Stream Deceleration Score: A novel perioperative metric to predict post-operative incontinence outcomes in patients undergoing Holmium Laser Enucleation of the Prostate
Syed Rahman, MD, Christopher Hayden, MD, Ankur Choksi, MD, Soum Lokeswhar, MD, Mursal Gardezi, MD, Amir Khan, MD, Tashzna Jones, MD, Victoria Kong, BS, Shayan Smani, BS, Gregory Lacy, MD, Daniel Kellner, MD.
Yale School of Medicine, New Haven, CT, USA.
BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) has been presented as an alternative to TURP for treating BPH secondary to medium- and large-sized prostates. There is growing interest in urologists learning HoLEP. However, there is growing interest in optimizing metrics to help predict commonly asked patient outcomes such as early incontinence. We present a peri-operative metric known as the Stream Deceleration Score (SDS) to help predict post-operative incontinence outcomes to aid in patient counseling.
METHODS: Using a database approved by an institutional review board, we performed a retrospective review of the initial 400 consecutive patients who underwent HoLEP by a single surgeon between April 2019 and June 2022. In our institution, we utilize a thermadex fluid management system with a set pressure of 60mmHg. At the end of the procedure when removing the cystoscope we calculate SDS by measuring the time to stream deceleration. If less than 2 seconds then a score of 0 is calculated, if more than 0 seconds then a score of 1 is calculated. We correlated SDS scores with incontinence rates from 1 month to 12 months across prostate sizes. We also performed a multivariable logistic regression while adjusting for clinical and demographic variables. Incontinence was defined as >2 pads per day.
RESULTS: In our database there were 357 patients with available SDS scores and incontinence data available. For all patients with an SDS of 0 incontinence rates of 41%, 24%, 8%, and 0.5% were noted at 1, 3, 6, and 12 months. For patients with an SDS of 1 rates of 21%, 10.9%, 5.2%, and 1% were noted. When stratified across prostate sizes we identified that for 100g+ prostates there is a significant difference in 1 and 3 month incontinence rates across SDS values (26.0% vs 30.2% and 15.0% vs. 9.4% respectively, p<0.05) and in 1 month rates for 50-100g prostates (38.0% and 23.8%, p<0.05). Additionally, SDS was associated with 1 month and 3 month incontinence rates in multivariable logistic regression (OR 1.57 [1.08-3.13] and OR 2.48 [1.25-6.54] respectively). CONCLUSIONS: SDS correlates to early incontinence at 1 and 3 months particularly in large volume prostates. SDS may be used as a metric to counsel patients on time frame of return of continence outcomes post-operatively. 
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