ObjectivesTo compare the mid‐term safety and efficacy of holmium laser enucleation of the prostate versus bipolar transurethral resection of the prostate in the management of large‐volume benign prostatic hyperplasia.MethodsFrom December 2016 to March 2018, patients with benign prostatic hyperplasia (≥80 cc) were randomized (block randomization, computer‐generated random list) to holmium laser enucleation of the prostate (57 patients) or bipolar transurethral resection of the prostate (55 patients). Patients were excluded if they had an International Prostate Symptom Score <13, a maximum urinary flow rate >15 mL/s or presence of prostate cancer, bladder stone, urethral stricture, neurogenic bladder, or previous prostate surgery. The primary outcome was hemoglobin loss. The analysis was intention‐to‐treat. Postoperative findings (36 months) were compared to baseline characteristics. Univariate and logistic regression analyses were performed for risk factors predicting hemoglobin loss or operative time in all patients.ResultsThere was no significant difference in baseline characteristics between the two groups. Holmium laser enucleation of the prostate was associated with significantly better operative time (P = 0.019), operative efficiency (P < 0.001), hemoglobin loss (P < 0.001), catheterization duration (P < 0.001) and hospital stay (P < 0.001) compared to bipolar transurethral resection of prostate. Both procedures were safe, with no significant difference in total complications (P = 0.128). Blood transfusion (P = 0.026) and capsular perforation (P = 0.239) were reported only in the bipolar transurethral resection of the prostate group. There was no significant difference in rates of urinary tract infections (P = 0.714), urethral strictures (P = 0.359), or transient stress incontinence (P = 0.717). At the last follow‐up (3 years), holmium laser enucleation of the prostate was associated with significantly better International Prostate Symptom Scores, prostate‐specific antigen levels and maximum urinary flow rates compared to bipolar transurethral resection of the prostate (P < 0.05). In logistic regression analyses, prostate size and bipolar transurethral resection of the prostate were associated with significantly greater hemoglobin loss, whereas prostate size, capsular perforation, and bipolar transurethral resection of the prostate were associated with significantly longer operative time.ConclusionHolmium laser enucleation of the prostate and bipolar transurethral resection of the prostate are effective and safe for the management of moderate‐to‐severe lower urinary tract symptoms attributable to large‐volume benign prostatic hyperplasia (≥80 cc). However, if both techniques are available, holmium laser enucleation of the prostate is preferred due its better efficacy and safety profile.