Impact of Preoperative Continence on HoLEP Symptom Recovery: A Close Investigation of Patient-Reported Outcomes

Introduction: Holmium laser enucleation of the prostate (HoLEP) is an increasingly utilized surgical intervention for benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS). It is unclear how pre-HoLEP voiding performance (including pre-HoLEP incontinence) affects post-HoLEP urinary symptom performance and recovery which challenges effective patient counseling. Methods: This is a single-institution retrospective analysis of 266 patients who underwent HoLEP. Pre-HoLEP continence status was determined by patient report. Continence (severity and bother, severity broken into urge and stress) and LUTS (total IPSS score and QoL) were assessed preoperatively and 1 week (1wk), 1 month (1m), 3 months (3m), and 1-year (1y) post-HoLEP using the Michigan Incontinence Symptom Index (MISI) and International Prostate Symptom Score (IPSS), respectively. Primary outcome measures were MISI differences between groups at each time point. Results: Of the 376 patients who underwent HoLEP from two surgeons from 11/6/2020 to 12/18/2023, 266 were included in the study. Inclusion criteria were patients undergoing HoLEP during this period. There were no exclusion criteria. A total of 178 participants were continent and 88 were incontinent pre-HoLEP. Average age at time of HoLEP was 70.3 and 70.8 respectively, average preoperative prostate size measured by ultrasound or axial imaging was 109.0 g and 113.7 g, respectively. Based on MISI stress (#1-3) and urge (#4-6) items, pre-HoLEP Stress:Urge ratio in continent pre-HoLEP patients was 1.29:3.02. In the incontinent pre-HoLEP group, Stress:Urge was 2.45:6.18. MISI scores were statistically similar between cohorts at 1wk. Preop incontinent patients had a statistical and clinically significant improvement in MISI severity score at 1y post-HoLEP (5.62 n = 11 vs 10.170 n = 50, p = 0.013). IPSS total scores were statistically similar between cohorts at 1m and IPSS QoL scores were statistically similar at preop. At preop evaluation, urge symptoms were worse than stress symptoms in all cohorts. Conclusions: Preoperative incontinence should not be considered a predictor of poor intermediate or long-term post-HoLEP outcomes. Pre-HoLEP incontinence is likely largely urge-related.