With the worldwide increase in the aging population, the demand for surgical intervention for benign prostatic enlargement (BPE) in elderly patients is expected to increase. However, only a few studies have evaluated the safety and efficacy of holmium laser enucleation of the prostate (HoLEP) and transurethral vaporization in this population. Therefore, we aimed to conduct a retrospective study at two regional centers to compare the surgical outcomes of HoLEP and transurethral vaporization of the prostate. We assessed the safety and feasibility of these surgeries in the elderly population. Also, this was very first study to determine whether ageing affects the need for medications after prostate surgeries.

We retrospectively analyzed clinical data from two regional centers that used HoLEP and transurethral vaporization techniques for BPE treatment. The study population consisted of male patients with lower urinary tract symptoms, divided into elderly and non-elderly groups. Patient characteristics and outcomes were compared between the elderly and non-elderly in each HoLEP and vaporization group. Changes in international prostate symptom score (IPSS) and IPSS QoL were calculated as the difference between the 6-month postoperative values and the preoperative values. Specific cutoff point for patient age associated with medication requirements at 6 months post-operatively were determined for each HoLEP and transurethral vaporization procedure.

Total 477 of 872 patients remained in the study, of which 198 were classified as elderly (age ≥75 years) and 279 as non-elderly (age <75 years). The postoperative decrease in IPSS was significantly lower in the elderly groups, and advanced age was associated with less IPSS decline only after vaporization (P=0.003) but not after HoLEP (Table 1A). In both surgeries, the duration of postoperative catheterization was significantly longer in the elderly group than in the non-elderly group, and hemoglobin drop at 1 day postoperatively showed no age-related difference. The most common complication after HoLEP was intermittent incontinence, which was more frequent in the elderly group (15.0%) than in the non-elderly group (6.2%, P=0.038). 
Regardless of age, the overall rate of medication use at 6 months postoperatively was significantly higher after HoLEP (32/190, 16.8%) than after transurethral vaporization (30/287, 10.5%) (P=0.042). The majority of postoperative medications were for OAB in both HoLEP and vaporization (Table 1B). ROC curve analysis showed that age 70 and 75 years served as a specific cutoff for the need of postoperative medications after HoLEP and vaporization with an area under the curve of 0.550 and 0.591, respectively (Figure 1). Subsequently, separate cohort analysis by these specific patient ages suggested that the need for medication was higher in the elderly for both HoLEP and vaporization than in the non-elderly groups (Table 1B).

We found that HoLEP improved IPSS and IPSS-QoL regardless of patient age, but transurethral vaporization showed less improvement with advanced patient age. Advanced age (≥75 years) was a predictor of IPSS decline only after transurethral vaporization, but not after HoLEP. The overall rate of medication use at 6 months postoperatively was significantly higher after HoLEP than after vaporization. Interestingly, the specific cutoff of patient age associated with postoperative medication use differed slightly between HoLEP (70 years) and vaporization (75 years), and in both procedures, elderly patients required postoperative medication more frequently than non-elderly patients.

Elderly patients with BPE had relatively worse surgical outcomes, including a higher need for postoperative medications and prolonged catheterization. HoLEP demonstrated a reduction in IPSS regardless of age and transurethral vaporization did not, although it was associated with a higher rate of intermittent incontinence.