Anatomical Foundations, surgical technique and early outcome of the No Stress In-continence Enucleation (NIcE) Template for Holmium Laser Enucleation of the Prostate (HoLEP)

Anatomical Foundations, surgical technique and early outcome of the No Stress In-continence Enucleation (NIcE) Template for Holmium Laser Enucleation of the Prostate (HoLEP) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Anatomical Foundations, surgical technique and early outcome of the No Stress In-continence Enucleation (NIcE) Template for Holmium Laser Enucleation of the Prostate (HoLEP) Aravindh RATHINAM, Archan Khnadekar, Adam Williams, Hasim Bakbak, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7623679/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Transient stress urinary incontinence (TSUI) remains a significant issue following Holmium laser enucleation of prostate (HoLEP). Herein we describe a novel technique called No stress-Incontience Enucleation (NIcE) designed to preserve both striated and smooth muscles within the anterior fibromuscular stroma and its overlying mucosa. The primary objective was to evaluate continence immediately after catheter removal. The secondary goal was to compare perioperative and early voiding outcomes in patients undergoing HoLEP using the NIcE technique vs standard en-bloc technique. Methods: Patients undergoing HoLEP with NIcE modification from May 2024 were prospectively enrolled. The procedure used the Moses 2.0 holmium laser (2J, 30 Hz) with a specific template designed to preserve the anterior urethral mucosa between the 10 and 2 o’clock positions from the bladder neck to the external urethral sphincter. Perioperative data, complications, voiding outcomes and PSA at 3 months were retrospectively compared with a matched cohort of patients undergoing HoLEP with the standard en-bloc technique. Results: 38 patients treated with NIcE were compared with 80 control patients treated with the en-bloc technique. Demographic and baseline characteristics were comparable. All patients in the NIcE group who had complete preservation of the anterior urethral mucosa were continent immediately after catheter removal. Postoperative Qmax, PVR, and PSA levels showed no significant differences between groups. Conclusions: NIcE HoLEP prevents TSUI immediately after catheter removal, providing safe and effective relief from benign prostatic obstruction (BPO). Early results suggest it may offer a viable alternative to standard HoLEP techniques. Benign prostatic obstruction BPH following Holmium laser enucleation of prostate HoLEP Transient stress urinary incontinence No stress-Incontience Enucleation postoperative urinary incontinence Figures Figure 1 Figure 2 Introduction Endoscopic enucleation of prostate (EEP) is an established technique for treating benign prostatic obstruction (BPO). This procedure gained momentum after development of transurethral morcellator and description of Holmium laser enucleation of the prostate (HoLEP) by Gilling et al in 1998. ​ 1, ​​ 2 ​ , ​ 3 ​. The perceived steep learning curve and risk of postoperative urinary incontinence (UI) are often cited as the main obstacles to the broader adoption of HoLEP in the real world.​ 4,5 Recently, many modifications of standard HoLEP technique were developed with an attempt to minimize incidence of UI​ 6–15 ​. Most of these studies do not report on incidence of transient stress UI (TSUI) immediately after catheter removal that is reported in up to 44% patients and can negatively impact patient’s quality of life 16–18 . However, modification by Tunc et al and Takiuchi et al reported incidence of TSUI after catheter removal < 5%​ 9,10 . The basic science literature on the anatomy of the urethral sphincter has confirmed the presence of smooth and skeletal muscles in the anterior fibromuscular tissue (AFT) of prostate predominantly between 10 and 2 o clock. It is believed that these muscles play an active role in urinary continence ​ 13,14 . Based on this understanding, the technique of complete ventral mucosa-sparing bipolar EEP technique was introduced by Dr. Herrmann TRW at the 2020 UA Surgery Week SIU training course and later presented at SIU Academy e-grand rounds on October 6, 2021. 19 It was subsequently demonstrated as semi-live surgery at major conferences, including EAU 2021, Deutsche Gesellschaft für Urologie 2022, and the 2nd Endourology Symposium in 2023, among others. We herewith mimicked template suggested by Dr. Herrmann and utilized Moses 2.0 laser for the technical modification which we termed the No stress Incontinence Enucleation (NIcE) technique, where both the AFT and the overlying prostatic urethral mucosa between the 10 and 2 o’clock positions are preserved. We hypothesized that this would help in prevention of TSUI. In this pilot study, we describe the NIcE HoLEP technique in detail and retrospectively compare outcomes of patients undergoing HoLEP with the NIcE technique versus the standard en-bloc technique. Patients and Methods In this prospective study, all patients undergoing HoLEP at our institution from May 2024 using NIcE technique were enrolled as study group. Patients treated with standard en-bloc technique without preservation of AFT and overlying mucosa prior to May 2024 were included as control group. This study was approved by our institutional Review Board (Number- 20180511). Before surgery, all patients completed the international prostate symptom score (IPSS) questionnaire and underwent uroflowmetry for maximum flow rate(Qmax) and post-void residual (PVR), unless a Foley catheter was placed. Baseline data included comorbidities and anticoagulant use. Prostate size was assessed via MRI, CT, or ultrasound. Patients with elevated PSA received multiparametric MRI and fusion biopsy to rule out prostate cancer. Surgical technique: All HoLEP were performed under general anesthesia by a single experienced endourologist with active involvement of residents and fellows. We used 26-Fr continuous-irrigation resectoscope with a laser working element (Karl Storz, Tuttlingen, Germany) and Holmium: YAG laser with pulse modulation MOSES TM 1.0 or 2.0 (Boston Scientific, Massachusetts, USA). A 550 µm laser fiber was used at setting of 2 J and 30 Hz for the entire surgery. Morcellation of the enucleated adenoma was performed using the Piranha morcellator (Richard Wolf Medical Instruments Corporation, Vernon Hills, USA). NIcE HoLEP technique: Initial cystoscopy is performed to assess the anatomy of the external sphincter, verumontanum, prostate, and bladder. Using a laser resectoscope, longitudinal mucosal incisions are made at the 2 and 10 o’clock positions from the bladder neck to the level of the verumontanum, preserving the mucosal strip between them. The underlying adenoma is not incised until both mucosal cuts are complete to maintain anatomical orientation. Care is taken not to incise underlying adenoma before completing both mucosal incisions at 2 and 10 o'clock as this might result in deviation of apical mucosa strip on one side thereby distorting the anatomical orientation The 2 o’clock incision is then deepened to the prostatic capsule, followed by an inverted U-shaped incision in front of the verumontanum, which is extended laterally to define the enucleation plane. The left apical lobe is enucleated with combination of blunt and laser dissection in anticlockwise direction from 6 to 3 O’clock. Similarly, right apical lobe is then enucleated in clockwise direction from 6 o’clock to 9 o'clock position separating adenoma from the surgical capsule. The 3 o’clock posterior mucosal incision is connected with the anterior 2 o’clock incision, and similarly, the 10 o’clock incision is joined to the 9 o’clock incision, creating continuity of the mucosal plane. Once the lateral lobes are fully separated, the posterior adenoma is detached from the capsule (Fig. 1 A). The enucleated prostate, including both lateral and the median lobe is pushed into the bladder to facilitate the release of bladder neck mucosal attachments while preserving the ureteric orifices. Hemostasis is checked throughout the prostatic fossa. The integrity of anterior mucosal strip between 2 and 10 o'clock from bladder neck to membranous urethra is once again confirmed. The procedure was completed with morcellation using a Piranha morcellator and placement of a 22 Fr. Foley catheter over a pre-placed sensor wire, balloon inflated with 50–60 mL sterile water. Enbloc technique: All patients in control group underwent HoLEP with Enbloc technique without any early apical release (EAR) or anterior fibromuscular stroma with mucosal preservation (AFMP) as previously described​ 15 ​ . Postoperative management: All patients