pISSN: 2287-4208 / eISSN: 2287-4690

Original Article
World J Mens Health 2015 August 33(2): 88-94
http://dx.doi.org/10.5534/wjmh.2015.33.2.88

Risk Factors for Transient Urinary Incontinence after Holmium

Laser Enucleation of the Prostate
Jong Kil Nam1, Hyeon Woo Kim2, Dong Hoon Lee1, Ji-Yeon Han1, Jeong Zoo Lee2, Sung-Woo Park1,3
1 2
Department of Urology, Pusan National University Yangsan Hospital, Yangsan, Department of Urology, Pusan National University Hospital,
Busan, 3Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan,
Korea

Purpose: To investigate the factors associated with the occurrence of and recovery from transient urinary incontinence (TUI) after
holmium laser enucleation of the prostate (HoLEP).
Materials and Methods: From March 2009 to December 2012, 391 consecutive patients treated with HoLEP for benign prostatic
hyperplasia were enrolled. Information regarding age, prostate volume, International Prostate Symptom Score, Overactive
Bladder Symptom Score, peak urinary flow rate, postvoid residual urine, and operation time was collected. TUI was defined as
a patient complaint of urine leakage, regardless of type. Logistic regression was used to investigate the factors associated with the
occurrence of TUI, and the Kaplan-Meier test was used to analyze the TUI recovery period.
Results: TUI after HoLEP occurred in 65 patients (16.6%), 52 patients of whom (80.0%) showed recovery within three months.
Stress and urge urinary incontinence and postvoid dribbling occurred in 16 patients (4.1%), 29 patients (7.4%), and 33 patients
(8.4%), respectively. Age (odds ratio [OR]=3.494; 95% confidence interval [CI]=1.565∼7.803; p=0.002) and total operation
time (OR=3.849; 95% CI=1.613∼9.185; p=0.002) were factors that significantly affected the occurrence of TUI.
Conclusions: TUI, defined as any type of urine leakage, occurred after HoLEP in some patients, most of whom recovered within
three months. Stress urinary incontinence occurred in only 4% of patients after HoLEP. Age and total operation time were
associated with the occurrence of postoperative TUI.

Key Words: Lasers; Prostatic hyperplasia; Urinary incontinence

INTRODUCTION tate-size-independent procedure for treating benign pro-

static hyperplasia (BPH) with a low complication rate [2-5].
Holmium laser enucleation of the prostate (HoLEP), The postoperative outcomes of HoLEP, such as urinary
which was introduced to clinical practice by Gilling et al stream and patient satisfaction, are comparable to those of
[1] in 1998, has been proven to be a safe, efficient, and pros- transurethral resection of the prostate, which has been a

Received: Apr 12, 2015; Revised: Apr 23, 2015; Accepted: Apr 27, 2015
Correspondence to: Sung-W oo Park
Department of Urology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National
University Yangsan Hospital, 20 Geumo-ro, Mulgeum-eup, Yangsan 50612, Korea.
Tel: +82-55-360-2134, Fax: +82-55-360-2164, E-mail: psw@pusan.ac.kr
Copyright © 2015 Korean Society for Sexual Medicine and Andrology
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
 Jong Kil Nam, et al: Transient Urinary Incontinence after HoLEP 89

