Holmium laser transurethral incision of the prostate: Can prostate size predict the long-term outcome?

Introduction: We determine the impact of prostate size on the long-term outcome of holmium laser transurethral incision of the prostate (Ho-TUIP) for bladder outlet obstruction (BOO) secondary to benign prostate enlargement (BPE). Methods: A retrospective review of prospectively collected data was performed for patients undergoing Ho-TUIP by a single surgeon for patients presenting with lower urinary tract symptoms (LUTS) secondary to BOO. Patients were stratified into 2 groups: Group 1 included patients with prostate <= 30 cc and Group 2 included patients with prostate >30 cc. Demographic, operative and follow-up data were recorded and analyzed. In addition, intraoperative and long-term adverse events were included. Results: In total, 82 patients underwent surgery between March 1998 and March 2013, including 9 (11%) reoperated patients. Only prostate size independently predicted reoperation after Ho-TUIP (adjusted odds ratio [aOR], 95% confidence interval [CI] 7.12 [2.92-9.14], p = 0.01). The receiver operating characteristic (ROC) analysis showed an optimal cutoff value of prostate volume of 29 cc to characterize long-term reoperation after TUIP, with area under the curve (AUC) of 0.96, sensitivity of 89.7 and specificity of 88.9. Group 1 included 51 patients and Group 2 included 31 patients. The international prostate symptoms score (IPSS) and peak flow rate (Qmax) significantly improved in both groups at different follow-up points. At the 12-month follow-up, the percent change in IPSS and Qmax were comparable between both groups. However, after 12 months, the degree of improvement in all voiding parameters was significantly higher in Group 1 (p < 0.001 at all points of follow-up). After a median follow-up of 5.3 years (range: 1-13), both groups had comparable early and late adverse events with significantly higher reoperation rate in Group 2 (3.9% vs. 22.6%, p = 0.02). Overall retrograde ejaculation was detected in 25.6% of sexually active men and it was comparable between both groups (23.5% vs. 29%, p = 0.61). On multivariable analysis, patients with prostate volume >30 cc were associated with significantly higher reoperation for BOO (aOR 95% CI 5.72 [2.83-8.14], p = 0.02), significantly higher IPSS (aOR 1.72), higher quality of life index (aOR 1.72) and lower Qmax (aOR 0.28). Conclusion: Ho-TUIP is a durable, safe and efficient treatment of BOO secondary to a small-sized prostate. The long-term outcome could be improved and the re-operation rate could be minimized with appropriate selection of cases, with prostate glands no bigger than 30 cc.