The article by Mmeje et al.  from the Mayo Clinic succinctly describes a large series of 311 holmium laser enucleation of the prostate (HoLEP) procedures carried out over 4 years in men analysed by age group in four decades. It is a single-centre case series but clearly shows that, in expert hands in high-volume centres, it is possible to achieve excellent results with this complex procedure, regardless of the patient age.
Since the National Institute for Health and Care Excellence (NICE) guidelines  for the management of LUTS released in 2010, which recommended HoLEP as a treatment for benign prostatic enlargement, urologists have gained more interest in HoLEP. NICE currently specifies that HoLEP should only be performed at a centre specializing in the technique or with mentorship arrangements in place, which indicates the increased complexity of this technique. The main concerns for those not yet carrying out this procedure are the potential lengthy learning period, longer operating times, worries regarding the morbidity of the morcellation phase, and the complexity of the operation when compared with TURP. The present paper goes some way to addressing these issues.
Many endoscopists would have specific reservations regarding the safety of this often lengthy and complicated procedure in older men. The study goes some way towards reassuring us regarding the peri-operative morbidity and medium-term continence associated with HoLEP. Certainly the older men (>80 years) had a longer period of catheterization (3.4 vs 1.6 days in younger men) but hospital stay was equivalent and this may be attributable to higher preoperative retention rates in the older men. Although there were only 45 men in the >80 years age group vs 153 men aged 70–79 years, other factors such as postoperative incontinence were not significantly different, with an 88% continence rate for the oldest men vs 93% for those aged 70–79 years.
There was a 10% transfusion rate in these older men (vs 3.2% for men aged 70–79 years) which was higher than expected (although not quite statistically significant), but more of this group (53%) were on anticoagulant treatment and more prostatic tissue was enucleated in the older men.
As with other new complex skills, HoLEP takes time, dedication and effort to grasp but with appropriate commitment to learn by means of courses and structured mentoring, not just competence but proficiency can be achieved. HoLEP is a hugely satisfying procedure to perform that can transform the lives of men with large prostates and LUTS/urinary retention. Many editorials call for a randomized controlled trial to shed further light on the issues, but in HOLEP several of these already exist  and it is now time for urologists to attempt to replicate the excellent results displayed here in their own units after appropriate training and mentoring in the HoLEP procedure.