Holmium laser enucleation of the prostate after prostatic urethral lift: the state of bother.

Introduction: We sought to investigate the effect PUL has on pre-operative irritative voiding symptoms in patients presenting for HoLEP, and if this leads to different post-operative outcomes.

Methods: This is a single-institution retrospective analysis of our prospective HoLEP registry. Propensity score matching of prostate size and history of urinary retention was used to match the patients who had prior PUL with patients without prior benign prostatic hyperplasia (BPH) surgery 1:2. We analyzed baseline demographics, operative details, post-operative outcomes, and pre-operative/post-operative International Prostate Symptom Score (IPSS) and Michigan Incontinence Symptom Index (MISI).

Results: Of the 2114 patients who underwent HoLEP, 1242 had sufficient data. There were 59 patients who had a HoLEP after prior PUL and a control cohort was made consisting of 118 patients. At baseline, the control group had more alpha blocker use (69% vs 54% (p=0.05)) and higher American Association of Anesthesia scores. Enucleation efficiency was similar between groups (1.82 vs 1.94 g/min (p=0.634)) but morcellation efficiency was lower in the PUL arm (9.8 vs 7.2 g/min (p<0.001)). More patients in the PUL cohort required anti-cholinergics and beta-3 agonists post-operatively (8.5% vs 19%, p=0.084). With regards to symptom scores, pre-operative MISI severity scores were significantly higher in the PUL group (median 6 vs 3 (p = 0.011)) and no other differences were noted.

Conclusions: Patients presenting for HoLEP after prior PUL have significantly higher MISI severity scores. This does not translate to differences in post-operative outcomes compared to those who had HoLEP as their first BPH surgery.