Membranous Urethral Length as a Predictor for Urinary Incontinence After Holmium Enucleation of the Prostate for Benign Prostatic Hyperplasia

Purpose Holmium laser enucleation of the prostate (HoLEP) is as an effective, size-independent treatment for benign prostatic hyperplasia (BPH) with durable outcomes. However, one of its adverse outcomes is post-operative stress urinary incontinence (SUI). We sought to determine if membranous urethral length (MUL) as measured on preoperative magnetic resonance imaging is a predictor for post-operative SUI in patients undergoing HoLEP for BPH. Methods A single-center, retrospective observational study was conducted on 147 consecutive patients who underwent HoLEP for BPH between 2018 and 2024. Preoperative baseline characteristics, perioperative details, and SUI outcomes at 1, 3, and 6 months were collected. Binary logistic regression was used to assess the association between MUL and SUI at each follow-up interval. Results Median MUL was 8.2mm (IQR 6.1–11.0), and post-operative SUI incidences were 73 (49.7%), 36 (24.5%), and 16 (10.9%) at 1, 3, and 6 months respectively. Longer MUL was significantly associated with lower odds of SUI at 1 month (OR: 0.86, 95% CI: 0.77–0.96, p = 0.009), 3 months (OR: 0.77, 95% CI: 0.65–0.91, p = 0.002), and 6 months (OR: 0.65, 95% CI: 0.49–0.87, p = 0.004). Internal validation demonstrated good discrimination (areas under the curve of 0.73, 0.75, and 0.83 at 1, 3, and 6 months) with well-calibrated models, and decision curve analysis confirmed clinical utility within prespecified risk thresholds. Conclusions Longer MUL is significantly associated with lower rates of SUI following HoLEP at 1, 3, and 6 months. Longer MUL may serve as a valuable predictive factor for continence recovery and should be considered during preoperative counseling and surgical decision planning.