Anatomical Foundations, surgical technique and early outcome of the No Stress In-continence Enucleation (NIcE) Template for Holmium Laser Enucleation of the Prostate (HoLEP)

Introduction: Transient stress urinary incontinence (TSUI) remains a significant issue following Holmium laser enucleation of prostate (HoLEP). Herein we describe a novel technique called No stress-Incontience Enucleation (NIcE) designed to preserve both striated and smooth muscles within the anterior fibromuscular stroma and its overlying mucosa. The primary objective was to evaluate continence immediately after catheter removal. The secondary goal was to compare perioperative and early voiding outcomes in patients undergoing HoLEP using the NIcE technique vs standard en-bloc technique. Methods: Patients undergoing HoLEP with NIcE modification from May 2024 were prospectively enrolled. The procedure used the Moses 2.0 holmium laser (2J, 30 Hz) with a specific template designed to preserve the anterior urethral mucosa between the 10 and 2 o’clock positions from the bladder neck to the external urethral sphincter. Perioperative data, complications, voiding outcomes and PSA at 3 months were retrospectively compared with a matched cohort of patients undergoing HoLEP with the standard en-bloc technique. Results: 38 patients treated with NIcE were compared with 80 control patients treated with the en-bloc technique. Demographic and baseline characteristics were comparable. All patients in the NIcE group who had complete preservation of the anterior urethral mucosa were continent immediately after catheter removal. Postoperative Qmax, PVR, and PSA levels showed no significant differences between groups. Conclusions: NIcE HoLEP prevents TSUI immediately after catheter removal, providing safe and effective relief from benign prostatic obstruction (BPO). Early results suggest it may offer a viable alternative to standard HoLEP techniques.