International Neurourology Journal 2016 20 59 68 Comparison

International Neurourology Journal 2016; 20: 59 -68 Comparison of Predictive Factors for Postoperative Incontinence of Holmium Laser Enucleation of the Prostate by the Surgeons’ Experience During Learning Curve Katsumi Shigemura, Kazushi Tanaka, Fukashi Yamamichi, Koji Chiba, Masato Fujisawa Division of Urology, Department of Organ Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine, Kobe, Japan This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http: //creativecommons. org/licenses/by-nc/3. 0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

International Neurourology Journal 2016; 20: 59 -68 PURPOSE • To detect predictive factors for postoperative incontinence following holmium laser enucleation of the prostate (Ho. LEP) according to surgeon experience (beginner or experienced) and preoperative clinical data.

International Neurourology Journal 2016; 20: 59 -68 Methods • Of 224 patients, a total of 203 with available data on incontinence were investigated. • The potential predictive factors for post-Ho. LEP incontinence included clinical factors, such as patient age, and preoperative urodynamic study results, including detrusor overactivity (DO). • We also classified the surgeons performing the procedure according to their Ho. LEP experience: beginner (<21 cases) and experienced (≥ 21 cases).

International Neurourology Journal 2016; 20: 59 -68 Results • Our statistical data showed DO was a significant predictive factor at the super-short period (the next day of catheter removal: odds ratio [OR], 3. 375; P=0. 000). • Additionally, patient age, surgeon mentorship (inverse correlation), and prostate volume were significant predictive factors at the 1 -month interval after Ho. LEP (OR, 1. 072; P=0. 004; OR, 0. 251; P=0. 002; and OR, 1. 008; P=0. 049, respectively). • With regards to surgeon experience, DO and preoperative International Prostate Symptom Score (inverse) at the super-short period, and patient age and mentorship (inverse correlation) at the 1 -month interval after Ho. LEP (OR, 3. 952; P=0. 002; OR, 1. 084; P=0. 015; and OR, 1. 084; P=0. 015; OR, 0. 358; P=0. 003, respectively) were significant predictive factors for beginners, and first desire to void (FDV) at 1 month after Ho. LEP (OR, 1. 009; P=0. 012) was a significant predictive factor for experienced surgeons in multivariate analysis.

International Neurourology Journal 2016; 20: 59 -68 Conclusions • Preoperative DO, IPSS, patient age, and surgeon mentorship were significant predictive factors of postoperative patient incontinence for beginner surgeons, while FDV was a significant predictive factors for experienced surgeons. • These findings should be taken into account by surgeons performing Ho. LEP to maximize the patient’s quality of life with regards to urinary continence.

International Neurourology Journal 2016; 20: 59 -68 Table 1. Patients’ characteristics (n=203) Characteristic Age (yr), median (range) Value 71 (34– 90) Prostate volume (m. L) 76. 1± 41. 1 Resected prostate weight (g) 52. 9± 35. 3 Surgical time (min) 172± 63. 4 Enucleation time (min) 113± 45. 3 Morcellation time (min) 29. 6± 28. 4 Surgeons, n (%) 　  Performed by experienced 84 (41. 4)  Performed by beginners 119 (58. 6) Prostate cancer, n (%) 16 (7. 88) Values are presented as mean±standard deviation unless otherwise indicated.