were observed overnight with continuous bladder irrigation without catheter traction. The Foley catheter was removed the next day, except in suspected underactive bladder cases, where it remained for 2–4 weeks. TSUI was assessed by a follow-up phone call the day after catheter removal. Postoperative data included catheter duration, hospital stay, complications categorized using the Modified Clavien-Dindo classification, and histopathology findings. Follow-up at 6 and 12 weeks assessed IPSS, Qmax, and PVR, with nadir PSA levels evaluated at 3 months. Statistical analysis: In our review of 50 patients, we observed a 45% incidence of TSUI immediately after catheter removal following en-bloc HoLEP, like the 44% previously reported​ 20 ​. We hypothesized that the NIcE technique would reduce this to 5%. Using an alpha of 0.2 and 80% power, 38 patients were needed in the study group and 76 in the control group. Patients were matched 1:2 using the nearest-neighbor method based on age, prostate size, and anticoagulant use. The perioperative and 3- month follow-up data was collected. Operation time (total time spent by patient in OR) and any intraoperative complications were recorded. Continuous variables were reported using mean ± standard deviation or median and interquartile range and were compared using Wilcoxon signed rank test. Categorical variables were reported using proportions and frequencies and were analyzed using Chi-squared or Fischer’s exact test as needed. Statistical analysis was performed using RStudio version 2023.09.0 (RStudio Inc, Boston, MA). A p-value < 0.05 was considered statistically significant. We also reviewed literature on various technical modifications described with goal of minimizing TSUI. Results The data of 38 patients in the study group was compared with 80 patients in the control group. Demographic factors and baseline variables were comparable amongst both groups (Table 1 ). There was no significant difference in demographic factors, baseline PSA levels, IPSS, Qmax, preoperative prostate volumes and PVR between the study and control groups. (Table 1 ) The indications for surgery were comparable in both groups. Table 1 Baseline demographic, perioperative and postoperative outcome. NIcE HoLEP Enbloc HoLEP p-value N 38 80 Age (years) (mean, STD) 67.7 (9.5) 68.7 (9.3) 0.4971 BMI (mean, STD) 27.0 (3.7) 28.0 (5.0) 0.2558 Ethnicity Hispanic 20 (52.6%) 31 (38.8%) Non-Hispanic 17 (44.7%) 46 (57.5%) 0.3624 Unknown 1 (2.7%) 3 (3.7%) Race White 13 (34.2%) 36 (45%) Black 4 (10.5%) 15 (18.8%) 0.4571 Asian 0 1 (1.2%) Other/ Not reported 21 (55.3%) 28 (35%) Associated medical co-morbidities Diabetes 5 (13.2%) 16 (20%) 0.3639 Hypertension 15 (39.5%) 33 (41.3%) 0.8544 Dyslipidemia 3 (7.9%) 23 (28.8%) 0.0107 On anticoagulants 6 (15.8%) 10 (12.5%) 0.6258 Use of bladder relaxants for OAB 2 (5.3%) 2 (2.5%) 0.4383 Preoperative use of pads. 2 (5.3%) 1 (1.3%) 0.1956 Baseline parameters (median, IQR) Baseline creatinine mg/dl 0.99 (0.83, 1.19) 1.06 (0.93, 1.20) 0.1842 Prostate Volume (g) 120 (65, 173) 112 (72, 161) 0.7888 Preoperative PSA ng/dl 5.2 (3.0, 8.4) 5.1 (2.7, 10.4) 0.8094 IPSS 15 (11, 24) 18 (14, 25) 0.2091 Maximum uroflow rate (Qmax) ml/sec 7.8 (5.1, 10.2) 6.0 (4.1, 8.7) 0.3721 Post-void residual urine ml/sec 86 (23, 228) 141 (58, 245) 0.3709 Low grade prostate cancer on active surveillance 8 (21.1%) 8 (10.0%) 0.1031 Prior procedure for BPO 12 (31.6%) 10 (12.5%) 0.0129 Indication of surgery Recurrent urine retention 17 (44.7%) 24 (30%) 0.1162 Bothersome LUTS 29 (76.3%) 34 (42.5%) 0.0006 Recurrent gross hematuria 9 (23.7%) 10 (12.5%) 0.1125 Recurrent UTI 5 (13.2%) 6 (7.5%) 0.3233 Associated vesical calculus 9 (23.7%) 8 (10%) 0.0479 Obstructive uropathy (HN and/or AKI) 2 (5.3%) 7 (8.8%) 0.5049 Intraoperative and immediate postoperative characteristics Median Operative Time (mins) 253 (180, 297) 158 (118, 228) < .0001 Median Hospital Stay (days) 1 (1, 1) 1 (1, 1) 0.1302 Resected prostate volume (gm) 80.3 (42.3, 125) 82.9 (46.5, 114) 0.9220 Complications n (%) Grade I Transient Stress Urinary Incontinence 3 (7.9%) 40 (50%) < .0001 Grade II Blood Transfusion Requirement 2 (5.3%) 2 (2.5%) 0.5123 Urinary Tract Infection 2 (5.3%) 10 (12.5%) 0.2243 Grade IIIA Failure to void on POD1 3 (7.9%) 19 (23.8%) 0.0388 Urethral stricture 0 (0%) 2 (2.5%) 0.3256 Bladder neck stenosis 0 (0%) 2 (2.5%) 0.3256 Incidental prostate cancer diagnosis % 6 (15.8%) 8 (10%) 0.8258 Voiding outcome at 6 weeks IPSS 2 (1, 5) 2 (0, 5) 0.5881 Q max 22.4 (14.0, 28.9) 17.7 (11.0, 26.9) 0.2297 PVR 12 (2, 29) 11 (0, 33) 0.8099 Incontinence 5 (13.2%) 41 (51.3%) < .0001 Voiding outcome at 12 weeks IPSS 3 (1, 4) 1 (0, 3) 0.0119 Q max 19.6 (17, 26.7) 19.7 (12, 28) 0.7801 PVR 7 (0, 51) 25 (0, 60) 0.3322 Incontinence 0 40 (50%) < .0001 PSA at 3 months (ng/dl) 0.49 (0.27, 0.75) 0.46 (0.21, 0.90) 0.8326 Intraoperatively out of 38 patients from the study group, we could not preserve mucosa completely in 15 patients. All the patients with complete AFMP had no TSUI after catheter removal during the first postoperative period (POD). The 3 patients (7.9%) who had TSUI on first POD had an incomplete AFMP. The median total operation room time was higher with study group (253 vs158 minutes, p < 0.0001). Both groups had a median catheter duration and hospital stay of 1 day. All patients in the study group, except two, had successful voiding trials on the first postoperative day. One patient had a preoperative bladder capacity > 2 liters and the other had clot retention. Both patients voided spontaneously after 3 additional weeks of catheterization. There were no intraoperative or postoperative complications during the 3-month follow-up in both groups. All the patients were completely continent at 12 weeks follow up in the NIcE group (Table 1 ). The median post operative PSA were comparable between the groups (0.49 vs 0.46 ng/dl, p = 0.8326). The literature review is summarized in table 2. Discussion ​Post-HoLEP TSUI is believed to result from prolonged sphincter stretching and traction required to reach the surgical capsule​ 18,21 ​. On contrary urge urinary incontinence (UUI) is commonly attributed to urinary tract infections and thermal injury to the prostatic capsule caused by high laser energy during the procedure​ 17 ​ .The concept of EAR during en-bloc prostate enucleation was introduced by Saitta et al. in 2019 reported reduced rate of TSUI with EAR ranging from 3.5 to 5.1% at 4- 6-week after surgery​ 22,23 . It is important to note that none of the studies on EAR had mentioned rate of incontinence immediate after catheter removal​ (Table 2). The Omega sign modification of traditional 3-lobe technique introduced by Tunc et al was aimed in preserving mucosa at prostatic apex between 2 and 10 O’clock positions thereby leaving a mucosal flap to help preserve external sphincter which is in anterior lateral part of prostate apex in a horseshoe or omega shape. These authors noted the incidence of SUI and UUI immediately after catheter removal at mean duration of 1-day post-HoLEP was found to be 3% and 4% respectively​ 9 ​. Preserving apical adenoma between 10–2 o’clock as first reported by Takiuchi H et al with monopolar TUR reduced SUI at discharge from 46% to 0% in 17 patients 11 . Endo et al suggested retrograde apical dissection in conventional HoLEP may stretch the inner longitudinal muscle causing UI. They introduced anteroposterior HoLEP, reducing TSUI at 2 weeks from 25.2% to 2.7% 7 . Fugisaki Y et al preserved anterior urethral mucosa between 1–11 o’clock, lowering immediate post-catheter removal incontinence from 14.7% to 4.1% 10 Another study that preserved urethral mucosa from the bladder neck to the tip of the prostate resulted in a higher immediate postoperative continence rate of 98.23% 12 . These authors used electrocautery loop for enucleation and recommend “preserving some prostate tissue and mucosa” at apex by not extending beyond the verumontanum. 12 . Anatomical basis of NIcE HoLEP: In 1873, Henle identified the external urinary sphincter as the “Musculus sphincter vesicae externus,” made up of striated muscle fibers between the bladder base and prostate, along with the caudally positioned “Musculus compressor prostatae,” both essential for continence.​ 24 ​. In 1980, Oelrich identified the male urethral sphincter as an independent muscle, separate from the levator ani 13 . He observed that prostate development as a urethral diverticulum thins the sphincter muscle, and its rapid pubertal growth displaces the sphincter anteriorly. 13 . McNeal ( 1988 ) described the anterior fibromuscular stroma(AFS) as a non-glandular smooth muscle layer from bladder neck to apex. Surrounding it is a striated sphincter incomplete posterolaterally, covering the prostatic urethra anteriorly ​ 25 ​. Dorschner and Stolzenburg later described it as horseshoe-shaped with smooth inner muscle.