Persistent Incontinence Rates and Incontinence Surgeries Are Low after Holmium Laser Enucleation of the Prostate: A Retrospective Analysis of a Large National Claims Database

Abstract

Purpose:

Data on complications following holmium laser enucleation of the prostrate (HoLEP) are primarily single-center experiences. Although postoperative urethral stricture rates are well described in the literature, secondary urinary incontinence surgeries (UIS) are poorly characterized. We aimed to quantify the incidence of long-term complications, notably UIS, following HoLEP using a large national dataset.

Methods:

We retrospectively reviewed a limited dataset from the TriNetX Research Network Database, which carries clinical data of 104 US academic medical centers and health care organizations. A search query between 1 year prior to and 2 years after HoLEP identified patients of interest from 45 providers. The following diagnoses and procedures were queried: HoLEP, urinary incontinence, anti-spasmodic prescription, artificial urethral sphincter (AUS), male sling, cystourethroscopy with injection for chemodenervation, injection of urethral bulking material, meatotomy/meatoplasty, urethrotomy, transurethral resection of bladder neck contracture, urethroplasty, and urinary retention.

Results:

Of the 11,559 patients that underwent HoLEP, 2391 (20.7%) were diagnosed with urinary incontinence, and 1921 (16.6%) were prescribed urinary antispasmodics in the year preceding the surgical procedure. The risk of short-term incontinence in the first 3 months following the surgical procedure was 1185 (10.3%). This decreased to 551 (4.8%) between 1 and 2 years after the surgical procedure. Thirteen (0.1%) underwent insertion of an AUS or sling placement, 90 (0.8%) had cystoscopy with chemodenervation, and 10 (0.10%) underwent urethral bulking in the 2 years following HoLEP. The same dataset shows 209 (1.8%) patients required surgical treatment of postoperative urethral stricture disease, excluding bladder neck contracture, in the 24 months following HoLEP.

Conclusion:

Data from a large national database show a low rate (4.8%) of persistent urinary incontinence beyond 1 year following HoLEP and an expected low rate of urinary incontinence procedures.

Keywords

benign prostatic hyperplasia (BPH)prostate enucleation incontinence sling artificial urinary sphincter chemodenervation urethral stricture

Introduction

Holmium laser enucleation of the prostate (HoLEP) is the only size-agnostic prostate outlet procedure that can also be used in medically complex patients with a high risk of bleeding, according to national guidelines.¹ Since its inception in 1996, there are an abundance of retrospective and prospective studies showing its efficacy with overall low complication rates.^2–5 Most of these studies are single-institution, if not single-surgeon, series completed at academic centers. There has been a national increase in HoLEP in the recent past, comprising 4.8% of benign prostatic hyperplasia (BPH) surgeries in 2015 and 7.6% in 2020.⁶ This is in part from the significant increase in fellowship programs offering HoLEP, from only 6/49 (12%) in 2019 to 23/41 (53%) of U.S.-based endourology or combined robotic programs in 2024.⁷ Consequently, more centers, academic and private practice alike, are now offering this procedure in the complement of BPH surgeries.

From a surgeon perspective, the learning curve remains the biggest barrier to widespread adoption, with a recent meta-analysis recommending at least 25–50 cases with mentorship to allow for proficiency.⁸ Notably, rates of postoperative incontinence have been shown to correspond with a surgeon’s learning curve.^9–11 Postoperative incontinence is a major consideration for patient selection and patient decision when alternative surgeries may be offered. Nonetheless, national guidelines recommend offering patients a secondary incontinence surgical procedure if this remains bothersome 1 year out from the index prostate surgical procedure.¹²

We sought to characterize the incidence and management of post-HoLEP incontinence in a national dataset that is heterogenous in surgeon representation and practice type. Furthermore, we wanted to capture the rates of secondary urinary incontinence surgeries (UIS) in patients with long-term urinary incontinence. We hypothesized that incontinence rates are higher in the real world compared to high-volume, single-surgeon academic center experiences.

Methods

Data used in this study were collected and analyzed in July 2025 from the TriNetX LLC Research Network, a national database that provides data from electronic medical records (diagnoses, procedures, medications, laboratory values, and genomic information) for approximately 52 million patients from 104 healthcare organizations (HCO) and 99% of U.S. health plans. 70%–80% of HCOs in this research network are academic centers. Data for analysis are limited to demographics, diagnoses from the International Classification of Diseases (ICD) codes, procedures from the Current Procedural Terminology (CPT) codes, and medications. Medication data were obtained from prescriptions, orders, inpatient medication reconciliations, and charted medications.

