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. The Michigan Incontinence Symptom Index (MISI) was used to assess continence (severity and bother, severity broken into urge and stress). The International Prostate Symptom Score (IPSS) was used to assess LUTS (total IPSS score and Quality of Life (QoL)). Surveys were completed pre-operatively and one week (1wk), one month (1m), three months (3m), and one-year (1y) post-HoLEP. Primary outcome measures were MISI differences between groups at each time point. Results Of the 266 patients evaluated, 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 statistically 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 pre-op. 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.