The Impact of External Sphincter Grading after Early Apical Release Holmium Laser Enucleation of the Prostate on Postoperative Stress Urinary Incontinence

Background: Postoperative stress urinary incontinence (SUI) after Holmium Laser Enucleation of the Prostate (HoLEP) has improved with the early apical release (EAR) technique. However, some patients develop SUI despite using EAR HoLEP. The aim of this study is to investigate whether a novel classification of the external sphincter is correlated with postoperative SUI. Methods: The data of 98 patients who underwent EAR HoLEP for benign prostatic hyperplasia were prospectively analyzed. We propose a novel endoscopic classification of external sphincter appearance after HoLEP graded from 0 (best preserved) to 3 (most degraded). Patients were followed for 6 months postoperatively and administered validated questionnaires. A logistic regression was performed to compare moderate SUI rates at sphincter grade 3, controlling for age, obesity, catheter dependency, and grams resected at 6 weeks and 3 months. Results: The sphincter grades included 6 grade 0, 47 grade 1, 30 grade 2, and 15 grade 3. Patients were divided into a group without SUI (n = 51), and a group with SUI (n = 47) at 6 weeks postoperatively by International Consultation on Incontinence Questionnaire (ICIQ). Patients with reported SUI on ICIQ were more likely to have sphincter grades ≥2 at 6 weeks (p= 0.001) and 3 months (p < 0.0001). At 6 months, persistent SUI was associated with sphincter grade 3 (p < 0.0001). Logistic regression demonstrated that sphincter grade 3 was associated with clinically significant SUI at 3 months (p < 0.01). Conclusions: Lower sphincter grades are associated with improved return of continence after EAR HoLEP.