Impact of Prior Holmium Laser Enucleation of the Prostate on Outcomes After Robot-Assisted Radical Prostatectomy

Impact of Prior Holmium Laser Enucleation of the Prostate on Outcomes After Robot-Assisted Radical Prostatectomy | 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 Impact of Prior Holmium Laser Enucleation of the Prostate on Outcomes After Robot-Assisted Radical Prostatectomy Takato Nishino, Masaki Shimbo, Tomohiko Oguchi, Masayuki Sano, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9018515/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 Purpose We evaluated the perioperative, oncologic, and continence outcomes of robot-assisted radical prostatectomy (RARP) in patients with and without prior holmium laser enucleation of the prostate (HoLEP). Methods We reviewed 419 RARP cases, including 27 patients with prior HoLEP, and performed 1:2 propensity score matching. Urinary continence was assessed longitudinally using pad counts at scheduled intervals, with 12-month continence as the primary endpoint. Secondary endpoints included perioperative outcomes and biochemical recurrence (BCR). Results Perioperative outcomes, pathological findings, and BCR-free survival were comparable between patients with and without prior HoLEP. At 12 months, functional continence (≤ 1 pad/day) was achieved in 100.0% of patients without prior HoLEP and in 85.2% of those with prior HoLEP (p = 0.011). Kaplan–Meier analysis demonstrated no significant difference in time to recovery (log-rank p = 0.068); however, a subset of patients with prior HoLEP experienced persistent incontinence beyond 12 months. Exploratory analyses implied an association between longer adjunctive transurethral coagulation time during HoLEP and worse functional continence. Conclusions Prior HoLEP did not compromise perioperative safety or oncologic outcomes after RARP; however, it was associated with a lower 12-month functional continence rate in a subset of patients. Post-enucleation anatomical changes should be considered during surgical planning and preoperative counseling. Holmium laser enucleation of the prostate Robot-assisted radical prostatectomy Urinary continence Functional outcomes Prostate cancer Benign prostatic hyperplasia Figures Figure 1 Figure 2 Background Holmium laser enucleation of the prostate (HoLEP) is an established surgical treatment for benign prostatic hyperplasia [1,2]. Given its widespread use, subsequent diagnosis of prostate cancer requiring definitive local therapy is not uncommon. Radical prostatectomy is a standard treatment option in this setting; however, anatomical alterations and energy-related tissue effects after HoLEP may complicate surgical dissection and potentially affect functional outcomes [3]. Previous studies have suggested impaired continence recovery after radical prostatectomy in patients with prior transurethral resection of the prostate (TURP) [4, 5]. In contrast, evidence regarding outcomes of radical prostatectomy after HoLEP remains limited and inconsistent [6,7]. We investigated the impact of prior HoLEP on urinary continence recovery after robot-assisted radical prostatectomy (RARP). Methods Study population The Institutional Review Board of St. Luke’s International University approved the study protocol. We retrospectively reviewed 1,276 patients who underwent RARP between 2011 and 2024. Patients who underwent salvage or cytoreductive surgery, received neoadjuvant or adjuvant therapy, or had < 12 months of follow-up were excluded. Because RARP after HoLEP was performed by two expert surgeons, analyses were restricted to procedures performed by these surgeons (n = 419). Pad use was assessed at 1, 3, 6, 9, and 12 months postoperatively. The primary endpoint was urinary continence at 12 months after RARP. Secondary endpoints included perioperative outcomes and biochemical recurrence (BCR). Surgical procedures All HoLEP procedures were performed at our institution using a previously described anteroposterior enucleation technique [8, 9]. Enucleation and hemostasis were achieved using a holmium laser, with adjunctive bipolar transurethral coagulation (TUC) used selectively for hemostasis. Incidental prostate cancer detected in HoLEP specimens was generally managed with active surveillance. Patients with a high tumor burden or adverse Gleason grade underwent early treatment at the physician’s discretion. During surveillance, prostate-specific antigen (PSA) levels were monitored, and biopsy was performed if PSA levels increased. RARP was considered when clinically significant cancer was confirmed. RARP was performed using a conventional robotic approach regardless of prior HoLEP [10]. Nerve-sparing was attempted when oncologically appropriate, and pelvic lymph node dissection was considered in intermediate- or high-risk cases [11–13]. RARP after HoLEP requires specific technical considerations (Fig. 1). During bladder neck transection, post-enucleation changes may obscure the boundary between the bladder and the prostate. Because the prostatic lumen remains widely open, transection is initiated on the bladder side to avoid inadvertent incision into the prostate (Fig. 1a, b). The bladder neck is reconstructed before urethrovesical anastomosis. Lateral dissection may be complicated by thermal adhesions and collapse of the enucleation cavity; packing gauze into the cavity helps maintain the prostatic contour and facilitates dissection (Fig. 1c). Definitions Functional continence was defined as the use of ≤ 1 pad/day, and strict continence was defined as the use of 0 pads/day, consistent with prior studies [15]. BCR was defined as a PSA level of ≥ 0.2 ng/mL [15]. Statistical analysis Propensity score matching (1:2) was performed with adjustment for age, body mass index (BMI), prostate volume at RARP, clinical T stage, biopsy Grade Group, and surgical period. Propensity scores were estimated using logistic regression, and covariate balance was assessed using standardized mean differences (SMDs), with an absolute SMD < 0.1 indicating adequate balance. PSA was excluded from the matching model because levels are typically reduced after transition-zone removal. Time to continence recovery and BCR-free survival were analyzed using the Kaplan–Meier method and compared using log-rank tests. Categorical variables were compared using Fisher’s exact test, and continuous variables were compared using the Mann–Whitney U test. Statistical analyses were performed using R software (version 4.2.3; R Foundation for Statistical Computing, Vienna, Austria), and a two-sided p-value < 0.05 was considered statistically significant. Results Of 419 eligible patients, 392 had no history of HoLEP, and 27 had undergone HoLEP before RARP (Online Resource 1). Baseline characteristics were adjusted using propensity score matching based on age, BMI, prostate volume at RARP, clinical T stage, biopsy Grade Group, and surgical period (Table 1). Before matching, patients with prior HoLEP were older and more frequently underwent RARP during the later surgical period. Adequate covariate balance was achieved after matching (Online Resource 2). No patient reported pad use preoperatively. Table 2 presents the perioperative and postoperative outcomes in the matched cohort. Operative time, estimated blood loss, nerve-sparing rate, complication rate, and pathological findings, including Grade Group, pathological T stage, and positive surgical margin, did not differ significantly between groups. In addition, BCR–free survival was comparable (log-rank p = 0.68; Online Resource 3). Grade 3 complications occurred in both groups and were not specific to patients with prior HoLEP (Online Resource 4). In the HoLEP group, two cases each of anastomotic leakage and stricture were observed. For functional continence, 12-month recovery was achieved in 100% of patients without prior HoLEP and 85.2% of those with prior HoLEP (p = 0.011). Kaplan–Meier analysis demonstrated no significant difference in time to recovery (log-rank p = 0.068; Fig. 2a). Up to 6 months postoperatively, pad usage was similar; however, two patients with prior HoLEP continued to require 3 pads/day at 12 months (Online Resource 5). For strict continence, 12-month recovery rates were 72.2% in patients without prior HoLEP and 66.7% in those with prior HoLEP (p = 0.62), with no significant difference in time to recovery (log-rank p = 0.59; Fig. 2b). In an exploratory analysis restricted to the HoLEP cohort, patients with persistent functional incontinence at 12 months tended to be older (76 vs 71 years, p = 0.08) and have longer bipolar TUC time during HoLEP (23 vs 10 min, p = 0.05; Table 3). Discussion In our study, prior HoLEP did not affect perioperative or oncologic outcomes after RARP but was associated with a lower 12-month functional continence rate, implying a potential adverse effect on postoperative urinary recovery in a subset of patients. Gellhaus and Abedali et al. [ 3 , 14 ] reported matched analyses from the same institution across different periods. In their cohort of 27 patients with prior HoLEP, functional continence rates were 59% versus 81% (p = 0.156), and strict continence rates were 22% versus 74% (p < 0.001) in patients with and without prior HoLEP, implying worse outcomes, particularly for pad-free recovery. However, continence was not assessed at a uniform postoperative time point, and the cohort had a