Membranous Urethral Length as a Predictor for Urinary Incontinence After Holmium Enucleation of the Prostate for Benign Prostatic Hyperplasia

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However, one of its adverse outcomes is post-operative stress urinary incontinence (SUI). We sought to determine if membranous urethral length (MUL) as measured on preoperative magnetic resonance imaging is a predictor for post-operative SUI in patients undergoing HoLEP for BPH. Methods A single-center, retrospective observational study was conducted on 147 consecutive patients who underwent HoLEP for BPH between 2018 and 2024. Preoperative baseline characteristics, perioperative details, and SUI outcomes at 1, 3, and 6 months were collected. Binary logistic regression was used to assess the association between MUL and SUI at each follow-up interval. Results Median MUL was 8.2mm (IQR 6.1–11.0), and post-operative SUI incidences were 73 (49.7%), 36 (24.5%), and 16 (10.9%) at 1, 3, and 6 months respectively. Longer MUL was significantly associated with lower odds of SUI at 1 month (OR: 0.86, 95% CI: 0.77–0.96, p = 0.009), 3 months (OR: 0.77, 95% CI: 0.65–0.91, p = 0.002), and 6 months (OR: 0.65, 95% CI: 0.49–0.87, p = 0.004). Internal validation demonstrated good discrimination (areas under the curve of 0.73, 0.75, and 0.83 at 1, 3, and 6 months) with well-calibrated models, and decision curve analysis confirmed clinical utility within prespecified risk thresholds. Conclusions Longer MUL is significantly associated with lower rates of SUI following HoLEP at 1, 3, and 6 months. Longer MUL may serve as a valuable predictive factor for continence recovery and should be considered during preoperative counseling and surgical decision planning. Benign Prostatic Hyperplasia Holmium Laser Enucleation of the Prostate Magnetic Resonance Imaging Membranous Urethral Length Prostate Volume Urinary Continence Figures Figure 1 Figure 2 Introduction Benign prostatic hyperplasia (BPH) is a highly prevalent condition worldwide, particularly among aging men [ 1 ]. It is often associated with lower urinary tract symptoms (LUTS), which may significantly reduce patients’ quality of life (QoL). Over the years, growing evidence has established holmium laser enucleation of the prostate (HoLEP) as an effective and safe treatment for BPH, regardless of prostate size and volume, with extremely durable outcomes [ 2 , 3 ]. HoLEP involves endoscopic enucleation of prostatic lobes from the surgical capsule in retrograde fashion using a high powered holmium:YAG laser, followed by hemostasis and tissue morcellation [ 3 ]. When compared to transurethral resection of the prostate (TURP), HoLEP patients have superior improvements in LUTS with lower perioperative morbidity and lower retreatment rates at 7-year long-term follow-up [ 4 – 7 ]. A prospective study comparing outcomes between HoLEP and simple prostatectomy demonstrated similar functional results at 2-year follow-up, with reduced blood loss, catheterization rates, and hospital stay in HoLEP patients [ 8 ]. However, one of the main complications following HoLEP is post-operative stress urinary continence (SUI) [ 9 ]. While most cases resolve within the first 3 to 6 months, it can have a significantly negative impact on QoL and plays an important role in guiding treatment decisions [ 10 ]. The membranous urethral length (MUL), defined as the segment of urethra between the prostate apex and the penile bulb, can play an important role for certain prostate-related functional outcomes [ 11 ]. For instance, in patients undergoing radical prostatectomy (RP) for prostate cancer, studies have demonstrated a significant association between longer preoperative MUL on magnetic resonance imaging (MRI) and post-operative return to continence [ 12 – 16 ]. However, the association between MUL and continence in patients undergoing HoLEP for BPH, has not yet been described in depth. The objective of this study is to describe the association between preoperative MUL measured on multiparametric prostate MRI and post-operative continence in patients undergoing HoLEP for BPH. Materials and Methods Patients This is an observational retrospective study approved by the Institutional Review Board at the Centre Hospitalier de l’Université de Montréal (2025–12665). A total of 147 consecutive patients undergoing HoLEP for BPH by two fellowship-trained, highly experienced urologists (N.B. and M.M.) at the Centre Hospitalier de l’Université de Montréal between 2018 and 2024 were included. All the data was collected retrospectively. Inclusion criteria were adult males who had a clinical, radiological, and/or biochemical diagnosis of BPH, who underwent subsequent HoLEP, and who had an available preoperative multiparametric prostate MRI. Patients who had a previous prostate surgery, had been diagnosed with prostate cancer or had histological evidence of prostate cancer on enucleated tissue specimens, had a previous history of SUI, or had symptoms of acute/chronic prostatitis, a positive urine culture, and/or a Foley catheter at the moment of MRI were excluded. Outcomes Preoperative baseline characteristics included age, patient comorbidities (diabetes mellitus, hypertension, chronic obstructive pulmonary disease), body mass index, last available serum prostate-specific antigen (PSA) value, and preoperative medication (5-alpha reductase inhibitors, anticholinergic bladder medication, β3-adrenergic agonist bladder medication). Perioperative data included duration of the HoLEP procedure. Post-operative outcomes included the presence or absence of SUI, defined as the use of ≥ 1 pads at 1, 3, and 6 months post-operatively. MRI measures MRI parameters were assessed independently by a fellowship-trained radiologist (D.O.) and a urologist with experience in interpreting and measuring multiparametric prostate MRI (C.N.), both of whom were blinded to the SUI outcomes. Any differences in MUL measurement exceeding 4mm, which corresponds to the thickness of one slice of MRI at our institution, was remeasured together by both parties. MUL measurement was performed using a standardized and reproducible method described in the literature and having previously demonstrated high intra- and inter-observer agreement [ 11 , 16 ]. Sagittal T2 and coronal T2-weighted planes were used to measure MUL. Statistical Analysis All statistical analyses were performed using R statistical software (Version 4.3.2) within the RStudio environment (Build 563). Descriptive statistics were used for patient characteristics. Continuous variables were reported as mean or median with associated standard deviation (SD) or interquartile range (IQR) as appropriate. Categorical variables were reported as counts and percentages. Binary logistic regression was used to model the association between MUL measurements and post-operative incontinence at 1, 3, and 6 months. Multivariable models adjusted for potential confounders, including age at time of MRI, body mass index, last available PSA, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, use of 5-alpha reductase inhibitors, use of bladder medication, and surgery duration [ 17 – 22 ]. Results were reported as odds ratios (OR) with associated 95% confidence intervals (CI). A p-value < 0.05 was considered statistically significant for all analyses. Observations with missing data in any variable included in a specific model were excluded via listwise deletion. To evaluate the internal validity of the predictive models, internal validity testing was performed for each time point. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC) with corresponding 95% confidence intervals. Calibration was examined by comparing predicted probabilities with observed outcomes to determine the degree of agreement between model estimates and actual risk. Clinical utility was further evaluated through decision curve analysis to quantify the net benefit of the models across a range of clinically relevant risk thresholds. Results A total of 147 participants were included in the analysis. Baseline demographic, clinical, and imaging characteristics are summarized in Table 1 . The median age at the time of MRI was 66.0 years (IQR 60.0–70.0), and most of the sample was overweight (median body mass index 26.0, IQR 24.0–30.0). Preoperative MRI measurements indicated a median MUL of 8.2mm (IQR 6.1–11.0). Post-operative SUI showed a decreasing trend with time as incidence decreased from 73 (49.7%) at 1 month, to 36 (24.5%) at 3 months, and finally to 16 (10.9%) at 6 months. Table 1 Baseline characteristics, perioperative data, and post-operative outcomes Characteristics (N = 147) Median (IQR) or Frequency (%) Membranous Urethral Length (mm) 8.2 (6.1–11.0) Prostate Width (mm) 64.0 (56.0–67.0) Prostate Length (mm) 53.0 (47.0–58.0) Prostate Height (mm) 72.0 (63.0–78.0) Prostate Volume (g) 125.4 (94.6-158.4) Age (years, at time of MRI) 66.0 (60.0–70.0) Body Mass Index (kg/m 2) 26.0 (24.0–30.0) Comorbidities Diabetes Hypertension Chronic Obstructive Pulmonary Disease 19 (12.9%) 54 (36.7%) 13 (8.8%) Medication 5-Alpha Reductase Inhibitors Bladder Medication 69 (46.9%) 18 (12.2%) Prostate-Specific Antigen (ng/mL) 7.9 (5.1–11.7) Surgery Duration (minutes) 102.0 (78.0-119.0) MUL and Post-Operative SUI In the univariable analysis, longer MUL was significantly associated with lower odds of SUI at 1 month (OR: 0.89, 95% CI: 0.81–0.97, p = 0.012). This association remained statistically significant in the multivariable model, in which each mm increase in MUL predicted a 13.9% reduction in the