INTRODUCTION
Benign prostatic hyperplasia (BPH) is the main etiology of lower urinary tract symptoms (LUTS) in ageing male.1 For several decades, transurethral resection of prostate (TURP) has been accepted and applied as the standard endoscopic treatment for symptomatic LUTS in patients not responding to or cannot tolerate medical therapy as well as in those developing BPH-related complications (e.g., bladder stone, urinary retention, or renal insufficiency).2However, following its clinical introduction by Gilling et al. in 1998, Holmium Laser Enucleation of the Prostate (HoLEP) proved itself to be a minimally invasive, size-independent endoscopic management alternative in the effective treatment of LUTS secondary to BPH. Several RCT’s have shown comparable (even superior) long-term results to open prostatectomy (OP) and TURP.3-6 Based on the successful outcomes obtained, HoLEP has been considered as potentially “new gold standard” endo-surgical treatment of BPH.7, 8 Complete removal of the obstructing adenomatous tissue via enucleation, simultaneous coagulation of the capsular surface and effective mechanical morcellation are the distinct characteristics of HoLEP which make it superior to other modalities. Despite its excellent outcomes however, HoLEP has still not been widely adopted in urology practice, due to its prolonged learning curve and limited access to HP laser devices.9 Although various technical modifications have been described to minimize the learning curve and increase the efficiency of the procedure over the past 20 years10, 11, improved functional outcomes and low complication rates seem to be correlated with the level of experience obtained and the surgical technique applied.12Beginning with its first clinical use in 1998, HoLEP procedure was performed with HP holmium laser devices (≥80W).13During the following years, the popularity of the procedure increased and even more powerful devices (140-150W) were introduced into clinical practice with the perception that a more effective enucleation can be performed with such laser devices creating relatively higher powers. Related with this issue however, HP laser devices are still not available in many urology clinics due to their higher costs and available low-medium power (<80W) laser devices are being used mainly for lithotripsy purposes in many hospitals.14Regarding the dilemma concerning the power of the device and its real efficacy in adenoma enucleation, the first study evaluating the efficacy and safety of medium power (MP) (50W) laser was published by Rassweiller et al.in 2008.15 In the following years, several studies focusing on the efficacy of low power (LP) and MP HoLEP have been performed. 14, 16-20 Although these limited number of studies have revealed that LP-HoLEP could achieve comparable outcomes with HP-HoLEP, many urologist still prefer using HP-laser devices. Taking the ongoing controversy about the efficacy and safety of LP vs HP laser systems particularly in the removal of large prostatic adenomas as well as the the importance of surgeon’s experience with particular techniques created rather than the power of laser used into account, in this first prospective , comparative study evaluating the efficacy of both power levels (MP vs HP) with two different laser devices we aimed to demonstrate the applicability of MP laser devices for HoLEP procedure with high efficiency and limiter or no technical difficulties.