relatively high mean BMI (~ 28), both of which should be considered when interpreting these findings. A European two-center matched study, including 43 patients with prior HoLEP, evaluated 12-month pad-free continence and reported rates of 65% versus 79% (p = 0.09) in patients with and without prior HoLEP [ 16 ]. Although the difference was not statistically significant, a trend toward inferior continence was observed in the HoLEP group. Interpretation is limited by the inclusion of open prostatectomy in nearly one-half of cases and by follow-up shorter than 12 months in approximately 30% of patients. In our study, continence was assessed longitudinally using pad counts at 3-month intervals, with 12-month continence as the primary endpoint. When functional continence was defined as ≤ 1 pad/day, the 12-month recovery rate was 100.0% in patients without prior HoLEP and 85.2% in those with prior HoLEP. These findings indicate that patients with prior HoLEP were more likely to experience delayed or incomplete continence recovery. Notably, the 100% recovery rate observed in the matched non-HoLEP cohort was not attributable to the matching process. In the full unmatched cohort, 98% (384 of 392) of patients without prior HoLEP achieved functional continence within 12 months, demonstrating that continence recovery remained consistently high in the non-HoLEP population before and after matching. Kaplan–Meier analysis demonstrated that approximately 80% of patients in both groups regained continence within 6 months; however, persistent incontinence beyond 12 months was observed in a subset of patients with prior HoLEP. Although time to recovery did not differ significantly on log-rank testing, the lower 12-month recovery rate in the HoLEP group implies that prior HoLEP may predispose certain patients to prolonged residual incontinence. When strict continence was defined as the use of 0 pads/day, no statistically significant difference was observed between groups. Strict pad-free definitions may be influenced by patient behavior, such as the use of a “safety pad,” as well as by baseline bladder function or other nonsurgical factors. These influences may partly explain discrepancies with previous HoLEP–RARP studies [ 3 , 14 ]. These findings imply that prior HoLEP does not necessarily preclude eventual continence recovery but may increase the likelihood of clinically meaningful persistent incontinence requiring the use of multiple pads. Within the HoLEP cohort, longer bipolar TUC time was associated with worse 12-month functional continence in exploratory analyses. Bipolar electrocautery penetrates more deeply than holmium laser energy (holmium vs TUC, approximately 0.4 vs 2.4 mm), and prolonged coagulation may cause ischemic or structural damage to continence-related regions [ 17 , 18 ]. In some patients, lateral dissection and nerve-sparing were performed relatively easily despite prior HoLEP (Fig. 1 d). In contrast, in a patient who required prolonged TUC, dense apical adhesions with obliteration of normal anatomic planes were observed (Fig. 1 e). Blunt dissection was not feasible, necessitating sharp dissection with electrocautery, and the urethral wall showed focal thickening and whitish discoloration consistent with ischemic change (Fig. 1 f). In such cases, preservation of continence-related periurethral structures may be technically challenging, potentially impairing postoperative functional recovery. From a safety perspective, oncologic outcomes and most perioperative outcomes were comparable, consistent with prior studies [ 4 , 5 , 7 ]. Anastomotic leakage and stricture occurred in a small number of patients with prior HoLEP. Although these complications are not unique to post-HoLEP prostatectomy, potential periurethral ischemia or tissue fragility warrants meticulous urethral handling and careful anastomotic reconstruction. Our study has several limitations. This was a retrospective, single-center analysis, and all procedures were performed by experienced surgeons, which may limit generalizability. The number of patients with prior HoLEP was relatively small, and analyses of HoLEP-related predictors were exploratory. Conclusion RARP is a reasonable definitive treatment option for prostate cancer diagnosed after HoLEP. Although prior HoLEP did not appear to compromise perioperative safety or oncologic outcomes, a subset of patients experienced prolonged or severe postoperative urinary incontinence. Surgeons should be aware of post-HoLEP anatomic changes and counsel patients regarding the potential risk of delayed continence recovery. Abbreviations BCR, Biochemical recurrence BMI, Body mass index HoLEP, Holmium laser enucleation of the prostate PSA, Prostate-specific antigen PSM, Propensity score matching RARP, Robot-assisted radical prostatectomy SMD, Standardized mean difference TUC, Transurethral coagulation TURP, Transurethral resection of the prostate Declarations Funding The authors did not receive support from any organization for the submitted work. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Ethics Approval This retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of St Luke’s International University approved this study (Research number: 23-R152). Consent to Participate This retrospective study was conducted using an opt-out approach approved by the institutional review board. Formal written informed consent was waived due to the retrospective nature of the study. Data Availability The data supporting the findings of this study are not publicly available due to privacy or ethical restrictions but are available from the corresponding author upon reasonable request. Authors’ contribution Nishino T: Project development, Data collection, Data management, Data analysis, Manuscript writing Shimbo M: Project development, Data collection, Data management, Manuscript editing Oguchi T: Data collection Sano M: Data collection Narimoto K: Data collection Hattori K: Project development, Data collection, Data management Endo F: Project development, Data collection, Data management, Manuscript editing All authors reviewed and approved the final version of the manuscript. References Sun F, Yao H, Bao X, Wang X, Wang D, Zhang D, et al. The efficacy and safety of HoLEP for benign prostatic hyperplasia with large volume: a systematic review and meta-analysis. Am J Mens Health. 2022 Jul;16(4):15579883221113203. Shvero A, Calio B, Humphreys MR, Das AK. HoLEP: the new gold standard for surgical treatment of benign prostatic hyperplasia. Can J Urol. 2021 Aug; 28(2): 6-10. Gellhaus PT, Monn MF, Leese J, Flack CK, Lingeman JE, Koch MO, et al. Robot-assisted radical prostatectomy in patients with a history of holmium laser enucleation of the prostate: feasibility and evaluation of initial outcomes. J Endourol. 2015 Jul;29(7):764–9. Hu A, Lin Y, Zhu X, Li J, Luo F, Yu X. Does transurethral resection of the prostate before robot-assisted radical prostatectomy have adverse effects on patients diagnosed with prostate cancer: a comparative evidence-based analysis? J Robot Surg. 2025 Feb 20;19(1):74. Liu Y, Qin J, Li K peng, Wen Z, Huang J, Jiang Y, et al. Perioperative, functional, and oncologic outcomes in patients undergoing robot-assisted radical prostatectomy previous transurethral resection of prostate: a systematic review and meta-analysis of comparative trials. J Robot Surg. 2023 Mar 17;17(4):1271–85. Ditonno F, Ronca M, Pettenuzzo G, Montanaro F, Costantino S, Malandra S, et al. Impact of prior holmium laser enucleation of the prostate on robot-assisted radical prostatectomy outcomes: a systematic review and meta-analysis of comparative studies. J Endourol. 2026 Jan 21;08927790261415936. Katsimperis S, Tzelves L, Markopoulos T, Bellos T, Douroumis K, Kostakopoulos N, et al. Radical prostatectomy following holmium laser enucleation of the prostate (HoLEP): a systematic review of perioperative, oncological, and functional outcomes. Cancers. 2025 Nov 18;17(22):3685. Endo F, Shimbo M, Komatsu K, Ohwaki K, Hattori K. Optimal interval for delayed retrieval surgery with reciprocating morcellators after enucleation of giant prostatic hyperplasia in holmium laser enucleation of the prostate. Asian J Urol. 2024 Jul;11(3):423–8. Endo F, Shiga Y, Minagawa S, Iwabuchi T, Fujisaki A, Yashi M, et al. Anteroposterior dissection HoLEP: a modification to prevent transient stress urinary incontinence. Urology. 2010 Dec;76(6):1451–5. Patel VR, Thaly R, Shah K. Robotic radical prostatectomy: outcomes of 500 cases. BJU Int. 2007 May;99(5):1109–12. Nishino T, Shimbo M, Sano M, Oguchi T, Narimoto K, Hattori K, et al. Incidence, risk factors, and clinical characteristics of late biochemical recurrence following robot‐assisted radical prostatectomy. Int J Urol. 2025 Nov;32(11):1688–95. Shimbo M, Hattori K, Endo F, Matsushita K, Iwabuchi T, Tobisu K, et al. Modified anterior approach to the bladder neck: Simple and reproducible procedure for anterior bladder neck transection during robot‐assisted radical prostatectomy. Int J Urol. 2014 Sep;21(9):946–8. Shimbo M, Endo F, Tominaga K, Sano M, Nishino T, Kyono Y, et al. Optimizing first trocar access for robot‐assisted radical prostatectomy: Optical trocar access through the upper abdominal quadrant using the Kii Fios First Entry trocar. Asian J Endosc Surg. 2021 Jul;14(3):443–50. Abedali ZA, Calaway AC, Large T, Koch MO, Lingeman JE, Boris RS. Robot-assisted radical prostatectomy in patients with a history of holmium laser enucleation of the prostate: The Indiana University experience. J Endourol. 