To evaluate the effect of detrusor underactivity (DUA) on the postoperative outcomes of holmium laser enucleation of the prostate (HoLEP) in patients with benign prostatic hyperplasia (BPH).
Patients with BPH who underwent HoLEP between January 2018 and December 2022 were enrolled in this prospective database study. Patients were divided into DUA (bladder contractility index [BCI] <100) and non-DUA (BCI ≥100) groups. Objective (maximum urinary flow rate [Qmax], post-void residual urine volume [PVR]) and subjective outcomes (International Prostate Symptom Score [IPSS], Overactive Bladder Symptom Score [OABSS], satisfaction with treatment question [STQ], overall response assessment [ORA], and willingness to undergo surgery question [WUSQ]) were compared between the two groups before surgery, and at 3 and 6 months after HoLEP.
A total of 689 patients, with a mean (standard deviation [SD]) age of 69.8 (7.1) years, were enrolled. The mean (SD) BCI in the non-DUA (325 [47.2%]) and DUA (364 [52.8%]) groups was 123.4 (21.4) and 78.6 (14.2), respectively. Both objective (Qmax and PVR) and subjective (IPSS, IPSS-quality of life, and OABSS) outcomes after surgery significantly improved in both groups. The Qmax was lower in the DUA than in the non-DUA group postoperatively. At 6 months postoperatively, the total IPSS was higher in the DUA than in the non-DUA group. There were no significant differences in surgical complications between the two groups. Responses to the STQ, ORA, and WUSQ at 6 months postoperatively demonstrated that the patients were satisfied with the surgery (90.5% in the DUA group; 95.2% in the non-DUA group), their symptoms improved with surgery (95.9% in the DUA group; 100.0% in the non-DUA group), and they were willing to undergo surgery again (95.9% in the DUA group; 97.9% in the non-DUA group). There were no significant differences in the responses to the STQ and WUSQ between the two groups.
Our midterm results demonstrated that patients with BPH and DUA showed minimal differences in clinical outcomes after HoLEP compared to those without DUA. The overall satisfaction was high in the DUA group.
The traditional belief is that surgery for benign prostatic obstruction (BPO) is less satisfactory in patients with detrusor underactivity (DU). Recent evidence from the UPSTREAM study found that a bladder contractility index (BCI) of <123 predicted a poor outcome from BPO surgery. However, this trial was primarily based on patients undergoing TURP.
The article from Jeong et al. in this month’s issue of BJUI adds further weight to the growing body of evidence showing that maximal de-obstruction with HoLEP leads to satisfactory outcomes in men with DU and BPH. In this prospective comparative study, 689 patients underwent HoLEP for BPO. Patients were divided into 2 groups – those with DU (BCI <100) and those without DU (BCI ≥100). The mean prostate volume in the DU group was 64ml, with a mean enucleation weight of 24g. The study found that both objective (Qmax) and subjective (IPSS -international prostate symptom score, IPSS-quality of life, and OABSS – overactive bladder symptom score) outcomes after surgery significantly improved in both groups. The total IPSS was higher in the DU group at 6 months, and 90.5% of DU patients were satisfied with the outcome of their surgery. However, the degree of satisfaction in the DU group decreased as post-void residual (PVR) increased.
Overall, this study shows that patients with DU and low PVR may achieve comparable short-term (6 month) outcomes from surgery compared to those without DU, with a surgical technique that results in a greater degree of de-obstruction than TURP. However, long-term evaluation of outcomes in this group is needed.