TriNetX assumes responsibility for deidentification of the data in a process that adheres to Section x164.514(b) (1) of the Health Insurance Portability and Accountability Act Privacy Rule. This retrospective study is exempt from informed consent and used only deidentified patient records. Our study did not involve the collection, use, or transmittal of individually identifiable data and thus was exempt from the institutional review board.

Data from 2007 through July 2025 were included. Our initial cohort query included males 18–90 years old who had undergone HoLEP (CPT 52649). Patients with a diagnosis of prostate cancer (C61, C80.1, Z85.46, D07.5) were excluded from analysis. 104 HCOs with data from 45 providers responded to our query. The cohort was also queried for incontinence visit (ICD N39.3, N39.4-39.42, 39.45, 39.46, 39.49, 39.498, R32, R39.81) and bladder antispasmodic prescription (GU201, GU209) in the year prior to and the year following HoLEP.

The primary outcome of interest was incontinence surgeries in the 2 years following the procedure, including AUS (53445), male sling (53440), urethral bulking (51715), and cystourethroscopy with injection for chemodenervation (52287). Secondary outcomes of interest were secondary surgeries for urethral stricture disease or bladder neck contracture, including meatotomy/meatoplasty (1008396, 53450), urethrotomy (1008396, 52276, 1008334, 52281, 1008395), transurethral resection of bladder neck contracture (TURBNC) (52640, 1008395, 52500, 52450), or urethroplasty (1008424, 53410, 53415).

Further risk factor analysis was performed via additional queries to elucidate characteristics of patients who had undergone secondary surgical procedures for persistent incontinence. Preoperative characteristics, including the aforementioned coding for incontinence, meatal stenosis (N35.911, N99.110, N35.811, N35.010, N35.111, N35.813), urethral stricture disease (N35, N35.919, N35.9, N35.8, N99.1, N35.91, N35.81, N99.11, N35.01, N35.011-14, N99.111-114, N35.112-114, N35.119, N35.912-14, N35.812-4), diabetes mellitus (ICD E08-E13), obesity (ICD E66), preoperative urinary retention (R33), history of transient ischemic attack (ICD Z86.73), cerebral infarction (ICD I63), Parkinson’s disease (G20), and age were compared between patients who had undergone HoLEP and did not require an incontinence procedure in the 2 years postoperatively and those that did. Notably, TrinetX rounds to 10 any patient outcome that falls between 1 and 10 to protect patient privacy. Thus, only outcomes that affect greater than 10 patients can be used for comparison. For this reason, the following codes for meatal stenosis (N35.111, N99.115) and urethral stricture disease (N35.0, N35.014, N35.01, N35.011, N99.11-4, N35.112, N35.119, N35.913-4, N35.813-4) were excluded. Denominators for this analysis are expected to be different than in the primary analysis because of constant variability in “active” HCOs at the time a query is run.

Results

A total of 11,559 HoLEP patients returned in the query. The mean age at the time of the surgical procedure was 70.5 years. 79% of patients were white, 9% were Black or African American, 7% were of unknown race, 3% were of other race, and 2% were Asian. Patients carried the following diagnoses in the year preceding the surgical procedure: 19% with diabetes mellitus, 14% with obesity, 4% with a history of transient ischemic attack, 3% with cerebral infarction, 2% with Parkinson’s disease, 55% with preoperative urinary retention, 0.35% with meatal stenosis, and 7.6% with urethral stricture. In the year preceding the surgical procedure, 2391 (20.7%) were diagnosed with urinary incontinence, and 1921 (16.6%) were prescribed urinary antispasmodics. 17% of patients underwent urodynamics (CPT 1020197) in the year preceding HoLEP.

Postoperative rates of an incontinence diagnosis or antispasmodic prescription are detailed in Table 1. Specifically, rates of urge (N39.41) and stress incontinence (N39.45, N39.3) were outlined. In the 2 years postoperatively, 13 (0.1%) underwent insertion of an AUS or sling placement, 90 (0.8%) had cystoscopy with chemodenervation, and 10 (0.10%) underwent urethral bulking. As detailed in Table 1, chemodenervation utilization peaked in the 6–12 month range (40 patients) and decreased to 38 in the 1–2 years following HoLEP.