2020 Feb 1;34(2):163–8. Morgan TM, Boorjian SA, Buyyounouski MK, Chapin BF, Chen DYT, Cheng HH, et al. Salvage therapy for prostate cancer: AUA/ASTRO/SUO Guideline Part I: Introduction and treatment decision-making at the time of suspected biochemical recurrence after radical prostatectomy. J Urol. 2024 Apr;211(4):509–17. Kretschmer A, Mazzone E, Barletta F, Leni R, Heidegger I, Tsaur I, et al. Initial experience with radical prostatectomy following holmium laser enucleation of the prostate. Eur Urol Focus. 2021 Nov;7(6):1247–53. Gravas S, Bachmann A, Reich O, Roehrborn CG, Gilling PJ, De La Rosette J. Critical review of lasers in benign prostatic hyperplasia (BPH). BJU Int. 2011 Apr;107(7):1030–43. Maddox M, Pareek G, Ekish SA, Thavaseelan S, Mehta A, Mangray S, et al. Histopathologic changes after bipolar resection of the prostate: depth of penetration of bipolar thermal injury. J Endourol. 2012 Oct;26(10):1367–71. The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: http://www.textcheck.com/certificate/8Ojx1O Tables Table 1. Preoperative clinical characteristics of patients undergoing RARP, stratified by prior HoLEP status, before and after propensity score matching Unmatched Matched Overall No HoLEP HoLEP |SMD| Overall No HoLEP HoLEP |SMD| (n = 419) (n = 392) (n = 27) (n = 81) (n = 54) (n = 27) median (IQR) median (IQR) Age (years) 68 (63, 73) 67 (63, 72) 73 (71, 76) 1.49 73 (70, 77) 74 (69, 78) 73 (71, 76) 0.08 BMI (kg/m 2 ) 23.7 (22.0, 25.6) 23.7 (22.0, 25.3) 23.9 (21.2, 26.0) 0.07 23.8 (21.4, 25.8) 23.8 (21.7, 25.3) 23.9 (21.2, 26.0) 0.00 PSA at RARP (ng/mL) 6.23 (4.80, 9.10) 6.24 (4.86, 9.30) 5.90 (4.45, 7.76) 0.64 6.29 (4.60, 8.74) 6.50 (4.70, 10.9) 5.90 (4.45, 7.76) 0.97 PV at RARP (mL) 28 (23, 37) 29 (23, 37) 25 (21, 32) 0.12 25 (22, 35) 25 (22, 35) 25 (21, 32) 0.09 Surgical case order † 705 (362, 1022) 675 (349, 1003) 986 (756, 1100) 0.79 984 (739, 1125) 981 (711, 1126) 986 (756, 1100) 0.04 Follow-up period from RARP (month) 57 (28, 87) 59 (28, 89) 44 (24, 73) 0.26 50 (28, 70) 50 (29, 65) 44 (24, 73) 0.01 n (%) n (%) Biopsy GG 1–2 213 (50.8) 208 (53.1) 5 (18.5) 0.35 16 (19.8) 11 (20.4) 5 (18.5) 0.02 3 76 (18.1) 67 (17.1) 9 (33.3) 0.16 26 (32.1) 17 (31.5) 9 (33.3) 0.02 4–5 130 (31.0) 117 (29.8) 13 (48.1) 0.18 39 (48.1) 26 (48.1) 13 (48.1) 0.00 Clinical T stage T1 68 (16.2) 63 (16.1) 5 (18.5) 0.02 13 (16.0) 8 (14.8) 5 (18.5) 0.04 T2 308 (73.5) 289 (73.7) 19 (70.4) 0.03 58 (71.6) 39 (72.2) 19 (70.4) 0.02 T3 43 (10.3) 40 (10.2) 3 (11.1) 0.01 10 (12.3) 7 (13.0) 3 (11.1) 0.02 Clinical N1 1 2 (0.5) 2 (0.5) 0 (0.0) 0.01 0 (0.0) 0 (0.0) 0 (0.0) 0.00 SMDs are used to assess covariate balance. |SMD| < 0.1 indicates adequate balance. PSA was not included in the matching model by design; residual imbalance remains. † Surgical case order indicates the chronological order of RARP at our institution (1 = first case) BMI, body mass index; GG, Grade Group; HoLEP, holmium laser enucleation of the prostate; PSA, prostate-specific antigen; PV, prostate volume; RARP, robot-assisted radical prostatectomy; SMD, standardized mean difference Table 2. Perioperative and postoperative outcomes of patients undergoing RARP in the propensity score–matched cohort, stratified by prior HoLEP status Overall No HoLEP HoLEP (n = 81) (n = 54) (n = 27) median (IQR) p-value Operation time (min) 272 (222, 309) 267 (228, 308) 272 (217, 312) 0.78 Estimated blood loss (mL) 100 (50, 200) 140 (50, 200) 100 (50, 213) 0.66 n (%) Nerve sparing None 26 (32.1) 15 (27.8) 11 (40.7) 0.50 Unilateral 35 (43.2) 24 (44.4) 11 (40.7) Bilateral 20 (24.7) 15 (27.8) 5 (18.5) Lymph node dissection 1 69 (85.2) 45 (83.3) 24 (88.9) 0.74 Pathological GG 1–2 39 (48.1) 25 (46.3) 14 (51.9) 0.80 3 31 (38.3) 22 (40.7) 9 (33.3) 4–5 11 (13.6) 7 (13.0) 4 (14.8) Pathological T stage pT2 58 (71.6) 36 (66.7) 22 (81.5) 0.45 pT3a 14 (17.3) 11 (20.4) 3 (11.1) pT3b 9 (11.1) 7 (13.0) 2 (7.4) Pathological N1 7 (8.6) 5 (9.3) 2 (7.4) 1.00 Positive surgical margin 1 12 (14.8) 9 (16.7) 3 (11.1) 0.74 BCR 1 21 (25.9) 15 (27.8) 6 (22.2) 0.79 CRPC 1 2 (2.5) 1 (1.9) 1 (3.7) 1.00 Leakage of vesicourethral anastomosis 1 3 (3.7) 1 (1.9) 2 (7.4) 0.26 Clavien-Dindo complications 0 58 (71.6) 42 (77.8) 16 (59.3) 0.24 1–2 21 (25.9) 11 (20.4) 10 (37.0) 3 2 (2.5) 1 (1.9) 1 (3.7) Functional continence at 1 year 77 (95.1) 54 (100.0) 23 (85.2) 0.011 Strict continence at 1 year 57 (70.4) 39 (72.2) 18 (66.7) 0.62 BCR, biochemical recurrence; CRPC, castration-resistant prostate cancer; GG, Grade Group; HoLEP, holmium laser enucleation of the prostate; IQR, interquartile range; RARP, robot-assisted radical prostatectomy Table 3. Clinical and HoLEP-related characteristics among patients with prior HoLEP, stratified by 12-month functional continence status (≤ 1 pad/day) after RARP Continence Incontinence p-value n = 23 n = 4 median (IQR) Age (years) 71 (70, 76) 76 (73, 80) 0.080 BMI (kg/m 2 ) 23.9 (21.2, 25.9) 24.8 (22.9, 26.6) 0.53 PV at RARP (mL) 25 (21, 32) 23 (17, 29) 0.45 Enucleation volume (g) 34 (20, 43) 25 (20, 30) 0.32 Total energy (kJ) 125 (110, 154) 110 (87, 141) 0.57 Enucleation time (min) 33 (26, 43) 33 (20, 48) 0.93 Coagulation time (min) 16 (7, 20) 10 (4, 16) 0.28 TUC, n (%) 5 (25.0) 2 (50.0) 0.69 TUC time (min) 10 (8, 19) 23 (23, 24) 0.053 Interval from HoLEP to RARP (months) 46 (23, 78) 36 (29, 46) 0.44 BMI, body mass index; HoLEP, holmium laser enucleation of the prostate; IQR, interquartile range; PV, prostate volume; RARP, robot-assisted radical prostatectomy; TUC, transurethral coagulation Additional Declarations No competing interests reported. Supplementary Files OnlineResource1.pdf Online Resource 1. Flowchart of patient selection. Patients undergoing RARP between 2011 and 2024 were screened and included according to predefined criteria. The final cohort was stratified by prior HoLEP history and adjusted using propensity score matching HoLEP, holmium laser enucleation of the prostate; RARP, robot-assisted radical prostatectomy OnlineResource2.pdf Online Resource 2. Love plot showing absolute standardized mean differences for baseline covariates before and after propensity score matching. Gray circles represent standardized mean differences before matching, and black circles represent those after matching. The vertical dashed line marks the threshold of |SMD| = 0.1, indicating acceptable balance SMD, standardized mean difference OnlineResource3.pdf Online Resource 3. Kaplan–Meier curves showing biochemical recurrence–free survival stratified by prior HoLEP status. The solid line represents patients without prior HoLEP, and the dashed line represents patients with prior HoLEP. There was no significant difference between groups (log-rank test, p = 0.68) HoLEP, holmium laser enucleation of the prostate OnlineResource4.pdf Online Resource 4. Postoperative complications according to the Clavien–Dindo classification OnlineResource5.pdf Online Resource 5. Pad usage at 3, 6, and 12 months after RARP, stratified by prior HoLEP status HoLEP, holmium laser enucleation of the prostate; RARP, robot-assisted radical prostatectomy 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-9018515","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603405890,"identity":"e6817eaa-e642-401b-bc1b-aa7bf54c5ca4","order_by":0,"name":"Takato Nishino","email":"","orcid":"","institution":"St. Luke's International Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takato","middleName":"","lastName":"Nishino","suffix":""},{"id":603405891,"identity":"766af131-4218-42df-b59f-3963725d3b0f","order_by":1,"name":"Masaki Shimbo","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIiWNgGAWjYHACNoYEhgMM/OwMzFCBA0RqkWwmSQtIlcFhuBYCQLf9+LMHD3PuyBkf5jE2+MBgJ8/AeBa/NWZncswNErc9MzYDakmcwZBs2MBwLgG/lgM5bBKJ2w4DEQ/QIgZmoPIzBvi1nH/+DKxlczNQyx+GeiK03EgwA2vZwMxjnMzAcJgYLW9AWp4ZSxxmKzbsMThu2EbQL+fTn0n+3HZHjr+9ebPEj4pqeX4JAiGGBoBOYpM4Q4oOMODvIVnLKBgFo2AUDG8AALGZR5FcmrVgAAAAAElFTkSuQmCC","orcid":"","institution":"St. Luke's International Hospital","correspondingAuthor":true,"prefix":"","firstName":"Masaki","middleName":"","lastName":"Shimbo","suffix":""},{"id":603405892,"identity":"dd4abc40-cbd2-455b-a58d-fc57b485c8df","order_by":2,"name":"Tomohiko Oguchi","email":"","orcid":"","institution":"St. Luke's International Hospital","correspondingAuthor":false,"prefix":"","firstName":"Tomohiko","middleName":"","lastName":"Oguchi","suffix":""},{"id":603405893,"identity":"4e5775e4-eba2-40c7-b929-df9e0908a3b0","order_by":3,"name":"Masayuki Sano","email":"","orcid":"","institution":"St. Luke's International Hospital","correspondingAuthor":false,"prefix":"","firstName":"Masayuki","middleName":"","lastName":"Sano","suffix":""},{"id":603405894,"identity":"2bea14bd-fc80-4390-a24e-0e2f871b36d5","order_by":4,"name":"Kazutaka Narimoto","email":"","orcid":"","institution":"St. Luke's International Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kazutaka","middleName":"","lastName":"Narimoto","suffix":""},{"id":603405895,"identity":"74281a4c-294f-4169-87d3-116f47b87040","order_by":5,"name":"Kazunori Hattori","email":"","orcid":"","institution":"St. Luke's International Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kazunori","middleName":"","lastName":"Hattori","suffix":""},{"id":603405896,"identity":"5e877fe6-50cf-40e7-9628-fb503e49e10a","order_by":6,"name":"Fumiyasu