Development of Postoperative Bladder Neck Contracture and Urethral Stricture after Holmium Laser Enucleation of the Prostate
Mursal Gardezi, MD, Michael Jalfon, MD, Amir I. Khan, MD, Benjamin Press, MD, Ankur U. Choksi, MD, Soum Lokeshwar, MD, Tashzna Jones, MD, Christopher S. Hayden, MD, Syed N. Rahman, MD, Gregory L. Lacy, MD, Jaime A. Cavallo, MD, Daniel Kellner, MD.
Yale School of Medicine, New Haven, CT, USA.
BACKGROUND: Holmium laser enucleation of the prostate (HoLEP) is an effective treatment for benign prostatic hyperplasia. Like other transurethral surgeries, complications such as bladder neck contracture (BNC) and urethral stricture (US) may occur and can lead to voiding dysfunction. This study compares perioperative variables in patients with and without BNC and US after HoLEP and hypothesizes that risk factors seen in other transurethral procedures will also be identified in patients with post-HoLEP BNC and US.
METHODS: We retrospectively identified patients who underwent HoLEP performed by a single surgeon between April 2019 and April 2022. Patients with postoperative BNC or US were identified. Perioperative characteristics including age, body mass index (BMI), medical history, intraoperative findings, operative time, length of stay, postoperative post void residual (PVR), and American Urological Association symptom score (AUASS) and quality of life (QOL) score were assessed. In order to assess the potential effects of experience on complication rate, cases were split into 12-month intervals and compared. Student's t-test and Pearson chi squared were used for statistical analysis using two-sided tests and significance was determined at a p-value less than 0.05.
RESULTS: Of 497 patients who underwent HoLEP, 17 (3.4%) developed BNC and 23 (4.6%) developed US with a mean follow up of 18.9 months (range 6-42.7 months). BNC and US were diagnosed, on average, 7.7 ± 4.1 and 7.9 ± 6.5 months after HoLEP surgery, respectively. Patients who developed BNC or US, respectively, were more likely to be older than 65 years of age (p=0.03, p =0.05) and have a history of myocardial infarction (MI) (p=0.004, p=0.03) compared to those without BNC or US. Intraoperatively, patients who developed US were more likely to have US at the time of HoLEP surgery (p=0.001). Patients who developed BNC or US were more likely to have increased postoperative PVRs (p<0.001, 0.02) and AUASS QOL scores (p=0.04, 0.02) at 3-6 months. Postoperative US was more common in patients who developed BNC (p<0.001) and postoperative BNC was more common in patients who developed US (p<0.001). Other variables shown in Table 1. There were no significant differences seen in the rate of BNC (p= 0.22) or US (p=0.07) after HoLEP by year of experience (Table 2).
CONCLUSIONS: Postoperative US may be associated with intraoperative US at the time of HoLEP. Age greater than 65 years and history of myocardial infarction may be associated with postoperative BNC or US. The findings of this work suggest that PVRs at initial void trial and 1 month visit may not be sufficient to assess for impending BNC or US and longer follow up may be warranted in higher risk patients. The rates of postoperative BNC or US do not significantly decrease with increased case volume.
| Table 1: Perioperative Characteristics for Patients Undergoing HoLEP | ||||||
| No BNC | BNC | p-value | No US | US | p-value | |
| Age >65 years | 65.0% (286) | 88.2% (15) | 0.05 | 64.7% (281) | 89.0% (20) | 0.03 |
| BMI (kg/m2) | 27.8 ± 4.6 | 27.3 ± 3.4 | 0.65 | 27.8 ± 4.5 | 26.1 ± 4.8 | 0.07 |
| Pre-op Retention | 46.0% (202) | 58.8% (10) | 0.30 | 46.5% (202) | 45.5% (10) | 0.92 |
| Pre-op PVR (mL) | 233.8 ± 330.2 | 244.9 ± 199.9 | 0.91 | 234.7 ± 330.6 | 222.8 ± 243.9 | 0.88 |
| Hx BNC | 0.7% (3) | 0% (0) | 0.73 | 0.7% (3) | 0% (0) | 0.69 |
| Hx US | 3.2% (14) | 5.9% (1) | 0.54 | 3.0% (13) | 8.7% (2) | 0.14 |
| Hx MI | 5.9% (26) | 23.5% (4) | 0.004 | 6.0% (26) | 17.4% (4) | 0.03 |
| Hx Diabetes | 16.8% (74) | 29.4% (5) | 0.18 | 17.3% (75) | 17.4% (4) | 0.99 |
| Hx CKD | 4.8% (21) | 5.9% (1) | 0.83 | 5.1% (22) | 0% (0) | 0.27 |
| Intraop BNC | 0.2% (1) | 0% (0) | 0.84 | 0.2% (1) | 0% (0) | 0.82 |
| Intraop US | 2.5% (11) | 0% (0) | 0.51 | 1.8% (8) | 13.0% (3) | 0.001 |
| Prostate Size (grams) | 68.6 ± 55.4 | 56.1 ± 39.9 | 0.36 | 68.9 ± 55.7 | 54.0 ± 35.2 | 0.21 |
| Operative Time (min) | 112.4 ± 53.2 | 98.4 ± 37.9 | 0.28 | 112.1 ± 53.4 | 109.3 ± 40.4 | 0.81 |
| Days Admitted | 0.5 ± 0.9 | 0.4 ± 0.5 | 0.39 | 0.6 ± 0.9 | 0.2 ± 0.4 | 0.07 |
| Catheterization Duration (days) | 2.1 ± 2.8 | 2.3 ± 1.3 | 0.71 | 2.1 ± 1.8 | 2.5 ± 1.4 | 0.34 |
| PVR at VT (mL) | 47.2 ± 78.3 | 46.4 ± 55.5 | 0.97 | 45.9 ± 77.9 | 69.8 ± 67.8 | 0.19 |
| PVR 1 mo PO (mL) | 44.7 ± 97.3 | 57.0 ± 102.0 | 0.81 | 43.9 ± 97.6 | 74.6 ± 83.1 | 0.41 |
| PVR 3-6 mo PO (mL) | 41.3 ± 95.2 | 163.75 ± 194.68 | <0.001 | 41.5 ± 95.5 | 108.1 ± 166.1 | 0.02 |
| AUASS QOL 1 month | 11.3 ± 8.4 | 12.5 ± 12.7 | 0.78 | 11.0 ± 8.2 | 18.5 ± 14.2 | 0.08 |
| AUASS QOL 3-6 month | 7.8 ± 6.5 | 14.5 ± 5.7 | 0.04 | 7.8 ± 6.2 | 14 ± 11.0 | 0.02 |
| PO US | 3.4% (15) | 47.1% (8) | <0.001 | - | - | - |
| PO BNC | - | - | - | 2.1% (9) | 34.8% (8) | <0.001 |
| Table 2: Postoperative US and BNC after HoLEP by year | ||||
| Year 1 | Year 2 | Year 3 | p-value | |
| BNC | 0/56 (0%) | 8/157 (5.1%) | 9/244 (3.7%) | 0.22 |
| US | 0/56 (0%) | 12/157 (7.6%) | 11/244 (4.5%) | 0.07 |
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