Commentary on “Incidence of urinary incontinence following endoscopic laser enucleation of the prostate by en-bloc and non-en-bloc techniques: a multicenter, real-world experience of 5068 patients”

Laser enucleation of the prostate is a proven and effective size-independent method for the surgical management of symptomatic benign prostatic hyperplasia (BPH) and is considered as the "gold standard" by many clinicians. Two major hurdles that stand in the way of this becoming a universally used procedure for BPH are the steep learning curve associated with mastering the procedure and possibility of perioperative transient incontinence. Many advances in teaching methodologies have helped tackle the difficulty in learning it and increased the number of urologists utilizing the procedure. As for the second hurdle, transient incontinence rates postlaser enucleation of the prostate have improved with the advent of newer techniques of enucleation. Castellani et al.1 assesses the incidence of stress, urge, and mixed urinary incontinence following laser enucleation of the prostate by comparing en-bloc and non-en-bloc techniques in a multicenter series of 5068 men with BPH. There are several variations of laser enucleation of the prostate including the classic 3-lobe, modified 2-lobe, and en-bloc enucleation techniques. The enucleation techniques differ in the incisions of the urethral mucosa down to the surgical capsule and the direction of dissection.2 The classic 3-lobe technique was first described by Gilling et al.3 and involves separate enucleation of the median and lateral lobes. This technique is possibly the easiest to learn and offers improved endoscopic visibility as each lobe is enucleated. The modified 2-lobe technique involves enucleating a single lateral lobe and then enucleating the remaining lateral lobe with the median lobe. The en-bloc technique involves complete detachment of all 3 prostatic lobes and simultaneous enucleation of all 3 lobes in a distal-to-proximal approach.4 There are theories that en-bloc enucleation may lead to improved postoperative continence outcomes, and literature has described differing outcomes between the various techniques. Enikeev et al.5 described in a retrospective study of 1115 patients who underwent en-bloc versus 2-lobe holmium laser enucleation of the prostate (HoLEP) that there was no difference in enucleation time or 6-month functional outcomes. Morcellation was more efficient in the 2-lobe approach by about 30%. Others found en-bloc enucleation to be more time efficient than other techniques by up to 30%.6 There has been limited assessment of continence outcomes between the techniques. We commend the authors for completing the largest study assessing the urinary continence outcomes between en-bloc and non-en-bloc enucleation techniques. Non-en-bloc enucleation demonstrated higher rates of stress urinary incontinence within 1 month of surgery (40.1% vs 23.4%) compared to en-bloc technique. At >3 months postoperations, among the patients with incontinence, stress urinary incontinence rate was higher in the non-en-bloc group than that in the en-bloc group. Prostate volume (odds ratio [OR]: 2.178), surgical time (OR: 1.010), and no early apical release technique (OR: 2.915) were factors associated with higher odds of long-lasting incontinence. We congratulate the authors on this multi-institution, high-volume, and well-written paper revealing the association of en-bloc enucleation with lower rates of incontinence. However, we would like to highlight some possible confounding factors that may be influencing the outcomes. First, while the multicenter nature of the study is a strength, the study cannot control variations between surgeons. Surgeons at various institutions are more likely to perform a single technique, and the surgeon's experience and skill-level may make a bigger impact on the early continence than the technique itself. Second, the improved continence outcomes of en-bloc may be largely attributed to the early apical release. While 63.9% of en-bloc enucleations had early apical release, only 29.8% of non-en-bloc enucleations had early apical release. Finally, as the authors highlighted, there was no standardization or tracking of postoperative management and Kegels protocol which can greatly influence continence outcomes. This study demonstrates the importance of early apical release in improved continence. Further studies controlling for confounding factors (apical release, surgeon skill/experience, and postoperative management) will be needed to determine the impact of enucleation technique on continence outcomes. In the end, we believe that the choice of technique should be mostly dependent on the surgeon's comfort and experience level. Early apical release should be completed in every case when possible and it likely has the biggest impact on early continence. Surgeons should always counsel and educate their patients regarding the possibility of postoperative urinary incontinence and strategies for achieving earlier continence. COMPETING INTERESTS All authors declare no competing interests.