Holmium laser enucleation of the prostate (HoLEP) is as an effective, size-independent treatment for benign prostatic hyperplasia (BPH) with durable outcomes. However, one of its adverse outcomes is post-operative stress urinary incontinence (SUI). We sought to determine if membranous urethral length (MUL) as measured on preoperative magnetic resonance imaging is a predictor for post-operative SUI in patients undergoing HoLEP for BPH.
A single-center, retrospective observational study was conducted on 147 consecutive patients who underwent HoLEP for BPH between 2018 and 2024. Preoperative baseline characteristics, perioperative details, and SUI outcomes at 1, 3, and 6 months were collected. Binary logistic regression was used to assess the association between MUL and SUI at each follow-up interval.
Median MUL was 8.2 mm (IQR 6.1–11.0), and post-operative SUI incidences were 73 (49.7%), 36 (24.5%), and 16 (10.9%) at 1, 3, and 6 months respectively. Longer MUL was significantly associated with lower odds of SUI at 1 month (OR: 0.86, 95% CI: 0.77–0.96, p = 0.009), 3 months (OR: 0.77, 95% CI: 0.65–0.91, p = 0.002), and 6 months (OR: 0.65, 95% CI: 0.49–0.87, p = 0.004). Internal validation demonstrated good discrimination (areas under the curve of 0.73, 0.75, and 0.83 at 1, 3, and 6 months) with well-calibrated models, and decision curve analysis confirmed clinical utility within prespecified risk thresholds.
Longer MUL is significantly associated with lower rates of SUI following HoLEP at 1, 3, and 6 months. Longer MUL may serve as a valuable predictive factor for continence recovery and should be considered during preoperative counseling and surgical decision planning.
Membranous urethral length (MUL) has been well-studied as a predictor of stress urinary incontinence (SUI) after radical prostatectomy, but it’s role in predicting SUI after holmium laser enucleation of the prostate (HoLEP) is unclear. This retrospective study aimed to evaluate whether preoperative MUL, measured on multiparametric prostate MRI, predicts postoperative SUI after HoLEP for benign prostatic enlargement (BPE).
Conducted at a single centre in Montreal, Canada, it included 147 consecutive patients from 2018–2024 who underwent HoLEP by two experienced surgeons using an en-bloc technique. MUL was measured by blinded reviewers on T2-weighted MRI, with SUI defined as ≥1 pad use at 1, 3, and 6 months. Binary logistic regression adjusted for confounders (e.g., age, BMI, diabetes, prostate volume, operative time). Overall incontinence rates were 49.7% at 1 month, 24.5% at 3 months and 10.9% at 6 months.
The key finding was that a longer MUL was significantly associated with lower odds of SUI following HoLEP at 1, 3, and 6 months (OR 0.86, 0.77, 0.65 at 1, 3, 6 months; all p<0.01).
On multivariate analysis, MUL remained a strong predictor of SUI, with each mm increase in MUL corresponding to a 35.0% decrease in the odds of SUI at 6 months. At 6 months, patients who were incontinent had a median MUL of 5.4 mm (IQR 4.7–8.4), while those who were continent had a median MUL of 8.2 mm (IQR 6.3– 10.3).
Certain limitations need to be considered. This is a retrospective analysis with limitations inherent to this study design. Further, the assessment of incontinence was defined by how many pads a patient needed, but as the authors acknowledge, future studies should use validated incontinence questionnaires to assess severity, bother, and to ascertain the type of incontinence.
Overall, this is an interesting and novel study that requires further prospective validation. The findings could potentially aid pre-operative counselling and shared decision-making prior to surgery and may help patients to decide between the different surgical treatment options for BPE. It may also help identify those patients that would benefit from targeted interventions, such as pelvic floor muscle training. Future research should include prospective, multicentre trials with standardised SUI metrics.