likelihood of SUI at 1 month (OR: 0.86, 95% CI: 0.77–0.96, p = 0.009). Among the adjusted covariates, longer surgery duration was significantly associated with increased odds of 1-month SUI (OR: 1.02, 95% CI: 1.00-1.03, p = 0.029). Similarly, longer MUL was associated with significantly lower odds of SUI at 3 months in the univariable model (OR: 0.81, 95% CI: 0.71–0.93, p = 0.003), as well as in the multivariable analysis. Each mm increase was associated with a 23.1% reduction in the probabilities of SUI at 3 month follow up (OR: 0.77, 95% CI: 0.65–0.91, p = 0.002). Lower incontinence rates at 6 months were also significantly associated with longer MUL in the univariable analysis (OR = 0.71, 95% CI: 0.56–0.91 p = 0.006). In the fully adjusted multivariable model, MUL remained a strong predictor, with each mm increase corresponding to a 35.0% decrease in the odds of 6-month SUI (OR: 0.65, 95% CI: 0.49–0.87 p = 0.004). No other covariates were significantly associated with 6-month incontinence in the multivariable model. Multivariate associations between MUL size and incontinence across all three time periods is further presented in Fig. 1 . To assess the performance of these multivariable models, we performed an internal validation for each time point (Fig. 2 ). The model for 1-month SUI demonstrated acceptable discrimination with an area under the curve (AUC) of 0.73 (95% CI: 0.65–0.82). Decision curve analysis confirmed its clinical utility across a wide range of risk thresholds from approximately 5% to 65%. The model predicting 3-month SUI performed similarly, with an AUC of 0.75 (95% CI: 0.66–0.85) and provided a net benefit for risk thresholds up to 30%. The model’s predictive capacity was strongest for the 6-month outcome, achieving excellent discrimination (AUC 0.83, 95% CI: 0.72–0.94) and demonstrating clinical utility for risk thresholds as high as 50%. At all time points, the models appeared well-calibrated, with good agreement between predicted probabilities and observed outcomes. Discussion This study looks at the association between the membranous urethra and post-operative SUI in patients undergoing HoLEP for BPH. We observed, through adjusted and unadjusted models, that longer MUL on preoperative MRI is a significant protective factor against SUI at 1, 3, and 6 months post-operatively. The cohort had an overweight profile, while diabetes mellitus, hypertension, and chronic obstructive pulmonary disease were present in less than one third of patients. These findings are consistent with previously documented risk factors for BPH including obesity, metabolic syndrome, and possibly chronic obstructive pulmonary disease [ 17 , 18 ]. MUL and post-operative continence We observed a significant association between longer MUL and lower SUI following HoLEP at 1, 3, and 6 months post-operatively. To our knowledge, very few studies in the literature have assessed this relationship. A recent study observed that longer MUL is significantly associated with reduced incontinence risk at 1 month, where MUL < 14mm are at nearly 4-fold increased odds of incontinence [ 23 ]. Two studies in Japan determined that longer preoperative MUL was independently associated with lower rates of incontinence at 1 and 3 months post-operatively, while there was no difference at 6 months [ 22 , 24 ]. Our findings are consistent with these studies and extend these observations by revealing a sustained association at 6 months, while further demonstrating internal validity of our models. A last study identified membranous urethral volume as a protective factor against post-operative incontinence at 1 month, while no significant association was found with MUL [ 25 ]. Our median MUL was 8.2mm, which is relatively shorter compared to values described in previous series, which may reflect differences in patient populations or imaging methodology across institutions [ 12 – 16 , 22 – 25 ]. Nonetheless, despite these lower absolute values, the prognostic association between MUL and SUI outcomes were consistent with these series, supporting the robustness and generalizability of our findings. Stress Urinary Incontinence following HoLEP The incidence of transient SUI following HoLEP can vary between 5.3% and 43.1% [ 9 , 10 , 22 – 27 ]. The rate of SUI progressively decreases over time following surgery, with most cases resolving within six months. Other studies have reported rates of incontinence up to 43.1%, 15.0%, and 7.4% at 1 month, 3 months, and 6 months, respectively [ 9 , 10 , 22 – 28 ]. Our results similarly revealed a decreasing trajectory in incontinence rates over time. Risk factors for the development of transient SUI include older age, obesity, diabetes mellitus, greater preoperative prostate volume/specimen weight, and longer operative time [ 19 , 20 , 26 ]. Longer enucleation and morcellation time are directly associated with larger prostate volume and a history of urinary tract infection or retention [ 21 ]. In men, urinary continence is maintained by the internal and external sphincters, composed of smooth and skeletal muscle, respectively [ 29 ]. A longer MUL potentially indicates a more robust external sphincter, offering more resistance to intraoperative trauma, partial excision, or excessive stretching [ 22 ]. This mechanism also explains the same association which has been described for patients undergoing RP for prostate cancer [ 12 – 15 , 30 ]. HoLEP also requires a wider range of motion compared to TURP, leading to an increased risk of intraoperative manipulation and damage to the sphincters by the sheath of the scope [ 22 ]. Some techniques that help minimize trauma include the use of smaller scopes, anteroposterior dissection, which separates the sphincter from the urethra, thus preserving the internal sphincter, as well as early apical release, which can reduce traction and trauma to the external sphincter [ 31 – 33 ]. HoLEP procedures are associated with a steeper learning curve and often require additional training or fellowship experience. Surgeon experience is directly associated with post-operative SUI outcomes [ 34 ]. In our study, both urologists are fellowship-trained and have extensive experience operating in high-volume, quaternary care centers, so the results of the study were minimally influenced by surgical technique. The role of MRI in the preoperative assessment of patients undergoing BPH surgery remains limited. In fact, in our own study, the indication for MRI in all patients were to rule out a suspicion of prostate cancer, and preoperative MRI is not routinely performed prior to HoLEP cases at our institution. Still, many patients who undergo prostate MRI for this reason go on to receive a subsequent therapy for BPH [ 35 ]. MRI has the potential to be useful in both the pre-procedural workup and the post-treatment evaluation of BPH [ 35 ]. We believe that the use of MRI will become more prevalent and pertinent, especially in a context where some variables such as the MUL can provide predictive value on post-operative outcomes. Limitations This study has limitations that should be considered. The retrospective design potentially introduces selection bias and unmeasured confounding variables. Although we adjusted for key covariates, residual confounding from unaccounted factors (e.g. urodynamic parameters, pelvic floor muscle function) may influence the observed associations. The relatively small sample size and single-center nature of the study may limit generalizability. Furthermore, the definition of post-operative SUI relied on clinical documentation rather than standardized questionnaires, which may lead to misclassification bias. As preoperative MRI is not routinely performed prior to HoLEP cases at our institution, this could introduce selection bias. The lack of long-term follow-up beyond six months precludes assessment of persistent SUI. While the models appear well-calibrated, the precision of this assessment is limited by the sample size, as reflected in the wide confidence intervals on the calibration plots. Finally, the exclusion of patients with prior prostate surgery or prostate cancer may limit the applicability of findings to broader populations. Future prospective, multicenter studies incorporating urodynamic assessments and longer standardized follow-up are needed to validate these findings and enhance clinical utility. Conclusion This study demonstrates that pre-operative MUL as measured on MRI is a significant and independent predictor of post-operative SUI following HoLEP for BPH, with longer MUL associated with lower SUI rates at 1, 3, and 6 months. These findings suggest that MUL assessment may enhance preoperative counseling and surgical planning, particularly in patients at higher risk for incontinence. Declarations Authors’ Contribution Nick Lee: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/editing Tarek Benzouak: Data collection or management, Data analysis, Manuscript writing/editing David-Dan Nguyen: Data collection or management, Data analysis, Manuscript writing/editing Sébastien Belliveau: Data collection or management, Manuscript writing/editing Liam Murad: Data collection or management, Manuscript writing/editing Lynda Kadi: Data collection or management Nathan Perlis: Data collection or management, Manuscript writing/editing Rodney H. Breau: Data analysis, Manuscript writing/editing Dean Elterman: Data collection or management, Manuscript writing/editing Bilal Chughtai: Data collection or management, Manuscript writing/editing Dan R. Gralnek: Data collection or management, Manuscript writing/editing Damien Olivié: Data collection or management, Manuscript writing/editing Malek Meskawi: Data collection or management, Manuscript writing/editing Cristina Negrean: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/editing Naeem Bhojani: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/editing Compliance with Ethical Standards None of the contributing authors have any competing interests or conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript. There is no funding or financial support to declare. This study does not involve human participants or animals. