Since Holmium laser enucleation of the prostate (HoLEP) was introduced in the 1990s as an endoscopic treatment modality for bladder outflow obstruction (BOO) secondary to BPH, several reports have concluded that HoLEP  compares favourably to TURP in relieving BOO. However, there has been no consensus regarding the efficacy of surgical management of men with Detrusor Underactivity (DU) and BOO. Recently, there have been a number of reports suggesting HoLEP may be an effective treatment option for this cohort of patients. The aim of this review is to assess the current evidence in the literature in terms of the effectiveness of HoLEP in this patient population based on perioperative outcomes

We performed a literature search of PubMed, Google Scholar, Scopus, and Web of Science databases. All studies that provided data on the effectiveness of HoLEP in men with BOO and DU were assessed. The primary outcome for men who were catheter-dependant preoperatively was catheter-free rate after surgery whereas the primary outcome for men not dependent upon catheter preoperatively was the change of IPSS. Secondary outcomes included changes in Qmax and PVR.

Results: Nine studies were identified in the literature with a follow-up range between 6 and 60 months. Only one prospective study was identified where investigators performed urodynamic studies (UDS) before and after the intervention. In addition to a significant improvement of voiding parameters, they reported partial recovery of detrusor muscle contractility in approximately 80% of patients. Two out of the nine studies reported on the number of patients who achieved catheter-free status following the intervention. In one of these studies, 95% of patients were voiding spontaneously following HoLEP without the need to do clean intermittent self-catheterization (CIC) while investigators in the other study found that 73% of patients achieved catheter-free status following HoLEP and the remaining patients needed to do CIC for high post-void residuals. Furthermore, all other studies reported an improvement in all outcome parameters and proved the efficacy of HoLEP in patients with DU and BOO

Our review suggests that more than 80% of men with DU and BOO are likely to void spontaneously after HoLEP. This may be explained by the comprehensiveness of prostate tissue enucleation attainable with HoLEP, permitting voiding through a wide-open channel in the prostatic urethra. Therefore, patients with urodynamically proven DU should not be denied HoLEP as there is a high probability that the procedure will be successful; however, they should be appropriately counseled on the risks and benefits of the procedure and the chance of failure.

Conclusion: The current literature underpins the efficacy of HoLEP in patients with impaired bladder contractility. However, current research is limited and the majority of the published data are retrospective in nature. Therefore, more well-conducted prospective randomized studies are needed to reinforce high-level evidence for this hypothesis.