Comment on Trotsenko et al. Early Results after Thulium Laser Enucleation of the Prostate in Patients with Urodynamically Proven Detrusor Underactivity. Soc. Int. Urol. J. 2024, 5, 160–168

In this study, AEEP (anatomical enucleation of the prostate) with a thulium laser was performed in 115 men at a single institution between January 2019 and March 2022 for surgical treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) [1]. Of the 115 men, 15 patients (13%) were retrospectively identified to have had preoperative urodynamic testing (UDS), as indicated by EAU guidelines. Of these fifteen patients, eight patients had a diagnosis of detrusor underactivity (DU) defined as a bladder contractility index (BCI) less than 100. Prior to AEEP, 3/8 patients with DU were Foley catheter-dependent. Following AEEP, all patients with DU were voiding without a catheter and had significant improvement in all voiding parameters.

These findings question the role of UDS in the preoperative evaluation of men undergoing AEEP. Here, despite the diagnosis of DU, all eight men were catheter-free and had significantly improved voiding after AEEP. Though this was a smaller study, these outcomes parallel several other studies demonstrating the efficacy of AEEP in men with DU [2,3,4]. So why did men need preoperative UDS testing before AEEP if the postoperative outcome is no different? Although generally well-tolerated, UDS is not entirely a benign diagnostic test—studies have demonstrated that patients can find UDS to provoke anxiety, discomfort, and embarrassment [5,6]. The EAU even recommends judicious use of UDS “due to the invasive nature of the test” [7].

This study contributes to the growing evidence that the maximal de-obstruction offered by AEEP obviates the need for preoperative UDS. Whether performed with a thulium laser, a holmium laser, or other energy sources, the successful outcomes of AEEP are maintained despite a diagnosis of DU. We assert that AEEP enables successful voiding even in men with DU and patients undergoing AEEP can be spared UDS evaluation preoperatively.