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declarations of interest: none. References GBD 2019 Benign Prostatic Hyperplasia Collaborators (2022) The global, regional, and national burden of benign prostatic hyperplasia in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Healthy Longev 3(11):e754–e776. 10.1016/S2666-7568(22)00213-6 Tamalunas A, Westhofen T, Schott M et al (2022) Holmium laser enucleation of the prostate: A truly size-independent method? [published correction appears in Low Urin Tract Symptoms. ;14(5):405. doi: 10.1111/luts.12458.]. Low Urin Tract Symptoms . 2022;14(1):17–26. 10.1111/luts.12404 Gilling P (2008) Holmium laser enucleation of the prostate (HoLEP). BJU Int 101(1):131–142. 10.1111/j.1464-410X.2007.07341.x Kuntz RM, Ahyai S, Lehrich K, Fayad A (2004) Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. J Urol 172(3):1012–1016. 10.1097/01.ju.0000136218.11998.9e Montorsi F, Naspro R, Salonia A et al (2004) Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. J Urol 172(5 Pt 1):1926–1929. 10.1097/01.ju.0000140501.68841.a1 Tan AH, Gilling PJ, Kennett KM, Frampton C, Westenberg AM, Fraundorfer MR (2003) A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol 170(4 Pt 1):1270–1274. 10.1097/01.ju.0000086948.55973.00 Gilling PJ, Wilson LC, King CJ, Westenberg AM, Frampton CM, Fraundorfer MR (2012) Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int 109(3):408–411. 10.1111/j.1464-410X.2011.10359.x Naspro R, Suardi N, Salonia A et al (2006) Holmium laser enucleation of the prostate versus open prostatectomy for prostates > 70 g: 24-month follow-up. Eur Urol 50(3):563–568. 10.1016/j.eururo.2006.04.003 Das AK, Teplitsky S, Chandrasekar T et al (2020) Stress Urinary Incontinence post-Holmium Laser Enucleation of the Prostate: a Single-Surgeon Experience. Int Braz J Urol 46(4):624–631. 10.1590/S1677-5538.IBJU.2019.0411 Vavassori I, Valenti S, Naspro R et al (2008) Three-year outcome following holmium laser enucleation of the prostate combined with mechanical morcellation in 330 consecutive patients. Eur Urol 53(3):599–604. 10.1016/j.eururo.2007.10.059 Veerman H, Hagens MJ, Hoeks CM et al (2023) A standardized method to measure the membranous urethral length (MUL) on MRI of the prostate with high inter- and intra-observer agreement. Eur Radiol 33(5):3295–3302. 10.1007/s00330-022-09320-2 Mac Curtain BM, Sugrue DD, Qian W, O'Callaghan M, Davis NF (2024) Membranous urethral length and urinary incontinence following robot-assisted radical prostatectomy: a systematic review and meta-analysis. BJU Int 133(6):646–655. 10.1111/bju.16170 Mungovan SF, Sandhu JS, Akin O, Smart NA, Graham PL, Patel MI (2017) Preoperative Membranous Urethral Length Measurement and Continence Recovery Following Radical Prostatectomy: A Systematic Review and Meta-analysis. Eur Urol 71(3):368–378. 10.1016/j.eururo.2016.06.023 von Bodman C, Matsushita K, Savage C et al (2012) Recovery of urinary function after radical prostatectomy: predictors of urinary function on preoperative prostate magnetic resonance imaging. J Urol 187(3):945–950. 10.1016/j.juro.2011.10.143 Paparel P, Akin O, Sandhu JS et al (2009) Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral fibrosis measured by preoperative and postoperative endorectal magnetic resonance imaging. Eur Urol 55(3):629–637. 10.1016/j.eururo.2008.08.057 Negrean C, Alam A, Hickling D et al (2025) Preoperative Magnetic Resonance Imaging Membranous Urethral Length as a Predictor of Urinary Continence After Radical Prostatectomy: A Systematic Review and Meta-analysis. Eur Urol Focus . Published online March 6. 10.1016/j.euf.2025.02.002 Parsons JK (2007) Modifiable risk factors for benign prostatic hyperplasia and lower urinary tract symptoms: new approaches to old problems. J Urol 178(2):395–401. 10.1016/j.juro.2007.03.103 Peng YH, Huang CW, Liao WC et al (2017) Association between chronic obstructive pulmonary disease and increased risk of benign prostatic hyperplasia: a retrospective nationwide cohort study. BMJ Open 7(6):e015581 Published 2017 Jun 23. 10.1136/bmjopen-2016-015581 Elmansy HM, Kotb A, Elhilali MM (2011) Is there a way to predict stress urinary incontinence after holmium laser enucleation of the prostate? J Urol 186(5):1977–1981. 10.1016/j.juro.2011.06.063 Wu SW, Tseng CS, Yuan LH et al (2024) Prospective study of urinary incontinence recovery following endoscopic enucleation of the prostate. BJU Int 134(5):818–825. 10.1111/bju.16475 Monn MF, El Tayeb M, Bhojani N et al (2015) Predictors of Enucleation and Morcellation Time During Holmium Laser Enucleation of the Prostate. Urology 86(2):338–342. 10.1016/j.urology.2015.04.028 Oka S, Kobayashi K, Matsuda K, Takai K (2020) Significance of Membranous Urethral Length for Recovery From Postoperative Urinary Incontinence Following Holmium Laser Enucleation of the Prostate. Int Neurourol J 24(4):358–364. 10.5213/inj.2040042.021 Smani S, Khan AI, Choksi AU et al (2025) Can Anatomical Measurements on Preoperative Pelvic Magnetic Resonance Imaging Predict Postoperative Urinary Incontinence after Holmium Laser Enucleation of the Prostate? J Endourol 39(7):731–737. 10.1089/end.2025.0006 Ueki H, Takahashi K, Yasufuku T, Yuen K, Yamashita M (2020) Is the membranous urethral length related to postoperative urinary incontinence after holmium laser enucleation of the prostate? Int J Urol 27(10):893–898. 10.1111/iju.14322 Fan X, Zhang J, Zhu H, Huang F, Shadike A, Jiang C (2024) Predictive factors of stress urinary incontinence after Holmium Laser Enucleation of the Prostate: a magnetic resonance imaging-based retrospective study. Transl Androl Urol 13(9):1775–1785. 10.21037/tau-24-71 Elsaqa M, Zhang Y, Papaconstantinou H, Tayeb MME (2023) Incidence and predictors of urinary incontinence rates post-holmium laser enucleation of prostate. Low Urin Tract Symptoms 15(5):185–190. 10.1111/luts.12494 Ye OD, Tadrist A, Di Crocco E, Karsenty G, Toledano H (2023) Incontinence urinaire post énucléation endoscopique de la prostate au laser Holmium: aspects évolutifs et facteurs prédictifs associés [Urinary incontinence after endoscopic enucleation of the prostate with the Holmium laser: Evolutionary aspects and associated predictive factors]. Prog Urol 33(4):198–206. 10.1016/j.purol.2022.10.006 Yang M, Huang Y, Gao F, He L, Yu X, Yu Q (2024) Meta-analysis of postoperative urinary incontinence incidence and risk factors in HoLEP. Ther Adv Urol 16:17562872241281578 Published 2024 Sep 20. 10.1177/17562872241281578 Schwalenberg T, Neuhaus J, Dartsch M, Weissenfels P, Löffler S, Stolzenburg JU (2010) Funktionelle Anatomie des männlichen Kontinenzmechanismus [Functional anatomy of the male continence mechanism]. Urologe A 49(4):472–480. 10.1007/s00120-010-2262-3 Coakley FV, Eberhardt S, Kattan MW, Wei DC, Scardino PT, Hricak H (2002) Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol 168(3):1032–1035. 10.1016/S0022-5347(05)64568-5 Endo F, Shiga Y, Minagawa S et al (2010) Anteroposterior dissection HoLEP: a modification to prevent transient stress urinary incontinence. Urology 76(6):1451–1455. 10.1016/j.urology.2010.03.071 Saitta G, Becerra JEA, Del Álamo JF et al (2019) En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol 37(11):2451–2458. 10.1007/s00345-019-02671-4 Taha T, Savin Z, Lifshitz K, Veredgorn Y, Mendelson T, Bar-Yosef Y, Yossepowitch O, Sofer M (2023) Mini-HoLEP (MILEP) vs HoLEP: a propensity score-matched analysis. World J Urol 41(10):2801–2807. 10.1007/s00345-023-04562-1 Epub 2023 Aug 25. PMID: 37626182 Houssin V, Olivier J, Brenier M et al (2021) Predictive factors of urinary incontinence after holmium laser enucleation of the prostate: a multicentric evaluation. World J Urol 39(1):143–148. 10.1007/s00345-020-03169-0 Walker SM, Turkbey B (2020) Role of mpMRI in Benign Prostatic Hyperplasia Assessment and Treatment. Curr Urol Rep 21(12):55 Published 2020 Oct 26. 10.1007/s11934-020-01005-x Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Jan, 2026 Read the published version in World Journal of Urology → Version 1 posted Editorial decision: Revision requested 04 Nov, 2025 Reviews received at journal 01 Nov, 2025 Reviewers agreed at journal 01 Nov, 2025 Reviewers agreed at journal 26 Oct, 2025 Reviews received at journal 26 Oct, 2025 Reviewers agreed at journal 25 Oct, 2025 Reviews received at journal 23 Oct, 2025 Reviewers agreed at journal 23 Oct, 2025 Reviewers invited by journal 23 Oct, 2025 Editor assigned by journal 03 Oct, 2025 Submission checks completed at journal 03 Oct, 2025 First submitted to journal 26 Sep, 2025 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. 