Stesura Seveso Archivio Italiano di Urologia e Andrologia 2022; 94, 2174 ORIGINAL PAPER No conflict of interest declared. symptoms (slow stream, splitting or spraying, intermit- tency, hesitancy, straining, terminal dribbling) and stor- age symptoms (day-time urinary frequency, nocturia, urgency, urinary incontinence) (3). These LUTS are among the most common clinical com- plaints in adult men with reported increasing prevalence with aging (4). The storage LUTS may also be termed overactive bladder (OAB) symptoms and are largely encompassed by the term overactive bladder syndrome (OABS) (5). While the voiding symptoms are usually more prevalent, the storage symptoms are almost always more bothersome (6). Associated with a significant bur- den on both patients and society, these LUTS also have a major impact on patients’ quality of life (QoL) (7). As such, the American Urological Association (AUA) has devel- oped the International Prostate Symptom Score (IPSS) as one of the most reliable tools to evaluate the severity of LUTS associated with BPH which, in turn, plays a major role in determining the most appropriate treatment option for BPH (8-10). After being the preferred surgical treatment for BPH patients for more than 30 years, transurethral resection of prostate (TURP) has been replaced by holmium laser enu- cleation of prostate (HoLEP) as the gold standard surgical treatment for BPH (5, 11, 12). Introduced in 1995, HoLEP is a minimally invasive surgi- cal procedure that has become the first line treatment of BPH as it provides both effective and safe surgical treat- ment option for BPH without any size limitation, although at the expense of occasional complications (11, 13, 14). HoLEP has the advantage of enucleating the enlarging BPH adenoma without destroying the bladder neck thus relieving bladder outflow obstruction (BOO) immediately, safely, and effectively (5). Although improvement in both storage and voiding LUTS has been demonstrated after either medical treatment with an alpha-blocker or a 5-alpha-reductase inhibitor or surgical treatment with TURP for BPH patients, few stud- ies have been made to measure the outcomes of HoLEP in BPH-related voiding and/or storage LUTS (11). We performed our study with the aim to evaluate and compare the effectiveness and safety of HoLEP in reliev- ing either voiding or storage LUTS in BPH patients. Objective: To evaluate and compare the effectiveness and safety of holmium laser enucleation of prostate (HoLEP) in relieving either voiding or storage lower urinary tract symptoms (LUTS) in benign prostat- ic hyperplasia (BPH) patients. Materials and methods: The charts of patients with BPH who underwent HoLEP for either predominant voiding or predomi- nant storage LUTS at University of Cincinnati hospitals in the period between February 2015 and December 2020 were retro- spectively reviewed and analyzed for changes in voiding sympto- matology, storage symptomatology, hematuria, International Prostate Symptom Score (IPSS), peak flow rates (Qmax), pres- ence of detrusor overactivity (DO), and post-voiding residual urine (PVR) from baseline to up to 6 months postoperatively. Results: A total of 132 patients were included in the analysis. Patients were divided into two groups: Group 1 included BPH patients with predominant voiding LUTS (68 Patients) while group 2 involved those with predominant storage LUTS (64 Patients). HoLEP was equally effective in management of both groups with significant improvement in urodynamics study (UDS) parameters, patient voiding and storage symptomatology, and IPSS from preoperatively to up to 6 months postoperatively with relatively low procedure complication rate and postopera- tive need for medication or procedure. Conclusions: HoLEP is a safe, effective, and reliable minimally invasive surgical modality that can be relied on for BPH patients with either predominant voiding or predominant storage symp- toms with relatively low procedure complication rate and post- operative need for medication or procedure. KEY WORDS: Holmium Laser Enucleation of Prostate (HoLEP); Benign Prostatic Hyperplasia (BPH); Lower Urinary Tract Symptoms (LUTS). Submitted 28 March 2022; Accepted 14 May 2022 INTRODUCTION Benign prostatic hyperplasia (BPH) is a common condition affecting a large number of men over the age of 50 years and is the major cause of the highly prevalent lower uri- nary tract symptoms (LUTS) in men of this age