​ 26 ​ Watanabe et al. (2014) showed these muscles actively open the urethra during micturition ​ 27,28 ​. Considering the above detailed anatomy, we recommended a less aggressive approach to anterior prostatic urethra. We believe that the NIcE technique should preserve more muscularis sphincter largely present in between 10 and 2 O’ clock of the entire length of prostatic urethra as compared to previously described techniques. Use of laser with minimal depth of penetration rather than electrocautery would allow better preservation of these tissue that play vital role in urinary continence ​ 10,12 ​. The overall TSUI rate in the NIcE HoLEP group immediately after catheter removal on 1st post-operative day is 7.9% as compared to standard en-bloc technique of 50% (Table 1 ). But there is no TSUI if the complete anterior mucosal strip is preserved. We believe that the NicE technique preserves the AFS with its underlying muscles and ensures bladder neck - urethra mucosal continuity thus preserving the traction vector on the sphincter thereby preventing immediate postoperative continence. Preserving the entire mucosa during the procedure is technically challenging especially in patients with prostate > 150 cc. We, however, did not leave any adenoma tissue insitu in both groups, evident by < 1 ng/dl the post operative mean nadir PSA level (Table 1 ). Three patients who had postoperative MRI for evaluation of incidental prostate cancer revealed lack of any adenoma anteriorly and preserved AFT (Fig. 1 B). Leaving AFT by NIcE modification does not any way negatively influence outcome of HoLEP, including failure of void after surgery. It initially increased operative time, likely due to the learning curve. Though not analyzed, operative time notably improved over the study period. Limitations Our study carries limitations inherent with retrospective analysis of prospectively collected data, single center experience and lack of long-term outcome. All procedures were performed or supervised by a highly experienced single surgeon. Despite this limitation, our study provides a proof of concept that modified NIcE template during HoLEP help in prevent TSUI immediately after postoperative catheter removal on 1st post operative day. However further studies are needed to confirm reproducibility of our results. Conclusion HoLEP using the NIcE technique prevents TSUI immediately after catheter removal. It is safe and provide effective relief from BPO in early postoperative period. It not only permits complete removal of obstructing prostate adenoma as indicated by low nadir PSA level but also help in preserving intraprostatic anatomical structures responsible for maintaining continence. Declarations Funding declarations: No funding was received to conduct this research Ethics approval: This study was approved by the Institutional Review Board of the University of Miami (Protocol #20180511) Consent Declaration: Informed consent was obtained from all individual participants included in the study Author Contribution Aravindh Rathinam-Conceptualization, investigation, methodology, data curation, writing – original draft preparation, and writing – review and editingArchan Khandekar-Methodology, formal analysis, writing – original draft preparation, and writing – review and editingAdam Williams- Investigation and data curationHasim Bakbak- Methodology, and formal analysisAnsh Bhatia-: Conceptualization and methodologyJonathan Katz-Conceptualization, methodology, writing – original draft preparation, and writing – review and editingRobert Marcovich-Conceptualization, methodology and writing – review and editingThomas R W Herrmann-Conceptualization, methodology and writing – review and editingHemendra N. Shah-Conceptualization, investigation, methodology, writing – original draft preparation, and writing – review and editing Data Availability Data will be submitted if requested References Hiraoka Y, Akimoto M. Transurethral Enucleation of Benign Prostatic Hyperplasia. Journal of Urology . 1989;142(5):1247-1250. doi:10.1016/S0022-5347(17)39047-X GILLING PJ, KENNETT K, DAS AK, THOMPSON D, FRAUNDORFER MR. Holmium Laser Enucleation of the Prostate (HoLEP) Combined with Transurethral Tissue Morcellation: An Update on the Early Clinical Experience. J Endourol . 1998;12(5):457-459. doi:10.1089/end.1998.12.457 Reddy SK, Utley V, Gilling PJ. The Evolution of Endoscopic Prostate Enucleation: A historical perspective. Andrologia . 2020;52(8). doi:10.1111/and.13673 Ditonno F, Manfredi C, Licari LC, et al. Benign Prostatic Hyperplasia Surgery: A Snapshot of Trends, Costs, and Surgical Retreatment Rates in the USA. 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En-Bloc Holmium Laser Enucleation of the Prostate with Early Apical Release: Are We Ready for a New Paradigm? J Endourol . 2021;35(11):1675-1683. doi:10.1089/end.2020.1189 Heidenberg DJ, Choudry MM, Cheney SM. Reply to Editorial Comment on “The Impact of Standard vs Early Apical Release HoLEP Technique on Postoperative Incontinence and Quality of Life”. Urology . 2024;189:110-111. doi:10.1016/j.urology.2024.04.049 Henle, Jacob. Handbuch der systematischen Anatomie des Menschen. 1873;3. McNeal JE. Normal Histology of the Prostate. Am J Surg Pathol . 1988;12(8):619-633. doi:10.1097/00000478-198808000-00003 Dorschner W, Stolzenburg JU. A New Theory of Micturition and Urinary Continence Based on Histomorphological Studies. Urol Int . 1994;52(4):185-188. doi:10.1159/000282605 Watanabe H, Takahashi S, Ukimura O. Urethra actively opens from the very beginning of micturition: a new concept of urethral function. Int J Urol . 2014;21(2):208-211. doi:10.1111/iju.12212 Walz J, Epstein JI, Ganzer R, et al. A Critical Analysis of the Current Knowledge of Surgical Anatomy of the Prostate Related to Optimisation of Cancer Control and Preservation of Continence and Erection in Candidates for Radical Prostatectomy: An Update. Eur Urol . 2016;70(2):301-311. doi:10.1016/j.eururo.2016.01.026 Table Table 2 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7623679","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":526695056,"identity":"70a42124-8416-464a-b810-7377de717fa7","order_by":0,"name":"Aravindh RATHINAM","email":"","orcid":"","institution":"University of Miami","correspondingAuthor":false,"prefix":"","firstName":"Aravindh","middleName":"","lastName":"RATHINAM","suffix":""},{"id":526695057,"identity":"534e9210-e5d3-4e35-9db1-c0eb082397a2","order_by":1,"name":"Archan Khnadekar","email":"","orcid":"","institution":"University of 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Miami","correspondingAuthor":false,"prefix":"","firstName":"Ansh","middleName":"","lastName":"Bhatia","suffix":""},{"id":526695061,"identity":"94fa95e2-57e1-4960-8091-311097c6aab7","order_by":5,"name":"Jonathan Katz","email":"","orcid":"","institution":"University of Miami","correspondingAuthor":false,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Katz","suffix":""},{"id":526695062,"identity":"7e16df2a-fcf6-43bc-80c3-898f705a0dac","order_by":6,"name":"Robert Marcovich","email":"","orcid":"","institution":"University of Miami","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Marcovich","suffix":""},{"id":526695063,"identity":"9918b06d-7bc7-4eef-b468-e3d633392cc7","order_by":7,"name":"Thomas R W Herrmann","email":"","orcid":"","institution":"Spitial Thurgau AG (STGAG)","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"R W","lastName":"Herrmann","suffix":""},{"id":526695065,"identity":"39abdc66-b62d-45e6-b59d-8df8aafdd2e4","order_by":8,"name":"Hemendra Shah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCUlEQVRIiWNgGAWjYDCCAzxgirGBgYENSNowMEhAZdiI1JJGupbDCC24AN/tswcf3ai4I7u9/fizBz93nE/sn9188AFDjQ0Dn3QDVi2S5/KSjXPOPDOecybH3LD3zO3EGXeOJRswHEtjYJM5gFWLwRkeM+nctsOJMxhy2CR4224nNtzIMZMAuZBNIgGXFvPfuf+AWvifP5P823YucT4RWsyYcxuAWiQSzKR52w4kbiCkRfIMj7F0zrHDxjMk3phJy7YlG2+8kZZskHAsjQeXFr4zPIafc2oOy87gT38m+bbNTnbejeSDDz7U2MjJz8CuBQM4NoBIoGIe4tQDgT3RKkfBKBgFo2DEAAAkcmNL8n+k2QAAAABJRU5ErkJggg==","orcid":"","institution":"University of Miami","correspondingAuthor":true,"prefix":"","firstName":"Hemendra","middleName":"","lastName":"Shah","suffix":""}],"badges":[],"createdAt":"2025-09-15 19:23:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7623679/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7623679/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93329572,"identity":"ff2e253b-fff9-4862-947d-c5148a24bce8","added_by":"auto","created_at":"2025-10-12 