standard therapeutic option for BPH [6-8]. Moreover, stud- guidelines of the International Continence Society as in-
ies have proved that HoLEP provides not only a significant voluntary loss of urine that represents a hygienic or social
reduction in perioperative morbidity, reoperation rate, problem to the individual, as well as by the answer to the
catheter time, and hospital stay compared with transure- question “Do you have involuntary loss of urine?” [17].
thral resection of the prostate, but also equal suitability for The occurrence of TUI was evaluated at two weeks
small and large prostate glands, even up to a size exceed- postoperatively. In the patients with TUI, recovery of con-
ing 100 g, with clinical outcomes comparable to those of tinence was evaluated every month thereafter. The oper-
open prostatectomy [2,6,9-12]. Thus, based on all these ation time was calculated based only on the time of endo-
benefits, HoLEP has become an excellent therapeutic option scope use, including enucleation and morcellation time.
for BPH surgery and has gained increasing popularity [3]. An endoscope modified for HoLEP with a 26 Fr Stortz
However, postoperative transient urinary incontinence continuous irrigation system was used, through which a
TM
(TUI) has been observed as a bothersome complication of laser bridge adapter and a SlimLine 550 m end-firing la-
HoLEP in a small number of patients, occurring in a range ser fiber (Lumenis Inc., Yokneam, Israel) were inserted.
Ⓡ TM
of 1.3% to 10.7% of reported cases [4,13-15]. Although The VersaPulse PowerSuite Holmium laser (Lumenis
most cases with TUI recover spontaneously within three Inc.) was used with settings of 2.0 J and 40 Hz. A nephro-
Ⓡ
months, it remains one of the most troublesome complica- scope and a VersaCut morcellator (Lumenis Inc.) were
tions of this procedure, as it decreases the patients’ quality used for subsequent morcellation. We used an inverse
of life [16]. This has led to a loss of interest in adopting (downward) technique to prevent injury of the bladder
HoLEP, both by surgeons and patients, despite the many mucosa. A three-way 18 Fr urethral catheter was inserted af-
advantages that have been demonstrated [2,7,14]. ter the surgery, and was generally removed two days later.
Although many urologists agree with the seriousness of Differences in variables between the groups of patients
TUI after HoLEP, only a few studies have attempted to with and without postoperative TUI were compared and
identify the factors that affect its occurrence. Therefore, analyzed using Student’s t-test. A logistic regression test
we tried to identify factors that predict TUI after HoLEP, was used to investigate the factors associated with the oc-
and investigated the association between the duration of currence of postoperative TUI, and the Kaplan-Meier test
TUI and the factors that affected its recovery period was used to analyze the postoperative TUI recovery
concomitantly. period. Factors that affected the postoperative TUI recov-
ery period were investigated using the Cox regression test.
MATERIALS AND METHODS p values less than 0.05 were considered significant. All
statistical analyses were computed using PASW Statistics
After Pusan National University Yangsan Hospital ver. 18 (IBM Co., Armonk, NY, USA).
Institutional Review Board approval, a retrospective re-
view of 391 consecutive patients treated with HoLEP for RESULTS
BPH was performed. All patients were treated by a single
surgeon from March 2009 to December 2012 and were Postoperative TUI occurred during the second post-
followed-up for at least three months. Preoperative evalu- operative week in 65 patients (16.6%) of the 391 BPH pa-
ation included the collection of the patient’s age, Interna- tients who underwent HoLEP, 52 patients of whom
tional Prostate Symptom Score, and Overactive Bladder (80.0%) showed recovery within three months from the
Symptom Score. Additional objective parameters, such as date of the surgery (Fig. 1). Only one patient (0.3%) com-
prostate volume, maximal flow rate, and postvoid residual plained of TUI extending until one year after surgery.
urine volume, were also measured. Prostatic biopsy pre- Stress and urge urinary incontinence, and postvoid drib-
ceded HoLEP if serum prostate-specific antigen level bling occurred in 16 patients (4.1%), 29 patients (7.4%),
and/or digital rectal examination yielded suspicious and 33 patients (8.4%), respectively. Table 1 lists the pre-
results. Urinary incontinence was defined according to the operative and intraoperative parameters of all patients, as

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well as a comparison of these parameters between the two p=0.002) and total operation time (OR=3.849; 95%
groups of patients (with and without postoperative TUI). CI=1.613∼9.185; p=0.002) were factors that had a sig-
Age, International Prostate Symptom Score, postvoid re- nificant impact on the occurrence of postoperative TUI
sidual urine volume, and total operation time were sig- (Table 2). These results showed that age above 65 years
nificantly different between the two groups. and a total operation time longer than 65 minutes tended
Among the variables analyzed, age (odds ratio [OR]= to be associated with the occurrence of postoperative TUI.
3.494; 95% confidence interval [CI]=1.565∼7.803; Few other peri- and postoperative complications, other
than TUI, were observed. Urethral stricture needing surgi-
cal intervention, bladder neck contracture, regrowing ad-
enoma, 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.