Endo","email":"","orcid":"","institution":"St. Luke's International Hospital","correspondingAuthor":false,"prefix":"","firstName":"Fumiyasu","middleName":"","lastName":"Endo","suffix":""}],"badges":[],"createdAt":"2026-03-03 09:23:54","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9018515/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9018515/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104470234,"identity":"b4bd8b55-7fda-4f5a-a1e6-85bacef0c4d9","added_by":"auto","created_at":"2026-03-12 07:17:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":973891,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative findings during RARP after prior HoLEP\u003c/p\u003e\n\u003cp\u003e(a–b) Anatomical characteristics after HoLEP. (a) Following adenoma enucleation, the prostatic lumen remains widely open, increasing the risk of inadvertent prostatic incision during dissection. Transection is therefore initiated from the bladder side with careful attention to the enlarged cavity. (b) The enucleation cavity is widely exposed, with the verumontanum clearly identifiable\u003c/p\u003e\n\u003cp\u003e(c) Surgical tip for lateral dissection. After HoLEP, the enucleation cavity may collapse, producing a concave prostate and challenging lateral dissection. Packing gauze into the cavity maintains prostatic contour and facilitates stable dissection\u003c/p\u003e\n\u003cp\u003e(d) A case minimally affected by prior HoLEP. Enucleated tissue weight was 48 g, total laser energy was 166 kJ, with no adjunctive TUC. Post-RARP, pad-free continence was achieved at 1 month. Intraoperatively, the dissection plane was clearly identified and smoothly developed along the nerve-sparing layer\u003c/p\u003e\n\u003cp\u003e(e–f) A case strongly affected by prior HoLEP. Enucleated tissue weight was 30 g, total laser energy was 125 kJ, and adjunctive TUC was performed for 22 minutes. After RARP, the patient continued to use three pads/day at 12 months. (e) Dense adhesions extended from the lateral aspect to the prostatic apex, obscuring the dissection plane and precluding blunt dissection, necessitating sharp electrocautery dissection. (f) The dorsal venous complex, prostatic apex, and urethra were fused, producing an indistinct anatomical boundary. Adequate prostate traction was required, and sharp dissection was performed along an estimated plane. The urethral wall showed thickening with focal whitish discoloration, implying ischemic changes\u003c/p\u003e\n\u003cp\u003eHoLEP, holmium laser enucleation of the prostate; RARP, robot-assisted radical prostatectomy; TUC, transurethral coagulation\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9018515/v1/19a9d20c032cdecf92704a46.png"},{"id":104470235,"identity":"8e9423fc-13d3-4344-b6e5-e8fa3c4b9623","added_by":"auto","created_at":"2026-03-12 07:17:06","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":113606,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan–Meier curves showing time to continence recovery stratified by prior HoLEP status: (a) functional continence recovery and (b) strict continence recovery. The solid line represents patients without prior HoLEP, and the dashed line represents patients with prior HoLEP. Functional continence recovery appeared to plateau after approximately 6 months postoperatively in patients with prior HoLEP; however, no statistically significant differences were observed between groups for either definition (log-rank test: p = 0.068 for functional continence and p = 0.59 for strict continence)\u003c/p\u003e\n\u003cp\u003eHoLEP, holmium laser enucleation of the prostate; RARP, robot-assisted radical prostatectomy\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9018515/v1/f0f1b81cec3cf1d83483f08d.png"},{"id":109453235,"identity":"6ac9359c-4ebe-4011-9814-02809ebe9085","added_by":"auto","created_at":"2026-05-18 09:26:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1737615,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9018515/v1/387b1dd8-5710-4d2b-9cda-e068b3ed90cb.pdf"},{"id":104470233,"identity":"d0d31dcf-8372-43be-8891-3f22bb906ad8","added_by":"auto","created_at":"2026-03-12 07:17:05","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15391,"visible":true,"origin":"","legend":"\u003cp\u003eOnline Resource 1. Flowchart of patient selection. Patients undergoing RARP between 2011 and 2024 were screened and included according to predefined criteria. The final cohort was stratified by prior HoLEP history and adjusted using propensity score matching\u003c/p\u003e\n\u003cp\u003eHoLEP, holmium laser enucleation of the prostate; RARP, robot-assisted radical prostatectomy\u003c/p\u003e","description":"","filename":"OnlineResource1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9018515/v1/ca98a4e5c1847d6de5e51152.pdf"},{"id":104780656,"identity":"56d66a1f-c3dd-4a17-8f20-2aa60d26740c","added_by":"auto","created_at":"2026-03-17 07:53:31","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":73079,"visible":true,"origin":"","legend":"\u003cp\u003eOnline Resource 2. Love plot showing absolute standardized mean differences for baseline covariates before and after propensity score matching. Gray circles represent standardized mean differences before matching, and black circles represent those after matching. The vertical dashed line marks the threshold of |SMD| = 0.1, indicating acceptable balance\u003c/p\u003e\n\u003cp\u003eSMD, standardized mean difference\u003c/p\u003e","description":"","filename":"OnlineResource2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9018515/v1/43e5975286dd8b2c134bc500.pdf"},{"id":104780329,"identity":"93ec3eec-1885-4d7a-8f86-1154c50409de","added_by":"auto","created_at":"2026-03-17 07:52:20","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":47585,"visible":true,"origin":"","legend":"\u003cp\u003eOnline Resource 3. Kaplan–Meier curves showing biochemical recurrence–free survival stratified by prior HoLEP status. The solid line represents patients without prior HoLEP, and the dashed line represents patients with prior HoLEP. There was no significant difference between groups (log-rank test, p = 0.68)\u003c/p\u003e\n\u003cp\u003eHoLEP, holmium laser enucleation of the prostate\u003c/p\u003e","description":"","filename":"OnlineResource3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9018515/v1/e25491362e93513c85edaf19.pdf"},{"id":104470238,"identity":"643682c2-d8e7-4c18-a061-d6adb20d24b1","added_by":"auto","created_at":"2026-03-12 07:17:06","extension":"pdf","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":44508,"visible":true,"origin":"","legend":"\u003cp\u003eOnline Resource 4. Postoperative complications according to the Clavien–Dindo classification\u003c/p\u003e","description":"","filename":"OnlineResource4.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9018515/v1/cdcc0d97abed21a41356e3fb.pdf"},{"id":104780655,"identity":"6fb597a5-43bb-475b-990b-8647b22965cf","added_by":"auto","created_at":"2026-03-17 07:53:31","extension":"pdf","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":49749,"visible":true,"origin":"","legend":"\u003cp\u003eOnline Resource 5. Pad usage at 3, 6, and 12 months after RARP, stratified by prior HoLEP status\u003c/p\u003e\n\u003cp\u003eHoLEP, holmium laser enucleation of the prostate; RARP, robot-assisted radical prostatectomy\u003c/p\u003e","description":"","filename":"OnlineResource5.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9018515/v1/19ec559d437534ecc2fb6608.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Prior Holmium Laser Enucleation of the Prostate on Outcomes After Robot-Assisted Radical Prostatectomy","fulltext":[{"header":"Background","content":"\u003cp\u003eHolmium laser enucleation of the prostate (HoLEP) is an established surgical treatment for benign prostatic hyperplasia [1,2]. Given its widespread use, subsequent diagnosis of prostate cancer requiring definitive local therapy is not uncommon. Radical prostatectomy is a standard treatment option in this setting; however, anatomical alterations and energy-related tissue effects after HoLEP may complicate surgical dissection and potentially affect functional outcomes [3]. Previous studies have suggested impaired continence recovery after radical prostatectomy in patients with prior transurethral resection of the prostate (TURP) [4, 5]. In contrast, evidence regarding outcomes of radical prostatectomy after HoLEP remains limited and inconsistent [6,7]. We investigated the impact of prior HoLEP on urinary continence recovery after robot-assisted radical prostatectomy (RARP).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy population\u003c/p\u003e\n\u003cp\u003eThe Institutional Review Board of St. Luke’s International University approved the study protocol. We retrospectively reviewed 1,276 patients who underwent RARP between 2011 and 2024. Patients who underwent salvage or cytoreductive surgery, received neoadjuvant or adjuvant therapy, or had \u0026lt; 12 months of follow-up were excluded.\u003c/p\u003e\n\u003cp\u003eBecause RARP after HoLEP was performed by two expert surgeons, analyses were restricted to procedures performed by these surgeons (n = 419). Pad use was assessed at 1, 3, 6, 9, and 12 months postoperatively. The primary endpoint was urinary continence at 12 months after RARP. Secondary endpoints included perioperative outcomes and biochemical recurrence (BCR).