11:20:15","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":877336,"visible":true,"origin":"","legend":"","description":"","filename":"NiCEManuscript91925.docx","url":"https://assets-eu.researchsquare.com/files/rs-7623679/v1/365a11c4748dd7966f0a345f.docx"},{"id":93329489,"identity":"25ce5be8-db18-4c45-a175-fc505114da3c","added_by":"auto","created_at":"2025-10-12 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11:12:15","extension":"xml","order_by":9,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":80357,"visible":true,"origin":"","legend":"","description":"","filename":"33759be4b3f743778b836390800b2df31structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7623679/v1/8726f16095998d2ec66fc548.xml"},{"id":93329498,"identity":"526df144-b18a-48ba-9c68-836e1658189f","added_by":"auto","created_at":"2025-10-12 11:12:15","extension":"html","order_by":10,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":95492,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7623679/v1/2c15178a8eb1edd008181efb.html"},{"id":93329487,"identity":"6f74e172-ed94-4ac4-9390-f138c526fd96","added_by":"auto","created_at":"2025-10-12 11:12:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":410317,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e. 1a-1c : Transurethral view of the prostate median, both lateral lobes and veru, 2a-2c:Anterior incision at 2 and 10 ‘O clock deepened till the capsule, 3a-3b: inverted U shape incision is taken in front of veru,3c: posterior incision extended to 9’O Clock 4a-4c: 2’Oclock incision is joined to the 3’O Clock incision, 5a-5c: 10 ‘O Clock incision is joined to the 9 ‘O Clock incision, 6a-6c:Prostatic fossa after complete enucleation of adenoma with preserved mucosal strip.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7623679/v1/16c8e0cb17f1a6471a777718.png"},{"id":93329490,"identity":"ff89c10c-42b2-4c8e-8f5e-2791be7d972a","added_by":"auto","created_at":"2025-10-12 11:12:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":351579,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFigure 1B\u003c/strong\u003e: Preoperative MRI prostate (a)and post-operative MRI images (b) after HoLEP with NIcE technique. Note the preserved anterior fibromuscular stroma (red arrow).\u003c/p\u003e\n\u003cp\u003eThe representative images of MRI pre and post- HoLEP with NIcE technique reveal preserved anterior fibromuscular stroma.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7623679/v1/5660f5e204651ef5c18db4db.png"},{"id":109365881,"identity":"1e15cb24-8129-4969-887c-ac9c5fe6cbc6","added_by":"auto","created_at":"2026-05-16 09:55:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1297978,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7623679/v1/df00fa6d-5ff3-4e39-b245-2ef9ca6fbb41.pdf"},{"id":93329488,"identity":"ebb0eb88-085f-4a40-ac0e-c05c787b491f","added_by":"auto","created_at":"2025-10-12 11:12:15","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":433738,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7623679/v1/ade2ac81ca51df78b2327095.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eAnatomical Foundations, surgical technique and early outcome of the No Stress In-continence Enucleation (NIcE) Template for Holmium Laser Enucleation of the Prostate (HoLEP)\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEndoscopic enucleation of prostate (EEP) is an established technique for treating benign prostatic obstruction (BPO). This procedure gained momentum after development of transurethral morcellator and description of Holmium laser enucleation of the prostate (HoLEP) by Gilling et al in 1998. ​\u003csup\u003e1,\u003c/sup\u003e​​\u003csup\u003e2\u003c/sup\u003e​\u003csup\u003e,\u003c/sup\u003e​\u003csup\u003e3\u003c/sup\u003e​. The perceived steep learning curve and risk of postoperative urinary incontinence (UI) are often cited as the main obstacles to the broader adoption of HoLEP in the real world.​\u003csup\u003e4,5\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eRecently, many modifications of standard HoLEP technique were developed with an attempt to minimize incidence of UI​\u003csup\u003e6\u0026ndash;15\u003c/sup\u003e​. Most of these studies do not report on incidence of transient stress UI (TSUI) immediately after catheter removal that is reported in up to 44% patients and can negatively impact patient\u0026rsquo;s quality of life\u003csup\u003e16\u0026ndash;18\u003c/sup\u003e. However, modification by Tunc et al and Takiuchi et al reported incidence of TSUI after catheter removal\u0026thinsp;\u0026lt;\u0026thinsp;5%​\u003csup\u003e9,10\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe basic science literature on the anatomy of the urethral sphincter has confirmed the presence of smooth and skeletal muscles in the anterior fibromuscular tissue (AFT) of prostate predominantly between 10 and 2 o clock. It is believed that these muscles play an active role in urinary continence ​\u003csup\u003e13,14\u003c/sup\u003e. Based on this understanding, the technique of complete ventral mucosa-sparing bipolar EEP technique was introduced by Dr. Herrmann TRW at the 2020 UA Surgery Week SIU training course and later presented at SIU Academy e-grand rounds on October 6, 2021.\u003csup\u003e19\u003c/sup\u003e It was subsequently demonstrated as semi-live surgery at major conferences, including EAU 2021, Deutsche Gesellschaft f\u0026uuml;r Urologie 2022, and the 2nd Endourology Symposium in 2023, among others. We herewith mimicked template suggested by Dr. Herrmann and utilized Moses 2.0 laser for the technical modification which we termed the No stress Incontinence Enucleation (NIcE) technique, where both the AFT and the overlying prostatic urethral mucosa between the 10 and 2 o\u0026rsquo;clock positions are preserved. We hypothesized that this would help in prevention of TSUI. In this pilot study, we describe the NIcE HoLEP technique in detail and retrospectively compare outcomes of patients undergoing HoLEP with the NIcE technique versus the standard en-bloc technique.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eIn this prospective study, all patients undergoing HoLEP at our institution from May 2024 using NIcE technique were enrolled as study group. Patients treated with standard en-bloc technique without preservation of AFT and overlying mucosa prior to May 2024 were included as control group. This study was approved by our institutional Review Board (Number- 20180511).\u003c/p\u003e\u003cp\u003eBefore surgery, all patients completed the international prostate symptom score (IPSS) questionnaire and underwent uroflowmetry for maximum flow rate(Qmax) and post-void residual (PVR), unless a Foley catheter was placed. Baseline data included comorbidities and anticoagulant use. Prostate size was assessed via MRI, CT, or ultrasound. Patients with elevated PSA received multiparametric MRI and fusion biopsy to rule out prostate cancer.\u003c/p\u003e\u003cp\u003eSurgical technique:\u003c/p\u003e\u003cp\u003eAll HoLEP were performed under general anesthesia by a single experienced endourologist with active involvement of residents and fellows. We used 26-Fr continuous-irrigation resectoscope with a laser working element (Karl Storz, Tuttlingen, Germany) and Holmium: YAG laser with pulse modulation MOSES \u003csup\u003eTM\u003c/sup\u003e 1.0 or 2.0 (Boston Scientific, Massachusetts, USA). A 550 \u0026micro;m laser fiber was used at setting of 2 J and 30 Hz for the entire surgery. Morcellation of the enucleated adenoma was performed using the Piranha morcellator (Richard Wolf Medical Instruments Corporation, Vernon Hills, USA).\u003c/p\u003e\u003cp\u003eNIcE HoLEP technique:\u003c/p\u003e\u003cp\u003eInitial cystoscopy is performed to assess the anatomy of the external sphincter, verumontanum, prostate, and bladder. Using a laser resectoscope, longitudinal mucosal incisions are made at the 2 and 10 o\u0026rsquo;clock positions from the bladder neck to the level of the verumontanum, preserving the mucosal strip between them. The underlying adenoma is not incised until both mucosal cuts are complete to maintain anatomical orientation. Care is taken not to incise underlying adenoma before completing both mucosal incisions at 2 and 10 o'clock as this might result in deviation of apical mucosa strip on one side thereby distorting the anatomical orientation The 2 o\u0026rsquo;clock incision is then deepened to the prostatic capsule, followed by an inverted U-shaped incision in front of the verumontanum, which is extended laterally to define the enucleation plane. The left apical lobe is enucleated with combination of blunt and laser dissection in anticlockwise direction from 6 to 3 O\u0026rsquo;clock. Similarly, right apical lobe is then enucleated in clockwise direction from 6 o\u0026rsquo;clock to 9 o'clock position separating adenoma from the surgical capsule. The 3 o\u0026rsquo;clock posterior mucosal incision is connected with the anterior 2 o\u0026rsquo;clock incision, and similarly, the 10 o\u0026rsquo;clock incision is joined to the 9 o\u0026rsquo;clock incision, creating continuity of the mucosal plane. Once the lateral lobes are fully separated, the posterior adenoma is detached from the capsule (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). The enucleated prostate, including both lateral and the median lobe is pushed into the bladder to facilitate the release of bladder neck mucosal attachments while preserving the ureteric orifices. Hemostasis is checked throughout the prostatic fossa. The integrity of anterior mucosal strip between 2 and 10 o'clock from bladder neck to membranous urethra is once again confirmed. The procedure was completed with morcellation using a Piranha morcellator and placement of a 22 Fr. Foley catheter over a pre-placed sensor wire, balloon inflated with 50\u0026ndash;60 mL sterile water.