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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-7723381","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":539035384,"identity":"82b08b48-ce9a-4cad-b533-f64ac8d6a047","order_by":0,"name":"Nick Lee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACZiBkKGBg4IeLsBOlxYCBQbIBxEsAixBhD0iLwQFitZizMz82YDCwkTO+kZ34uPDHPTn+ZgbGDz/waLFsZjNOYDBIMza7kbvZeEZCsbHEYQZmyR48WgwO8zAfAJKJ227kbpPmSUhIbDjMwMbAQ1jL//rNMyBa6ucDtTD+IaAF6LADCQYSEC0JBkAtzPhtYTM2SDBINpxx5u1mY560BMONhxmbpWXwaTl/+LHEhwo7ef723I2PeWwS5OWONx/8+AaPFjBIQOUyNhDSMApGwSgYBaOAAAAALm9ChrdqvnYAAAAASUVORK5CYII=","orcid":"","institution":"Centre Hospitalier de l’Université de Montréal","correspondingAuthor":true,"prefix":"","firstName":"Nick","middleName":"","lastName":"Lee","suffix":""},{"id":539035385,"identity":"2c474a1c-623a-4ca7-9498-fe6474d2deee","order_by":1,"name":"Tarek Benzouak","email":"","orcid":"","institution":"McGill University","correspondingAuthor":false,"prefix":"","firstName":"Tarek","middleName":"","lastName":"Benzouak","suffix":""},{"id":539035386,"identity":"79e99f97-8bcd-46d1-8a2e-175b90eaebcb","order_by":2,"name":"David-Dan Nguyen","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"David-Dan","middleName":"","lastName":"Nguyen","suffix":""},{"id":539035387,"identity":"6b2e29ba-cab8-47ea-b6c6-c5475307dbd1","order_by":3,"name":"Sébastien Belliveau","email":"","orcid":"","institution":"Centre Hospitalier de l’Université de Montréal","correspondingAuthor":false,"prefix":"","firstName":"Sébastien","middleName":"","lastName":"Belliveau","suffix":""},{"id":539035388,"identity":"8be32206-6491-4bdb-b9be-c5bada295e30","order_by":4,"name":"Liam Murad","email":"","orcid":"","institution":"McGill University","correspondingAuthor":false,"prefix":"","firstName":"Liam","middleName":"","lastName":"Murad","suffix":""},{"id":539035389,"identity":"a12147bd-c391-419e-8d16-dbf5e1dfc9d3","order_by":5,"name":"Lynda Kadi","email":"","orcid":"","institution":"Université de Montréal","correspondingAuthor":false,"prefix":"","firstName":"Lynda","middleName":"","lastName":"Kadi","suffix":""},{"id":539035390,"identity":"00cdfd96-6179-4c8c-a16b-9dedac5f45b2","order_by":6,"name":"Nathan Perlis","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Nathan","middleName":"","lastName":"Perlis","suffix":""},{"id":539035391,"identity":"a523713b-a735-41e1-9ccf-c974f0fe4932","order_by":7,"name":"Rodney H. Breau","email":"","orcid":"","institution":"Ottawa Hospital Research Institute, University of Ottawa","correspondingAuthor":false,"prefix":"","firstName":"Rodney","middleName":"H.","lastName":"Breau","suffix":""},{"id":539035392,"identity":"2e5ae5fd-7616-49f1-bf67-3b65b96819cf","order_by":8,"name":"Dean Elterman","email":"","orcid":"","institution":"University of Toronto","correspondingAuthor":false,"prefix":"","firstName":"Dean","middleName":"","lastName":"Elterman","suffix":""},{"id":539035393,"identity":"7c9d0250-714d-4393-a652-ada15d81ff62","order_by":9,"name":"Bilal Chughtai","email":"","orcid":"","institution":"Northwell Health","correspondingAuthor":false,"prefix":"","firstName":"Bilal","middleName":"","lastName":"Chughtai","suffix":""},{"id":539035394,"identity":"03ac92b5-bb80-4dd7-acbf-2c01100d9a15","order_by":10,"name":"Dan R. Gralnek","email":"","orcid":"","institution":"University of Wisconsin School of Medicine and Public Health","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"R.","lastName":"Gralnek","suffix":""},{"id":539035395,"identity":"e8e68d3e-633f-444e-acdd-e62e0a973276","order_by":11,"name":"Damien Olivié","email":"","orcid":"","institution":"Université de Montréal","correspondingAuthor":false,"prefix":"","firstName":"Damien","middleName":"","lastName":"Olivié","suffix":""},{"id":539035396,"identity":"42b1d0cd-4223-4e66-a58e-1c72f3c3ec6a","order_by":12,"name":"Malek Meskawi","email":"","orcid":"","institution":"Centre Hospitalier de l’Université de Montréal","correspondingAuthor":false,"prefix":"","firstName":"Malek","middleName":"","lastName":"Meskawi","suffix":""},{"id":539035397,"identity":"5e1ab6e7-5885-44b4-baed-6c093d61e875","order_by":13,"name":"Cristina Negrean","email":"","orcid":"","institution":"Centre Hospitalier de l’Université de Montréal","correspondingAuthor":false,"prefix":"","firstName":"Cristina","middleName":"","lastName":"Negrean","suffix":""},{"id":539035398,"identity":"21e10829-6153-45c6-84a6-87ef9d37d31f","order_by":14,"name":"Naeem Bhojani","email":"","orcid":"","institution":"Centre Hospitalier de l’Université de Montréal","correspondingAuthor":false,"prefix":"","firstName":"Naeem","middleName":"","lastName":"Bhojani","suffix":""}],"badges":[],"createdAt":"2025-09-26 15:53:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7723381/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7723381/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00345-026-06232-4","type":"published","date":"2026-01-30T15:58:28+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":95228469,"identity":"a90b903e-0097-4fb2-a13a-ea517bb03493","added_by":"auto","created_at":"2025-11-05 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06:30:32","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":107984,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7723381/v1/9da35b101560a2d687341481.html"},{"id":95170947,"identity":"cf1b9b6d-880a-4350-8b76-e497a120385b","added_by":"auto","created_at":"2025-11-05 06:30:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":14363,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssociations between membranous urethral length and predicted probability of post-operative SUI at 1, 3, and 6 months\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7723381/v1/b8f96ecb2c2ba193d513729d.png"},{"id":95170950,"identity":"5ac2fb45-d1fe-4d40-bcfa-761289ebce01","added_by":"auto","created_at":"2025-11-05 06:30:32","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":238028,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eInternal validation of multivariable models for predicting SUI at 1, 3, and 6 months: calibration plots (a-c) and decision curve analyses (d-f)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7723381/v1/92ec4a32a00cc20c39a9e711.png"},{"id":101690455,"identity":"b653a2f2-ca21-4c8e-80f0-54a369d02b0c","added_by":"auto","created_at":"2026-02-02 16:03:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":868404,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7723381/v1/8429c40b-ea32-437f-9d14-c51331590848.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Membranous Urethral Length as a Predictor for Urinary Incontinence After Holmium Enucleation of the Prostate for Benign Prostatic Hyperplasia","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBenign prostatic hyperplasia (BPH) is a highly prevalent condition worldwide, particularly among aging men [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It is often associated with lower urinary tract symptoms (LUTS), which may significantly reduce patients\u0026rsquo; quality of life (QoL). Over the years, growing evidence has established holmium laser enucleation of the prostate (HoLEP) as an effective and safe treatment for BPH, regardless of prostate size and volume, with extremely durable outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHoLEP involves endoscopic enucleation of prostatic lobes from the surgical capsule in retrograde fashion using a high powered holmium:YAG laser, followed by hemostasis and tissue morcellation [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. When compared to transurethral resection of the prostate (TURP), HoLEP patients have superior improvements in LUTS with lower perioperative morbidity and lower retreatment rates at 7-year long-term follow-up [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. A prospective study comparing outcomes between HoLEP and simple prostatectomy demonstrated similar functional results at 2-year follow-up, with reduced blood loss, catheterization rates, and hospital stay in HoLEP patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, one of the main complications following HoLEP is post-operative stress urinary continence (SUI) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. While most cases resolve within the first 3 to 6 months, it can have a significantly negative impact on QoL and plays an important role in guiding treatment decisions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe membranous urethral length (MUL), defined as the segment of urethra between the prostate apex and the penile bulb, can play an important role for certain prostate-related functional outcomes [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. For instance, in patients undergoing radical prostatectomy (RP) for prostate cancer, studies have demonstrated a significant association between longer preoperative MUL on magnetic resonance imaging (MRI) and post-operative return to continence [\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, the association between MUL and continence in patients undergoing HoLEP for BPH, has not yet been described in depth.\u003c/p\u003e\u003cp\u003eThe objective of this study is to describe the association between preoperative MUL measured on multiparametric prostate MRI and post-operative continence in patients undergoing HoLEP for BPH.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatients\u003c/h2\u003e\u003cp\u003eThis is an observational retrospective study approved by the Institutional Review Board at the Centre Hospitalier de l\u0026rsquo;Universit\u0026eacute; de Montr\u0026eacute;al (2025\u0026ndash;12665). A total of 147 consecutive patients undergoing HoLEP for BPH by two fellowship-trained, highly experienced urologists (N.B. and M.M.) at the Centre Hospitalier de l\u0026rsquo;Universit\u0026eacute; de Montr\u0026eacute;al between 2018 and 2024 were included. All the data was collected retrospectively. Inclusion criteria were adult males who had a clinical, radiological, and/or biochemical diagnosis of BPH, who underwent subsequent HoLEP, and who had an available preoperative multiparametric prostate MRI. Patients who had a previous prostate surgery, had been diagnosed with prostate cancer or had histological evidence of prostate cancer on enucleated tissue specimens, had a previous history of SUI, or had symptoms of acute/chronic prostatitis, a positive urine culture, and/or a Foley catheter at the moment of MRI were excluded.