How does symptom severity impact clinical outcomes of men with lower urinary tract symptoms after holmium laser enucleation or transurethral resection of the prostate?

Introduction: International Prostate Symptom Score (IPSS) is a validated outcome measure for the evaluation of patients with lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). When treating patients with transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP), patient selection is key to achieve the best clinical outcome. Therefore, we analyzed how the severity of LUTS as determined by IPSS influenced postoperative functional outcomes. Material and methods: We conducted a retrospective, matched-pair analysis of 2,011 men who underwent HoLEP or TURP for LUTS/BPO between 2013-2017. We included 195 patients in the final analysis (HoLEP n = 97; TURP n = 98), who were matched for prostate size (50 cc), age, and body mass index. Patients were then stratified by IPSS. Groups were compared for perioperative parameters, safety and short-term functional outcomes. Results: While preoperative symptom severity was a significant predictor of postoperative clinical improvement, patients who received HoLEP showed superior postoperative functional results with higher peak flow rates and 2-fold greater improvement in IPSS. In patients presenting with severe symptoms, we observed 3- to 4-fold less Clavien-Dindo grade ≥II and overall complications after receiving HoLEP compared to TURP. Conclusions: Patients with severe LUTS were more likely to experience clinically significant improvement after surgery than patients with moderate LUTS, and HoLEP showed superior functional outcomes than TURP. However, patients with moderate LUTS should not be denied surgery, but may warrant a more comprehensive clinical work-up.