group that often necessitate surgical intervention (1, 2). The LUTS associated with BPH are generally divided into voiding Is Holmium Laser Enucleation of Prostate equally effective in management of benign prostatic hyperplasia patients with either voiding or storage lower urinary tract symptoms? A comparative study Mostafa M. Mostafa 1, 2, Nilesh Patil 1, Mahmoud Khalil 2, Mohammed A. Elgammal 2, Ayman Mahdy 1 1 Division of Urology, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati (US); 2 Asiut University Hospitals, Asiut, Egypt. DOI: 10.4081/aiua.2022.2.174 Summary 175Archivio Italiano di Urologia e Andrologia 2022; 94, 2 HoLEP for voiding or storage LUTS MATERIALS AND METHODS After our study protocol approval by University of Cincinnati Institutional Review Board (IRB ID:2021-0666), we started reviewing the charts of all patients who under- went HoLEP at University of Cincinnati hospitals in the period between February 2015 and December 2020. All patients had routine initial evaluation with complete med- ical history, digital rectal examination (DRE), IPSS ques- tionnaire, urinalysis, serum creatinine level, determination of serum prostate-specific antigen (PSA) when needed, tran- srectal ultrasonography (TRUS), peak flow rate (Qmax), post- voiding residual urine (PVR), and urodynamic study (UDS) before proceeding to any surgical intervention. Our inclusion criteria included patients with BPH who underwent HoLEP for either predominant voiding or pre- dominant storage LUTS. We excluded patients who underwent the procedure for BPH with concomitant bladder stones and/or neurogenic bladder. We also excluded patients with predominant storage LUTS along with PVR of 150 ml or more, patients taking medications that may mimic or aggravate the LUTS such as antidepressants, diuretics, bronchodilators, anticholinergics, sympathomimetics, and antihistamines (15), and those having uncontrolled diabetes mellitus (DM) or recurrent urinary tract infections (UTIs). For proper allocation of patients to either of our two com- parative groups (BPH patients with predominant voiding symptoms versus those with predominant storage symp- toms), we used the principal indication for surgical inter- vention as determined by both subjective and objective parameters as the main allotment tool. Regarding the sub- jective parameters, we analyzed nine symptoms in all patients and categorized them into two main categories in order to determine the type of patient predominant symptomatology: storage symptoms (frequency, urgency, nocturia, and urinary incontinence) and voiding symp- toms (hesitancy, intermittency, terminal dribbling, strain- ing, and urinary retention) (3). We also analyzed hema- turia, a relevant symptom that is not specific for either group. Analysis of symptoms was performed by the attending physician at the patient’s first presentation via asking the patient an open-ended question about the patient’s main complaint that urged him to seek medical care followed by closed-ended or binary questions to confirm the absence of the other relevant symptoms. Additionally, to both confirm the proper allocation of each patient to the pertinent group and avoid reporting bias, we used UDS as an objective parameter. As such, we identified patients with predominant voiding symptoms as those who reported their voiding symptoms as the more bothersome, whose voiding symptoms were the main drive for intervention, and whose UDS showed a predominant obstructive pattern with urodynamic evi- dence of BOO (BOO index > 40 using ICS nomogram (16). On the other hand, patients with predominant stor- age symptoms were defined as those who identified their storage symptoms as the more bothersome, who had no history of urinary retention, whose storage symptoms were the only indication for intervention, and whose UDS showed a predominant OAB pattern with volume to first contraction less than 350 mL and DO (involuntary detru- sor contraction ≥ 10 cm H2O) (17). All the cases included were performed by one highly skilled surgeon in the procedure (AM) to avoid the inter- ference of below optimum surgical skills or learning curve complications in our results. Treatment efficacy, which was the primary outcome, was evaluated by comparing the preoperative UDS parameters, patient symptomatology, and IPSS with their postoperative counterparts. UDS parameters (Qmax, PVR, and demonstra- tion of DO) were reported twice: at baseline and