Urethral complications after holmium laser enucleation of the prostate are more common in patients with smaller prostates.

Background: Holmium laser enucleation of the prostate (HoLEP) is a bladder outlet obstruction procedure used for the treatment of benign prostatic hyperplasia (BPH). While early postoperative complications and outcomes are reported, data regarding the incidence and management of delayed urethral complications (UC), including bladder neck contracture (BNC) and urethral stricture disease (USD) are limited. We aim to define the incidence and outcomes of patients with UC following HoLEP.

Methods: A retrospective chart review was performed for 1,374 patients operated on between 07/2020-12/2023. We defined the occurrence of BNC or USD as requiring surgical treatment postoperatively. Current procedural terminology (CPT) codes were utilized to identify patients who underwent direct vision internal urethrotomy, cystoscopy with urethral dilation, urethroplasty, meatotomy, or incision of BNC. UC patients were compared to available patient metrics from our prospectively maintained database. Mann-Whitney tests, Fisher exact tests, and logistic regression were performed in GraphPad Prism version 10.3.1.

Results: Of 1,374 patients, 20 (1.5%) had a UC postoperatively, including 14 BNC (70%), 3 USD (15%), and 3 who had both BNC and USD (15%). UC patients had significantly lower prostate volumes, surgical specimen weights, lesser enucleation and morcellation times than those without UC (P<0.05), while morcellation and enucleation efficiency were not. Logistic regression resulted in an odds ratio (OR) of 0.987 [95% confidence interval (CI): 0.974-0.997]. Presentation of UC occurred at a mean 148 days (range, 75-205 days) after surgery, with 10 (50%) of patients needing multiple surgical treatments for UC. Fifteen (75%) UC patients had a postoperative urinary tract infection (UTI) defined by presence of positive urinalysis, symptoms, and prescription of antibiotics.

Conclusions: We find that UC after HoLEP occurs with a low incidence of 1.5% and is associated with smaller prostate volume. We also characterize a complicated postoperative course for these patients, marked by high UTI rates and need for multiple UC surgeries. Further investigation into potential pathophysiologic mechanisms driving the association between small prostate volume and UC after HoLEP.