Safety and efficacy of a modified technique of holmium laser enucleation of the prostate (Holep) for benign prostatic hyperplasia

Holmium laser enucleation of the prostate (HoLEP) is a valid alternative to transurethral resection of the prostate and open simple prostatectomy for the treatment of a larger prostate, demonstrating comparable efficacy and lower morbidity. One of the most bothersome symptoms after HoLEP is urinary incontinence (UI), which is present in almost 20% of patients, with a recovery rate of over 80% at 3 months. A relevant risk factor linked to UI is the damage of the external sphincter during the enucleation of adenoma tissue close to it. In our modified HoLEP technique named Cap HoLEP, we preserve the anterior prostate portion proximal to the external sphincter. This cap of adenoma could reduce mechanical stress and laser energy widespread on the sphincter, acting as a protective barrier. The aim of this study was to describe the Cap HoLEP technique and to evaluate its safety and efficacy by assessing peri-operative and functional outcomes. We enrolled all patients who consecutively underwent Cap HoLEP from December 2017 to October 2019 in our hospital. Baseline characteristics; the International Prostate Symptom Score; uroflow findings; intraoperative data, intraoperative, and postoperative complications; and UI were all assessed. The median operative time was 122 min with 138 kJ of laser energy delivered. Median ∆Hb was 0.8 gr/dL. Seven low-grade complications were recorded. At 1 month, 34.8% of patients presented UI, 16.7% urge incontinence, 13.6% stress incontinence, and 4.5% mixed incontinence. At 3 months, UI showed a significant improvement, decreasing to 12.1%. At 6 and 12 months, UI was 7.6% and 3%, respectively. Our modified HoLEP technique is safe and effective, allowing significant improvement in the postoperative UI rate.