\u003c/p\u003e\n\u003cp\u003eSurgical procedures\u003c/p\u003e\n\u003cp\u003eAll HoLEP procedures were performed at our institution using a previously described anteroposterior enucleation technique [8, 9]. Enucleation and hemostasis were achieved using a holmium laser, with adjunctive bipolar transurethral coagulation (TUC) used selectively for hemostasis. Incidental prostate cancer detected in HoLEP specimens was generally managed with active surveillance. Patients with a high tumor burden or adverse Gleason grade underwent early treatment at the physician’s discretion. During surveillance, prostate-specific antigen (PSA) levels were monitored, and biopsy was performed if PSA levels increased. RARP was considered when clinically significant cancer was confirmed.\u003c/p\u003e\n\u003cp\u003eRARP was performed using a conventional robotic approach regardless of prior HoLEP [10]. Nerve-sparing was attempted when oncologically appropriate, and pelvic lymph node dissection was considered in intermediate- or high-risk cases [11–13]. RARP after HoLEP requires specific technical considerations (Fig. 1). During bladder neck transection, post-enucleation changes may obscure the boundary between the bladder and the prostate. Because the prostatic lumen remains widely open, transection is initiated on the bladder side to avoid inadvertent incision into the prostate (Fig. 1a, b). The bladder neck is reconstructed before urethrovesical anastomosis. Lateral dissection may be complicated by thermal adhesions and collapse of the enucleation cavity; packing gauze into the cavity helps maintain the prostatic contour and facilitates dissection (Fig. 1c).\u003c/p\u003e\n\u003cp\u003eDefinitions\u003c/p\u003e\n\u003cp\u003eFunctional continence was defined as the use of ≤ 1 pad/day, and strict continence was defined as the use of 0 pads/day, consistent with prior studies [15]. BCR was defined as a PSA level of ≥ 0.2 ng/mL [15].\u003c/p\u003e\n\u003cp\u003eStatistical analysis\u003c/p\u003e\n\u003cp\u003ePropensity score matching (1:2) was performed with adjustment for age, body mass index (BMI), prostate volume at RARP, clinical T stage, biopsy Grade Group, and surgical period. Propensity scores were estimated using logistic regression, and covariate balance was assessed using standardized mean differences (SMDs), with an absolute SMD \u0026lt; 0.1 indicating adequate balance.\u003c/p\u003e\n\u003cp\u003ePSA was excluded from the matching model because levels are typically reduced after transition-zone removal. Time to continence recovery and BCR-free survival were analyzed using the Kaplan–Meier method and compared using log-rank tests. Categorical variables were compared using Fisher’s exact test, and continuous variables were compared using the Mann–Whitney U test. Statistical analyses were performed using R software (version 4.2.3; R Foundation for Statistical Computing, Vienna, Austria), and a two-sided p-value \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOf 419 eligible patients, 392 had no history of HoLEP, and 27 had undergone HoLEP before RARP (Online Resource 1). Baseline characteristics were adjusted using propensity score matching based on age, BMI, prostate volume at RARP, clinical T stage, biopsy Grade Group, and surgical period (Table 1). Before matching, patients with prior HoLEP were older and more frequently underwent RARP during the later surgical period. Adequate covariate balance was achieved after matching (Online Resource 2). No patient reported pad use preoperatively.\u003c/p\u003e\n\u003cp\u003eTable 2 presents the perioperative and postoperative outcomes in the matched cohort. Operative time, estimated blood loss, nerve-sparing rate, complication rate, and pathological findings, including Grade Group, pathological T stage, and positive surgical margin, did not differ significantly between groups. In addition, BCR–free survival was comparable (log-rank p = 0.68; Online Resource 3). Grade 3 complications occurred in both groups and were not specific to patients with prior HoLEP (Online Resource 4). In the HoLEP group, two cases each of anastomotic leakage and stricture were observed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor functional continence, 12-month recovery was achieved in 100% of patients without prior HoLEP and 85.2% of those with prior HoLEP (p = 0.011). Kaplan–Meier analysis demonstrated no significant difference in time to recovery (log-rank p = 0.068; Fig. 2a). Up to 6 months postoperatively, pad usage was similar; however, two patients with prior HoLEP continued to require 3 pads/day at 12 months (Online Resource 5). For strict continence, 12-month recovery rates were 72.2% in patients without prior HoLEP and 66.7% in those with prior HoLEP (p = 0.62), with no significant difference in time to recovery (log-rank p = 0.59; Fig. 2b).\u003c/p\u003e\n\u003cp\u003eIn an exploratory analysis restricted to the HoLEP cohort, patients with persistent functional incontinence at 12 months tended to be older (76 vs 71 years, p = 0.08) and have longer bipolar TUC time during HoLEP (23 vs 10 min, p = 0.05; Table 3).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, prior HoLEP did not affect perioperative or oncologic outcomes after RARP but was associated with a lower 12-month functional continence rate, implying a potential adverse effect on postoperative urinary recovery in a subset of patients.\u003c/p\u003e \u003cp\u003eGellhaus and Abedali et al. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] reported matched analyses from the same institution across different periods. In their cohort of 27 patients with prior HoLEP, functional continence rates were 59% versus 81% (p\u0026thinsp;=\u0026thinsp;0.156), and strict continence rates were 22% versus 74% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in patients with and without prior HoLEP, implying worse outcomes, particularly for pad-free recovery. However, continence was not assessed at a uniform postoperative time point, and the cohort had a relatively high mean BMI (~\u0026thinsp;28), both of which should be considered when interpreting these findings.\u003c/p\u003e \u003cp\u003eA European two-center matched study, including 43 patients with prior HoLEP, evaluated 12-month pad-free continence and reported rates of 65% versus 79% (p\u0026thinsp;=\u0026thinsp;0.09) in patients with and without prior HoLEP [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Although the difference was not statistically significant, a trend toward inferior continence was observed in the HoLEP group. Interpretation is limited by the inclusion of open prostatectomy in nearly one-half of cases and by follow-up shorter than 12 months in approximately 30% of patients.\u003c/p\u003e \u003cp\u003eIn our study, continence was assessed longitudinally using pad counts at 3-month intervals, with 12-month continence as the primary endpoint. When functional continence was defined as \u0026le;\u0026thinsp;1 pad/day, the 12-month recovery rate was 100.0% in patients without prior HoLEP and 85.2% in those with prior HoLEP. These findings indicate that patients with prior HoLEP were more likely to experience delayed or incomplete continence recovery. Notably, the 100% recovery rate observed in the matched non-HoLEP cohort was not attributable to the matching process. In the full unmatched cohort, 98% (384 of 392) of patients without prior HoLEP achieved functional continence within 12 months, demonstrating that continence recovery remained consistently high in the non-HoLEP population before and after matching.\u003c/p\u003e \u003cp\u003eKaplan\u0026ndash;Meier analysis demonstrated that approximately 80% of patients in both groups regained continence within 6 months; however, persistent incontinence beyond 12 months was observed in a subset of patients with prior HoLEP. Although time to recovery did not differ significantly on log-rank testing, the lower 12-month recovery rate in the HoLEP group implies that prior HoLEP may predispose certain patients to prolonged residual incontinence.\u003c/p\u003e \u003cp\u003eWhen strict continence was defined as the use of 0 pads/day, no statistically significant difference was observed between groups. Strict pad-free definitions may be influenced by patient behavior, such as the use of a \u0026ldquo;safety pad,\u0026rdquo; as well as by baseline bladder function or other nonsurgical factors. These influences may partly explain discrepancies with previous HoLEP\u0026ndash;RARP studies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. These findings imply that prior HoLEP does not necessarily preclude eventual continence recovery but may increase the likelihood of clinically meaningful persistent incontinence requiring the use of multiple pads.\u003c/p\u003e \u003cp\u003eWithin the HoLEP cohort, longer bipolar TUC time was associated with worse 12-month functional continence in exploratory analyses. Bipolar electrocautery penetrates more deeply than holmium laser energy (holmium vs TUC, approximately 0.4 vs 2.4 mm), and prolonged coagulation may cause ischemic or structural damage to continence-related regions [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In some patients, lateral dissection and nerve-sparing were performed relatively easily despite prior HoLEP (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ed). In contrast, in a patient who required prolonged TUC, dense apical adhesions with obliteration of normal anatomic planes were observed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ee). Blunt dissection was not feasible, necessitating sharp dissection with electrocautery, and the urethral wall showed focal thickening and whitish discoloration consistent with ischemic change (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ef). In such cases, preservation of continence-related periurethral structures may be technically challenging, potentially impairing postoperative functional recovery.