## 4 Discussion
One of the advantages of HoLEP is to be less bleeding in comparison to OSP and TURP. In our study cohort, median bleeding was evaluated by calculating the difference between preoperative and postoperative (at 24 h after surgery) Hb values and it was about 0.8 gr/dL. The reduced risk of intra- and postoperative bleeding is due to enucleation performed by developing the natural plane between adenoma and the peripheral zone. Consequently, HoLEP can also be safely performed in patients under anticoagulant or antiplatelet therapy [30]. In our experience, anticoagulant and antiplatelet therapies have been discontinued in all patients except those at greater thromboembolic risk, in whom they have been switched to low-molecular-weight heparin therapy. In our series, the mean operative time was 122 min, longer than that reported by [PERSON] et al. [41] and [PERSON] et al. [42] in their experiences (79 min and 97 min, respectively), probably due to the greater mean prostate volume of our cases (91 mL vs. 66 mL and 75 mL) as well as the inclusion of learning curve cases of this new technique. The median catheterization time and LOS were 32 h and 48 h, respectively, compared to 1.8-3.9 days reported by [PERSON] et al. and 2 days reported by [PERSON] et al. [43]. HoLEP, as well as TURP, OSP, and other endoscopic enucleation of the prostate, allows performing the histological examination of the removed tissue. Our findings showed an iPCa detection rate of 3%. This result is in line with data of the literature, reporting a detection rate of 5.6-8.1% [44]. Unfortunately, the short duration of our follow-up did not allow to evaluate the medium- and long-term oncological outcomes of our patients. Regarding complications, we reported an overall complication rate of 10.6%, all minor grade. These findings are consistent with those reported in the literature, showing a range of 12-17% [19]. No patient needed any re-intervention during the follow-up, thus demonstrating the mid-term durability of the effectiveness of HoLEP. Concerning functional outcomes, our results are comparable to those found in the literature. [PERSON] [45] and [PERSON] [46] reported a mean postoperative increase of Qmax of 16 mL/s and 20 mL/s, respectively, while the IPSS decreased by 18 and 15.4 points, respectively. In our study, the mean increase of Qmax was 17.7 mL/s at 1 month, with further 7 mL/s improvement at 6 months. The IPSS decreased by 7.9 points after 1 month and then by a further 7.1 and 1.6 points at 3 and 6 months, respectively. The postoperative continence status is one of the most important goals of HoLEP, and different techniques have been described to improve this outcome by reducing the potential damage of the external urinary sphincter, which is a key factor for continence. However, currently, which of these techniques is the gold standard has not been established. [PERSON] et al. described a decreased transient SUI rate to 2.7% through their anteroposterior dissection HoLEP technique, which reproduces the steps of the antegrade open simple prostatectomy procedure in order to prevent damage to the external sphincter [47]. This technique appeared safe and effective also for inexperienced surgeons according to [PERSON] et al., who also demonstrated an improvement in terms of continence by preoperative pelvic floor muscle training [48; 49]. An anatomical study by [PERSON] et al. demonstrated that the superior part of the external sphincter covers the anterior parts of the prostate and urethra, with a larger contact surface at the level of the 10-2 o'clock positions [50]. We feel that the increased risk for SUI following HoLEP could be due to both widespread laser energy and the mechanical stretching of the sphincter during apical dissection. The most important step in our technique is the early incision of the mucosa that is performed about 1 cm proximal to the sphincter between the 10 and 2 o'clock positions, leaving a small part of the anterior adenoma attached to the sphincter.