Objective
To test for differences in recovery of lower urinary tract symptoms (LUTS) between patients with storage-positive vs -negative symptoms after laser enucleation of the prostate (LEP).
Patients and methods
Consecutive storage-positive (severe storage symptoms, International Prostate Symptom Score [IPSS] storage subscore >8) vs storage-negative patients treated with LEP (November 2017–September 2022) within our tertiary-care database were identified. Mixed linear models tested for changes in IPSS and quality of life (QoL) at 1, 3 and 12 months after LEP. Multiple linear regression models tested for LUTS and QoL recovery risk factors at 1, 3 and 12 months.
Results
Of 291 study patients, 180 (62%) had storage-positive symptoms. There were no differences between storage-positive and -negative patients in mean adjusted total IPSS, IPSS-storage, IPSS-voiding and QoL at 12 months after LEP. In multiple linear regression models, storage-positive status was identified as a risk factor for higher IPSS at 1 month (β coefficient 2.98, P = 0.004) and 3 months (β coefficient 2.24, P = 0.04), as well as for more unfavourable QoL at 1 month (β coefficient 0.74, P = 0.006) and 3 months (β coefficient 0.73, P = 0.004) after LEP. Conversely, at 12 months there were no differences between storage-positive vs -negative patients.
Conclusion
Storage-positive patients appear to experience similar long-term benefits from LEP compared to storage-negative patients. However, significant storage symptoms are associated with higher total IPSS and less favourable QoL at 1 and 3 months after LEP. These findings advocate for the consideration of LEP also in storage-positive cases with the need for thorough patient education especially in the initial post-LEP period.
Benign prostatic obstruction (BPO) commonly leads to bladder dysfunction. Longstanding obstruction causes ultrastructural changes in the bladder wall, leading to detrusor hypertrophy, detrusor overactivity, and ultimately detrusor underactivity. These secondary bladder effects, with their resultant storage lower urinary tract symptoms (LUTS), are the commonest reasons for men to seek urological care as they lead to the most bother. Early surgical treatment of BPO may prevent further deterioration of this secondary bladder dysfunction but reports of outcomes of BPO surgery in this group are mixed.
The recent study from Cano Garcia et al. in the BJUI adds to the body of evidence addressing the question of whether surgical treatment of BPO in men with storage LUTS is beneficial over the longer-term. This cohort study analysed IPSS data of 291 patients who underwent LEP over a 5-year period. Patients were stratified into storage-positive (IPSS-Storage subscore >8) and storage-negative (IPSS-Storage subscore ≤7) groups, and the authors analysed improvement in IPSS at 1, 3, and 12 months post-LEP. Storage-positive patients (62% of the cohort) exhibited higher total IPSS and less favourable QoL at 3 months post-LEP compared to storage-negative patients, with a greater requirement for anticholinergic therapy in this early post-operative period. However, by 12 months, there were no significant differences in LUTS recovery (total IPSS) or QoL between the two groups, demonstrating similar long-term benefits. These results challenge the notion that storage-positive men have poorer outcomes from BPO surgery and highlight the effectiveness of LEP in patients with storage symptoms.
This study is commendable for its stratification based on IPSS-Storage subscores, its large cohort and longer-term follow-up period compared to other studies. However, there are some limitations which need to be considered. The IPSS score is limited in the assessment of storage LUTS and lacks any questioning on the presence of incontinence. Patients with incontinence may possibly represent a group with more severe bladder dysfunction, and so outcomes in this group need to be studied to aid patient counselling prior to BPO surgery. Secondly, there is no assessment of urodynamic parameters, which may provide important predictive factors for positive and negative surgical outcomes. This is a key area for future study to enable preservation of bladder health through early surgical intervention in those that would benefit most.