at the 6- month follow-up visit. We collected and compared them between the two groups. Patient voiding symptomatology, storage symptomatology, hematuria, and IPSS were report- ed at baseline, 3-month, and 6-month postoperatively. We also collected, analyzed, and compared them between the two groups. For the secondary outcome (treatment safety), any reported complication within the first 6 post- operative months was collected and analyzed. We also collected, analyzed, and compared the postoperative need for medication (antimuscarinic alone or antimus- carinic+ beta-3 agonist) or procedure (Botox injection, urethral dilatation, or open prostatectomy) within the first 6 postoperative months between the two groups. Table 1. Demographic and baseline characteristics of the studied groups. Figure 1. Flowchart on inclusion and exclusion steps. Variables Group 1 (n = 68) Group 2 (n = 64) P-value Age (years) Mean ± SD 75.2 ± 6.1 74.9 ± 5.5 0.767 BMI (kg/m2) Mean ± SD 25.6 ± 2.68 25.6 ± 1.2 0.916 Ethnicity White 26 (38.2%) 26 (40.0%) 0.214 Black/African American 30 (44.1%) 20 (31.3%) Hispanic 12 (17.6%) 18 (28.1%) Smoking 32 (47.1%) 30 (46.9%) 0.983 Diabetes mellitus 26 (38.2%) 30 (46.9%) 0.315 Heart failure 25 (36.8%) 21 (32.8%) 0.634 Hypertension 37 (54.4%) 33 (51.6%) 0.743 SD: Standard deviation. Archivio Italiano di Urologia e Andrologia 2022; 94, 2 M.M. Mostafa, N. Patil, M. Khalil, M.A. Elgammal, A. Mahdy 176 Statistical analysis All statistical analyses were conducted using the IBM SPSS software package version 20.0 (Armonk, NY: IBM Corp). Quantitative variables are presented as means ± standard deviation, and qualitative variables are expressed as fre- quencies with percentages. Results were compared between two groups using Student’s t-test and Mann- Whitney U test for quantitative variables and chi-square test and McNemar’s test for qualitative variables. A P-value of < 0.05 was considered significant. RESULTS In total, 132 patients met the inclusion criteria, had com- plete follow-up data in their charts with preoperative and postoperative documentation of various voiding and stor- age symptomatology, IPSS, and UDS parameters and were included in our study. We allocated these patients into two groups: Group 1 (68 patients) included those with predominant voiding symptoms while group 2 (64 patients) involved those with predominant storage symp- toms (Figure 1). Demographic and baseline characteristics of the studied groups The median age was 75.2 ± 6.1 and 74.9 ± 5.5 years for groups 1 and 2, respectively with no significant differ- ences in demographic and baseline characteristics between the two groups (Table 1). UDS parameters of the studied groups The mean preoperative peak flow rates (Qmax) were 8.6 ± 2 and 12.5 ± 1.9 for groups 1 and 2, respectively with a significant increase in Qmax postoperatively with p-value of increase of < 0.001 for both groups. With reference to DO, there was a remarkable decrease in the presence of DO after the procedure in both groups (4 out of 16 patients and 12 out of 64 patients with preop- erative DO for groups 1 and 2, respectively) with signifi- cantly higher decrease in DO after the procedure in group 2 (p-value = < 0.001) than in group 1 (p-value = 0.008). As to post-voiding residual urine (PVR), there was a significant decrease in PVR after HoLEP in both groups with p-value of improvement of < 0.001 for both groups (Table 2). Patient symptomatology of the studied groups There was a significant decrease in the frequency of the 4 studied storage symptoms and the 5 studied voiding symptoms in both groups from preoperatively to both 3- and 6- month postoperatively. Eleven (16.2%) and Seven (10.9%) patients from groups 1 and 2, respectively had preoperative hematuria that was completely alleviated after HoLEP (Table 3). IPSS of the studied groups The mean preoperative IPSS was 28.4 ± 3.4 and 26.9 ± 3 for groups 1 and 2, respectively, and there was significant decrease in IPSS from preoperatively to both 3- and 6- month postoperatively in both studied groups with p- value of decrease of < 0.001. Interestingly, even though the preoperative IPSS was significantly higher in group 1 than in group 2 (p-value = 0.010), there was non-signifi- cant difference in the decrease in IPSS between both groups at both 3-month follow-up (p-value = 0.842) and 6-month follow-up (p-value = 0.483) (Table 4). Procedure complication rate and postoperative need for medication