While the entirety of BPH literature would benefit from more in-depth inclusion of PROs, Holmium laser enucleation of the prostate (HoLEP) has a unique post-operative clinical course (such as transient incontinence and improved hematuria outcomes) and therefore was the sole focus of this review. The purpose of this review was to qualitatively assess the top twenty cited HoLEP studies and their inclusion of six overarching aspects of PROs after HoLEP: LUTS, incontinence, sexual function, pain, hematuria, and patient satisfaction. Further, we discuss the current gaps in the literature and recommend the inclusion of specific PRO measures (PROMs) in future HoLEP studies.
LUTS: All twenty of the top cited HoLEP studies assessed LUTS PROs, either by the International Prostate Symptom Score (IPSS) or American Urological Association Symptom Score (AUASS). For patients who are bothered by bladder overactivity, the IPSS storage subscore is less sensitive than the overactive bladder symptom score (OABSS) in identifying overactive bladder severity. Adding the OABSS provides value and is encouraged. However, given time constraints in clinics to minimize workflow disruptions, many clinicians may choose to only administer IPSS; if so, the authors encourage future research to report storage and voiding symptoms separately to provide a nuanced view into bladder overactivity and LUTS after HoLEP.
Incontinence: Among the top cited studies, only two utilized incontinence PROMs. 14 of the remaining 18 studies mentioned percentages of stress urinary incontinence (SUI) by self-report, but few discussed the degree and duration. Only 4 of the top cited studies shared patient reported urge urinary incontinence (UUI) percentages, with no studies detailing duration or severity. The authors recommend utilizing the Michigan Incontinence Symptom Index (M-ISI) to report incontinence after HoLEP as it clearly delineates SUI versus UUI, assesses pad use, and includes incontinence-specific QoL items.
Sexual Function: 5 of the top cited studies detailed sexual function PROs after HoLEP, with 2 of these studies utilizing the International Index of Erectile Function-5 (IIEF-5). Importantly, IIEF-5 only measures erectile function and therefore misses critical aspects of sexual function after HoLEP such as orgasmic and ejaculatory function. Overall, the authors advocate for using IIEF-15 as it incorporates all aspects of sexual function (erectile function, orgasmic function, sexual desire, ejaculation, intercourse satisfaction, and overall satisfaction) and isn’t as time-intensive as the Male Sexual Health Questionnaire (MSHQ). For more detailed ejaculation outcomes, the addition of the four-item MSHQ-Ejaculatory Dysfunction Short Form is encouraged.
Pain: Six of the most frequently cited HoLEP outcome studies address pain and/or dysuria as it is a known potential perioperative complication. These studies include the percent of patients experiencing dysuria but don’t assess duration or severity. No standardized PROM exists for reporting dysuria or pain specific to HoLEP patients. The authors recommend using a visual analog scale for dysuria and pain and encourage the development of a validated PROM for use after endourological procedures.
Hematuria: Self-reported hematuria was not identified in any of the top-cited HoLEP studies. While six of these studies reported hematuria complication rates, these were related to adverse event reporting by providers and not self-reported by patients. Gross hematuria visual scales exist as a tool to improve communication among providers, but this has not been utilized with patients’ reporting. We encourage the validation of this visual hematuria scale for patient use to capture their hematuria PROs including color scale, hematuria duration, clot presence, and bother.
Patient Satisfaction: 14 of the 20 studies assessing patient satisfaction after HoLEP relied upon the single QoL question via IPSS to report patient satisfaction. This method falls short of comprehensively addressing patients' overall HrQoL following HoLEP. To minimize the questionnaire burden, the authors recommend using PROMs that incorporate domain-specific HrQoL questions (LUTS QoL via IPSS, sexual satisfaction via IIEF-15, incontinence QoL via M-ISI). These items give a global view of patients’ post-HoLEP HrQoL without the burden of an additional questionnaire.
Conclusion: Of the top 20 cited HoLEP studies, not one included all six PROs domains. We feel that increased inclusion of the patient experience will benefit the critical assessment of surgical technique. Implementing uniformity will enhance the precision and comparability of results across various HoLEP studies, thereby contributing to a more accurate and comprehensive understanding of the patient experience after surgery.
Written by: Laena Hines, MD, Department of Urology, University of Rochester Medical Center, Rochester, NY.
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