Trifecta and Pentafecta in HoLEP: Predictors of functional success in a prospective multicentre cohort study

To evaluate the achievement of the Trifecta and Pentafecta excellence criteria in patients undergoing HoLEP and to determine the preoperative predictive factors for their attainment.

A multicentre prospective observational study was conducted. Trifecta criteria were defined as Qmax ≥ 15 mL/s, complete continence, and Clavien-Dindo score < 2 at 3 months. Pentafecta was defined as Trifecta plus a significant response in IPSS and ICIQ-SF. Descriptive and comparative analyses were performed, along with multivariate logistic regression models to identify predictors of success.

A total of 376 patients were included for the Trifecta analysis, with a success rate of 53.2%. Preoperatively, there were no significant differences in the univariate analysis between the Trifecta and non-successful groups in Qmax (8.0 [6.2 - 10.4] vs. 8.15 [6.0 - 10.0] mL/s; p = 0.812), total IPSS (23.0 [17.3 - 28.0] vs. 23.0 [18.0 - 27.3]; p = 0.547), or ICIQ-SF (2.0 [0.0 - 9.5] vs. 4.0 [0.8 - 10.0]; p = 0.118). Postoperatively, the Trifecta group achieved significantly better results in Qmax (27.0 [21.0 - 34.8] vs. 14.0 [9.9 - 23.1] mL/s), IPSS (4.0 [2.0 - 7.0] vs. 8.0 [3.8 - 14.0]), and ICIQ-SF (1.0 [0.0 - 5.0] vs. 5.0 [1.0 - 10.5]), all with p < 0.001. In the multivariate analysis, the absence of previous treatment for storage symptoms (OR: 2.49; 95% CI: 1.18 - 5.23; p = 0.017) was independent predictors of Trifecta achievement. For Pentafecta (n = 245), the success rate was 44.5%, highlighting a lower baseline ICIQ-SF score in the success group (p < 0.001) CONCLUSION: The absence of previous treatment for storage symptoms was identified as the main independent determinant of surgical excellence in HoLEP.