or procedure in the studied groups There was no significant difference between the studied groups as regarding procedure complication rate and postoperative need for medication or procedure. The most encountered complication was urinary tract infection occurring in 22 (32.4%) and 14 (21.9%) group 1 and 2 patients, respectively followed by urinary incon- tinence, bleeding, urethral stricture, and finally residual prostatic tissue. Most patients didn’t require postopera- tive medication or procedure with only 10.3% and 4.4% of group 1 patients and 23.4% and 4.7% group 2 patients requiring postoperative medica- tion and procedure, respectively (Table 5). DISCUSSION To the best of our knowledge, we performed the first large study comparing the outcomes of HoLEP in BPH patients with predominant voiding symptoms and those with predominant storage symptoms in subjective outcomes (patient symptomatol- ogy and IPSS), objective out- comes (UDS parameters), proce- dure complication rate and post- operative need for medication or procedure. Our study confirms that HoLEP is associated with significant improvement in UDS Table 2. Changes in urodynamic study (UDS) parameters at 6-month postoperatively and comparison with preoperatively. Variables Group 1 (n = 68) Group 2 (n = 64) P-value Peak flow rate (Qmax) Preoperatively (Mean ± SD) 8.6 ± 2 12.5 ± 1.9 < 0.001 (ml/s) 6-month Postoperatively (Mean ± SD) 14.2 ± 2.4 15.6 ± 1.7 < 0.001 P-value from preoperatively to 6-month postoperatively < 0.001 < 0.001 Increase (Mean ± SD) 5.6 ± 2.2 3.1 ± 1.9 < 0.001 Detrusor over Preoperatively activity (DO) No 52 (76.5%) 0 (0%) < 0.001 Yes 16 (23.5%) 64 (100%) 6-month postoperatively No 64 (94.1%) 52 (81.3%) 0.024 Yes 4 (5.9%) 12 (18.8%) P-value from preoperatively to 6-month postoperatively 0.008 < 0.001 Post-voiding Preoperatively (Mean ± SD) 239.4 ± 69.7 104.7 ± 22.6 < 0.001 residual urine 6-month Postoperatively (Mean ± SD) 53.7 ± 26.9 48.3 ± 15.3 0.156 (PVR) (ml) P-value from preoperatively to 6-month postoperatively < 0.001 < 0.001 Decrease (Mean ± SD) 185.7 ± 72.1 56.4 ± 24.86 < 0.001 SD: Standard deviation. 177Archivio Italiano di Urologia e Andrologia 2022; 94, 2 HoLEP for voiding or storage LUTS parameters, patient storage and voiding symptomatology, and IPSS from preoperatively to both 3- and 6- month postoperatively with remarkably low procedure compli- cation rate and postoperative need for either medication or procedure and with similar efficacy in BPH patients with either predominant voiding or predominant storage symptoms. Vavassori et al. performed a study evaluating outcomes of HoLEP in 330 consecutive patients and reported signifi- cant improvement in Qmax, IPSS, and QoL after 3-year follow-up with 8.5% of their patients having postopera- tive transient irritative symptoms, 7.3% having transient postoperative urinary incontinence, and 2.7% having persistent BOO requiring reoperation (18). Our results confirm the reported improvement in Qmax and IPSS and the possibility of transient postoperative irritative symp- toms or urinary incontinence after HoLEP. However, we also noted significant improvement in both PVR and DO and com- parable efficacy in management of both voiding and storage LUTS after HoLEP. Pyun et al performed a study to compare the outcomes of HoLEP between 3 groups: BOO-only, BOO with detrusor underactivity (DU), and BOO with DO and concluded that the improvement in the IPSS and Qmax was higher in the BOO-only group than in the BOO with DO and BOO with DU groups (19). In contrast to their results, our results confirm that HoLEP has a comparable efficacy in manage- ment of BPH patients with either predominant voiding or predom- inant storage symptoms with sig- nificant improvement in UDS parameters, patient symptoma- tology, and IPSS in both groups of patients, and we can assume that the difference between our results can be attributed to the fact that they had significantly higher number of patients in the BOO-only group (138 patients) compared to BOO with DO group (56 patients) and BOO with DU group (33 patients) and that they included a group hav- ing DU in the comparison denoting including patients with late stage bladder dysfunction in their study. Besides, we would like to point that it is better to compare the preop- erative with the postoperative Qmax for each of the studied groups rather than the degree of increase in Qmax between the studied groups because the lower