International Neurourology Journal 2016; 20: 59 -68 Table 2. Predictive factors for incontinence at 1 month after Ho. LEP in all surgeons Odds ratio 1. 038 Univariate 95% CI 0. 997– 1. 080 P-value 0. 067 Odds ratio 　 Preoperative IPSS 0. 987 0. 944– 1. 031 0. 551 　 　 　 Quality of life 0. 992 0. 687– 1. 434 0. 968 　 　 　 Operation time 1. 007 1. 003– 1. 012 0. 002* 0. 999 0. 988– 1. 011 0. 894 1. 009 0. 995– 1. 023 0. 216 Variable Age Multivariate 95% CI 　 P-value 　 Enucleation time 1. 010 1. 003– 1. 017 0. 003* Morcellation time 1. 008 0. 997– 1. 018 0. 141 　 　 　 Mentorship 0. 697 0. 367– 1. 323 0. 270 　 　 　 0. 997 0. 972– 1. 022 0. 815 Resected prostate weight 1. 009 1. 001– 1. 017 0. 036* Prostate volume 1. 007 1. 000– 1. 014 0. 049* 1. 006 0. 986– 1. 027 0. 546 MVP 1. 007 1. 000– 1. 014 0. 067 　 　 　 Compliance 0. 990 0. 980– 1. 000 0. 056 　 　 　 Detrusor overactivity 3. 336 1. 826– 6. 095 < 0. 000* 3. 375 1. 790– 6. 363 0. 000* Schafer 1. 171 0. 921– 1. 490 0. 198 　 　 　 First desire to void 0. 998 0. 994– 1. 002 0. 419 　 　 　 MCC 0. 998 0. 996– 1. 001 0. 136 　 　 　 Residual volume 1. 000 0. 997– 1. 002 0. 899 　 　 　 Ho. LEP, holmium laser enucleation of the prostate; CI, confidence interval; IPSS, International Prostate Symptom Score; MVP, maximum voiding pressure; MCC, maximum cystometric capacity. *P<0. 05, statistical significance.

International Neurourology Journal 2016; 20: 59 -68 Table 3. Predictive factors for incontinence at 1 month after Ho. LEP in all surgeons Odds ratio 1. 086 Univariate 95% CI 1. 036– 1. 137 P-value 0. 001* Preoperative IPSS 0. 975 0. 932– 1. 021 0. 281 　 　 　 Quality of life 0. 749 0. 517– 1. 086 0. 127 　 　 　 Operation time 1. 005 1. 000– 1. 009 0. 055 　 　 　 Enucleation time 1. 006 1. 000– 1. 013 0. 062 　 　 　 Morcellation time 1. 005 0. 995– 1. 016 0. 292 　 　 　 Mentorship 0. 225 0. 095– 0. 534 0. 001* 0. 251 0. 104– 0. 609 0. 002* Resected prostate weight 1. 008 1. 000– 1. 016 0. 057 　 　 　 Prostate volume 1. 008 1. 001– 1. 015 0. 024* 1. 008 1. 000– 1. 015 0. 049* MVP 1. 003 0. 995– 1. 010 0. 503 　 　 　 Compliance 0. 994 0. 985– 1. 004 0. 237 　 　 　 Detrusor overactivity 1. 055 0. 582– 1. 910 0. 861 　 　 　 Schafer 1. 027 0. 809– 1. 303 0. 829 　 　 　 First desire to void 1. 003 0. 999– 1. 008 0. 107 　 　 　 MCC 1. 001 0. 998– 1. 003 0. 637 　 　 　 Residual volume 1. 001 0. 999– 1. 004 0. 316 　 　 　 Variable Age Multivariate Odds ratio 95% CI 1. 072 1. 023– 1. 124 P-value 0. 004* Ho. LEP, holmium laser enucleation of the prostate; CI, confidence interval; IPSS, International Prostate Symptom Score; MVP, maximum voiding pressure; MCC, maximum cystometric capacity. *P<0. 05, statistical significance.

