optilume BPH

If one name currently deserves special attention in this second wave, it is Optilume BPH.

It is probably one of the most advanced candidates in the emerging block. It offers a clear narrative: low burden, preserved function, and an interesting hybrid therapeutic concept.

That deserves attention.

But for exactly that reason, it should be asked the same hard questions as everything else: in which anatomy does it perform best? what is its true durability? where does it sit relative to Rezūm, PUL, or iTIND? where does it sit relative to Aquablation or HoLEP? is its value mainly functional, logistical, or genuinely therapeutic?

Until those questions are answered with more maturity, the right response is interest combined with restraint.

What any new LIST should be required to prove

Before a new technique claims a stable role, it should be able to answer five questions clearly:

• What anatomy is it really for?
• What is the retreatment burden at meaningful follow-up?
• What does it add over existing LISTs?
• What does it add over Aquablation or HoLEP?
• Is its main value functional, logistical, or truly therapeutic?

If it cannot answer those questions, it is probably still closer to a promise than to a standard.

So how should we read what is coming?

With curiosity, yes. But also with discipline.

Innovation in BPH care is necessary. Not everything new is smoke, and the field still needs better solutions for patients who currently feel caught between treatments that are too weak and surgeries they perceive as too aggressive.

But that is precisely why the standards should be demanding.

It is not enough for a technology to be new. It is not enough for it to be elegant. It is not enough for it to preserve ejaculation better. It is not enough for it to have a modern personalization narrative.

It has to show that it truly improves the balance between deobstruction, function, durability, and treatment burden.

Conclusion

The next wave of LISTs may bring real innovation. But it may also bring an inflation of promises.

The line between those two possibilities will not be drawn by marketing or by device sophistication. It will be drawn by a very simple question:

Does this technology add something clinically meaningful that we cannot already achieve with existing options, and does it do so without merely shifting the problem elsewhere?

Until that becomes clear, this field deserves attention—but not automatic admiration.

Because the future of LISTs will not be decided by novelty alone. It will be decided by whether they can genuinely improve patients' lives without promising more than they can deliver.

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ICUA take-home message
The second generation of LISTs deserves serious attention, but not automatic enthusiasm. The relevant innovation will be the one that truly improves the balance between efficacy, function, and treatment burden—not the one that simply refines the language in which it is presented.

Suggested reading

• Next-gen minimally invasive surgical therapies for BPH. PMID 40923125
• State-of-the-art in minimally invasive treatments for benign prostatic obstruction. PMID 41469901
• Selecting Minimally Invasive Surgical Treatments for BPH. Eur Urol Focus 2025. PMID 40348622
• Impact of minimally invasive surgical therapies on sexual function in BPH. PMID 40891476
• Device profile of Optilume BPH Catheter System. PMID 40853744
• Systematic Review of Functional and Sexual Outcomes of MISTs for BPO. European Urology

EEP Made Practical: Expert Lessons from the BEAM 2025 Meeting

A new expert consensus paper has just been published in the World Journal of Urology (April 2026), bringing together practical recommendations from international high-volume surgeons — each with more than 1,000 endoscopic enucleation of the prostate (EEP) procedures — based on structured panel discussions held at the BEAM 2025 meeting (Belgian Endourological Association Meeting) in Ghent, Belgium.

I had the privilege of contributing to this collaborative effort alongside colleagues Martin Kanne, Cesare Marco Scoffone, Felipe Figueiredo, Thomas Herrmann, Peter Schatteman, Thomas Tailly, Carl Van Haute, and Pieter Uvin, coordinated by Gaëtan Devos.

Why does this paper matter?

Endoscopic enucleation of the prostate — whether performed with Holmium laser (HoLEP), Thulium laser (ThuLEP), or other energy sources — is now recognised as the gold standard for surgical treatment of benign prostatic obstruction (BPO), regardless of prostate size. Both the AUA and EAU guidelines endorse it. Yet its adoption worldwide remains limited, primarily because the learning curve is considerably steeper (30–50 cases) than that of traditional TURP (~10 cases).

This paper was born from a simple premise: if the most experienced EEP surgeons in the world could distil their collective know-how into practical, actionable guidance, we could help shorten that learning curve and make EEP safer and more accessible.

