To evaluate the safety and efficacy of Thulium Fibre Laser Enucleation of the Prostate (ThuFLEP) in patients with benign prostatic hyperplasia (BPH) across a wide range of prostate volumes, including very large glands (> 150 cc).

We retrospectively reviewed all consecutive patients who underwent ThuFLEP for drug-refractory or complicated BPH in our department between 2022 and 2024. Patients were stratified into three groups according to preoperative prostate volume: Group 1 (30–80 cc), Group 2 (> 80–150 cc), and Group 3 (> 150 cc). Perioperative outcomes, complications (according to the Clavien–Dindo classification), and functional results at 3 months were compared. Logistic regression was used to identify independent predictors of postoperative complications.

A total of 281 patients were included: 110 (Group 1), 143 (Group 2), and 25 (Group 3). Mean prostate volumes were 64.9 ± 12.7 cc, 105.4 ± 17.1 cc, and 185.0 ± 41.0 cc, respectively. Operative time increased significantly with prostate size (79.1 ± 34.6 min vs. 99.3 ± 43.9 min vs. 133.0 ± 62.3 min; p < 0.01). The overall complication rate was 9.1%, 9.8%, and 40.0% in Groups 1, 2, and 3, respectively (p < 0.01), however, severe complications (Clavien-Dindo > = 3) were not different between the 3 groups. Multivariable analysis identified prostate volume > 150 cc (OR 36.3, 95% CI 4.6–411.5; p < 0.01) and preoperative IPSS (OR 1.2, 95% CI 1.1–1.3; p < 0.01) as independent risk factors for postoperative complications. At 3 months, functional outcomes were similar between groups, with significant IPSS improvement (ΔIPSS = − 10, p = 0.2) and low stress urinary incontinence rates (8.2%, 7.0%, 4.0%; p = 0.2).

ThuFLEP is a safe and effective surgical option for BPH across all prostate sizes, including very large glands. Although complication rates are higher for prostates > 150 cc, severe complications do not differ compared to smaller prostates and functional outcomes are preserved, supporting ThuFLEP as a feasible minimally invasive alternative for high-volume BPH. Larger multicenter prospective studies are warranted to confirm these findings.