The procedures utilized were mixed and included 12 transurethral resection series, 2 plasma kinetic enucleation/transurethral vaporization series, and 16 laser enucleation series, including holmium enucleation, photoselective vaporization, and mixed approaches.
Multiple possible prognostic factors were examined, including baseline demographics such as age, body mass index, and smoking status; comorbidities such as diabetes, hypertension, and preoperative anxiety score; baseline preoperative symptom burden, including storage burden, mainly from the International Prostate Symptom Score (IPSS), voiding burden, and urinary retention; prostate characteristics, including total prostate volume, PSA, transition zone volume, transition zone index, and prostatic urethral angle; urodynamic factors, including detrusor overactivity with subtypes where possible, detrusor underactivity, bladder capacity by maximum cystometric and diary-based functional measures, bladder sensation, bladder contractility index, bladder outlet obstruction index, peak flow rate, detrusor pressure at peak flow, post-void residual, and combinations of various urodynamic factors; and urine biomarkers, when available, including nerve growth factor and matrix metalloproteinase-1.
A variable number of these factors were present in each series reviewed. Between-procedure comparisons were attempted, but no significant differences were found, and conclusions were limited by the relatively small numbers in some studies.
The authors concluded: “Current evidence is of limited quality; no preoperative factor demonstrated robust prognostic value. Older age and a greater storage symptom burden may be associated with persistence in some adjusted models, whilst urodynamic prognostic factors remain uncertain.”
The percentage of patients who fail to improve symptomatically after deobstruction procedures varies from report to report, with low and high estimates ranging from 20% to 50%. Improvement in storage symptoms is generally agreed to be slower and less consistent than improvement in voiding symptoms. Most such studies were based on symptoms after transurethral resection.
Paul Abrams and colleagues were among the first to report on such parameters. In 1979, they reported on 152 patients followed after transurethral resection. In that cohort, 75.5% were categorized as improved symptomatically with obstruction relieved; 16% as improved symptomatically with partial relief of obstruction; 4% as improved symptomatically but with obstruction unrelieved; 11% as unimproved symptomatically but with obstruction relieved; and 6% as unimproved symptomatically with obstruction unrelieved.
Frequency, defined as more than seven episodes, was reduced from 77% of patients to 24%. Nocturia, defined as more than once per night, decreased from 75% to 33%. Slow stream decreased from 86% to 8%, hesitancy from 66% to 6%, urgency from 49% to 20%, and urgency urinary incontinence from 27% to 10%.
In the patients treated in Bristol, 53% had preoperative detrusor overactivity; in the London patients, 71% had preoperative detrusor overactivity. Postoperatively, the corresponding percentages were 36% and 54%.
In a later report, Housami and Abrams cited reports of 25% to 30% of patients having an “unfavorable” outcome after prostatectomy, primarily due to storage symptomatology. In their analysis of patients with such an outcome, postoperative assessment showed detrusor overactivity in 24% to 63%, residual obstruction in 9% to 36%, detrusor underactivity in 9% to 55%, and “poor relaxation of the urethra” in 19%.
What does all of this mean? To me, it means that not every man has an excellent result after procedures intended to correct bladder outlet obstruction. It also means that the percentage of patients with persistent symptoms probably varies depending on whether the evaluation is based on someone else’s series or one’s own. Various factors could contribute, including:
- Infection
- Inflammation
- Detrusor overactivity
- Detrusor underactivity
- Small bladder capacity
- Persistent large residual urine volume
- Persistent or newly developed obstruction from prostatic tissue, bladder neck contracture, or urethral stricture
- Neurogenic disease
- Undoubtedly, other factors
Individual patient preferences regarding certain adverse events should also be considered. Full disclosure and shared decision-making are of primary importance in avoiding unhappy patients.
Written by: Alan Wein, MD, PhD, FACS, Professor of Clinical Urology, Department of Urology, Desai Sethi Urology Institute (DSUI), University of Miami Miller School of Medicine, University of Miami Health Systems, Miami, FL
References:
- Loufopoulos I, et al. Prognostic factors of persistent overactive bladder/storage symptoms following deobstruction surgery for benign prostatic enlargement in males: A systematic review. European Urology Focus. 2025. doi:10.1016/j.euf.2025.12.005.
- Kim SJ, et al. Lower urinary tract symptoms following transurethral resection of prostate. Current Urology Reports. 2008;19:85. doi:10.1007/s11934-018-08384.
- Abrams P, et al. The results of prostatectomy: A symptomatic and urodynamic analysis of 152 patients. Journal of Urology. 1979;121:640-642.
- Housami F, Abrams P. Persistent detrusor overactivity after transurethral resection of the prostate. Current Urology Reports. 2008;92:284-290.