International Neurourology Journal 2016; 20: 59 -68 Table 4. Predictive factors for incontinence at 1 month after Ho. LEP in all surgeons Variable Age Univariate Odds ratio 95% CI 1. 053 0. 996– 1. 114 P-value 0. 071 Multivariate Odds ratio 95% CI P-value 　 　 　 Preoperative IPSS 1. 007 0. 951– 1. 067 0. 802 　 　 　 Quality of life 0. 943 0. 594– 1. 497 0. 803 　 　 　 Operation time 1. 003 0. 997– 1. 009 0. 291 　 　 　 Enucleation time 1. 001 0. 992– 1. 010 0. 849 　 　 　 Morcellation time 1. 004 0. 991– 1. 016 0. 581 　 　 　 Mentorship 0. 509 0. 184– 1. 406 0. 192 　 　 　 Resected prostate weight 1. 006 0. 996– 1. 016 0. 230 　 　 　 Prostate volume 1. 006 0. 998– 1. 015 0. 143 　 　 　 MVP 0. 996 0. 986– 1. 006 0. 407 　 　 　 Compliance 0. 997 0. 984– 1. 010 0. 681 　 　 　 Detrusor overactivity 1. 328 0. 601– 2. 932 0. 483 　 　 　 Schafer 0. 852 0. 633– 1. 147 0. 290 　 　 　 First desire to void 1. 005 1. 000– 1. 010 0. 047 1. 004 MCC 1. 001 0. 998– 1. 004 0. 496 　 　 　 Residual volume 1. 001 0. 998– 1. 004 0. 393 　 　 　 0. 992– 1. 016 0. 516 Ho. LEP, holmium laser enucleation of the prostate; CI, confidence interval; IPSS, International Prostate Symptom Score; MVP, maximum voiding pressure; MCC, maximum cystometric capacity. *P<0. 05, statistical significance.

International Neurourology Journal 2016; 20: 59 -68 Table 5. Predictive factors for incontinence at the next day of catheter removal after Ho. LEP in beginner surgeons Variable Univariate Multivariate Odds ratio 95% CI P-value Age 1. 021 0. 971– 1. 073 0. 422 　 　 　 Preoperative IPSS 0. 933 0. 879– 0. 990 0. 022* 0. 892 0. 828– 0. 962 0. 003* Quality of life 1. 113 0. 707– 1. 752 0. 643 　 　 　 Operation time 1. 003 0. 998– 1. 009 0. 257 　 　 　 Enucleation time 1. 003 0. 994– 1. 012 0. 490 　 　 　 Morcellation time 1. 003 0. 991– 1. 016 0. 585 　 　 　 Mentorship 0. 642 0. 305– 1. 350 0. 243 　 　 　 Resected prostate weight 1. 006 0. 995– 1. 018 0. 273 　 　 　 Prostate volume 1. 005 0. 994– 1. 015 0. 396 　 　 　 MVP 1. 009 1. 000– 1. 019 0. 055 　 　 　 Compliance 0. 991 0. 979– 1. 002 0. 118 　 　 　 Detrusor overactivity 3. 561 1. 568– 8. 089 0. 002* 7. 069 2. 235– 22. 358 0. 001* Schafer 1. 291 0. 922– 1. 807 0. 137 　 　 　 First desire to void 0. 994 0. 988– 1. 000 0. 044 0. 992 0. 980– 1. 004 0. 189 MCC 0. 996 0. 992– 0. 999 0. 019 1. 000 0. 993– 1. 007 0. 961 Residual volume 0. 999 0. 995– 1. 003 0. 504 　 　 　 Ho. LEP, holmium laser enucleation of the prostate; CI, confidence interval; IPSS, International Prostate Symptom Score; MVP, maximum voiding pressure; MCC, maximum cystometric capacity. *P<0. 05, statistical significance.

International Neurourology Journal 2016; 20: 59 -68 Table 6. Predictive factors for incontinence at 1 month after Ho. LEP in beginner surgeons Variable Univariate Odds ratio Multivariate 95% CI P-value Odds ratio 95% CI P-value 1. 084 1. 016– 1. 157 0. 015* Age 1. 099 1. 028– 1. 174 0. 005* Preoperative IPSS 0. 961 0. 900– 1. 026 0. 234 　 　 　 Quality of life 0. 818 0. 515– 1. 299 0. 395 　 　 　 Operation time 1. 004 0. 998– 1. 011 0. 169 　 　 　 Enucleation time 1. 007 0. 997– 1. 016 0. 172 　 　 　 Morcellation time 1. 001 0. 988– 1. 014 0. 855 　 　 　 Mentorship 0. 304 0. 127– 0. 730 0. 008* 0. 358 0. 145– 0. 883 0. 026* Resected prostate weight 1. 004 0. 992– 1. 016 0. 520 　 　 　 Prostate volume 1. 001 0. 990– 1. 013 0. 838 　 　 　 MVP 0. 999 0. 989– 1. 009 0. 880 　 　 　 Compliance 0. 995 0. 984– 1. 007 0. 404 　 　 　 Detrusor overactivity 1. 203 0. 531– 2. 727 0. 658 　 　 　 Schafer 0. 974 0. 700– 1. 356 0. 878 　 　 　 First desire to void 1. 000 0. 994– 1. 006 0. 926 　 　 　 MCC 0. 998 0. 995– 1. 002 0. 337 　 　 　 Residual volume 1. 000 0. 996– 1. 005 0. 852 　 　 　 Ho. LEP, holmium laser enucleation of the prostate; CI, confidence interval; IPSS, International Prostate Symptom Score; MVP, maximum voiding pressure; MCC, maximum cystometric capacity. *P<0. 05, statistical significance.