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcomes\u003c/h3\u003e\n\u003cp\u003ePreoperative baseline characteristics included age, patient comorbidities (diabetes mellitus, hypertension, chronic obstructive pulmonary disease), body mass index, last available serum prostate-specific antigen (PSA) value, and preoperative medication (5-alpha reductase inhibitors, anticholinergic bladder medication, β3-adrenergic agonist bladder medication). Perioperative data included duration of the HoLEP procedure. Post-operative outcomes included the presence or absence of SUI, defined as the use of \u0026ge; 1 pads at 1, 3, and 6 months post-operatively.\u003c/p\u003e\n\u003ch3\u003eMRI measures\u003c/h3\u003e\n\u003cp\u003eMRI parameters were assessed independently by a fellowship-trained radiologist (D.O.) and a urologist with experience in interpreting and measuring multiparametric prostate MRI (C.N.), both of whom were blinded to the SUI outcomes. Any differences in MUL measurement exceeding 4mm, which corresponds to the thickness of one slice of MRI at our institution, was remeasured together by both parties. MUL measurement was performed using a standardized and reproducible method described in the literature and having previously demonstrated high intra- and inter-observer agreement [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Sagittal T2 and coronal T2-weighted planes were used to measure MUL.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll statistical analyses were performed using R statistical software (Version 4.3.2) within the RStudio environment (Build 563). Descriptive statistics were used for patient characteristics. Continuous variables were reported as mean or median with associated standard deviation (SD) or interquartile range (IQR) as appropriate. Categorical variables were reported as counts and percentages. Binary logistic regression was used to model the association between MUL measurements and post-operative incontinence at 1, 3, and 6 months. Multivariable models adjusted for potential confounders, including age at time of MRI, body mass index, last available PSA, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, use of 5-alpha reductase inhibitors, use of bladder medication, and surgery duration [\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Results were reported as odds ratios (OR) with associated 95% confidence intervals (CI). A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for all analyses. Observations with missing data in any variable included in a specific model were excluded via listwise deletion.\u003c/p\u003e\u003cp\u003eTo evaluate the internal validity of the predictive models, internal validity testing was performed for each time point. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC) with corresponding 95% confidence intervals. Calibration was examined by comparing predicted probabilities with observed outcomes to determine the degree of agreement between model estimates and actual risk. Clinical utility was further evaluated through decision curve analysis to quantify the net benefit of the models across a range of clinically relevant risk thresholds.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 147 participants were included in the analysis. Baseline demographic, clinical, and imaging characteristics are summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The median age at the time of MRI was 66.0 years (IQR 60.0\u0026ndash;70.0), and most of the sample was overweight (median body mass index 26.0, IQR 24.0\u0026ndash;30.0). Preoperative MRI measurements indicated a median MUL of 8.2mm (IQR 6.1\u0026ndash;11.0). Post-operative SUI showed a decreasing trend with time as incidence decreased from 73 (49.7%) at 1 month, to 36 (24.5%) at 3 months, and finally to 16 (10.9%) at 6 months.\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBaseline characteristics, perioperative data, and post-operative outcomes\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003cp\u003e(N\u0026thinsp;=\u0026thinsp;147)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMedian (IQR) or Frequency (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMembranous Urethral Length (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8.2 (6.1\u0026ndash;11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProstate Width (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.0 (56.0\u0026ndash;67.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProstate Length (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53.0 (47.0\u0026ndash;58.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProstate Height (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e72.0 (63.0\u0026ndash;78.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProstate Volume (g)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e125.4 (94.6-158.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years, at time of MRI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e66.0 (60.0\u0026ndash;70.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBody Mass Index (kg/m\u003csup\u003e2)\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26.0 (24.0\u0026ndash;30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003cp\u003eChronic Obstructive Pulmonary Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e19 (12.9%)\u003c/p\u003e\n \u003cp\u003e54 (36.7%)\u003c/p\u003e\n \u003cp\u003e13 (8.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMedication\u003c/p\u003e\n \u003cp\u003e5-Alpha Reductase Inhibitors\u003c/p\u003e\n \u003cp\u003eBladder Medication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003e69 (46.9%)\u003c/p\u003e\n \u003cp\u003e18 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eProstate-Specific Antigen (ng/mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e7.9 (5.1\u0026ndash;11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSurgery Duration (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e102.0 (78.0-119.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eMUL and Post-Operative SUI\u003c/h2\u003e\n \u003cp\u003eIn the univariable analysis, longer MUL was significantly associated with lower odds of SUI at 1 month (OR: 0.89, 95% CI: 0.81\u0026ndash;0.97, p\u0026thinsp;=\u0026thinsp;0.012). This association remained statistically significant in the multivariable model, in which each mm increase in MUL predicted a 13.9% reduction in the likelihood of SUI at 1 month (OR: 0.86, 95% CI: 0.77\u0026ndash;0.96, p\u0026thinsp;=\u0026thinsp;0.009). Among the adjusted covariates, longer surgery duration was significantly associated with increased odds of 1-month SUI (OR: 1.02, 95% CI: 1.00-1.03, p\u0026thinsp;=\u0026thinsp;0.029).\u003c/p\u003e\n \u003cp\u003eSimilarly, longer MUL was associated with significantly lower odds of SUI at 3 months in the univariable model (OR: 0.81, 95% CI: 0.71\u0026ndash;0.93, p\u0026thinsp;=\u0026thinsp;0.003), as well as in the multivariable analysis. Each mm increase was associated with a 23.1% reduction in the probabilities of SUI at 3 month follow up (OR: 0.77, 95% CI: 0.65\u0026ndash;0.91, p\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e\n \u003cp\u003eLower incontinence rates at 6 months were also significantly associated with longer MUL in the univariable analysis (OR\u0026thinsp;=\u0026thinsp;0.71, 95% CI: 0.56\u0026ndash;0.91 p\u0026thinsp;=\u0026thinsp;0.006). In the fully adjusted multivariable model, MUL remained a strong predictor, with each mm increase corresponding to a 35.0% decrease in the odds of 6-month SUI (OR: 0.65, 95% CI: 0.49\u0026ndash;0.87 p\u0026thinsp;=\u0026thinsp;0.004). No other covariates were significantly associated with 6-month incontinence in the multivariable model. Multivariate associations between MUL size and incontinence across all three time periods is further presented in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cp\u003eTo assess the performance of these multivariable models, we performed an internal validation for each time point (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). The model for 1-month SUI demonstrated acceptable discrimination with an area under the curve (AUC) of 0.73 (95% CI: 0.65\u0026ndash;0.82). Decision curve analysis confirmed its clinical utility across a wide range of risk thresholds from approximately 5% to 65%. The model predicting 3-month SUI performed similarly, with an AUC of 0.75 (95% CI: 0.66\u0026ndash;0.85) and provided a net benefit for risk thresholds up to 30%. The model\u0026rsquo;s predictive capacity was strongest for the 6-month outcome, achieving excellent discrimination (AUC 0.83, 95% CI: 0.72\u0026ndash;0.94) and demonstrating clinical utility for risk thresholds as high as 50%. At all time points, the models appeared well-calibrated, with good agreement between predicted probabilities and observed outcomes.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study looks at the association between the membranous urethra and post-operative SUI in patients undergoing HoLEP for BPH. We observed, through adjusted and unadjusted models, that longer MUL on preoperative MRI is a significant protective factor against SUI at 1, 3, and 6 months post-operatively.