\u003c/p\u003e\u003cp\u003eEnbloc technique:\u003c/p\u003e\u003cp\u003eAll patients in control group underwent HoLEP with Enbloc technique without any early apical release (EAR) or anterior fibromuscular stroma with mucosal preservation (AFMP) as previously described​\u003csup\u003e15\u003c/sup\u003e​ .\u003c/p\u003e\u003cp\u003ePostoperative management:\u003c/p\u003e\u003cp\u003eAll patients were observed overnight with continuous bladder irrigation without catheter traction. The Foley catheter was removed the next day, except in suspected underactive bladder cases, where it remained for 2\u0026ndash;4 weeks. TSUI was assessed by a follow-up phone call the day after catheter removal. Postoperative data included catheter duration, hospital stay, complications categorized using the Modified Clavien-Dindo classification, and histopathology findings. Follow-up at 6 and 12 weeks assessed IPSS, Qmax, and PVR, with nadir PSA levels evaluated at 3 months.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis:\u003c/h2\u003e\u003cp\u003eIn our review of 50 patients, we observed a 45% incidence of TSUI immediately after catheter removal following en-bloc HoLEP, like the 44% previously reported​\u003csup\u003e20\u003c/sup\u003e​. We hypothesized that the NIcE technique would reduce this to 5%. Using an alpha of 0.2 and 80% power, 38 patients were needed in the study group and 76 in the control group. Patients were matched 1:2 using the nearest-neighbor method based on age, prostate size, and anticoagulant use. The perioperative and 3- month follow-up data was collected. Operation time (total time spent by patient in OR) and any intraoperative complications were recorded. Continuous variables were reported using mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median and interquartile range and were compared using Wilcoxon signed rank test. Categorical variables were reported using proportions and frequencies and were analyzed using Chi-squared or Fischer\u0026rsquo;s exact test as needed. Statistical analysis was performed using RStudio version 2023.09.0 (RStudio Inc, Boston, MA). A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. We also reviewed literature on various technical modifications described with goal of minimizing TSUI.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe data of 38 patients in the study group was compared with 80 patients in the control group. Demographic factors and baseline variables were comparable amongst both groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). There was no significant difference in demographic factors, baseline PSA levels, IPSS, Qmax, preoperative prostate volumes and PVR between the study and control groups. (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) The indications for surgery were comparable in both groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline demographic, perioperative and postoperative outcome.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNIcE HoLEP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEnbloc HoLEP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years) (mean, STD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e67.7 (9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68.7 (9.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.4971\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI (mean, STD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27.0 (3.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.0 (5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2558\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (52.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (38.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-Hispanic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (44.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46 (57.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3624\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (2.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (34.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (45%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (10.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (18.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.4571\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther/ Not reported\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21 (55.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (35%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAssociated medical co-morbidities\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (13.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (20%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3639\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (39.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (41.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8544\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDyslipidemia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (7.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (28.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.0107\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOn anticoagulants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (15.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6258\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUse of bladder relaxants for OAB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.4383\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative use of pads.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1956\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBaseline parameters (median, IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBaseline creatinine mg/dl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.99 (0.83, 1.19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.06 (0.93, 1.20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1842\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProstate Volume (g)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e120 (65, 173)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e112 (72, 161)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7888\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePreoperative PSA ng/dl\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.2 (3.0, 8.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.1 (2.7, 10.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8094\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIPSS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (11, 24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (14, 25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2091\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMaximum uroflow rate (Qmax) ml/sec\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7.8 (5.1, 10.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.0 (4.1, 8.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3721\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePost-void residual urine ml/sec\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e86 (23, 228)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e141 (58, 245)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3709\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow grade prostate cancer on active surveillance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (21.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (10.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1031\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrior procedure for BPO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (31.