DISCUSSION

TUI is one of the most bothersome postoperative com-

Fig. 1. Recovery ratio of transient urinary incontinence depen- plications of HoLEP, both for patients and clinicians
ding on its duration. Eighty percent of the patients who com- [2,7,14]. Involuntary loss of urine with a hygienic or social
plained transient urinary incontinence after holmium laser
enucleation of the prostate showed recovery within 3 months
problem decreases the quality of life of patients sig-
from the date of the surgery (n=65). nificantly, and the complaints of the symptoms of incon-

Table 1. Baseline characteristics and perioperative data

Variable Patients without TUI (n=326) Patients with TUI (n=65) p value
Baseline characteristic
Age (yr) 65.3±7.2 68.8±6.5 ＜0.001
Diabetes 65 14 0.764
Prostate volume (mL) 54.1±25.2 50.7±20.1 0.307
International Prostate Symptom Score
Voiding symptoms 10.4±5.4 12.9±5.0 0.007
Storage symptoms 6.8±3.8 8.1±3.6 0.051
Total score 17.2±8.4 21.0±7.6 0.009
Quality of life score 3.9±1.3 4.5±1.4 0.019
Overactive Bladder Symptom Score 5.6±3.3 7.1±3.3 0.074
Max flow rate (mL/s) 12.9±14.5 10.2±5.2 0.211
Postvoid residual urine (mL) 60.1±67.9 95.7±148.5 0.013
Serum PSA (ng/mL) 5.3±10.6 4.5±5.3 0.545
Perioperative data
Total operation time (min) 59.1±36.0 81.7±50.9 ＜0.001
Morcellation time (min) 14.9±16.2 19.7±21.5 0.040
Resected volume (mL) 23.1±20.0 25.6±18.4 0.352
Values are presented as mean±standard deviation or number only.
TUI: transient urinary incontinence, PSA: prostate-specific antigen.
 Jong Kil Nam, et al: Transient Urinary Incontinence after HoLEP 91

Table 2. Univariate and multivariate predictors of postoperative transient incontinence

Variable Univariate analysis Multivariate analysis

Odds ratio (95% CI) p value Odds ratio (95% CI) p value
Age (＜65 vs. ≥65), yr 2.85 (1.55∼5.21) 0.001 3.49 (1.57∼7.80) 0.002
Prostate volume (＜50 vs. ≥50), g 0.98 (0.53∼1.80) 0.940 0.89 (0.49∼1.25) 0.489
International Prostate Symptom Score (＜17 vs. ≥17) 1.98 (1.00∼3.98) 0.047 1.61 (0.74∼3.46) 0.228
Overactive Bladder Symptom Score (＜5 vs. ≥5) 1.73 (0.57∼5.25) 0.330 – –
Max flow rate (＜13 vs. ≥13), mL/s 0.64 (0.31∼1.34) 0.644 – –
Postvoid residual urine (＜70 vs. ≥70), mL 1.45 (0.71∼2.94) 0.299 – –
Total operation time (＜65 vs. ≥65), min 2.17 (1.26∼3.72) 0.005 3.85 (1.61∼9.19) 0.002
CI: confidence interval.