\u003c/p\u003e\u003cp\u003eThe cohort had an overweight profile, while diabetes mellitus, hypertension, and chronic obstructive pulmonary disease were present in less than one third of patients. These findings are consistent with previously documented risk factors for BPH including obesity, metabolic syndrome, and possibly chronic obstructive pulmonary disease [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eMUL and post-operative continence\u003c/h3\u003e\n\u003cp\u003eWe observed a significant association between longer MUL and lower SUI following HoLEP at 1, 3, and 6 months post-operatively. To our knowledge, very few studies in the literature have assessed this relationship. A recent study observed that longer MUL is significantly associated with reduced incontinence risk at 1 month, where MUL\u0026thinsp;\u0026lt;\u0026thinsp;14mm are at nearly 4-fold increased odds of incontinence [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Two studies in Japan determined that longer preoperative MUL was independently associated with lower rates of incontinence at 1 and 3 months post-operatively, while there was no difference at 6 months [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our findings are consistent with these studies and extend these observations by revealing a sustained association at 6 months, while further demonstrating internal validity of our models. A last study identified membranous urethral volume as a protective factor against post-operative incontinence at 1 month, while no significant association was found with MUL [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Our median MUL was 8.2mm, which is relatively shorter compared to values described in previous series, which may reflect differences in patient populations or imaging methodology across institutions [\u003cspan additionalcitationids=\"CR13 CR14 CR15\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Nonetheless, despite these lower absolute values, the prognostic association between MUL and SUI outcomes were consistent with these series, supporting the robustness and generalizability of our findings.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eStress Urinary Incontinence following HoLEP\u003c/h2\u003e\u003cp\u003eThe incidence of transient SUI following HoLEP can vary between 5.3% and 43.1% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The rate of SUI progressively decreases over time following surgery, with most cases resolving within six months. Other studies have reported rates of incontinence up to 43.1%, 15.0%, and 7.4% at 1 month, 3 months, and 6 months, respectively [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26 CR27\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Our results similarly revealed a decreasing trajectory in incontinence rates over time. Risk factors for the development of transient SUI include older age, obesity, diabetes mellitus, greater preoperative prostate volume/specimen weight, and longer operative time [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Longer enucleation and morcellation time are directly associated with larger prostate volume and a history of urinary tract infection or retention [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn men, urinary continence is maintained by the internal and external sphincters, composed of smooth and skeletal muscle, respectively [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A longer MUL potentially indicates a more robust external sphincter, offering more resistance to intraoperative trauma, partial excision, or excessive stretching [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This mechanism also explains the same association which has been described for patients undergoing RP for prostate cancer [\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. HoLEP also requires a wider range of motion compared to TURP, leading to an increased risk of intraoperative manipulation and damage to the sphincters by the sheath of the scope [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Some techniques that help minimize trauma include the use of smaller scopes, anteroposterior dissection, which separates the sphincter from the urethra, thus preserving the internal sphincter, as well as early apical release, which can reduce traction and trauma to the external sphincter [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. HoLEP procedures are associated with a steeper learning curve and often require additional training or fellowship experience. Surgeon experience is directly associated with post-operative SUI outcomes [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In our study, both urologists are fellowship-trained and have extensive experience operating in high-volume, quaternary care centers, so the results of the study were minimally influenced by surgical technique.\u003c/p\u003e\u003cp\u003eThe role of MRI in the preoperative assessment of patients undergoing BPH surgery remains limited. In fact, in our own study, the indication for MRI in all patients were to rule out a suspicion of prostate cancer, and preoperative MRI is not routinely performed prior to HoLEP cases at our institution. Still, many patients who undergo prostate MRI for this reason go on to receive a subsequent therapy for BPH [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. MRI has the potential to be useful in both the pre-procedural workup and the post-treatment evaluation of BPH [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. We believe that the use of MRI will become more prevalent and pertinent, especially in a context where some variables such as the MUL can provide predictive value on post-operative outcomes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis study has limitations that should be considered. The retrospective design potentially introduces selection bias and unmeasured confounding variables. Although we adjusted for key covariates, residual confounding from unaccounted factors (e.g. urodynamic parameters, pelvic floor muscle function) may influence the observed associations. The relatively small sample size and single-center nature of the study may limit generalizability. Furthermore, the definition of post-operative SUI relied on clinical documentation rather than standardized questionnaires, which may lead to misclassification bias. As preoperative MRI is not routinely performed prior to HoLEP cases at our institution, this could introduce selection bias. The lack of long-term follow-up beyond six months precludes assessment of persistent SUI. While the models appear well-calibrated, the precision of this assessment is limited by the sample size, as reflected in the wide confidence intervals on the calibration plots. Finally, the exclusion of patients with prior prostate surgery or prostate cancer may limit the applicability of findings to broader populations. Future prospective, multicenter studies incorporating urodynamic assessments and longer standardized follow-up are needed to validate these findings and enhance clinical utility.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that pre-operative MUL as measured on MRI is a significant and independent predictor of post-operative SUI following HoLEP for BPH, with longer MUL associated with lower SUI rates at 1, 3, and 6 months. These findings suggest that MUL assessment may enhance preoperative counseling and surgical planning, particularly in patients at higher risk for incontinence.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNick Lee: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eTarek Benzouak: Data collection or management, Data analysis, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eDavid-Dan Nguyen: Data collection or management, Data analysis, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eS\u0026eacute;bastien Belliveau: Data collection or management, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eLiam Murad: Data collection or management, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eLynda Kadi: Data collection or management\u003c/p\u003e\n\u003cp\u003eNathan Perlis: Data collection or management, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eRodney H. Breau: Data analysis, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eDean Elterman: Data collection or management, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eBilal Chughtai: Data collection or management, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eDan R. Gralnek: Data collection or management, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eDamien Olivi\u0026eacute;: Data collection or management, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eMalek Meskawi: Data collection or management, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eCristina Negrean: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003eNaeem Bhojani: Protocol/project development, Data collection or management, Data analysis, Manuscript writing/editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the contributing authors have any competing interests or conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript. There is no funding or financial support to declare. This study does not involve human participants or animals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclarations of interest:\u003c/strong\u003e none.