Intradetrusor OnabotulinumtoxinA Injections at the Time of Holmium Laser Enucleation of the Prostate for Men with Overactive Bladder Symptoms - Beyond the Abstract

Most men with benign prostatic hyperplasia (BPH) and severe storage symptoms are likely to experience an improvement in their storage symptoms in the first three to six months after surgical treatment of their BPH.1,2 Why then would one offer concurrent intradetrusor Onabotulinumtoxin A (OTA) at the time of surgical BPH treatment?

A retrospective study examining patient recovery after laser enucleation of the prostate demonstrated that improvements in objective incontinence scores may be delayed up to a year after treatment.3 Persistence of severe storage symptoms has been shown to be associated with poor quality of life after BPH surgery.4 In our opinion, any interventions that may alleviate severe storage symptoms in the first few months of laser enucleation recovery, have the potential to improve patient quality of life and their perceptions of procedural success.

Patients within our study were offered OTA concurrently at the time of holmium laser enucleation of the prostate (HoLEP) if they had urge incontinence requiring daily incontinence pads. Patients that received OTA concurrently with HoLEP did not appear to be negatively affected in their peri-operative or post-operative course. We hypothesize that a maximally decreased outlet resistance (associated with laser enucleation) contributed to the low rates of prolonged urinary retention (> 1 week) observed within the OTA + HoLEP cohort (0/41, 0%). In addition, intra-detrusor injections did not increase overall procedural time (59mins vs 55mins, p=0.2). Based on our experience and the findings of our study, we will continue to offer OTA injections to patients with severe storage symptoms who are set to undergo HoLEP after a shared discussion regarding the benefits, perceived risks, and costs.

The positive findings of our proof-of-concept study encourages further prospective evaluation of the effects of concurrent OTA at time of laser enucleation in men suffering from severe pre-operative urinary storage symptoms.

Written by: Nicholas Dean, MD, Mitchell Huang, MD, and Amy Krambeck, MD

Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA


  1. Kwon O, Lee HE, Bae J, Oh JK, Oh SJ. Effect of holmium laser enucleation of prostate on overactive bladder symptoms and urodynamic parameters: a prospective study. Urology. 2014;83(3):581-585.
  2. Gormley EA, Griffiths DJ, McCracken PN, Harrison GM, McPhee MS. Effect of transurethral resection of the prostate on detrusor instability and urge incontinence in elderly males. Neurourol Urodyn. 1993;12(5):445-453.
  3. Castellani D, Di Rosa M, Saredi G, et al. Change in Postoperative Storage Symptoms and De Novo Urge Incontinence After Thulium:YAG Laser Enucleation of the Prostate: Results from a Prospective Multicenter Study. J Endourol. 2022;36(9):1223-1230.
  4. Rassweiler J, Teber D, Kuntz R, Hofmann R. Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention. Eur Urol. 2006;50(5):969-980.
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