\u003c/p\u003e \u003cp\u003eFrom a safety perspective, oncologic outcomes and most perioperative outcomes were comparable, consistent with prior studies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Anastomotic leakage and stricture occurred in a small number of patients with prior HoLEP. Although these complications are not unique to post-HoLEP prostatectomy, potential periurethral ischemia or tissue fragility warrants meticulous urethral handling and careful anastomotic reconstruction.\u003c/p\u003e \u003cp\u003eOur study has several limitations. This was a retrospective, single-center analysis, and all procedures were performed by experienced surgeons, which may limit generalizability. The number of patients with prior HoLEP was relatively small, and analyses of HoLEP-related predictors were exploratory.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eRARP is a reasonable definitive treatment option for prostate cancer diagnosed after HoLEP. Although prior HoLEP did not appear to compromise perioperative safety or oncologic outcomes, a subset of patients experienced prolonged or severe postoperative urinary incontinence. Surgeons should be aware of post-HoLEP anatomic changes and counsel patients regarding the potential risk of delayed continence recovery.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBCR, Biochemical recurrence\u003c/p\u003e\n\u003cp\u003eBMI, Body mass index\u003c/p\u003e\n\u003cp\u003eHoLEP, Holmium laser enucleation of the prostate\u003c/p\u003e\n\u003cp\u003ePSA, Prostate-specific antigen\u003c/p\u003e\n\u003cp\u003ePSM, Propensity score matching\u003c/p\u003e\n\u003cp\u003eRARP, Robot-assisted radical prostatectomy\u003c/p\u003e\n\u003cp\u003eSMD, Standardized mean difference\u003c/p\u003e\n\u003cp\u003eTUC, Transurethral coagulation\u003c/p\u003e\n\u003cp\u003eTURP, Transurethral resection of the prostate\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors did not receive support from any organization for the submitted work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective chart review study involving human participants was in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The Human Investigation Committee (IRB) of St Luke’s International University approved this study (Research number: 23-R152).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study was conducted using an opt-out approach approved by the institutional review board. Formal written informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are not publicly available due to privacy or ethical restrictions but are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNishino T: Project development, Data collection, Data management, Data analysis, Manuscript writing\u003c/p\u003e\n\u003cp\u003eShimbo M: Project development, Data collection, Data management, Manuscript editing\u003c/p\u003e\n\u003cp\u003eOguchi T: Data collection\u003c/p\u003e\n\u003cp\u003eSano M: Data collection\u003c/p\u003e\n\u003cp\u003eNarimoto K: Data collection\u003c/p\u003e\n\u003cp\u003eHattori K: Project development, Data collection, Data management\u003c/p\u003e\n\u003cp\u003eEndo F: Project development, Data collection, Data management, Manuscript editing\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final version of the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSun F, Yao H, Bao X, Wang X, Wang D, Zhang D, et al. The efficacy and safety of HoLEP for benign prostatic hyperplasia with large volume: a systematic review and meta-analysis. Am J Mens Health. 2022 Jul;16(4):15579883221113203. \u003c/li\u003e\n\u003cli\u003eShvero A, Calio B, Humphreys MR, Das AK. HoLEP: the new gold standard for surgical treatment of benign prostatic hyperplasia. Can J Urol. 2021 Aug; 28(2): 6-10.\u003c/li\u003e\n\u003cli\u003eGellhaus PT, Monn MF, Leese J, Flack CK, Lingeman JE, Koch MO, et al. Robot-assisted radical prostatectomy in patients with a history of holmium laser enucleation of the prostate: feasibility and evaluation of initial outcomes. J Endourol. 2015 Jul;29(7):764\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eHu A, Lin Y, Zhu X, Li J, Luo F, Yu X. Does transurethral resection of the prostate before robot-assisted radical prostatectomy have adverse effects on patients diagnosed with prostate cancer: a comparative evidence-based analysis? J Robot Surg. 2025 Feb 20;19(1):74. \u003c/li\u003e\n\u003cli\u003eLiu Y, Qin J, Li K peng, Wen Z, Huang J, Jiang Y, et al. Perioperative, functional, and oncologic outcomes in patients undergoing robot-assisted radical prostatectomy previous transurethral resection of prostate: a systematic review and meta-analysis of comparative trials. J Robot Surg. 2023 Mar 17;17(4):1271\u0026ndash;85. \u003c/li\u003e\n\u003cli\u003eDitonno F, Ronca M, Pettenuzzo G, Montanaro F, Costantino S, Malandra S, et al. Impact of prior holmium laser enucleation of the prostate on robot-assisted radical prostatectomy outcomes: a systematic review and meta-analysis of comparative studies. J Endourol. 2026 Jan 21;08927790261415936. \u003c/li\u003e\n\u003cli\u003eKatsimperis S, Tzelves L, Markopoulos T, Bellos T, Douroumis K, Kostakopoulos N, et al. Radical prostatectomy following holmium laser enucleation of the prostate (HoLEP): a systematic review of perioperative, oncological, and functional outcomes. Cancers. 2025 Nov 18;17(22):3685. \u003c/li\u003e\n\u003cli\u003eEndo F, Shimbo M, Komatsu K, Ohwaki K, Hattori K. Optimal interval for delayed retrieval surgery with reciprocating morcellators after enucleation of giant prostatic hyperplasia in holmium laser enucleation of the prostate. Asian J Urol. 2024 Jul;11(3):423\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eEndo F, Shiga Y, Minagawa S, Iwabuchi T, Fujisaki A, Yashi M, et al. Anteroposterior dissection HoLEP: a modification to prevent transient stress urinary incontinence. Urology. 2010 Dec;76(6):1451\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003ePatel VR, Thaly R, Shah K. Robotic radical prostatectomy: outcomes of 500 cases. BJU Int. 2007 May;99(5):1109\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eNishino T, Shimbo M, Sano M, Oguchi T, Narimoto K, Hattori K, et al. Incidence, risk factors, and clinical characteristics of late biochemical recurrence following robot‐assisted radical prostatectomy. Int J Urol. 2025 Nov;32(11):1688\u0026ndash;95. \u003c/li\u003e\n\u003cli\u003eShimbo M, Hattori K, Endo F, Matsushita K, Iwabuchi T, Tobisu K, et al. Modified anterior approach to the bladder neck: Simple and reproducible procedure for anterior bladder neck transection during robot‐assisted radical prostatectomy. Int J Urol. 2014 Sep;21(9):946\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eShimbo M, Endo F, Tominaga K, Sano M, Nishino T, Kyono Y, et al. Optimizing first trocar access for robot‐assisted radical prostatectomy: Optical trocar access through the upper abdominal quadrant using the Kii Fios First Entry trocar. Asian J Endosc Surg. 2021 Jul;14(3):443\u0026ndash;50. \u003c/li\u003e\n\u003cli\u003eAbedali ZA, Calaway AC, Large T, Koch MO, Lingeman JE, Boris RS. Robot-assisted radical prostatectomy in patients with a history of holmium laser enucleation of the prostate: The Indiana University experience. J Endourol. 2020 Feb 1;34(2):163\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eMorgan TM, Boorjian SA, Buyyounouski MK, Chapin BF, Chen DYT, Cheng HH, et al. Salvage therapy for prostate cancer: AUA/ASTRO/SUO Guideline Part I: Introduction and treatment decision-making at the time of suspected biochemical recurrence after radical prostatectomy. J Urol. 2024 Apr;211(4):509\u0026ndash;17. \u003c/li\u003e\n\u003cli\u003eKretschmer A, Mazzone E, Barletta F, Leni R, Heidegger I, Tsaur I, et al. Initial experience with radical prostatectomy following holmium laser enucleation of the prostate. Eur Urol Focus. 2021 Nov;7(6):1247\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eGravas S, Bachmann A, Reich O, Roehrborn CG, Gilling PJ, De La Rosette J. Critical review of lasers in benign prostatic hyperplasia (BPH). BJU Int. 2011 Apr;107(7):1030\u0026ndash;43. \u003c/li\u003e\n\u003cli\u003eMaddox M, Pareek G, Ekish SA, Thavaseelan S, Mehta A, Mangray S, et al. Histopathologic changes after bipolar resection of the prostate: depth of penetration of bipolar thermal injury. J Endourol. 