the Qmax, the higher the room for increase. For example, in our study, the Qmax was preoperatively significantly lower in group 1 having recurrent attacks of urinary retention, and so, although there was a higher increase in Qmax after HoLEP in group 1, the postoperative Qmax was still higher in group 2. Jeong et al. conducted a study to evaluate the effect of the presence of preoperative detrusor overactivity on the functional outcomes of HoLEP and concluded that although the storage symptoms improved in patients who had preoperative DO and those who did not, a significant Table 3. Changes in patient symptomatology at 3- and 6- month postoperatively and comparison with preoperatively Variables Group 1 (n = 68) Group 2 (n = 64) P-value Storage symptoms Frequency Preoperatively 24 (35.3%) 54 (84.4%) < 0.001 3-month postoperatively 9 (13.2%) 24 (37.5%) 0.001 6-month postoperatively 6 (8.8%) 16 (25%) 0.013 P-value from preoperatively to 3-and 6-month postoperatively < 0.001 <0.001 Urgency Preoperatively 19 (27.9%) 53 (82.8%) < 0.001 3-month postoperatively 9 (13.2%) 19 (29.7%) 0.021 6-month postoperatively 3 (4.4%) 8 (12.5%) 0.093 P-value from preoperatively to 3-and 6-month postoperatively < 0.001 < 0.001 Nocturia Preoperatively 30 (44.1%) 52 (81.3%) < 0.001 3-month postoperatively 12 (17.6%) 26 (40.6%) 0.004 6-month postoperatively 6 (8.8%) 6 (9.4%) 0.912 P-value from preoperatively to 3-and 6-month postoperatively < 0.001 < 0.001 Urinary incontinence Preoperatively 8 (11.8%) 38 (59.4%) < 0.001 3-month postoperatively 2 (2.9%) 9 (14.1%) 0.021 6-month postoperatively 0 (0%) 3 (4.7%) 0.111 P-value from preoperatively to 3-and 6-month postoperatively 0.006 < 0.001 Voiding symptoms Hesitancy Preoperatively 54 (79.4%) 10 (15.6%) < 0.001 3-month postoperatively 16 (23.5%) 5 (7.8%) 0.014 6-month postoperatively 8 (11.8%) 2 (3.1%) 0.098 P-value from preoperatively to 3-and 6-month postoperatively < 0.001 0.047 Intermittency Preoperatively 52 (76.5%) 8 (12.5%) < 0.001 3-month postoperatively 16 (23.5%) 4 (6.3%) 0.006 6-month postoperatively 5 (7.4%) 0 (0%) 0.058 P-value from preoperatively to 3-and 6-month postoperatively < 0.001 0.018 Terminal dribbling Preoperatively 56 (82.4%) 10 (15.6%) < 0.001 3-month postoperatively 22 (32.4%) 4 (6.3%) < 0.001 6-month postoperatively 5 (7.4%) 1 (1.6%) 0.209 P-value from preoperatively to 3-and 6-month postoperatively < 0.001 0.011 Straining Preoperatively 50 (73.5%) 24 (37.5%) < 0.001 3-month postoperatively 34 (50%) 15 (23.4%) 0.002 6-month postoperatively 9 (13.2%) 6 (9.4%) 0.485 P-value from preoperatively to 3-and 6-month postoperatively < 0.001 < 0.001 Urinary retention Preoperatively 68 (100%) 0 (0%) < 0.001 3-month postoperatively 1 (1.5%) 0 (0%) 1.000 6-month postoperatively 0 (0%) 0 (0%) – P-value from preoperatively to 3-and 6-month postoperatively < 0.001 – Hematuria Preoperatively 11 (16.2%) 7 (10.9%) 0.381 3-month postoperatively 2 (2.9%) 1 (1.6%) 1.000 6-month postoperatively 0 (0%) 0 (0%) – P-value from preoperatively to 3-and 6-month postoperatively < 0.001 0.005 Archivio Italiano di Urologia e Andrologia 2022; 94, 2 M.M. Mostafa, N. Patil, M. Khalil, M.A. Elgammal, A. Mahdy 178 number of those who had preoperative DO required post- operative anticholinergics (11). We agree with their results that patients with preoperative DO on UDS would require transient postoperative anticholinergic therapy and can add that there is significant improvement in both voiding and storage symptoms after HoLEP in patients with and without preoperative DO on UDS. Study limitations The retrospective nature of the study and the absence of comparative groups including patients who underwent other BPH procedures to compare the effectiveness and complication rate of HoLEP with those of other BPH pro- cedures can affect the generalizability of our results. Although we would have preferred to use the IPSS void- ing subscore (IPSS-V) and the IPSS storage subscore (IPSS-S) rather than the total IPSS (IPSS-T) to facilitate assignment of the patients to either of the two groups, we could not do so as we retrospectively reviewed the charts of patients after the IPSS-T rather than the IPSS-V and IPSS-S had already been calculated at the time of the patients’ visits. However, we used both subjective and objective parameters to compensate for the lack of data regarding the IPSS subscores and to ensure the proper allocation of patients to the relevant study groups. CONCLUSIONS