International Neurourology Journal 2016; 20: 59 -68 Table 7. Predictive factors for incontinence at 3 months after Ho. LEP in beginner surgeons Variable Univariate Multivariate Odds ratio 95% CI P-value Age 1. 064 0. 989– 1. 144 0. 099 　 　 　 Preoperative IPSS 0. 906 0. 828– 0. 991 0. 031* 0. 911 0. 834– 0. 996 0. 040* Quality of life 1. 081 0. 620– 1. 884 0. 784 　 　 　 Operation time 1. 008 1. 000– 1. 015 0. 046 1. 005 0. 994– 1. 016 0. 375 Enucleation time 1. 01 0. 998– 1. 021 0. 097 　 　 　 Morcellation time 1. 004 0. 990– 1. 019 0. 539 　 　 　 Mentorship 0. 573 0. 210– 1. 559 0. 276 　 　 　 Resected prostate weight 1. 005 0. 991– 1. 019 0. 499 　 　 　 Prostate volume 1. 002 0. 988– 1. 016 0. 767 　 　 　 MVP 1. 001 0. 989– 1. 013 0. 859 　 　 　 Compliance 1. 000 0. 989– 1. 011 0. 981 　 　 　 Detrusor overactivity 1. 071 0. 401– 2. 862 0. 891 　 　 　 Schafer 1. 090 0. 736– 1. 614 0. 668 　 　 　 First desire to void 1. 003 0. 996– 1. 009 0. 433 　 　 　 MCC 1. 002 0. 998– 1. 006 0. 454 　 　 　 Residual volume 1. 003 0. 998– 1. 008 0. 220 　 　 　 Ho. LEP, holmium laser enucleation of the prostate; CI, confidence interval; IPSS, International Prostate Symptom Score; MVP, maximum voiding pressure; MCC, maximum cystometric capacity. *P<0. 05, statistical significance.

International Neurourology Journal 2016; 20: 59 -68 Table 8. Predictive factors for incontinence at the next day of catheter removal after Ho. LEP in experienced surgeons Variable Univariate Multivariate Odds ratio 95% CI P-value Age 1. 067 0. 999– 1. 139 0. 053 　 　 　 Preoperative IPSS 0. 995 0. 925– 1. 072 0. 905 　 　 　 Quality of life 0. 775 0. 405– 1. 484 0. 442 　 　 　 Operation time 1. 016 1. 007– 1. 025 0. 001* 1. 004 0. 987– 1. 022 0. 625 Enucleation time 1. 023 1. 011– 1. 036 0. 000* 1. 017 0. 994– 1. 041 0. 152 Morcellation time 1. 017 0. 999– 1. 036 0. 071 　 　 　 0. 6 0. 425– 1. 024 0. 979 　 　 　 Resected prostate weight 1. 011 0. 999– 1. 023 0. 062 　 　 　 Prostate volume 1. 009 1. 000– 1. 019 0. 060 　 　 　 MVP 1. 003 0. 991– 1. 015 0. 612 　 　 　 Compliance 0. 988 0. 968– 1. 008 0. 242 　 　 　 Detrusor overactivity 3. 208 1. 288– 7. 992 0. 012* 2. 624 0. 964– 7. 138 0. 059 Schafer 1. 052 0. 743– 1. 487 0. 776 　 　 　 First desire to void 1. 004 0. 997– 1. 010 0. 236 　 　 　 MCC 1 0. 997– 1. 004 0. 773 　 　 　 Residual volume 1 0. 998– 1. 003 0. 747 　 　 　 Mentorship Ho. LEP, holmium laser enucleation of the prostate; CI, confidence interval; IPSS, International Prostate Symptom Score; MVP, maximum voiding pressure; MCC, maximum cystometric capacity. *P<0. 05, statistical significance.

