HoLEP: Risk Factors for Transient Incontinence after Holmium Laser Enucleation (This post will appear in both patient-info and steadyhealth as each forum has a large number of readers interested in HoLEP.)
This post is for readers who are considering HoLEP, but are hesitating as they are concerned about Transient Urinary Incontinence (TUI) and would like to understand what factors in the operation cause it and what precautions they could take to reduce the chance of having UTI. Also, it will give them ideas what to discuss with their urologists.
Some urologists had suggested that HoLEP is the new gold standard for BPH replacing TURP because it has the best functional outcomes ( such as IPSS, Qmax, PVR,...), long term durability and shorter hospital stay and catheter time than TURP, as well as low retreatment and complication rates. For large prostrate, it is better than open prostatectomy because it has less blood loss. However, the downsides are it has the highest rate of retrograde ejaculation (70-80%) and incontinence (10-20%). [The techniques of Ejaculation Preservation when applied to HoLEP did not work well. The success rate is only about 40% as opposed to EP-GLL (green light laser) which could achieve a success rate of as high as 80-90%.]
I found the following (only) paper which specifically investigated UTI.
"Risk Factors for Transient Urinary Incontinence after Holmium Laser Enucleation of the Prostate" by Jong Kil Nam, et al., published in 2015 online, World J Mens Health. 2015 Aug.
Key findings: The risk factors are: Age, Time length of the operation, and Diabetes and a large prostate "Older age and a longer operation time ...cause postoperative TUI more often, as well as delays in the recovery from this complication. We suggest that these factors are associated with urethral sphincter damage because of its compression, stretching, and tearing by the resectoscope during the operation. " Diabetes weaken muscle control and nerve supply. A large prostate increases operation time length.
What is UTI ? "Any involuntary urine leak as TUI, including stress or urge urinary incontinence and postvoid dribbling." "TUI is one of the most bothersome postoperative complications of HoLEP, both for patients and clinicians [2,7,14]. Involuntary loss of urine with a hygienic or social problem decreases the quality of life of patients significantly, and the complaints of the symptoms of incontinence can be very stressful to clinicians."
What are the percentages of HoLEP UTI in published studies? "In several studies, TUI after HoLEP was shown to occur in up to 20% of patients, most of whom recovered within one year [2,7,14,16]. Shah et al  reported postoperative TUI in 10.7% of their sample; all but two of the patients showed improvement after a mean duration of 42.3 days (range, 1~110 days). In the present study, postoperative TUI occurred in 16.6% of all patients, 80.0% of whom showed recovery within three months." Only one patient took about a year to recover.
...the occurrence of postoperative TUI varied widely across studies. The main cause of these differences may have been the variation in the definition of postoperative TUI in each study. We defined any involuntary urine leak as TUI, including stress or urge urinary incontinence and postvoid dribbling. However, many other authors defined TUI exclusively as a complaint of stress urinary incontinence." [Note: To be consistent, we should only use data in this paper.]
About the patients: "391 consecutive patients treated with HoLEP.... age, prostate volume, International Prostate Symptom Score, Overactive Bladder Symptom Score, peak urinary flow rate, postvoid residual urine, and operation time was collected. "
"All patients were treated by a single surgeon from March 2009 to December 2012 and were followed-up for at least three months. Preoperative evaluation included the collection of the patient's age, International Prostate Symptom Score, and Overactive Bladder Symptom Score. Additional objective parameters, such as prostate volume, maximal flow rate, and postvoid residual urine volume, were also measured. Prostatic biopsy preceded HoLEP if serum prostate-specific antigen level and/or digital rectal examination yielded suspicious results..... The occurrence of TUI was evaluated at two weeks postoperatively. In the patients with TUI, recovery of continence was evaluated every month thereafter. The operation time was calculated based only on the time of endoscope use, including enucleation and morcellation time."
Results "TUI after HoLEP occurred during the second postoperative week in 65 patients (16.6%) of the 391 BPH patients , 52 patients of whom (80.0%) showed recovery within three months. Only one patient (0.3%) complained of TUI extending until one year after surgery." [Note: 17% patients had UTI. Of those 80% recovered within 3 months. But 0.3% took a year to recover. The rest 20% took more than 3 months to recover.]
