March 14, 2026 · London, United Kingdom
41st Annual Congress of the European Association of Urology (EAU26) · ExCeL London
Dr. Fernando Gómez Sancha · ICUA – Instituto de Cirugía Urológica Avanzada · Clínica CEMTRO, Madrid · March 2026
Introduction
The 41st Annual EAU Congress brought together over 10,000 urologists in London. Among the sessions that caught my attention most, Abstract Session 21 — "Enucleation is enucleation: Comparing efficacies across technologies" — delivered exactly what its title promised: a clear, evidence-based confirmation that endoscopic enucleation of the prostate (EEP) has matured beyond the debate of which laser to use.
I reviewed all 35 abstracts presented at EAU26 that focused on prostate enucleation. What follows is my personal reading of the most relevant findings — and why, in my view, they consistently reinforce HoLEP as the benchmark technique against which all others should be measured.
1. Miniaturisation Has Level-1 Evidence Now
Two independent randomised controlled trials — the MILES trial (A0353) from Sechenov University and A0357 — compared a 22F miniaturised resectoscope (MiLEP) against the standard 26F instrument for laser enucleation. The results were strikingly consistent:
- Enucleation efficiency: equivalent in both arms
- Operative time: no significant difference
- Functional outcomes at 1 and 3 months: comparable
- Early stress urinary incontinence (SUI): 6.5% with 22F vs 29.5% with 26F (p=0.04)
This is the finding of the congress for enucleation surgeons. Two RCTs showing a fourfold reduction in early SUI with the smaller sheath — without any compromise in efficacy — elevates miniaturisation from expert opinion to solid evidence.
From a HoLEP perspective, this is particularly relevant. The holmium laser is perfectly compatible with 22F sheaths, and the anatomical enucleation technique does not require a large working channel. The data from these trials should accelerate the adoption of miniaturised instruments across the field.
2. "Enucleation is Enucleation" — The Data Agree
Multiple abstracts across Session 21 and the Expert-Guided Poster sessions compared different energy sources for enucleation: HoLEP, ThuLEP (pulsed Thulium:YAG), GreenLEP, AEEP. The conclusion is consistent with what experienced enucleation surgeons have been saying for years:
"Enucleation is enucleation." The anatomical plane, not the laser wavelength, determines outcomes.
Abstract P0584 — a prospective non-randomised trial comparing pulsed Thulium:YAG versus Holmium:YAG for enucleation — found equivalent functional results, with Thulium showing marginal advantages in haemostasis. A decade of surgical trends at LMU Munich (A0345) documented the complete transition from TURP to laser enucleation as the institutional standard for BPO management.
My interpretation: the technology choice matters less than the surgeon's command of the anatomical enucleation technique. This is the argument I make in every HoLEP training course I run — the laser is just the tool. The surgical concept is what we are teaching.
3. Tranexamic Acid in Anticoagulated Patients: Practice-Changing Data
Abstract P0731 — a multicenter prospective study by the EAU Endourology Section — is one of the most clinically applicable findings from the entire congress. With 932 patients across 30 centres:
- Intraoperative TXA reduced bleeding complications: OR 0.17 (p<0.001)
- Haemostasis time was significantly shorter in TXA groups
- No impact on functional outcomes at 3 months
- Independent risk factors for bleeding: ongoing anticoagulation (OR 2.93), dual therapy (OR 4.31), longer operative time
For surgeons operating on patients who cannot safely discontinue antithrombotic therapy — a growing population — this evidence provides a practical, low-cost intervention that significantly reduces haemorrhagic risk. Intraoperative tranexamic acid deserves a place in our routine protocol for anticoagulated patients undergoing EEP.
4. Patients and Surgeons Don't Prioritise the Same Things
The ENUC-TR study (P0723) — a multicenter cross-sectional survey across four Turkish urology clinics involving 82 urologists and 622 patients — surfaced a finding that should make every enucleation surgeon pause:
- Surgeons ranked continence as the top priority (45.7%)
- 35.9% of patients placed ejaculation preservation among their top 3 priorities
- 14.8% of urologists did not inform patients about ejaculatory dysfunction before surgery
- 30.9% did not discuss erectile function
No surgeon ranked ejaculation as a first priority. But more than one in three patients did. This is a disconnect we need to address — not by changing what we do surgically, but by changing how we talk to patients before we operate.
In my practice, I discuss ejaculatory outcomes explicitly with every patient considering enucleation. Retrograde ejaculation is an expected consequence in most cases, and patients deserve to understand this — and to factor it into their decision.
5. Bladder Neck Contracture: Predictable and Preventable
A retrospective analysis of 1,740 patients (P0733) identified independent risk factors for bladder neck contracture (BNC) following laser enucleation of the prostate:
- Preoperative urinary tract infection: OR 4.42 (p<0.01) — significant risk factor
- Larger anteroposterior prostatic diameter: OR 0.44 (p<0.01) — protective
- Prediction model AUC: 0.736
The practical message is clear: screen for and treat urinary tract infection before enucleation.
6. The HoLEP Perspective: Why These Results Matter
Reading these abstracts as a HoLEP surgeon and international trainer, what strikes me most is the coherence of the evidence. Every major finding from EAU26 on enucleation reinforces the same message: the technique is what matters.
HoLEP — performed with proper anatomical dissection, with or without a miniaturised sheath, in large or small prostates, in anticoagulated or standard patients — continues to deliver the most robust and reproducible outcomes in the literature.
The debate is no longer HoLEP vs TURP. It's not even HoLEP vs ThuLEP or AEEP. The debate is: how do we train more surgeons to enucleate properly?
At ICUA, we have been running international HoLEP training programmes for surgeons from over 50 countries. What these abstracts confirm is that the investment in anatomical enucleation training — regardless of the laser platform — is the most impactful intervention we can make for patients with benign prostatic obstruction.
Conclusions
- Miniaturisation (22F) is now evidence-based: same efficacy, significantly less early SUI.
- "Enucleation is enucleation": anatomical technique, not laser choice, determines outcomes.
- Intraoperative TXA significantly reduces bleeding risk in anticoagulated patients — a practice-ready finding.
- Patients care more about ejaculatory function than surgeons assume — pre-operative counselling must improve.
- Preoperative UTI is a modifiable risk factor for bladder neck contracture — screen and treat before enucleating.
The evidence from EAU26 does not complicate the picture — it clarifies it. Enucleation, done right, is the standard. The challenge now is disseminating the technique.
— Dr. Fernando Gómez Sancha, March 2026
Medical Director, ICUA · Clínica CEMTRO, Madrid
icua.es | @fgomsan
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