International Neurourology Journal 2016; 20: 59 -68 Table 9. Predictive factors for incontinence at 1 month after Ho. LEP in experienced surgeons Variable Univariate Multivariate Odds ratio 95% CI P-value Age 0. 990 0. 930– 1. 053 0. 741 　 　 　 Preoperative IPSS 1. 017 0. 948– 1. 092 0. 632 　 　 　 Quality of life 1. 173 0. 623– 2. 210 0. 621 　 　 　 Operation time 1. 000 0. 993– 1. 008 0. 926 　 　 　 Enucleation time 1. 004 0. 994– 1. 014 0. 416 　 　 　 Morcellation time 0. 992 0. 972– 1. 013 0. 465 　 　 　 Mentorship 0. 733 0. 468– 1. 149 0. 979 　 　 　 Resected prostate weight 0. 995 0. 984– 1. 007 0. 454 　 　 　 Prostate volume 0. 997 0. 987– 1. 007 0. 528 　 　 　 MVP 1. 006 0. 994– 1. 019 0. 320 　 　 　 Compliance 1. 005 0. 987– 1. 023 0. 578 　 　 　 Detrusor overactivity 1. 705 0. 692– 4. 204 0. 246 　 　 　 Schafer 1. 098 0. 771– 1. 562 0. 605 　 　 　 First desire to void 1. 009 1. 002– 1. 017 0. 012* 　 　 　 MCC 1. 002 0. 999– 1. 005 0. 243 　 　 　 Residual volume 1. 000 0. 997– 1. 003 0. 877 　 　 　 Ho. LEP, holmium laser enucleation of the prostate; CI, confidence interval; IPSS, International Prostate Symptom Score; MVP, maximum voiding pressure; MCC, maximum cystometric capacity. *P<0. 05, statistical significance.

International Neurourology Journal 2016; 20: 59 -68 Table 10. Predictive factors for incontinence at 3 months after Ho. LEP in experienced surgeons Variable Univariate Multivariate Odds ratio 95% CI P-value Age 0. 956 0. 873– 1. 048 0. 335 　 　 　 Preoperative IPSS 0. 977 0. 881– 1. 083 0. 658 　 　 　 Quality of life 1. 261 0. 485– 3. 280 0. 634 　 　 　 Operation time 0. 990 0. 977– 1. 003 0. 123 　 　 　 Enucleation time 0. 984 0. 966– 1. 003 0. 096 　 　 　 Morcellation time 0. 994 0. 965– 1. 025 0. 709 　 　 　 Mentorship 0. 167 0. 088– 0. 316 0. 981 　 　 　 Resected prostate weight 0. 991 0. 971– 1. 011 0. 372 　 　 　 Prostate volume 0. 994 0. 977– 1. 010 0. 451 　 　 　 MVP 0. 988 0. 969– 1. 007 0. 216 　 　 　 Compliance 1. 003 0. 979– 1. 027 0. 795 　 　 　 Detrusor overactivity 0. 968 0. 269– 3. 482 0. 960 　 　 　 Schafer 0. 718 0. 427– 1. 208 0. 212 　 　 　 First desire to void 0. 995 0. 985– 1. 005 0. 343 　 　 　 MCC 0. 995 0. 989– 1. 002 0. 166 　 　 　 Residual volume 0. 996 0. 990– 1. 003 0. 300 　 　 　 Ho. LEP, holmium laser enucleation of the prostate; CI, confidence interval; IPSS, International Prostate Symptom Score; MVP, maximum voiding pressure; MCC, maximum cystometric capacity. *P<0. 05, statistical significance.