Table 1.

Rate of Incontinence Diagnosis and Antispasmodic Prescription at Various Postoperative Time Points

	Time (months) n (%)
Diagnosis or prescription	0–3	3–6	6–12	12–24
Incontinence	1185 (10.3)	911 (7.9)	688 (6.0)	551 (4.8)
Urge incontinence	408 (3.5)	267 (2.3)	237 (2.1)	201 (1.7)
Stress incontinence	407 (3.5)	389 (3.4)	260 (2.2)	186 (1.6)
Antispasmodic	2292 (19.8)	801 (6.9)	651 (5.6)	621 (5.4)
Chemodenervation	12 (0.1)	23 (0.2)	40 (0.3)	38 (0.3)

Incontinence: ICD N39.3, N39.4-39.42, 39.45, 39.46, 39.49, 39.498, R32, R39.81.

Stress: ICD N39.45 (continuous leakage) or N39.3 (stress incontinence).

Urge: ICD N39.41 (urge incontinence).

A new query was performed to elucidate risk factors for UIS, including the aforementioned characteristics in the year preceding HoLEP. 10,054 patients resulted from this query who underwent a HoLEP without a subsequent UIS (Cohort 1) and 65 patients who had chemodenervation in the 2 years after HoLEP (Cohort 2). The median follow-up was 713 vs 730 days for Cohorts 1 and 2, respectively. Patients in Cohort 2 were significantly more likely to have preoperative urge incontinence and carry a diagnosis of overweight and obesity in the year preceding HoLEP. There was no significant difference in age at the time of HoLEP. Figure 1 shows the timing of chemodenervation procedures is overall consistently distributed in the 2 years following HoLEP.

FIG. 1.

Chemodenervation procedures in 65 patients in 2 years following HoLEP.

A similar query was performed comparing Cohorts 1 to 12 patients that underwent either AUS or male sling in the 2 years following HoLEP (Cohort 3). The median follow-up was identical (730 days). There were no characteristics that were reliably statistically significant between these two cohorts due to the very small sample size of Cohort 3. Notably, there was no significant difference in age at index HoLEP. Figure 2 shows 4 patients had an AUS or sling implanted prior within 400 days of the surgical procedure, while the remaining 75% waited until at least 1.5 years from HoLEP.

FIG. 2.

AUS/Sling procedures in 12 patients in the 2 years following HoLEP.

Table 2 provides the risk of procedures necessary for bladder neck contracture or urethral stricture in the first 2 years following the surgical procedure. 1.8% of patients underwent any treatment for urethral stricture disease (excluding bladder neck contracture) in the 24 months following the surgical procedure.

Table 2.

Rate of Urethral Stricture or Bladder Neck Treatment at Various Postoperative Time Points

	Time (months) n (%)
Procedure	0–3	3–6	6–12	12–24
Total urethral stricture surgical procedures	54 (0.5)	65 (0.6)	53 (0.5)	37 (0.3)
TURBNC	10 (0.1)	36 (0.3)	46 (0.4)	27 (0.2)

Total urethral stricture: meatotomy, meatoplasty, urethrotomy, and urethroplasty.

Discussion

This study depicts real-world experiences for patients that have undergone HoLEP. Most other HoLEP series are single-center and authored by key opinion leaders at high-volume academic institutions. To our knowledge, this series includes the most surgeons to date and the most data from community hospitals that is often omitted in HoLEP series. The rising number of HoLEP surgeons in the country is likely multifactorial—increased fellowship programs offering HoLEP training, increased exposure in residency allowing for fellowship omission, and increased volume of courses allowing urologists in practice to learn HoLEP. Notably, however, postoperative stress incontinence has been shown to correspond with the surgeon’s learning curve.^10,11 Lerner at. al showed a clear association between transient UI at 3 months postoperatively and an increased number of days in between cases.¹¹ Elshal et. al showed that long term (>12 months) urinary incontinence after HoLEP was significantly associated with number of prior cases; however, this number was overall very low (2.2%) and never reached a plateau with an increasing number of cases.¹⁰