tinence can be very stressful to clinicians. sphincter is exposed for a longer period to a force that may
In several studies, TUI after HoLEP was shown to occur cause damage, leading to an increased chance of sphinc-
in up to 20% of patients, most of whom recovered within ter damage. Lerner et al [18] reported that even though oper-
one year [2,7,14,16]. Shah et al [4] reported postoperative ation time was not significantly related to postoperative TUI
TUI in 10.7% of their sample; all but two of the patients in their study, this factor was the most likely to affect TUI af-
showed improvement after a mean duration of 42.3 days ter HoLEP, because the analysis of total operation time in
(range, 1∼110 days). In the present study, postoperative their study was fraught with confounding issues. Those au-
TUI occurred in 16.6% of all patients, 80.0% of whom thors were not able to determine how much time was ac-
showed recovery within three months. As shown above, tually spent in the operation, because much of the oper-
the occurrence of postoperative TUI varied widely across ation time involved equipment set-up, equipment delays,
studies. The main cause of these differences may have teaching and demonstrating, etc. Therefore, no valuable
been the variation in the definition of postoperative TUI in information was collected from that dataset. Recently,
each study. We defined any involuntary urine leak as TUI, Elmansy et al [15] reported that the presence of diabetes
including stress or urge urinary incontinence and postvoid mellitus, large prostate volume (greater than 81 g), and a
dribbling. However, many other authors defined TUI ex- greater reduction in postoperative prostate-specific anti-
clusively as a complaint of stress urinary incontinence. gen (greater than 84% remained) were statistically sig-
Because postvoid dribbling can also disturb the lives of pa- nificant predictive factors of the development of stress uri-
tients, our definition of TUI (including any kind of urine nary incontinence (p＜0.001, p=0.02, and p=0.006, re-
leak) seems to be more appropriate. spectively). Their explanations for the two predictive factors
In the present study, the main predicting factors of the of postoperative TUI, diabetes mellitus and prostate vol-
occurrence of TUI after HoLEP were the age of the patient ume, were as follows. First, diabetes mellitus is a chronic
and the total operation time. Older age and a longer oper- disease that can affect the bladder, urethral sphincter, or
ation time seemed to cause postoperative TUI more often, the nerves involved in micturition functions in a variety of
as well as delays in the recovery from this complication. ways; consequently, diabetes mellitus may compromise
We suggest that these factors are associated with urethral the nerve supply of the external sphincter. Second, a large
sphincter damage because of its compression, stretching, prostate size is associated with longer operation time and
and tearing by the resectoscope during the operation. Older longer time of manipulation of the sheath located across
patients may have more fragile and sparse sphincteric tissue the external sphincter, which may lead to greater sphinc-
compared with younger ones; this may lead to increased ter damage. There are many confounding factors for the re-
susceptibility to damage caused by forcing the tissue. lationship between larger prostate size and longer oper-
Longer operation time implies a longer time during ation time. Although larger prostate size tends to cause
which the resectoscope is moving in the urethra; thus, the longer operation time, large prostates with well-encapsu-

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92 World J Mens Health Vol. 33, No. 2, August 2015

lated adenoma do not require a longer operation time. nence. However, the invasive nature of this technique,
Therefore, the present data suggest that mean longer oper- with a risk of side effects, may render it controversial, es-
ation times should not presuppose a larger prostate size, and pecially if most cases of postoperative incontinence last
that only longer operation time will cause TUI after HoLEP. only for a transient period.
The investigation of the association between diabetes melli- The learning curve must affect the incidence of TUI after
tus and TUI will be the subject of our future studies. HoLEP because of longer operation time, inappropriate
Similarly, many authors have proposed that external enucleation, and frequent complications in the early
sphincter damage caused by the resection of adenoma tis- phase [13,18]. One study has reported a significant de-
sue close to the external sphincter may damage the con- crease in the incidence of TUI in patients in their late 50s
tinence mechanisms temporarily [14,19,20]. Endo et al [19] (6%) compared with patients in their early 50s (28%) [25].
reported that the anteroposterior dissection technique, These results showed that an improvement in the learning
which dissects from the bladder neck to the apex, does not curve had the direct effect of decreasing complications.
stretch this inner layer of the external sphincter. Those au- Operation time will also be reduced as the learning curve
thors reported a reduction in postoperative TUI occur- improves. Moreover, the operation will be performed
rence when using this technique compared with conven- with less resectoscope movement and smaller force dur-
tional retrograde dissection (2.7% vs. 25.2%). However, it ing manipulation as the learning curve improves, which
has been debated whether anteroposterior dissection is ultimately reduces urethral sphincter damage and pre-
suitable for large prostates [15,19]. We focused on techni- vents postoperative TUI.
ques aimed at reducing postoperative TUI by shortening During the management of TUI after HoLEP, pel-
the operation time, which would consequently lessen the vic-floor muscle exercise might quicken the improvement
exposure to forces that cause urethral sphincter damage, of postoperative TUI, particularly during the immediate
rather than on anatomic methods, such as anteroposterior early postoperative period [4,26]. As the internal urethral
dissection. Unlike the conventional ‘three-lobe techni- sphincter is damaged after HoLEP, continence relies on a
que,’ which enucleates the median and both lateral lobes competent external urethral sphincter, which is reinforced
in each piece, we performed a ‘two-lobe technique,’ by pelvic-floor musculature [26]. Medications such as anti-
which enucleates via two steps; the left lateral lobe primar- cholinergic or anti-inflammatory agents would be effective
ily, followed by the median, which is incorporated into in the management of postoperative urge incontinence
the right lateral lobe as a piece [21,22]. This two-lobe tech- [4,8,23]. We have also used anticholinergic agents, anti-in-
nique reduced our operation time considerably; however, flammatory agents, and antibiotic treatments and recom-
the precise data on this were not investigated. mend pelvic-floor muscle exercises for patients complain-
Regarding TUI, sphincteric dysfunction does not repre- ing from dysuria, urgency, frequency, and TUI after HoLEP.
sent the whole problem; in addition, several mechanisms However, detailed investigations regarding the manage-
are proposed. Various studies have suggested that early ment of these patients were not performed in the present
postoperative incontinence is usually a symptomatic urge study. Further studies of the association between the dura-
caused by the healing of the fossa or is associated with uri- tion of postoperative TUI recovery and the management of
nary tract infection, detrusor instability caused by long-last- these patients are required.
ing benign prostatic hyperplasia, or thermal injury of the There are several limitations to our study. In our study,
prostatic capsule by holmium laser exposure [4,7,23]. data collection was done retrospectively. In addition,
Radical removal of adenoma can be one of the causes of there were no objective measurements, such as a pad test
TUI after HoLEP, because a large prostatic fossa leads to or voiding diary. Moreover, there was no uro-dynamic
urine trapping and leakage with stress maneuvers in the study to exclude cases with detrusor overactivity or
short term [24]. The type of postoperative incontinence sphincter disorders. The regression analysis lacks im-
may vary individually, and urodynamic studies would be portant variables which could predict stress urinary incon-
helpful in determining the types of postoperative inconti- tinence, such as presence of diabetes, and prostate specif-
 Jong Kil Nam, et al: Transient Urinary Incontinence after HoLEP 93

