Does size matter? Comparison of miniaturized (22 Fr) versus standard (26 Fr) instruments in pulsed thulium:YAG laser enucleation of the prostate

PURPOSE: Anatomic enucleation of the prostate is increasingly performed worldwide. While 26-Fr instruments are commonly used, miniaturized devices have been associated with fewer complications and improved recovery without compromising efficiency. We compared intraoperative and postoperative outcomes between 22-Fr and 26-Fr instruments in pulsed Thulium:YAG anatomic enucleation. METHODS: A total of 150 patients who underwent pulsed Thulium:YAG laser enucleation of the prostate between December 2024 and July 2025 were prospectively enrolled. MiLEP was performed in 70 patients, while standard AEEP was performed in 80. The primary endpoint was intraoperative efficiency, and secondary endpoints were postoperative complications and functional recovery, comparing miniaturized with standard instruments. RESULTS: The MiLEP group had a smaller median prostate volume (50.5 vs. 88 mL, p < 0.001) and shorter enucleation time (19 vs. 25 min, p < 0.001), although enucleation efficiency was higher in the standard group (3.6 vs. 2.7 g/min, p < 0.001). Irrigation volume was lower (13.5 vs. 21 L, p < 0.001), and no intraoperative urethrotomy/meatotomy was required in the MiLEP group compared with 10 patients (12.5%) in the standard group (p = 0.002). At 1 month, urethral stricture was identified in 1 (1.4%) MiLEP and 3 (3.8%) standard patients (p = 0.379), whereas incontinence occurred in 3 (4.3%) and 4 (5.0%), respectively (p = 0.836). CONCLUSIONS: MiLEP with pulsed Thulium:YAG laser represents an effective modality for anatomic enucleation of the prostate. It was associated with comparable intraoperative efficiency and favorable postoperative functional outcomes compared to standard resectoscope size. Our findings suggest that MiLEP may be a suitable option for selected patients, particularly those with lower urethral compliance and smaller prostate volume.