HoLEP and ThuLEP demonstrate outcomes equivalent to TURP for the treatment of men with LUTS/BPH. In a systematic review composed of 18 RCTs, HoLEP was compared to TURP in 2,150 men with a mean age of 60-73 years and a mean prostate volume of 36.3-136.3 cc with a median prostate volume of 61.4 cc.313 IPSSs were similar between HoLEP and TURP at 1, 3, 6, and 24 months postoperatively. Based on 9 RCTs including 1,050 patients, IPSS at 12 months favored HoLEP over TURP (WMD: -0.60 points; 95% CI: -1.03 to -0.17; I2=86%), however, there was high heterogeneity amongst the studies included. Qmax was similar between HoLEP and TURP at 1, 3, 6, and 36 months postoperatively; however, Qmax was higher in men undergoing HoLEP at 12 months (WMD: 0.88 mL/s; 95% CI: 0.12 to 1.65) and 24 months (WMD: 0.99 mL/s; 95% CI: 0.42 to 1.57). PVR was similar between HoLEP and TURP at 3 and 24 months postoperatively; but was lower for HoLEP at 1 (WMD: -2.60 mL; 95% CI: -4.76 to -0.44), 6 (WMD: -4.49 mL; 95% CI: -8.27 to -0.71), and 12 months (WMD: -8.55 mL; 95% CI: -15.56 to -1.54). There was no difference between HoLEP and TURP in quality of life scores at 1-, 3-, 6-, 12-, and 24-month follow-up and no difference in sexual function as measured by IIEF-5 at 6, 12, and 24 months postoperatively. Compared to TURP, HoLEP had a significantly lower rate of blood transfusion (RR: 0.17; 95% CI: 0.07 to 0.42; p<0.0001) and urethral stricture (RR: 0.48; 95% CI: 0.24 to 0.95; p=0.03). HoLEP patients also had shorter catheter duration (WMD: -15.73 hours; 95% CI: -21.37 to -10.08) and hospital stay (WMD: -15.50 hours; 95% CI: -21.95 to -9.04). In a separate RCT by Habib et al., total IPSS was significantly lower for HoLEP versus B-TURP at 3-year follow-up (MD: -3.02 points; 95% CI: -4.01 to 2.03).314 Three RCTs compared ThuLEP to TURP in men 62-74 years of age with prostate volumes 52-85.7 cc.315-317 Follow-up ranged from three months to five years. There was no significant difference in IPSS, Qmax, PVR, or quality of life score at last follow-up between ThuLEP and TURP. There was no difference in the rate of blood transfusion or urethral stricture between ThuLEP and TURP. In the study by Shoji et al., ThuLEP patients were less likely to report ED (17% [7/41] versus 44% [16/36]; RR: 0.38; 95% CI: 0.18 to 0.83) compared to TURP and had significantly higher sexual function scores (IIEF-5: 8 points versus 6 points; p=0.005) at 1 year follow-up.316 ThuLEP patients had shorter catheterization time compared to TURP (Shoji study: 2 days versus 3 days; p<0.0001; Yang study: 2.1 days versus 3.5 days; p=0.031) and shorter hospital stay (Shoji study: 2 days versus 3 days; p<0.0001; Yang study: 2.5 days versus 4.6 days; p=0.026).316, 317   A unique aspect of laser enucleation of the prostate is treatment efficacy independent of prostate volume, with particular benefit in men with large prostates (>80 cc). In a randomized cohort study, HoLEP (n=42) was compared with robotic-assisted simple prostatectomy (RASP; n=32) and laparoscopic simple prostatectomy (LSP; n=36) in men with a mean prostate volume of 144.8 cc (SD: 31.9 cc).318 The study analyzed patients up to three months according to the specific treatment received (HoLEP, RASP, or LSP) and at two-year follow-up, combining the RASP and LSP groups into one minimally invasive simple prostatectomy group (n=68). There were no differences between HoLEP and either LSP or RASP for IPSS, quality of life score, Qmax, and PVR or adverse events at three-month follow-up. Similarly, at 2-year follow-up there were no differences between HoLEP and the combined minimally invasive simple prostatectomy group for IPSS (mean: 8.9 points versus 8.72 points; p>0.05), quality of life score (mean: 1.82 points versus 1.79 points; p>0.05), Qmax (mean: 18.67 mL/s versus 18.45 mL/s; p>0.05), PVR (mean: 49.81 mL versus 52.13 mL; p>0.05), and IIEF-5 (mean: 16.51 points versus 16.35 points; p>0.05). HoLEP has also been compared to RASP for the treatment of very large prostates. In the study by Van der Jeugt et al., 31 patients undergoing RASP were compared to 22 patients undergoing HoLEP with a prostate volume ≥200 cc (RASP median: 226 cc versus HoLEP median: 204.5 cc).319 Both groups showed a significant improvement in Qmax at 14-month follow-up (+10.60 mL/s versus +10.70 mL/s; p=0.724), a reduction in IPSS (-12.50 points versus -9 points; p=0.246), and improvement in quality of life score (-3 points versus -3 points; p=0.880). Median operative time was similar for RASP and HoLEP (150 minutes versus 132.5 minutes; p=0.665) while the amount of resected tissue was greater for HoLEP (180 g versus 134.5 g; p=0.029). Median catheterization times were similar (RASP: 3 days versus HoLEP: 2 days; p=0.748) while the median hospitalization time was shorter for HoLEP (3 days versus 4 days; p=0.052). There was no difference in 30-day Clavien complication rates (RASP: 32% versus HoLEP: 36%; p=0.987) and no reported blood transfusions.   Patients undergoing laser enucleation of the prostate should be counseled regarding a 7% (range: 1.4-48.1%) risk of transient urinary incontinence in the first 3 months following surgery.320 Elderly and catheter-dependent patients as well as those with large prostates are at highest risk. The rate of persistent urinary incontinence is 0.9-3% (Appendix V). The incidence of retrograde ejaculation following laser enucleation of the prostate is 50-75% which is similar to the rate reported for TURP.321, 322  Laser enucleation of the prostate is recognized as having a steeper learning curve compared to other BPH procedures. Clinicians early in their learning curve may have longer operative times and higher rates of stress urinary incontinence. While the Panel recommends clinicians offer HoLEP and ThuLEP to patients for the treatment of LUTS/BPH, the decision to perform these procedures must be based on the expertise and experience of the clinician as well as equipment availability.