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.0129\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIndication of surgery\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecurrent urine retention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (44.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1162\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBothersome LUTS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (76.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (42.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.0006\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecurrent gross hematuria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (23.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1125\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRecurrent UTI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (13.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (7.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3233\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAssociated vesical calculus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (23.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (10%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.0479\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObstructive uropathy (HN and/or AKI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (8.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5049\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntraoperative and immediate postoperative characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian Operative Time (mins)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e253 (180, 297)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e158 (118, 228)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian Hospital Stay (days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (1, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1, 1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.1302\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eResected prostate volume (gm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80.3 (42.3, 125)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82.9 (46.5, 114)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.9220\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComplications n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGrade I\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTransient Stress Urinary Incontinence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (7.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGrade II\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood Transfusion Requirement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5123\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrinary Tract Infection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (5.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (12.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2243\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGrade IIIA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFailure to void on POD1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (7.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (23.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.0388\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrethral stricture\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3256\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBladder neck stenosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (2.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3256\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIncidental prostate cancer diagnosis %\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (15.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (10%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8258\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVoiding outcome at 6 weeks\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIPSS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (1, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (0, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5881\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQ max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22.4 (14.0, 28.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.7 (11.0, 26.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2297\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (2, 29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (0, 33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8099\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncontinence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (13.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (51.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVoiding outcome at 12 weeks\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIPSS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (1, 4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (0, 3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.0119\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQ max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.6 (17, 26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.7 (12, 28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7801\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePVR\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (0, 51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (0, 60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3322\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncontinence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.0001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePSA at 3 months (ng/dl)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.49 (0.27, 0.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.46 (0.21, 0.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8326\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIntraoperatively out of 38 patients from the study group, we could not preserve mucosa completely in 15 patients. All the patients with complete AFMP had no TSUI after catheter removal during the first postoperative period (POD). The 3 patients (7.9%) who had TSUI on first POD had an incomplete AFMP. The median total operation room time was higher with study group (253 vs158 minutes, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Both groups had a median catheter duration and hospital stay of 1 day. All patients in the study group, except two, had successful voiding trials on the first postoperative day. One patient had a preoperative bladder capacity\u0026thinsp;\u0026gt;\u0026thinsp;2 liters and the other had clot retention. Both patients voided spontaneously after 3 additional weeks of catheterization. There were no intraoperative or postoperative complications during the 3-month follow-up in both groups. All the patients were completely continent at 12 weeks follow up in the NIcE group (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The median post operative PSA were comparable between the groups (0.49 vs 0.46 ng/dl, p\u0026thinsp;=\u0026thinsp;0.8326). The literature review is summarized in table 2.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e​Post-HoLEP TSUI is believed to result from prolonged sphincter stretching and traction required to reach the surgical capsule​\u003csup\u003e18,21\u003c/sup\u003e​. On contrary urge urinary incontinence (UUI) is commonly attributed to urinary tract infections and thermal injury to the prostatic capsule caused by high laser energy during the procedure​\u003csup\u003e17\u003c/sup\u003e​ .The concept of EAR during en-bloc prostate enucleation was introduced by Saitta et al. in 2019 reported reduced rate of TSUI with EAR ranging from 3.5 to 5.1% at 4- 6-week after surgery​\u003csup\u003e22,23\u003c/sup\u003e. It is important to note that none of the studies on EAR had mentioned rate of incontinence immediate after catheter removal​ (Table\u0026nbsp;2). The Omega sign modification of traditional 3-lobe technique introduced by Tunc et al was aimed in preserving mucosa at prostatic apex between 2 and 10 O\u0026rsquo;clock positions thereby leaving a mucosal flap to help preserve external sphincter which is in anterior lateral part of prostate apex in a horseshoe or omega shape. These authors noted the incidence of SUI and UUI immediately after catheter removal at mean duration of 1-day post-HoLEP was found to be 3% and 4% respectively​\u003csup\u003e9\u003c/sup\u003e​.