We evaluate the effect of urinary retention (UR) on Holmium laser enucleation of the prostate (HoLEP) in patients with lower urinary tract symptoms (LUTS) and benign prostate hyperplasia (BPH)

A prospective cohort of LUTS/BPH patients who underwent HoLEP between January 2010 and December 2016 as a part of BPH Database Registry were enrolled for this study. The criteria for inclusion were patients whose age were over 50 years. Patients with genitourinary cancer, previous pelvic surgical history, and neurogenic bladder were excluded. Baseline evaluation included careful history taking, digital rectal examination, IPSS, Overactive Bladder Symptom Score (OABSS), serum PSA level, uroflowmetry, PVR measurement, urodynamic study, and prostate volume measured by transrectal ultrasonography. Under spinal or general anesthesia, HoLEP was performed with patient placed in a lithotomy position. Enucleation was performed using the 3 or 4 lobe technique with a 80W (2J x 40Hz) setting of Homium YAG laser, followed by morcellation of adenomas. Continuous bladder irrigation was performed with normal saline. Typically, on postoperative day one, urethral Foley catheter was removed. Intraoperative parameters included operative time, enucleation weight, and intraoperative complications. Postoperative evaluation was performed at 2 weeks, 3 months and 6 months. Patients were categorized as non-UR, AUR and CUR groups and clinical parameters were compared. Acute urinary retention (AUR) was defined as a sudden spontaneous onset of being unable to pass urine and chronic urinary retention (CUR) was defined non-transient voiding difficulty with a PVR more than 300 mL. A mean values with standard deviation (SD) were used for analysis of continuous variables. Categorical variables were analyzed by the ratio of events (%).Paired t-tests and ANOVA tests were used to compare the postoperative changes. Statistical significance was defined as a p-value ≤0.05.

A total of 903 patients (non-UR 732 patients; AUR 135 patients; CUR 36 patients) with a mean age of 68.8(± 6.4) years were identified. For temporary relief of AUR, CIC was adopted in 70.4% of the patients, urethral catheter indwelling in 22.2%, and urethral catheter indwelling followed by CIC in 7.4%. Mean duration of CIC was 2.2 (± 6.6) days and that of urethral catheter indwelling was 5.1 (± 16.6) days. For temporary relief of CUR, CIC was adopted in 33.3%, urethral catheter indwelling in 25.0%, and urethral catheter indwelling followed by CIC in 2.8%. The mean duration of CIC was 13.2 (± 38.0) days and that of urethral catheter indwelling was 3.5 (± 10.0) days (P<0.001). Mean baseline Qmax in non-UR, AUR and CUR group was 7.6 ml/s, 6.6 ml/s and 4.8ml/s, respectively (P<0.001); Mean total prostate volume was 66.1 (± 31.5), 89.9(± 44.8), 85.3 (± 38.1)ml (P< 0.001). Urodynamic detrusor underactivity was found in 28 (3.8%) of the non-UR patients, 11 (8.1%) of the AUR patients, and 2 (5.6%) of the CUR patients (P=0.082). Mean PdetQmax were 64.4, 74.3 and 77.7cmH2O (P<0.001); mean BOO index were 49.5, 61.1 and 69.4 (P<0.001); mean operation time were 54.0, 68.5, and 68.7 mins (P<0.001); mean enucleation weight were 20.7, 35.0 and 34.1 grams (p<0.001), respectively. There was no difference in intraoperative complication such as bladder injury, prostatic capsule perforation, or persistent bleeding. Necessity for additional continuous bladder irrigation was more frequent in AUR patients (p<0.001) than other groups during immediate postoperative period. There was no difference in mid-term postoperative complication such as delayed bleeding, stress urinary incontinence, urethral stricture, or bladder neck contracture up to 6 months followup. Postoperatively, IPSS, OABSS, and Qmax were improved in all three groups and there was no difference among the three groups. Mean PVR just before surgery in non-UR, AUR and CUR group was 55 ml, 75 ml and 333 ml, respectively, and its difference still remained significant among the three groups (15ml, 22 ml and 52 ml, respectively) at postoperative 6 months (P<0.001). None in both AUR and CUR group required CIC or urethral catheter at postoperative 6 months

Patients with UR had a larger prostate and more severe BOO compared to non-UR patients, which might have resulted in longer operation time and longer morcellation time in patients with UR. Nevertheless, our results showed that there was no significant difference in postoperative complications between Non-UR and UR groups. Our results also demonstrated that there was no significant difference in postoperative outcomes between Non-UR and UR groups, except for PVR volume in CUR patients. However, the mean volume of PVR at the postoperative 6 months in this particular group was 52.2 ml, which was clinically not meaningful. The scores of IPSS and OABSS showed significant improvement at postoperative 6 months.

Baseline history of AUR and CUR did not adversely affect the postoperative outcome of HoLEP, nor did these conditions increase postoperative complications.