<![CDATA[Background: Benign prostatic hyperplasia (BPH) is highly prevalent among aging men, and holmium laser enucleation of the prostate (HoLEP) is increasingly used in very elderly patients. However, comparative evidence regarding perioperative outcomes remains inconsistent. This systematic review and meta-analysis compared perioperative and postoperative outcomes of HoLEP between patients aged ≥80 years and those aged <80 years. Methods: This systematic review and meta-analysis followed PRISMA 2020 guidelines and searched PubMed/MEDLINE, ScienceDirect, Google Scholar, and Epistemonikos from database inception to June 2026. Eligible retrospective comparative cohort studies included patients undergoing HoLEP for BPH and compared patients aged ≥80 years with those aged <80 years. The exposure was age group, and the outcomes were 30-day readmission, perioperative blood transfusion requirement, operative time, and length of hospital stay. Risk of bias was assessed using the Newcastle–Ottawa Scale (NOS) for retrospective cohort studies, and certainty of evidence was rated using the GRADE approach. Pooled risk ratios (RR) and mean differences (MD) with 95% confidence intervals (CI) were calculated in RevMan 5.4; heterogeneity was quantified with the I² statistic, and fixed-effect or random-effects models were selected according to the degree of heterogeneity. Results: Five retrospective comparative cohort studies comprising 10,258 patients were included. Patients aged ≥80 years had higher risks of 30-day readmission (2 studies; RR 2.40, 95% CI 1.14–5.08; P = 0.02; I² = 83%) and blood transfusion requirement (2 studies; RR 4.36, 95% CI 2.86–6.63; P < 0.00001; I² = 0%) than patients aged <80 years. Operative time did not differ significantly between groups (2 studies; MD 12.44 minutes, 95% CI −1.24 to 26.11; P = 0.07; I² = 87%), nor did length of hospital stay (3 studies; MD 0.12 days, 95% CI −0.06 to 0.31; P = 0.17; I² = 74%). The absence of a statistically significant difference for these two outcomes should not be interpreted as evidence of equivalence, as no formal equivalence testing was undertaken. Overall risk of bias was low in three studies and moderate in two. Conclusion: HoLEP demonstrated comparable operative time and length of hospital stay between patients aged ≥80 years and younger patients, while octogenarians had higher risks of 30-day readmission and perioperative blood transfusion. These findings, derived from observational data, support individualized perioperative risk assessment and close postoperative monitoring when HoLEP is performed in very elderly patients, rather than using chronological age alone to determine surgical eligibility.]]>