\u003c/p\u003e\u003cp\u003ePreserving apical adenoma between 10\u0026ndash;2 o\u0026rsquo;clock as first reported by Takiuchi H et al with monopolar TUR reduced SUI at discharge from 46% to 0% in 17 patients\u003csup\u003e11\u003c/sup\u003e. Endo et al suggested retrograde apical dissection in conventional HoLEP may stretch the inner longitudinal muscle causing UI. They introduced anteroposterior HoLEP, reducing TSUI at 2 weeks from 25.2% to 2.7%\u003csup\u003e7\u003c/sup\u003e. Fugisaki Y et al preserved anterior urethral mucosa between 1\u0026ndash;11 o\u0026rsquo;clock, lowering immediate post-catheter removal incontinence from 14.7% to 4.1%\u003csup\u003e10\u003c/sup\u003e Another study that preserved urethral mucosa from the bladder neck to the tip of the prostate resulted in a higher immediate postoperative continence rate of 98.23%\u003csup\u003e12\u003c/sup\u003e. These authors used electrocautery loop for enucleation and recommend \u0026ldquo;preserving some prostate tissue and mucosa\u0026rdquo; at apex by not extending beyond the verumontanum.\u003csup\u003e12\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eAnatomical basis of NIcE HoLEP:\u003c/h3\u003e\n\u003cp\u003eIn 1873, Henle identified the external urinary sphincter as the \u0026ldquo;Musculus sphincter vesicae externus,\u0026rdquo; made up of striated muscle fibers between the bladder base and prostate, along with the caudally positioned \u0026ldquo;Musculus compressor prostatae,\u0026rdquo; both essential for continence.​\u003csup\u003e24\u003c/sup\u003e​. In 1980, Oelrich identified the male urethral sphincter as an independent muscle, separate from the levator ani\u003csup\u003e13\u003c/sup\u003e. He observed that prostate development as a urethral diverticulum thins the sphincter muscle, and its rapid pubertal growth displaces the sphincter anteriorly. \u003csup\u003e13\u003c/sup\u003e. McNeal (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1988\u003c/span\u003e) described the anterior fibromuscular stroma(AFS) as a non-glandular smooth muscle layer from bladder neck to apex. Surrounding it is a striated sphincter incomplete posterolaterally, covering the prostatic urethra anteriorly ​\u003csup\u003e25\u003c/sup\u003e​. Dorschner and Stolzenburg later described it as horseshoe-shaped with smooth inner muscle.​\u003csup\u003e26\u003c/sup\u003e​ Watanabe et al. (2014) showed these muscles actively open the urethra during micturition ​\u003csup\u003e27,28\u003c/sup\u003e​.\u003c/p\u003e\u003cp\u003eConsidering the above detailed anatomy, we recommended a less aggressive approach to anterior prostatic urethra. We believe that the NIcE technique should preserve more muscularis sphincter largely present in between 10 and 2 O\u0026rsquo; clock of the entire length of prostatic urethra as compared to previously described techniques. Use of laser with minimal depth of penetration rather than electrocautery would allow better preservation of these tissue that play vital role in urinary continence ​\u003csup\u003e10,12\u003c/sup\u003e​. The overall TSUI rate in the NIcE HoLEP group immediately after catheter removal on 1st post-operative day is 7.9% as compared to standard en-bloc technique of 50% (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). But there is no TSUI if the complete anterior mucosal strip is preserved. We believe that the NicE technique preserves the AFS with its underlying muscles and ensures bladder neck - urethra mucosal continuity thus preserving the traction vector on the sphincter thereby preventing immediate postoperative continence.\u003c/p\u003e\u003cp\u003ePreserving the entire mucosa during the procedure is technically challenging especially in patients with prostate\u0026thinsp;\u0026gt;\u0026thinsp;150 cc. We, however, did not leave any adenoma tissue insitu in both groups, evident by \u0026lt;\u0026thinsp;1 ng/dl the post operative mean nadir PSA level (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Three patients who had postoperative MRI for evaluation of incidental prostate cancer revealed lack of any adenoma anteriorly and preserved AFT (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). Leaving AFT by NIcE modification does not any way negatively influence outcome of HoLEP, including failure of void after surgery. It initially increased operative time, likely due to the learning curve. Though not analyzed, operative time notably improved over the study period.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003cp\u003eOur study carries limitations inherent with retrospective analysis of prospectively collected data, single center experience and lack of long-term outcome. All procedures were performed or supervised by a highly experienced single surgeon. Despite this limitation, our study provides a proof of concept that modified NIcE template during HoLEP help in prevent TSUI immediately after postoperative catheter removal on 1st post operative day. However further studies are needed to confirm reproducibility of our results.\u003c/p\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eHoLEP using the NIcE technique prevents TSUI immediately after catheter removal. It is safe and provide effective relief from BPO in early postoperative period. It not only permits complete removal of obstructing prostate adenoma as indicated by low nadir PSA level but also help in preserving intraprostatic anatomical structures responsible for maintaining continence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding declarations:\u0026nbsp;\u003c/strong\u003eNo funding was received to conduct this research\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval:\u003c/strong\u003eThis study was approved by the Institutional Review Board of the University of Miami (Protocol #20180511)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent Declaration:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAravindh Rathinam-Conceptualization, investigation, methodology, data curation, writing \u0026ndash; original draft preparation, and writing \u0026ndash; review and editingArchan Khandekar-Methodology, formal analysis, writing \u0026ndash; original draft preparation, and writing \u0026ndash; review and editingAdam Williams- Investigation and data curationHasim Bakbak- Methodology, and formal analysisAnsh Bhatia-: Conceptualization and methodologyJonathan Katz-Conceptualization, methodology, writing \u0026ndash; original draft preparation, and writing \u0026ndash; review and editingRobert Marcovich-Conceptualization, methodology and writing \u0026ndash; review and editingThomas R W Herrmann-Conceptualization, methodology and writing \u0026ndash; review and editingHemendra N. Shah-Conceptualization, investigation, methodology, writing \u0026ndash; original draft preparation, and writing \u0026ndash; review and editing\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData will be submitted if requested\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHiraoka Y, Akimoto M. Transurethral Enucleation of Benign Prostatic Hyperplasia. \u003cem\u003eJournal of Urology\u003c/em\u003e. 1989;142(5):1247-1250. doi:10.1016/S0022-5347(17)39047-X \u003c/li\u003e\n\u003cli\u003eGILLING PJ, KENNETT K, DAS AK, THOMPSON D, FRAUNDORFER MR. Holmium Laser Enucleation of the Prostate (HoLEP) Combined with Transurethral Tissue Morcellation: An Update on the Early Clinical Experience. \u003cem\u003eJ Endourol\u003c/em\u003e. 1998;12(5):457-459. doi:10.1089/end.1998.12.457 \u003c/li\u003e\n\u003cli\u003eReddy SK, Utley V, Gilling PJ. The Evolution of \u003cem\u003eEndoscopic\u003c/em\u003e Prostate Enucleation: A historical perspective. \u003cem\u003eAndrologia\u003c/em\u003e. 2020;52(8). doi:10.1111/and.13673 \u003c/li\u003e\n\u003cli\u003eDitonno F, Manfredi C, Licari LC, et al. Benign Prostatic Hyperplasia Surgery: A Snapshot of Trends, Costs, and Surgical Retreatment Rates in the USA. \u003cem\u003eEur Urol Focus\u003c/em\u003e. 2024;10(5):826-832. doi:10.1016/j.euf.2024.04.006 \u003c/li\u003e\n\u003cli\u003eShvero A, Kloniecke E, Capella C, Das AK. \u003cem\u003eAK. HoLEP Techniques-Lessons Learned\u003c/em\u003e. Vol 28.; 2021. \u003c/li\u003e\n\u003cli\u003eR\u0026uuml;cker F, Lehrich K, B\u0026ouml;hme A, Zacharias M, Ahyai SA, Hansen J. A call for HoLEP: en-bloc vs. two-lobe vs. three-lobe. \u003cem\u003eWorld J Urol\u003c/em\u003e. 2021;39(7):2337-2345. doi:10.1007/s00345-021-03598-5 \u003c/li\u003e\n\u003cli\u003eEndo F, Shiga Y, Minagawa S, et al. Anteroposterior dissection HoLEP: a modification to prevent transient stress urinary incontinence. \u003cem\u003eUrology\u003c/em\u003e. 2010;76(6):1451-1455. doi:10.1016/j.urology.2010.03.071 \u003c/li\u003e\n\u003cli\u003eLin YH, Chang SY, Tsao SH, et al. Anterior fibromuscular stroma-preserved endoscopic enucleation of the prostate: a precision anatomical approach. \u003cem\u003eWorld J Urol\u003c/em\u003e. 