HOLEP and detrusor underactivity
Reviewed by Arun K Sharma

Lower urinary tract symptoms (LUTS) are common among adult males, significantly influence quality of life (QoL) and contribute to pressure on the NHS. LUTS are conventionally associated with benign prostatic obstruction (BPO), which is commonly observed during the histological progression of benign prostatic hyperplasia (BPH). Nevertheless, an increasing number of studies have demonstrated that LUTS are often unrelated to the prostate but rather to bladder dysfunction, including detrusor underactivity (DU). Although the relationship between BPH and DU remains unclear, some studies have suggested that chronic urinary retention impairs detrusor muscle function, which gradually worsens over time. The treatment of patients with severe DU remains controversial. Some physicians believe that operations can improve voiding conditions, while others believe that surgical interventions have no benefit. Furthermore, DU with secondary renal dysfunction was historically considered a contraindication for transurethral resection of the prostate (TURP). Compared with alternative transurethral interventions for BPH, holmium laser enucleation of the prostate (HoLEP) exhibits superior effectiveness and leads to good long-term outcomes. Nevertheless, the literature on the postoperative efficacy of HoLEP is limited regarding patients with BPO complicated by DU and resulting secondary damage. Thus, the aim of this study was to analyse postoperative changes in DU and renal dysfunction, particularly in these patients. In this prospective analysis, 31 patients were studied. All patients had to meet the criteria of lower urinary tract obstruction, detrusor underactivity and renal dysfunction. Therefore, the inclusion criteria included urinary retention, a bladder outlet obstruction index (BOOI) greater than 40, a bladder contractility index (BCI) less than 100, abnormal renal function at the initial diagnosis (serum creatinine (Scr) >132µmol/L) and a renal pelvis anteroposterior diameter (PRAPD) >1.5cm bilaterally. In addition, the inclusion criteria also included a significant decrease in Scr and PRAPD two weeks after catheterisation. The data were collected at enrolment and at the one-month, three-month, and six-month follow-up appointments. The evaluation of all the patients included the International Prostate Symptom Score (IPSS), quality of life (QoL), maximal urinary flow rate (Qmax), postvoid residual volume (PVR), bladder wall thickness (BWT), digital rectal examination (DRE), RPAPD measured by ultrasound, serum prostate specific antigen (PSA) level, and urodynamic study (UDS). The UDS was conducted to obtain various parameters, including the preoperative Qmax, bladder detrusor pressure at maximum urinary flow rate (PdetQmax), BCI, and BOOI. The calculation methods for the BCI and BOOI are as follows: BCI = PdetQmax + 5Qmax, BOOI = PdetQmax − 2Qmax. The UDS was performed 14 days after indwelling catheterisation and after renal function (Scr) stabilised. The catheter was then reinserted and retained until the day of surgery. Standard HoLEP operation was performed by using the Gilling et al. technique. The SPSS software was used to calculate the mean, standard deviation and rate for the clinical data. Results showed the functional outcomes in terms of IPSS, QoL, Qmax, PVR, BWT, Scr and RPAPD at one, three and six months. Except BWT (p>0.05), all the other parameters showed significant improvements compared to the baseline values at six-month follow-up (p<0.05). Changes in the Qmax, PVR, and BWT observed during the follow-up assessments infer changes in bladder function. The results showed a significant increase in the Qmax and a notable decrease in the PVR compared to the preoperative values. A gradual decline in BWT was observed over time. Serum creatinine and RPAPD can serve as indicators of renal function changes. The results showed a significant improvement in postoperative renal function for patients with no further deterioration observed over time. This article will be of great value to urologists. In the past, many of these cases were doomed to long-term catheters / intermittent self catheterisation. 

Efficiency of HoLEP in patients with detrusor underactivity and renal dysfunction secondary to BPO.
Yang D, Sun Q, Li W, et al.
WORLD JOURNAL OF UROLOGY
2024;42:509.