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGBD 2019 Benign Prostatic Hyperplasia Collaborators (2022) The global, regional, and national burden of benign prostatic hyperplasia in 204 countries and territories from 2000 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Healthy Longev 3(11):e754\u0026ndash;e776. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S2666-7568(22)00213-6\u003c/span\u003e\u003cspan address=\"10.1016/S2666-7568(22)00213-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTamalunas A, Westhofen T, Schott M et al (2022) Holmium laser enucleation of the prostate: A truly size-independent method? [published correction appears in Low Urin Tract Symptoms. ;14(5):405. doi: 10.1111/luts.12458.]. \u003cem\u003eLow Urin Tract Symptoms\u003c/em\u003e. 2022;14(1):17\u0026ndash;26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/luts.12404\u003c/span\u003e\u003cspan address=\"10.1111/luts.12404\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGilling P (2008) Holmium laser enucleation of the prostate (HoLEP). BJU Int 101(1):131\u0026ndash;142. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1464-410X.2007.07341.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1464-410X.2007.07341.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuntz RM, Ahyai S, Lehrich K, Fayad A (2004) Transurethral holmium laser enucleation of the prostate versus transurethral electrocautery resection of the prostate: a randomized prospective trial in 200 patients. J Urol 172(3):1012\u0026ndash;1016. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.ju.0000136218.11998.9e\u003c/span\u003e\u003cspan address=\"10.1097/01.ju.0000136218.11998.9e\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMontorsi F, Naspro R, Salonia A et al (2004) Holmium laser enucleation versus transurethral resection of the prostate: results from a 2-center, prospective, randomized trial in patients with obstructive benign prostatic hyperplasia. J Urol 172(5 Pt 1):1926\u0026ndash;1929. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.ju.0000140501.68841.a1\u003c/span\u003e\u003cspan address=\"10.1097/01.ju.0000140501.68841.a1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTan AH, Gilling PJ, Kennett KM, Frampton C, Westenberg AM, Fraundorfer MR (2003) A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams). J Urol 170(4 Pt 1):1270\u0026ndash;1274. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/01.ju.0000086948.55973.00\u003c/span\u003e\u003cspan address=\"10.1097/01.ju.0000086948.55973.00\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGilling PJ, Wilson LC, King CJ, Westenberg AM, Frampton CM, Fraundorfer MR (2012) Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. BJU Int 109(3):408\u0026ndash;411. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1464-410X.2011.10359.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1464-410X.2011.10359.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNaspro R, Suardi N, Salonia A et al (2006) Holmium laser enucleation of the prostate versus open prostatectomy for prostates\u0026thinsp;\u0026gt;\u0026thinsp;70 g: 24-month follow-up. Eur Urol 50(3):563\u0026ndash;568. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eururo.2006.04.003\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2006.04.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDas AK, Teplitsky S, Chandrasekar T et al (2020) Stress Urinary Incontinence post-Holmium Laser Enucleation of the Prostate: a Single-Surgeon Experience. Int Braz J Urol 46(4):624\u0026ndash;631. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/S1677-5538.IBJU.2019.0411\u003c/span\u003e\u003cspan address=\"10.1590/S1677-5538.IBJU.2019.0411\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVavassori I, Valenti S, Naspro R et al (2008) Three-year outcome following holmium laser enucleation of the prostate combined with mechanical morcellation in 330 consecutive patients. Eur Urol 53(3):599\u0026ndash;604. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eururo.2007.10.059\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2007.10.059\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVeerman H, Hagens MJ, Hoeks CM et al (2023) A standardized method to measure the membranous urethral length (MUL) on MRI of the prostate with high inter- and intra-observer agreement. Eur Radiol 33(5):3295\u0026ndash;3302. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00330-022-09320-2\u003c/span\u003e\u003cspan address=\"10.1007/s00330-022-09320-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMac Curtain BM, Sugrue DD, Qian W, O'Callaghan M, Davis NF (2024) Membranous urethral length and urinary incontinence following robot-assisted radical prostatectomy: a systematic review and meta-analysis. BJU Int 133(6):646\u0026ndash;655. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/bju.16170\u003c/span\u003e\u003cspan address=\"10.1111/bju.16170\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMungovan SF, Sandhu JS, Akin O, Smart NA, Graham PL, Patel MI (2017) Preoperative Membranous Urethral Length Measurement and Continence Recovery Following Radical Prostatectomy: A Systematic Review and Meta-analysis. Eur Urol 71(3):368\u0026ndash;378. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eururo.2016.06.023\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2016.06.023\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evon Bodman C, Matsushita K, Savage C et al (2012) Recovery of urinary function after radical prostatectomy: predictors of urinary function on preoperative prostate magnetic resonance imaging. J Urol 187(3):945\u0026ndash;950. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.juro.2011.10.143\u003c/span\u003e\u003cspan address=\"10.1016/j.juro.2011.10.143\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePaparel P, Akin O, Sandhu JS et al (2009) Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral fibrosis measured by preoperative and postoperative endorectal magnetic resonance imaging. Eur Urol 55(3):629\u0026ndash;637. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.eururo.2008.08.057\u003c/span\u003e\u003cspan address=\"10.1016/j.eururo.2008.08.057\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNegrean C, Alam A, Hickling D et al (2025) Preoperative Magnetic Resonance Imaging Membranous Urethral Length as a Predictor of Urinary Continence After Radical Prostatectomy: A Systematic Review and Meta-analysis. \u003cem\u003eEur Urol Focus\u003c/em\u003e. Published online March 6. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.euf.2025.02.002\u003c/span\u003e\u003cspan address=\"10.1016/j.euf.2025.02.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eParsons JK (2007) Modifiable risk factors for benign prostatic hyperplasia and lower urinary tract symptoms: new approaches to old problems. J Urol 178(2):395\u0026ndash;401. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.juro.2007.03.103\u003c/span\u003e\u003cspan address=\"10.1016/j.juro.2007.03.103\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeng YH, Huang CW, Liao WC et al (2017) Association between chronic obstructive pulmonary disease and increased risk of benign prostatic hyperplasia: a retrospective nationwide cohort study. BMJ Open 7(6):e015581 Published 2017 Jun 23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmjopen-2016-015581\u003c/span\u003e\u003cspan address=\"10.1136/bmjopen-2016-015581\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElmansy HM, Kotb A, Elhilali MM (2011) Is there a way to predict stress urinary incontinence after holmium laser enucleation of the prostate? J Urol 186(5):1977\u0026ndash;1981. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.juro.2011.06.063\u003c/span\u003e\u003cspan address=\"10.1016/j.juro.2011.06.063\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWu SW, Tseng CS, Yuan LH et al (2024) Prospective study of urinary incontinence recovery following endoscopic enucleation of the prostate. BJU Int 134(5):818\u0026ndash;825. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/bju.16475\u003c/span\u003e\u003cspan address=\"10.1111/bju.16475\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMonn MF, El Tayeb M, Bhojani N et al (2015) Predictors of Enucleation and Morcellation Time During Holmium Laser Enucleation of the Prostate. Urology 86(2):338\u0026ndash;342. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.urology.2015.04.028\u003c/span\u003e\u003cspan address=\"10.1016/j.urology.2015.04.028\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOka S, Kobayashi K, Matsuda K, Takai K (2020) Significance of Membranous Urethral Length for Recovery From Postoperative Urinary Incontinence Following Holmium Laser Enucleation of the Prostate. Int Neurourol J 24(4):358\u0026ndash;364. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.5213/inj.2040042.021\u003c/span\u003e\u003cspan address=\"10.5213/inj.2040042.021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSmani S, Khan AI, Choksi AU et al (2025) Can Anatomical Measurements on Preoperative Pelvic Magnetic Resonance Imaging Predict Postoperative Urinary Incontinence after Holmium Laser Enucleation of the Prostate? J Endourol 39(7):731\u0026ndash;737. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1089/end.2025.0006\u003c/span\u003e\u003cspan address=\"10.1089/end.2025.0006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUeki H, Takahashi K, Yasufuku T, Yuen K, Yamashita M (2020) Is the membranous urethral length related to postoperative urinary incontinence after holmium laser enucleation of the prostate? Int J Urol 27(10):893\u0026ndash;898. