This study evaluates the efficacy of holmium laser enucleation of the prostate (HoLEP) as a deobstructive surgery for patients with detrusor underactivity (DU) or acontractile bladder (AcB).

Between April 2021 and May 2024, patients undergoing HoLEP for benign prostatic obstruction (BPO) were selected based on urodynamic study (UDS) results indicating DU or AcB. The primary outcome was the change in voiding efficiency (VE) following the HoLEP. Secondary outcomes included differences in VE between subgroups, such as the DU and the AcB group. The proportion of patients who discontinued Foley catheter or clean intermittent catheterization (CIC) postoperatively was also assessed. The VE trend over time was visualized using Python's Seaborn library with the locally weighted scatterplot smoothing (LOWESS) method, and the plots were generated using Matplotlib.

A total of 26 patients who underwent HoLEP were analyzed, including 14 with DU and 12 with AcB. The median age and prostate volume were 76.5 years and 48.6 cc in the DU group, and 74.5 years and 68.0 cc in the AcB group, respectively. Preoperatively, catheterization was required in 6 patients (43%) in the DU group and 11 patients (92%) in the AcB group. Postoperatively, 5 patients required temporary Foley catheters or CIC, and one patient underwent internal urethrotomy for bulbous urethral stricture. All patients in both groups achieved spontaneous voiding without the need for long-term catheterization. Voiding efficiency (VE) increased from 0% to a median of 81.3% following surgery. VE increased sharply up to one month postoperatively, then plateaued. (Figure 1). Median postvoid residual (PVR) decreased from 325 mL to 45 mL, and Qmax improved from 0 to 14.4 mL/s. Significant improvements were also observed in voiding symptom score (-9.5) and QoL score (-3.0). Subgroup analysis revealed that VE improved by 47.8% in the DU group and by 78.0% in the AcB group. Corresponding reductions in PVR were 116.5 mL and 351 mL, respectively, and Qmax improved by 5.8 mL/s in the DU group and reached 16.3 mL/s in the AcB group. VE trends over time showed sustained improvements in both groups, with no significant intergroup differences. (Figure 1).

HoLEP effectively improves voiding efficiency and symptoms as a deobstructive surgical intervention in patients with BPO and DU or AcB. There was no significant difference in outcomes between patients with DU and AcB.