Key recommendations

1. EEP is not TURP — adopt the right mindset. EEP is an anatomical dissection along the prostatic surgical capsule, not a debulking technique. Unlike TURP, EEP cannot be interrupted once initiated — it must be completed. Surgeons must embrace anatomical variability and adapt to each case rather than imposing a uniform approach.

2. Train the entire ecosystem. Preparation goes well beyond the surgeon. The full operating room team — nurses, anaesthesiologists, sterilisation units, biomedical engineers — must understand the instruments, the laser, the morcellation device, and common troubleshooting scenarios. Institutional support from the department chair is essential.

3. Respect the learning curve. Start with prostates of 50–60 g with no previous treatments. Limit yourself to no more than two cases per surgical day during the initial phase. Avoid expert-level cases early on: post-radiotherapy prostates, glands >120 g, morbid obesity (BMI >35), or patients with penile implants. Communicate openly with the OR team that the first procedures will take longer.

4. En-bloc technique with early apical release. Although there is no single standard enucleation technique, growing evidence supports the en-bloc approach as faster and more efficient than multi-lobe techniques. Importantly, regardless of whether a multi-lobe or en-bloc technique is used, performing an early apical release may reduce the risk of postoperative stress incontinence by minimising overstretching of the external urinary sphincter. This is a point we have consistently advocated from our experience at ICUA.

5. Choose the right dissection plane. One of the most frequent errors during apical enucleation is hesitating to initiate the dissection sufficiently distal to the verumontanum due to fear of sphincter injury. However, particularly in larger prostates, the optimal apical plane is often located well distal to the veru. A plane that is too proximal leads to false planes, bleeding, residual tissue, and frustration. Trust visual cues — fibrous bands, capsular glistening — over depth assumptions.

6. Invest in proper equipment. A high-power laser, an appropriate morcellator (oscillating devices demonstrate superior morcellation efficiency), continuous-flow resectoscope, heated irrigation fluid, adequate camera anti-fogging protection — these are not luxuries but essentials for delivering high-standard care and managing the learning curve.

7. Know when to stop or convert. When disoriented or facing poor vision, pull back the scope and reassess. The problem is almost always behind you. Converting to TURP is not a failure — it is a wise decision. Patient safety always takes priority over surgical ego.

8. Monitor your outcomes — always. Record your procedures. Use validated questionnaires such as the IPSS. Review your own videos even after 1,000+ cases. Discuss your results and complications with peers. Continuous self-assessment is what separates good from excellent.

Managing challenging anatomy

The paper provides detailed guidance on difficult scenarios: very large prostates (where instrument reach, intravesical protrusion and satellite nodules pose unique challenges), small prostates (<30 g, where the surgical capsule is poorly developed), and large median lobes (where the dissection plane near the bladder neck lies dangerously close to the ureteral orifices). Preoperative MRI assessment of anterior apical angulation and posterior base curvature is highlighted as a useful tool for estimating procedural difficulty.

Morcellation tips

Morcellation is often taught first because it seems simple, but serious complications — including bladder lacerations and even vesico-sigmoidal fistulas — can occur. The paper emphasises: meticulous hemostasis before morcellation, dual irrigation sources to prevent unexpected bladder emptying, eyes fixed on the screen at all times, and immediate pedal release if bladder injury is suspected.

Complication prevention

Key postoperative complications addressed include clot retention, transient stress incontinence, urethral stricture (most commonly bulbar), and bladder neck contracture. Prevention is paramount: adequate lubrication, adapting instrument size to urethral calibre (not vice versa), and performing en-bloc EEP with early apical release. The main risk factor for bladder neck sclerosis is a small prostate (<54–55 ml).

Full reference

Devos G, Kanne M, Gómez Sancha F, Scoffone CM, Figueiredo F, Herrmann T, Schatteman P, Tailly T, Van Haute C, Uvin P. Endoscopic enucleation of the prostate made practical: lessons from experts from the BEAM25 meeting. World J Urol. 2026;44:282.
doi:10.1007/s00345-026-06384-3

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Dr. Fernando Gómez Sancha — Medical Director, ICUA (Instituto de Cirugía Urológica Avanzada), Clínica CEMTRO, Madrid. Pioneer of the en-bloc HoLEP technique with early apical release. Over 10,000 EEP procedures. International training programme for urologists from 60+ countries.