"Stress and urge urinary incontinence and postvoid dribbling occurred in 16 patients (4.1%), 29 patients (7.4%), and 33 patients (8.4%), respectively. "
"Few other peri- and postoperative complications, other than TUI, were observed. Urethral stricture needing surgical intervention, bladder neck contracture, regrowing adenoma, bladder mucosal injury during morcellation, and acute urinary retention managed with recatheterization occurred in three patients (0.8%), two patients (0.5%), one patients (0.3%), one patients (0.3%), and nine patients (2.3%), respectively. Five patients (1.3%) were diagnosed as having prostate adenocarcinoma based on the final pathological report. [Note: 4.2% had other types of complications. Thus, total complications is 20.8%, out of which 16.6% is TUI. The ratio of TUI to other complications are 4:1.]
Table 1 lists the preoperative and intraoperative parameters of all patients, as well as a comparison of these parameters between the two groups of patients (with and without postoperative TUI). Age, International Prostate Symptom Score, postvoid residual urine volume, and total operation time were significantly different between the two groups.
Table 1 Variable without-TUI (n=326) with-TUI (n=65) Baseline: Age (yr) 65.3±7.2 68.8±6.5 Diabetes 65 14 Prostate volume (mL) 54.1±25.2 50.7±20.1 IPSS Voiding symptoms 10.4±5.4 12.9±5.0 Storage symptoms 6.8±3.8 8.1±3.6 Total score 17.2±8.4 21.0±7.6 Quality of life score 3.9±1.3 4.5±1.4 Overactive Bladder Symptom Score 5.6±3.3 7.1±3.3 Max flow rate (mL/s) 12.9±14.5 10.2±5.2 PVR (mL) 60.1±67.9 95.7±148.5 Serum PSA (ng/mL) 5.3±10.6 4.5±5.3 Perioperative data Total operation time (min) 59.1±36.0 81.7±50.9 Morcellation time (min) 14.9±16.2 19.7±21.5 Resected volume (mL) 23.1±20.0 25.6±18.4
These results showed that age above 65 years and a total operation time longer than 65 minutes tended to be associated with the occurrence of postoperative TUI."
I -- Age "Older patients may have more fragile and sparse sphincteric tissue compared with younger ones; this may lead to increased susceptibility to damage caused by forcing (rubbing and scratching ?) the tissue."
II -- Time length of operating "Longer operation time implies a longer time during which the resectoscope is moving in the urethra; thus, the sphincter is exposed for a longer period to a force (instrument?) that may cause damage, leading to an increased chance of sphincter damage. ....(Some) authors were not able to determine how much time was actually spent in the operation, because much of the operation time involved equipment set-up, equipment delays, teaching and demonstrating, etc. Therefore, no valuable information was collected from that dataset."
III --Diabetes and a large prostate "Elmansy et al  reported that the presence of diabetes mellitus, large prostate volume (greater than 81 g), and a greater reduction in postoperative prostate-specific antigen (greater than 84% remained) were statistically significant predictive factors of the development of stress urinary incontinence (p<0.001, p=0.02, and p=0.006, respectively). Their explanations for the two predictive factors of postoperative TUI, diabetes mellitus and prostate volume, were as follows. First, diabetes mellitus is a chronic disease that can affect the bladder, urethral sphincter, or the nerves involved in micturition functions in a variety of ways; consequently, diabetes mellitus may compromise the nerve supply of the external sphincter.
Second, a large prostate size is associated with longer operation time and longer time of manipulation of the sheath located across the external sphincter, which may lead to greater sphincter damage. There are many confounding factors for the relationship between larger prostate size and longer operation time. Although larger prostate size tends to cause longer operation time, large prostates with well-encapsulated adenoma do not require a longer operation time. Therefore, the present data suggest that mean longer operation times should not presuppose a larger prostate size, and that only longer operation time will cause TUI after HoLEP. The investigation of the association between diabetes mellitus and TUI will be the subject of our future studies."