HoLEP is a safe and reliable minimally invasive surgical modality with reported significant improvement in both subjective (measured by patients’ symptomatology and IPSS) and objective (measured by UDS parameters) aspects associated with BPH. It is highly efficient in alle- viating both voiding and storage symptoms and can be resorted to whether the patient is suffering from predom- inant voiding or predominant storage symptoms. Moreover, the procedure complication rate and postoper- ative need for medication or procedure are relatively low. REFERENCES 1. Porreca A, D'Agostino D, Vigo M, et al. "In-bore" MRI prostate biopsy is a safe preoperative clinical tool to exclude significant prostate cancer in symptomatic patients with benign prostatic obstruction before transurethral laser enucleation. Arch Ital Urol Androl. 2020; 91:224-9. 2. Lee YJ, Oh SA, Kim SH, Oh SJ. Patient satisfaction after holmium laser enucleation of the prostate (HoLEP): A prospective cohort study. PLoS One. 2017; 12:e0182230. 3. Gratzke C, Schlenker B, Seitz M, et al. Complications and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: results of a prospective multicenter study. 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Group 1 (n = 68) Group 2 (n = 64) P-value IPSS Preoperatively (Mean ± SD) 28.4 ± 3.4 26.9 ± 3 0.010 3-month postoperatively (Mean ± SD) 19.9 ± 5.2 18.3 ± 4.3 0.061 6-month postoperatively (Mean ± SD) 12.3 ± 5.7 10.3 ± 5.1 0.036 P-value from preoperatively to 3- and 6-month postoperatively < 0.001 < 0.001 Decrease in IPSS From preoperatively to 3-month postoperatively (Mean ± SD) 8.5 ± 3.8 8.6 ± 3.4 0.842 From preoperatively to 6-month postoperatively (Mean ± SD) 16 ± 4.6 16.6 ± 4.7 0.483 SD: Standard deviation. Table 5. Comparison of procedure complication rate and postoperative need for medication or procedure within the first 6 postoperative months between the two groups. Variables Group 1 (n = 68) Group 2 (n = 64) P-value Residual prostatic tissue 1 (1.5%) 0 (0%) 1.000 Bleeding 7 (10.3%) 4 (6.3%) 0.401 Urinary Tract Infection 22 (32.4%) 14 (21.9%) 0.177 Urinary incontinence 5 (7.4%) 7 (10.9%) 0.474 Urethral stricture 2 (2.9%) 1 (1.6%) 1.000 Postoperative need for medication 0.128 No 61 (89.7%) 49 (76.6%) Antimuscarinic alone 5 (7.4%) 11 (17.2%) Antimuscarinic + Beta-3 Agonist 2 (2.9%) 4 (6.2%) Postoperative need for procedure 0.466 No 65 (95.6%) 61 (95.3%) Botox 0 (0%) 2 (3.1%) Urethral dilatation 2 (2.9%) 1 (1.6%) Open prostatectomy 1 (1.5%) 0 (0%) 179Archivio Italiano di Urologia e Andrologia 2022; 94, 2 HoLEP for voiding or storage LUTS functional outcomes after Holmium laser enucleation of the prostate in patients with benign prostatic obstruction. Urology. 2015; 86:133-8. 12. Schiavina R, Bianchi L, Giampaoli M, et al. 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Clinical efficacy of transurethral resection of the prostate combined with oral anti- cholinergics or botulinum toxin - A injection to treat benign prostat- ic hyperplasia with overactive bladder: a case-control study. Clin Pharmacol. 2020; 12:75-81. 18. Vavassori I, Valenti S, Naspro R, et al. Three-year outcome fol- lowing holmium laser enucleation of the prostate combined with mechanical morcellation in 330 consecutive patients. Eur Urol. 2008; 53:599-604. 19. Pyun JH, Kang SG, Kang SH, et al. Efficacy of holmium laser enu- cleation of the prostate (HoLEP) in men with bladder outlet obstruction (BOO) and non-neurogenic bladder dysfunction. Kaohsiung J Med Sci. 2017; 33:458-63. Correspondence Mostafa M. Mostafa, MD (Corresponding Author) mostafmm@ucmail.uc.edu Research Fellow of Urology, Division of Urology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267 Assistant Lecturer of Urology, Asiut University Hospitals, Asiut, Egypt Nilesh Patil, MD patilnh@ucmail.uc.edu Associate Professor of Urology, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH 45267 Mahmoud Khalil, MD mahmoud.magdy51@gmail.com Lecturer of Urology, Asiut University Hospitals, Asiut, Egypt Mohammed A. Elgammal, MD mohammedelgammal@aun.edu.eg Professor of Urology, Asiut University Hospitals, Asiut, Egypt Ayman Mahdy, MD, PhD, MBA mahdyan@uc.edu Chief of Urology, Professor of Urology, R. Bruce and Barbara Bracken Endowed Chair in Surgical Urology, Director of Voiding Dysfunction and Female Urology, Medical Director of Urology, the West Chester Hospital, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0589, Cincinnati, OH 45267