ic antigen levels, as previously reported [15]. nign prostatic hyperplasia. J Urol 2004;172:1926-9.
8. Yin L, Teng J, Huang CJ, Zhang X, Xu D. Holmium laser
enucleation of the prostate versus transurethral resection of
CONCLUSIONS the prostate: a systematic review and meta-analysis of
randomized controlled trials. J Endourol 2013;27:604-11.
TUI, defined as any type of urine leakage, occurred after 9. Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation
of the prostate versus open prostatectomy for prostates
HoLEP in some patients (16.6%). However, most of these
greater than 100 grams: 5-year follow-up results of a rando-
recovered within three months. Stress urinary incon- mised clinical trial. Eur Urol 2008;53:160-6.
tinence occurred in only 4% patients after HoLEP. The age 10. Elzayat EA, Habib EI, Elhilali MM. Holmium laser enuclea-
of the patients and endoscopic operation time were asso- tion of prostate for patients in urinary retention. Urology
2005;66:789-93.
ciated with the occurrence of postoperative TUI. We sug-
11. Gilling PJ, Aho TF, Frampton CM, King CJ, Fraundorfer MR.
gest that a decrease in the occurrence of postoperative TUI Holmium laser enucleation of the prostate: results at 6
is possible by considering age in preoperative candidate years. Eur Urol 2008;53:744-9.
selection, and also by reducing the operation time based 12. Elzayat EA, Elhilali MM. Holmium laser enucleation of the
prostate (HoLEP): the endourologic alternative to open
on the development of operative skills and know-how.
prostatectomy. Eur Urol 2006;49:87-91.
13. Hwang JC, Park SM, Lee JB. Holmium laser enucleation of
CONFLICT OF INTEREST the prostate for benign prostatic hyperplasia: effectiveness,
safety, and overcoming of the learning curve. Korean J Urol
2010;51:619-24.
No potential conflict of interest relevant to this article
14. Seki N, Mochida O, Kinukawa N, Sagiyama K, Naito S.
was reported. Holmium laser enucleation for prostatic adenoma: analysis
of learning curve over the course of 70 consecutive cases. J
Urol 2003;170:1847-50.
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