To prospectively evaluate clinical characteristics, functional outcomes, and the exploratory predictive value of preoperative bladder contractility index (BCI) in patients with detrusor underactivity undergoing HoLEP.

A prospective observational study was conducted in two tertiary centres in Barcelona, Spain, including patients undergoing HoLEP between January 2023 and December 2025. Inclusion criteria were urodynamic evidence of DU and clinically significant BOO. Patients with prostate cancer, known neurological disease, incomplete urodynamic studies, or insufficient follow-up were excluded. Urodynamic studies were performed using MMS Solar Blue systems according to International Continence Society standards. DU was defined according to ICS terminology, while reduced contractility was operationally supported by BCI <100. Acontractile detrusor was defined as absence of measurable detrusor pressure increase during the voiding phase despite abdominal straining. BCI and BOOI were calculated using standard formulas. Follow-up was performed at 4 weeks, 3, 6, and 12 months. Primary outcomes were changes in Qmax, post-void residual volume (PVR), and catheter independence. Secondary outcomes included complications, I, and length of hospital stay.

A total of 135 urodynamic studies were reviewed, of which 17 patients (10.8%) met inclusion criteria. Median age was 68 years (IQR 61–74), and six patients (35.3%) had a preoperative indwelling catheter. Baseline median IPSS was 17 (IQR 13–24), prostate volume 45 g (IQR 32–68), and follow-up duration 12 months (IQR 8–19). Baseline urodynamic evaluation demonstrated severe voiding dysfunction, with median Qmax 4.0 mL/s (IQR 0–7), PdetQmax 50 cmH₂O (IQR 20–90), BCI 71 (IQR 46–89), BOOI 40 (IQR 25–55), and PVR 110 mL (IQR 60–225). A weak, non-significant correlation was observed between BCI and BOOI (Spearman ρ = 0.38, p = 0.14), suggesting relative independence between detrusor voiding contraction and outlet resistance.

At 3 months after HoLEP, median Qmax increased to 20 mL/s (IQR 15–28; p = 0.001), with a median voided volume of 278 mL (IQR 170–376), and median PVR decreased to 25 mL (IQR 5–60; p = 0.001). These improvements were sustained at 9–12 months, with Qmax 24 mL/s (IQR 18–30), median voided volume 305 mL (IQR 202–412), and PVR 10 mL (IQR 0–30). All patients achieved catheter independence at final follow-up, including those with acontractile detrusor. Predictive analysis showed no significant association between baseline BCI and PVR at baseline, 3 months, or 9–12 months. ROC analysis confirmed limited discriminative ability of preoperative BCI for predicting postoperative PVR <100 mL (AUC 0.53 at 3 months; 0.58 at 9–12 months). Complications were infrequent, with two Clavien–Dindo grade II urinary tract infections and no major complications.

Our findings support the concept that detrusor underactivity should not be considered a contraindication to deobstructive surgery when clinically relevant outlet obstruction is present. HoLEP was associated with marked improvement in Qmax, reduction in PVR, and complete catheter independence in this cohort, including patients with acontractile detrusor. These results suggest that a relevant component of voiding dysfunction in DU may be related to reversible outlet resistance rather than irreversible myogenic failure alone. In contrast, preoperative BCI showed limited predictive value for postoperative bladder emptying, indicating that contractility indices alone may be insufficient for surgical decision-making.

HoLEP provides significant and sustained improvement in voiding function in men with DU and BOO, including those with acontractile detrusor. These findings challenge the traditional view that severely impaired detrusor voiding contraction represents a contraindication to deobstructive surgery. Preoperative BCI showed limited predictive value, suggesting that impaired contractility alone should not determine surgical decision-making in carefully selected patients.

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Continence 19S (2026) 102564
DOI: 10.1016/j.cont.2026.102564