To our knowledge, this is the largest retrospective review on continence outcomes following HoLEP. This dataset shows overall low postoperative persistent incontinence rates (5%) between 1 and 2 years after the surgical procedure and a very low rate of secondary surgeries for the treatment of postoperative incontinence. Our results show incontinence rates that are consistent with other large-volume HoLEP series that describe long-term continence rates of 0.5–5.7.^13–15 To validate this data on incontinence and incontinence procedures, outcomes on strictures and contractures were also queried. Secondary surgeries for urethral strictures and bladder neck contracture were consistent with prior studies that report an incidence ranging from 1.5 to 3.9.^14,16–18

Data on subsequent continence surgeries following HoLEP are lacking in the literature. In Lingeman’s experience of over 1000 HoLEP patients, only 2 required urethral bulking injections.¹⁴ Humphreys et. al. published an incidence of 3.4% of patients requiring a continence procedure after HoLEP in a series of 88 patients with glands measuring >200cc.¹⁹ El Tayeb and colleagues had only three patients among 610 HoLEP patients with persistent, severe incontinence requiring male urethral sling placement.²⁰ Das et al. presented an abstract at the International Continence Society that showed low rates of long-term incontinence (1.6%) in a retrospective analysis of 515 patients that had undergone HoLEP.²¹ Among eight patients that experienced long-term incontinence, three underwent cystoscopy with chemical denervation of the bladder, and five had cystoscopy with injection of urethral bulking material. Romero-Otero et al. published a 10-year series of 963 HoLEP patients, of whom, only four underwent an incontinence procedure: one adjustable transobturator male system implant and three suburethral slings.¹⁶

There are several limitations to this study related to the limited retrospective perspective provided by TriNetX. Given the data are pulled from ICD coding, patient-level data on the severity of urinary incontinence are not accessible. Similarly, accuracy of stress vs urge incontinence is unpredictable given reliance on ICD coding instead of questionnaires, such as the Michigan Incontinence Symptom Index.²² It is possible that some patients were referred to a HoLEP surgeon captured in this platform but returned to their primary urologist at a facility that does not participate with TrinetX. This might also underestimate the degree of postoperative incontinence found in this study. However, it is our experience that most surgeons maintain longer follow-up with patients that experience unfavorable outcomes. Similarly, it is reasonable to assume that a patient with long-term incontinence who seeks a secondary incontinence procedure would have this performed within the health system where their HoLEP was performed.

TrinetX cannot provide patient-specific data to identify risk factors for prolonged continence recovery or the need for secondary surgeries. Preoperative metrics such as IPSS scores, uroflow, urodynamics, cystoscopic findings, or prostate volume would be of interest to the BPH community at large. Preoperative ICD coding for urinary retention may mean elevated post-void residual instead of capturing true catheterization dependence. Similarly, operative details such as total operative time and enucleation efficiency are not available. This is particularly relevant for elucidating patient predictors for secondary incontinence surgeries. We are also unable to track pelvic floor physical therapy referrals, which is yet another management strategy for prolonged incontinence following HoLEP and requires further study on its utilization.

As aforementioned, the TrinetX platform must round all outcomes with incidences fewer than 10 (aside from zero) to 10 due to privacy concerns. This applies to the category of urethral bulking and the risk factor analysis for AUS and slings, as all other outcomes have greater than 10 patients. We acknowledge this is a considerable shortcoming of using this database for low-frequency events, yet the clinical relevance for counseling purposes may not be significant. For example, this would result in a difference in incidence of net secondary surgical interventions for stress incontinence from 0.12% (14/11,559) to 0.2% (23/11,559), if the number “10” represented 1 or 10 patients, respectively.

In addition, the TrinetX platform functions by querying data that is pulled from a live network of HCOs. Thus, data are constantly refreshing, which can result in variability in responsive HCOs. Consequently, the cohort for the primary analysis may not be the same as that for the risk factor analysis. This is a nuance for TrinetX research and dataset evolution.

Conclusion

This is the largest retrospective review of a real-world dataset that captures postoperative incontinence rates in greater than 1300 patients who have undergone HoLEP. For many patients, long-term urinary incontinence is of greatest concern in determining procedure selection. Our data show that rates of long-term incontinence is very low. Moreover, the rates of additional procedures for long-term incontinence indicate this is a rare event.

Authors’ Contributions

C.M.: Conceptualization, methodology, software, validation, formal analysis, investigation, data curation, and writing—original draft. N.N.: Conceptualization, methodology, and writing—review and editing.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Abbreviations

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