Special resection techniques that greatly reduce TUI "many authors have proposed that external sphincter damage caused by the resection of adenoma tissue close to the external sphincter may damage the continence mechanisms temporarily [14,19,20]. Endo et al  reported that the anteroposterior dissection technique, which dissects from the bladder neck to the apex, does not stretch this inner layer of the external sphincter. Those authors reported a reduction in postoperative TUI occurrence when using this technique compared with conventional retrograde dissection (2.7% vs. 25.2%). However, it has been debated whether anteroposterior dissection is suitable for large prostates [15,19]. We focused on techniques aimed at reducing postoperative TUI by shortening the operation time, which would consequently lessen the exposure to forces that cause urethral sphincter damage, rather than on anatomic methods, such as anteroposterior dissection. Unlike the conventional 'three-lobe technique,' which enucleates the median and both lateral lobes in each piece, we performed a 'two-lobe technique,' which enucleates via two steps; the left lateral lobe primarily, followed by the median, which is incorporated into the right lateral lobe as a piece [21,22]. This two-lobe technique reduced our operation time considerably...."7 [Note: why not use both the anterior resection and two lobe techniques together? ]
Other possible mechanisms that cause TUI "Regarding TUI, sphincteric dysfunction does not represent the whole problem; in addition, several mechanisms are proposed. Various studies have suggested that early postoperative incontinence is usually a symptomatic urge caused by the healing of the fossa or is associated with urinary tract infection, detrusor instability caused by long-lasting benign prostatic hyperplasia, or thermal injury of the prostatic capsule by holmium laser exposure [4,7,23]. Radical removal of adenoma can be one of the causes of TUI after HoLEP, because a large prostatic fossa leads to urine trapping and leakage with stress maneuvers in the short term . The type of postoperative incontinence may vary individually, and urodynamic studies would be helpful in determining the types of postoperative incontinence. However, the invasive nature of this technique, with a risk of side effects, may render it controversial, especially if most cases of postoperative incontinence last only for a transient period."
Long learning curve of HoLEP "The learning curve must affect the incidence of TUI after HoLEP because of longer operation time, inappropriate enucleation, and frequent complications in the early phase [13,18]. One study has reported a significant decrease in the incidence of TUI in patients in their late 50s (6%) compared with patients in their early 50s (28%) . These results showed that an improvement in the learning curve had the direct effect of decreasing complications. Operation time will also be reduced as the learning curve improves. Moreover, the operation will be performed with less resectoscope movement and smaller force during manipulation as the learning curve improves, which ultimately reduces urethral sphincter damage and prevents postoperative TUI."
Pelvic exercise for quicker TUI recovery During the management of TUI after HoLEP, pelvic-floor muscle exercise might quicken the improvement of postoperative TUI, particularly during the immediate early postoperative period [4,26]. As the internal urethral sphincter is damaged after HoLEP, continence relies on a competent external urethral sphincter, which is reinforced by pelvic-floor musculature . Medications such as anticholinergic or anti-inflammatory agents would be effective in the management of postoperative urge incontinence [4,8,23]. We have also used anticholinergic agents, anti-inflammatory agents, and antibiotic treatments and recommend pelvic-floor muscle exercises for patients complaining from dysuria, urgency, frequency, and TUI after HoLEP. [Note: HoLEP will damage the internal sphincter. The authors did not say wether it will recover or not.]
Lesson I learned HoLEP is a complicated operation because it has two parts: the enucleation and the morcellation. Thus it will take a longer time than other type of BPH operations. To be good at it, the learning curve is long.
To reduce the chance of TUI, it is critical to find a very experienced HoLEP surgeon to reduce the time length of operation. Age matters. Don't wait until one is too old to do any BPH operations. Don't plan on having a succession of operations. Find a good operation and do it only once would be the best.
In comparison, aquablation's total operating time is 33 min (as oppose to HoLEP's 59 min) , which is about 1/2 of HoLEP's and resecting time is 4 min (which is included in the total operating time). Dr. Peter Gilling, the principal investigator of the aquablation multi continent trial, informed me via email that incontinence is not an issue for aquablation.