2023;41(8):2127-2132. doi:10.1007/s00345-022-04270-2 \u003c/li\u003e\n\u003cli\u003eTunc L, Yalcin S, Kaya E, et al. The \u0026ldquo;Omega Sign\u0026rdquo;: a novel HoLEP technique that improves continence outcomes after enucleation. \u003cem\u003eWorld J Urol\u003c/em\u003e. 2021;39(1):135-141. doi:10.1007/s00345-020-03152-9 \u003c/li\u003e\n\u003cli\u003eFujisaki Y, Otsuka I, Kobayashi T, et al. Use of the anterior prostatic urethral mucosa preservation technique during holmium laser enucleation of the prostate can reduce postoperative stress urinary incontinence. \u003cem\u003eAsian J Endosc Surg\u003c/em\u003e. 2024;17(1):e13256. doi:10.1111/ases.13256 \u003c/li\u003e\n\u003cli\u003eTakiuchi H, Nakao A, Ihara H. [Prevention of transient urinary incontinence in peri-operative period of modified holmium laser enucleation of the prostate (HoLEP)]. \u003cem\u003eHinyokika Kiyo\u003c/em\u003e. 2008;54(7):475-478. \u003c/li\u003e\n\u003cli\u003eQiu L, Gu Z, Pan Y, Zhang Y, Chen J. Observation on the efficacy and safety of Holmium laser enucleation of the prostate (HoLEP) with preservation of the urethral mucosa from the bladder neck to the tip of the prostate for the treatment of benign prostatic hyperplasia. \u003cem\u003eMedicine\u003c/em\u003e. 2024;103(46):e40571. doi:10.1097/MD.0000000000040571 \u003c/li\u003e\n\u003cli\u003eOewch TM. \u003cem\u003eThe Urethral Sphincter Muscle in the Male\u003c/em\u003e. Vol 158.; 1980. \u003c/li\u003e\n\u003cli\u003eBarlas IS, Aybal HC, Duvarci M, et al. Revisiting the external urethral sphincter: new anatomical insights from a human cadaver study. \u003cem\u003eWorld J Urol\u003c/em\u003e. 2024;42(1). doi:10.1007/s00345-024-05204-w \u003c/li\u003e\n\u003cli\u003eMartos M, Katz JE, Parmar M, et al. Impact of perioperative factors on nadir serum prostate-specific antigen levels after holmium laser enucleation of prostate. \u003cem\u003eBJUI Compass\u003c/em\u003e. 2021;2(3):202-210. doi:10.1002/bco2.68 \u003c/li\u003e\n\u003cli\u003eVavassori I, Valenti S, Naspro R, et al. Three-year outcome following holmium laser enucleation of the prostate combined with mechanical morcellation in 330 consecutive patients. \u003cem\u003eEur Urol\u003c/em\u003e. 2008;53(3):599-604. doi:10.1016/j.eururo.2007.10.059 \u003c/li\u003e\n\u003cli\u003eShah HN, Mahajan AP, Hegde SS, Bansal MB. Peri-operative complications of holmium laser enucleation of the prostate: experience in the first 280 patients, and a review of literature. \u003cem\u003eBJU Int\u003c/em\u003e. 2007;100(1):94-101. doi:10.1111/j.1464-410X.2007.06867.x \u003c/li\u003e\n\u003cli\u003eHout M, Gurayah A, Arbelaez MCS, et al. Incidence and risk factors for postoperative urinary incontinence after various prostate enucleation procedures: systemic review and meta-analysis of PubMed literature from 2000 to 2021. \u003cem\u003eWorld J Urol\u003c/em\u003e. 2022;40(11):2731-2745. doi:10.1007/s00345-022-04174-1 \u003c/li\u003e\n\u003cli\u003ehttps://academy.siu-urology.org/siu/2021/the-41st-SIU-Congress/347324/thomas.herrmann.tuep.html?f=listing%3D4%2Abrowseby%3D8%2Asortby%3D2%2Aspeaker%3D672770.\u003c/li\u003e\n\u003cli\u003eMontorsi F, Naspro R, Salonia A, et al. Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. \u003cem\u003eJ Urol\u003c/em\u003e. 2004;172(5 Pt 1):1926-1929. doi:10.1097/01.ju.0000140501.68841.a1 \u003c/li\u003e\n\u003cli\u003eSaitta G, Becerra JEA, Del \u0026Aacute;lamo JF, et al. \u0026ldquo;En Bloc\u0026rdquo; HoLEP with early apical release in men with benign prostatic hyperplasia. \u003cem\u003eWorld J Urol\u003c/em\u003e. 2019;37(11):2451-2458. doi:10.1007/s00345-019-02671-4 \u003c/li\u003e\n\u003cli\u003eTuccio A, Grosso AA, Sessa F, et al. En-Bloc Holmium Laser Enucleation of the Prostate with Early Apical Release: Are We Ready for a New Paradigm? \u003cem\u003eJ Endourol\u003c/em\u003e. 2021;35(11):1675-1683. doi:10.1089/end.2020.1189 \u003c/li\u003e\n\u003cli\u003eHeidenberg DJ, Choudry MM, Cheney SM. Reply to Editorial Comment on \u0026ldquo;The Impact of Standard vs Early Apical Release HoLEP Technique on Postoperative Incontinence and Quality of Life\u0026rdquo;. \u003cem\u003eUrology\u003c/em\u003e. 2024;189:110-111. doi:10.1016/j.urology.2024.04.049 \u003c/li\u003e\n\u003cli\u003eHenle, Jacob. Handbuch der systematischen Anatomie des Menschen. 1873;3. \u003c/li\u003e\n\u003cli\u003eMcNeal JE. Normal Histology of the Prostate. \u003cem\u003eAm J Surg Pathol\u003c/em\u003e. 1988;12(8):619-633. doi:10.1097/00000478-198808000-00003 \u003c/li\u003e\n\u003cli\u003eDorschner W, Stolzenburg JU. A New Theory of Micturition and Urinary Continence Based on Histomorphological Studies. \u003cem\u003eUrol Int\u003c/em\u003e. 1994;52(4):185-188. doi:10.1159/000282605 \u003c/li\u003e\n\u003cli\u003eWatanabe H, Takahashi S, Ukimura O. Urethra actively opens from the very beginning of micturition: a new concept of urethral function. \u003cem\u003eInt J Urol\u003c/em\u003e. 2014;21(2):208-211. doi:10.1111/iju.12212 \u003c/li\u003e\n\u003cli\u003eWalz J, Epstein JI, Ganzer R, et al. A Critical Analysis of the Current Knowledge of Surgical Anatomy of the Prostate Related to Optimisation of Cancer Control and Preservation of Continence and Erection in Candidates for Radical Prostatectomy: An Update. \u003cem\u003eEur Urol\u003c/em\u003e. 2016;70(2):301-311. doi:10.1016/j.eururo.2016.01.026 \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table","content":"\u003cp\u003eTable 2 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Benign prostatic obstruction, BPH, following Holmium laser enucleation of prostate, HoLEP, Transient stress urinary incontinence, No stress-Incontience Enucleation, postoperative urinary incontinence","lastPublishedDoi":"10.21203/rs.3.rs-7623679/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7623679/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eIntroduction:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eTransient stress urinary incontinence (TSUI) remains a significant issue following Holmium laser enucleation of prostate (HoLEP). Herein we describe a novel technique called No stress-Incontience Enucleation (NIcE) designed to preserve both striated and smooth muscles within the anterior fibromuscular stroma and its overlying mucosa. The primary objective was to evaluate continence immediately after catheter removal. The secondary goal was to compare perioperative and early voiding outcomes in patients undergoing HoLEP using the NIcE technique vs standard en-bloc technique.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods:\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients undergoing HoLEP with NIcE modification from May 2024 were prospectively enrolled. The procedure used the Moses 2.0 holmium laser (2J, 30 Hz) with a specific template designed to preserve the anterior urethral mucosa between the 10 and 2 o\u0026rsquo;clock positions from the bladder neck to the external urethral sphincter. Perioperative data, complications, voiding outcomes and PSA at 3 months were retrospectively compared with a matched cohort of patients undergoing HoLEP with the standard en-bloc technique.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults:\u003c/b\u003e\u003c/p\u003e\u003cp\u003e38 patients treated with NIcE were compared with 80 control patients treated with the en-bloc technique. Demographic and baseline characteristics were comparable. All patients in the NIcE group who had complete preservation of the anterior urethral mucosa were continent immediately after catheter removal. Postoperative Qmax, PVR, and PSA levels showed no significant differences between groups.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions:\u003c/b\u003e\u003c/p\u003e\u003cp\u003eNIcE HoLEP prevents TSUI immediately after catheter removal, providing safe and effective relief from benign prostatic obstruction (BPO). Early results suggest it may offer a viable alternative to standard HoLEP techniques.\u003c/p\u003e","manuscriptTitle":"Anatomical Foundations, surgical technique and early outcome of the No Stress In-continence Enucleation (NIcE) Template for Holmium Laser Enucleation of the Prostate (HoLEP)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-12 11:12:10","doi":"10.21203/rs.3.rs-7623679/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e08542ca-7576-4669-bdca-e31078def251","owner":[],"postedDate":"October 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-16T09:55:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-12 11:12:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7623679","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7623679","identity":"rs-7623679","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}