2012 Oct;26(10):1367\u0026ndash;71. \u003cbr\u003e\n \u003cp\u003eThe English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: \u003cu\u003ehttp://www.textcheck.com/certificate/8Ojx1O\u003c/u\u003e\u003c/p\u003e\n \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Preoperative clinical characteristics of patients undergoing RARP, stratified by prior HoLEP status, before and after propensity score matching\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eUnmatched\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\" valign=\"top\"\u003e\n \u003cp\u003eMatched\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo HoLEP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHoLEP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e|SMD|\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNo HoLEP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHoLEP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e|SMD|\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(n = 419)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(n = 392)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(n = 27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(n = 81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(n = 54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e(n = 27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;68 (63, 73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;67 (63, 72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;73 (71, 76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;73 (70, 77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;74 (69, 78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;73 (71, 76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;23.7 (22.0, 25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;23.7 (22.0, 25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;23.9 (21.2, 26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;23.8 (21.4, 25.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;23.8 (21.7, 25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;23.9 (21.2, 26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePSA at RARP (ng/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 6.23 (4.80, 9.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;6.24 (4.86, 9.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 5.90 (4.45, 7.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 6.29 (4.60, 8.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 6.50 (4.70, 10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; 5.90 (4.45, 7.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003ePV at RARP (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;28 (23, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;29 (23, 37)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;25 (21, 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;25 (22, 35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;25 (22, 35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;25 (21, 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eSurgical case order \u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;705 (362, 1022)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;675 (349, 1003)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;986 (756, 1100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;984 (739, 1125)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;981 (711, 1126)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;986 (756, 1100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003eFollow-up period from RARP (month)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;57 (28, 87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;59 (28, 89)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;44 (24, 73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;50 (28, 70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;50 (29, 65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;44 (24, 73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eBiopsy GG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;213 (50.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;208 (53.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;5 (18.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 16 (19.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 11 (20.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;5 (18.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;76 (18.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;67 (17.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 9 (33.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 26 (32.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 17 (31.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 9 (33.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4\u0026ndash;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;130 (31.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;117 (29.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 13 (48.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 39 (48.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 26 (48.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 13 (48.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003eClinical T stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;68 (16.2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;63 (16.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;5 (18.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 13 (16.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 8 (14.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;5 (18.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;308 (73.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;289 (73.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 19 (70.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 58 (71.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 39 (72.2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 19 (70.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;43 (10.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;40 (10.2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;3 (11.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;10 (12.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;7 (13.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;3 (11.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eClinical N1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2 (0.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2 (0.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;0 (0.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 0 (0.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 0 (0.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;0 (0.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eSMDs are used to assess covariate balance. |SMD| \u0026lt; 0.1 indicates adequate balance. PSA was not included in the matching model by design; residual imbalance remains.\u003c/p\u003e\n\u003cp\u003e\u0026dagger; Surgical case order indicates the chronological order of RARP at our institution (1 = first case)\u003c/p\u003e\n\u003cp\u003eBMI, body mass index; GG, Grade Group; HoLEP, holmium laser enucleation of the prostate; PSA, prostate-specific antigen; PV, prostate volume; RARP, robot-assisted radical prostatectomy; SMD, standardized mean difference\u003c/p\u003e\n\u003cp\u003eTable 2. Perioperative and postoperative outcomes of patients undergoing RARP in the propensity score\u0026ndash;matched cohort, stratified by prior HoLEP status\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003eNo HoLEP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eHoLEP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e(n = 81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e(n = 54)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e(n = 27)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eOperation time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e272 (222, 309)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e267 (228, 308)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e272 (217, 312)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eEstimated blood loss (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e100 (50, 200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e140 (50, 200)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e100 (50, 213)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eNerve sparing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 26 (32.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 15 (27.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 11 (40.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eUnilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 35 (43.2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 24 (44.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 11 (40.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eBilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 20 (24.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 15 (27.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;5 (18.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eLymph node dissection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 69 (85.2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 45 (83.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 24 (88.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003ePathological GG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 39 (48.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 25 (46.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 14 (51.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 31 (38.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 22 (40.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;9 (33.