Stress incontinence during the learning curve of holmium laser enucleation of the prostate

Holmium laser enucleation of the prostate (HoLEP) is an excellent surgical treatment for patients with benign prostatic hyperplasia, but surgical complications are not well described. We set out to determine the predictors of stress incontinence (SUI) after HoLEP during the learning curve.

A retrospective review of our institution's HoLEP database was performed. Patients were divided into two groups: No pads at 3 months (group 1); SUI and/or mixed incontinence necessitating ≥ one pad at 3 months (group 2).

Seventy-seven patients underwent HoLEP at our institution. Nine (12%) were excluded for pure urge symptoms and two (3%) were lost to follow-up, leaving 66 total patients. No differences were noted as regards age (P = 0.54), operating room time (P = 0.18), prostate size (P = 0.85), prostate-specific antigen level (P = 0.96), or International Prostate Symptom Score (P = 0.11). The number of days between cases, however, was higher in group 2 (44.5 vs 18.1, P = 0.02) and was associated with SUI in simple logistic regression models (odds ratio [OR] 1.25; 95% confidence interval [CI]: 1.04-1.51; P = 0.019). As the interval time between cases increased from 1, 3, and 5 weeks, the strength of the association increased (1 week: OR 2.75; 95% CI: 0.78-9.66; P = 0.12; 3 weeks: OR 2.86; 95% CI: 0.92-8.91; P = 0.07; 5 weeks: OR 4.69; 95% CI: 1.21-18.26; P = 0.026). SUI resolved in all but two patients by 1 year.

The major associated risk for SUI, a complication presumably related to surgical technique, was prolonged duration between cases. During the learning curve, surgeons should schedule patients frequently to enhance learning and decrease time to mastery of the technique, thereby reducing SUI.