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/iju.14322\u003c/span\u003e\u003cspan address=\"10.1111/iju.14322\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFan X, Zhang J, Zhu H, Huang F, Shadike A, Jiang C (2024) Predictive factors of stress urinary incontinence after Holmium Laser Enucleation of the Prostate: a magnetic resonance imaging-based retrospective study. Transl Androl Urol 13(9):1775\u0026ndash;1785. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/tau-24-71\u003c/span\u003e\u003cspan address=\"10.21037/tau-24-71\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElsaqa M, Zhang Y, Papaconstantinou H, Tayeb MME (2023) Incidence and predictors of urinary incontinence rates post-holmium laser enucleation of prostate. Low Urin Tract Symptoms 15(5):185\u0026ndash;190. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/luts.12494\u003c/span\u003e\u003cspan address=\"10.1111/luts.12494\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYe OD, Tadrist A, Di Crocco E, Karsenty G, Toledano H (2023) Incontinence urinaire post \u0026eacute;nucl\u0026eacute;ation endoscopique de la prostate au laser Holmium: aspects \u0026eacute;volutifs et facteurs pr\u0026eacute;dictifs associ\u0026eacute;s [Urinary incontinence after endoscopic enucleation of the prostate with the Holmium laser: Evolutionary aspects and associated predictive factors]. Prog Urol 33(4):198\u0026ndash;206. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.purol.2022.10.006\u003c/span\u003e\u003cspan address=\"10.1016/j.purol.2022.10.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang M, Huang Y, Gao F, He L, Yu X, Yu Q (2024) Meta-analysis of postoperative urinary incontinence incidence and risk factors in HoLEP. Ther Adv Urol 16:17562872241281578 Published 2024 Sep 20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/17562872241281578\u003c/span\u003e\u003cspan address=\"10.1177/17562872241281578\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchwalenberg T, Neuhaus J, Dartsch M, Weissenfels P, L\u0026ouml;ffler S, Stolzenburg JU (2010) Funktionelle Anatomie des m\u0026auml;nnlichen Kontinenzmechanismus [Functional anatomy of the male continence mechanism]. Urologe A 49(4):472\u0026ndash;480. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00120-010-2262-3\u003c/span\u003e\u003cspan address=\"10.1007/s00120-010-2262-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCoakley FV, Eberhardt S, Kattan MW, Wei DC, Scardino PT, Hricak H (2002) Urinary continence after radical retropubic prostatectomy: relationship with membranous urethral length on preoperative endorectal magnetic resonance imaging. J Urol 168(3):1032\u0026ndash;1035. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/S0022-5347(05)64568-5\u003c/span\u003e\u003cspan address=\"10.1016/S0022-5347(05)64568-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEndo F, Shiga Y, Minagawa S et al (2010) Anteroposterior dissection HoLEP: a modification to prevent transient stress urinary incontinence. Urology 76(6):1451\u0026ndash;1455. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.urology.2010.03.071\u003c/span\u003e\u003cspan address=\"10.1016/j.urology.2010.03.071\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSaitta G, Becerra JEA, Del \u0026Aacute;lamo JF et al (2019) En Bloc' HoLEP with early apical release in men with benign prostatic hyperplasia. World J Urol 37(11):2451\u0026ndash;2458. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00345-019-02671-4\u003c/span\u003e\u003cspan address=\"10.1007/s00345-019-02671-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaha T, Savin Z, Lifshitz K, Veredgorn Y, Mendelson T, Bar-Yosef Y, Yossepowitch O, Sofer M (2023) Mini-HoLEP (MILEP) vs HoLEP: a propensity score-matched analysis. World J Urol 41(10):2801\u0026ndash;2807. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00345-023-04562-1\u003c/span\u003e\u003cspan address=\"10.1007/s00345-023-04562-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003eEpub 2023 Aug 25. PMID: 37626182\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHoussin V, Olivier J, Brenier M et al (2021) Predictive factors of urinary incontinence after holmium laser enucleation of the prostate: a multicentric evaluation. World J Urol 39(1):143\u0026ndash;148. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00345-020-03169-0\u003c/span\u003e\u003cspan address=\"10.1007/s00345-020-03169-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWalker SM, Turkbey B (2020) Role of mpMRI in Benign Prostatic Hyperplasia Assessment and Treatment. Curr Urol Rep 21(12):55 Published 2020 Oct 26. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11934-020-01005-x\u003c/span\u003e\u003cspan address=\"10.1007/s11934-020-01005-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Benign Prostatic Hyperplasia, Holmium Laser Enucleation of the Prostate, Magnetic Resonance Imaging, Membranous Urethral Length, Prostate Volume, Urinary Continence","lastPublishedDoi":"10.21203/rs.3.rs-7723381/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7723381/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eHolmium laser enucleation of the prostate (HoLEP) is as an effective, size-independent treatment for benign prostatic hyperplasia (BPH) with durable outcomes. However, one of its adverse outcomes is post-operative stress urinary incontinence (SUI). We sought to determine if membranous urethral length (MUL) as measured on preoperative magnetic resonance imaging is a predictor for post-operative SUI in patients undergoing HoLEP for BPH.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA single-center, retrospective observational study was conducted on 147 consecutive patients who underwent HoLEP for BPH between 2018 and 2024. Preoperative baseline characteristics, perioperative details, and SUI outcomes at 1, 3, and 6 months were collected. Binary logistic regression was used to assess the association between MUL and SUI at each follow-up interval.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eMedian MUL was 8.2mm (IQR 6.1\u0026ndash;11.0), and post-operative SUI incidences were 73 (49.7%), 36 (24.5%), and 16 (10.9%) at 1, 3, and 6 months respectively. Longer MUL was significantly associated with lower odds of SUI at 1 month (OR: 0.86, 95% CI: 0.77\u0026ndash;0.96, p\u0026thinsp;=\u0026thinsp;0.009), 3 months (OR: 0.77, 95% CI: 0.65\u0026ndash;0.91, p\u0026thinsp;=\u0026thinsp;0.002), and 6 months (OR: 0.65, 95% CI: 0.49\u0026ndash;0.87, p\u0026thinsp;=\u0026thinsp;0.004). Internal validation demonstrated good discrimination (areas under the curve of 0.73, 0.75, and 0.83 at 1, 3, and 6 months) with well-calibrated models, and decision curve analysis confirmed clinical utility within prespecified risk thresholds.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eLonger MUL is significantly associated with lower rates of SUI following HoLEP at 1, 3, and 6 months. Longer MUL may serve as a valuable predictive factor for continence recovery and should be considered during preoperative counseling and surgical decision planning.\u003c/p\u003e","manuscriptTitle":"Membranous Urethral Length as a Predictor for Urinary Incontinence After Holmium Enucleation of the Prostate for Benign Prostatic Hyperplasia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-05 06:30:28","doi":"10.21203/rs.3.rs-7723381/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-04T12:38:23+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-01T16:08:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149765376650035972368751311711903123140","date":"2025-11-01T11:38:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285351209854072780096719695065632718103","date":"2025-10-26T06:51:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-26T04:04:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237656624948910677154974513683829921706","date":"2025-10-26T03:22:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-23T13:47:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62870420980215883882106507052850567637","date":"2025-10-23T13:20:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-23T11:53:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-04T00:53:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-03T16:20:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"World Journal of Urology","date":"2025-09-26T15:46:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"world-journal-of-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"wjur","sideBox":"Learn more about [World Journal of Urology](https://link.springer.com/journal/345)","snPcode":"345","submissionUrl":"https://submission.nature.com/new-submission/345/3","title":"World Journal of Urology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"57bcd96e-dc19-4418-bcec-60a12ce067b0","owner":[],"postedDate":"November 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T16:01:00+00:00","versionOfRecord":{"articleIdentity":"rs-7723381","link":"https://doi.org/10.1007/s00345-026-06232-4","journal":{"identity":"world-journal-of-urology","isVorOnly":false,"title":"World Journal of Urology"},"publishedOn":"2026-01-30 15:58:28","publishedOnDateReadable":"January 30th, 2026"},"versionCreatedAt":"2025-11-05 06:30:28","video":"","vorDoi":"10.1007/s00345-026-06232-4","vorDoiUrl":"https://doi.org/10.1007/s00345-026-06232-4","workflowStages":[]},"version":"v1","identity":"rs-7723381","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7723381","identity":"rs-7723381","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}