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e4\u0026ndash;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 11 (13.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 7 (13.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;4 (14.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003ePathological T stage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003epT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 58 (71.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 36 (66.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 22 (81.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003epT3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 14 (17.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 11 (20.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;3 (11.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003epT3b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;9 (11.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;7 (13.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2 (7.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003ePathological N1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; 7 (8.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;5 (9.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2 (7.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003ePositive surgical margin\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 12 (14.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;9 (16.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;3 (11.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eBCR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 21 (25.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 15 (27.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;6 (22.2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eCRPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2 (2.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1 (1.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1 (3.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eLeakage of vesicourethral anastomosis\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;3 (3.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1 (1.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2 (7.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eClavien-Dindo complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 58 (71.6)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 42 (77.8)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 16 (59.3)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 21 (25.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 11 (20.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 10 (37.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2 (2.5)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1 (1.9)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1 (3.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eFunctional continence at 1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 77 (95.1)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 54 (100.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 23 (85.2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.011\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 276px;\"\u003e\n \u003cp\u003eStrict continence at 1 year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 57 (70.4)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 136px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 39 (72.2)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; 18 (66.7)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBCR, biochemical recurrence; CRPC, castration-resistant prostate cancer; GG, Grade Group; HoLEP, holmium laser enucleation of the prostate; IQR, interquartile range; RARP, robot-assisted radical prostatectomy\u003c/p\u003e\n\u003cp\u003eTable 3. Clinical and HoLEP-related characteristics among patients with prior HoLEP, stratified by 12-month functional continence status (\u0026le; 1 pad/day) after RARP\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"949\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eContinence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eIncontinence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003en = 23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003en = 4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;71 (70, 76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;76 (73, 80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;23.9 (21.2, 25.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;24.8 (22.9, 26.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003ePV at RARP (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;25 (21, 32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;23 (17, 29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eEnucleation volume (g)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;34 (20, 43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;25 (20, 30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eTotal energy (kJ)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e125 (110, 154)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e110 (87, 141)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eEnucleation time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;33 (26, 43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;33 (20, 48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eCoagulation time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;16 (7, 20)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;10 (4, 16)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eTUC, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;5 (25.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;2 (50.0)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.69\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eTUC time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;10 (8, 19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;23 (23, 24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.053\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 249px;\"\u003e\n \u003cp\u003eInterval from HoLEP to RARP (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;46 (23, 78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u0026nbsp;36 (29, 46)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eBMI, body mass index; HoLEP, holmium laser enucleation of the prostate; IQR, interquartile range; PV, prostate volume; RARP, robot-assisted radical prostatectomy; TUC, transurethral coagulation\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":"Holmium laser enucleation of the prostate, Robot-assisted radical prostatectomy, Urinary continence Functional outcomes, Prostate cancer, Benign prostatic hyperplasia","lastPublishedDoi":"10.21203/rs.3.rs-9018515/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9018515/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe evaluated the perioperative, oncologic, and continence outcomes of robot-assisted radical prostatectomy (RARP) in patients with and without prior holmium laser enucleation of the prostate (HoLEP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe reviewed 419 RARP cases, including 27 patients with prior HoLEP, and performed 1:2 propensity score matching. Urinary continence was assessed longitudinally using pad counts at scheduled intervals, with 12-month continence as the primary endpoint. Secondary endpoints included perioperative outcomes and biochemical recurrence (BCR).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePerioperative outcomes, pathological findings, and BCR-free survival were comparable between patients with and without prior HoLEP. At 12 months, functional continence (≤ 1 pad/day) was achieved in 100.0% of patients without prior HoLEP and in 85.2% of those with prior HoLEP (p = 0.011). Kaplan–Meier analysis demonstrated no significant difference in time to recovery (log-rank p = 0.068); however, a subset of patients with prior HoLEP experienced persistent incontinence beyond 12 months. Exploratory analyses implied an association between longer adjunctive transurethral coagulation time during HoLEP and worse functional continence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior HoLEP did not compromise perioperative safety or oncologic outcomes after RARP; however, it was associated with a lower 12-month functional continence rate in a subset of patients. Post-enucleation anatomical changes should be considered during surgical planning and preoperative counseling.\u003c/p\u003e","manuscriptTitle":"Impact of Prior Holmium Laser Enucleation of the Prostate on Outcomes After Robot-Assisted Radical Prostatectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-12 07:17:01","doi":"10.21203/rs.3.rs-9018515/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":"ea178e9e-1db2-4965-97f8-738b871f1873","owner":[],"postedDate":"March 12th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-18T09:17:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-10T01:40:36+00:00","index":42,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-18T09:25:13+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-12 07:17:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9018515","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9018515","identity":"rs-9018515","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}