Bladder injury in anatomical endoscopic enucleation of the prostate and morcellation using the Bladder Injury Classification for Endoscopic Procedures: a European Association of Urology endourology prospective study

To prospectively assess the incidence, characteristics, and perioperative impact of Bladder Injury Classification for Endoscopic Procedures (BICEP)-classified bladder injuries during anatomical endoscopic enucleation of the prostate (AEEP) and morcellation across European centres.

A prospective observational study (ClinicalTrials.gov identifier: NCT06469125) was conducted at 12 European centres between May 2024 and June 2025 following ethics approval. Data were collected prospectively through a Research Electronic Data Capture. A total of 725 men undergoing AEEP for benign prostatic obstruction were included. Intraoperative bladder injuries were identified and classified by the surgeon according to the BICEP. The primary endpoint was the incidence and distribution of BICEP-classified injuries. Secondary endpoints included associations between BICEP category and perioperative parameters, as well as the influence of enucleation technique and morcellator type. Reporting adhered to the Strengthening the Reporting of Observational Studies in Epidemiology statement.

The mean (SD) age was 68.4 (8.2) years and mean (SD) prostate volume 82.5 (41.1) mL. Bladder injury of any grade (BICEP ≥1) occurred in 25.0%. Most injuries were minor BICEP 1 (15.9%) and BICEP 2a (6.1%). Severe injuries (BICEP ≥2c) were rare (0.5%). Increasing BICEP category correlated significantly with longer operative time, irrigation duration, catheterisation, and hospital stay, but not with baseline parameters or 1-month functional outcomes. Neither enucleation technique nor morcellator type independently predicted higher BICEP categories, although en bloc procedures showed shorter operative and hospital times overall.

Intraoperative bladder injury occurred in AEEP procedures, most being low-grade and self-limiting. Higher BICEP categories were associated with increased operative complexity and perioperative morbidity, supporting its value as a standardised reporting tool. The BICEP system enables objective, comparable documentation of bladder injuries across endoscopic urological procedures and may facilitate improved safety monitoring and quality benchmarks.