## 4 Discussion  
To date, HoLEP represents an effective and safe surgical option for the treatment of BPH, resulting in a valid alternative to TURP and OSP. During HoLEP, the adenoma is completely enucleated from the surgical capsule and displaced into the bladder before removal by a transurethral soft-tissue moreclator [15]. By taking advantage of the distinct anatomical planes to remove the entire prostatic transition zone, the HoLEP technique allows removal of more tissue than through TURP, thus leading to a lower retreatment rate [16]. As regard the durability of outcomes, several studies have shown they are stable up to a 10-year follow-up [17], similarly to those of OSP [18]. Conversely, compared to HoLEP, TURP provides lower long-term outcomes and, consequently, a higher reoperation rate [7; 19]. The main obstacle to the widespread use of HoLEP lies in the steepness of the learning curve, estimated from 20 to 50 cases, depending on the presence of a mentorship program [20; 21; 22]. HoLEP allows a less restricted selection of patients [3], extending the eligibility for surgery to those with smaller and larger glands [23; 24; 25; 26], to the elderly [27], to those on antithrombotic or antiplatelet therapy [28; 29; 30; 31], to men with obstructive BPH and urodynamic evidence of detrusor hypo- or acontractility [32], to cases requiring reoperation for adenoma regrowth after prior BPH surgery [33; 34], as well as concomitant surgery for other pathologies [35; 36; 37], including bladder stones, which can advantageously be treated using the same instrument [38; 39]. Moreover, HoLEP does not appear to be affected by previous prostate biopsy, allowing its possible use also in patients with prostate cancer under active surveillance [40]. \begin{table}
\begin{tabular}{c c c c c} \hline \hline
**Variable** & **1 Month** & **3 Months** & **6 Months** & **12 Months** \\ \hline Median Qmax, mL/s (range) & 24.5 (17.25–40.5) & 25 (18.5–39) & 27 (19.5–36) & 26 (19–38) \\ Median PVR, mL (range) & 0 (0–20) & 0 (0–22) & 0 (0–28) & 0 (0–24) \\ Median IPSS, pt. (range) & 10.5 (8–14.5) & 5 (2–5–6.5) & 5 (2–8) & 5 (2–10) \\ UI, \(n\) (\%) & 23 (34.8) & 8 (12.1\%) & 5 (7.6\%) & 2 (3\%) \\ UUI, \(n\) (\%) & 11 (16.7\%) & 2 (3\%) & 1 (1.5\%) & 1 (1.5\%) \\ SUI, \(n\) (\%) & 9 (13.6\%) & 6 (9.1\%) & 4 (6.1\%) & 1 (1.5\%) \\ MUI, \(n\) (\%) & 3 (4.5\%) & 0 (0\%) & 0 (0\%) & 0 (0\%) \\ \hline \hline \end{tabular}  
* Qmax: maximum flow rate; IQR: interquartile range; PVR: post-void residual; IPSS: International Prostate Symptom Score; UI: urinary incontinence; UUI: urge urinary incontinence; SUI: stress urinary incontinence; MUI: mixed urinary incontinence.  
\end{table} 
Table 4: Functional outcomes. \begin{table}
\begin{tabular}{c c c c} \hline \hline  & \multicolumn{3}{c}{**UI at One Postoperative Month**} \\ \cline{2-4}
**Variable** & \multicolumn{2}{c}{**Univariate Analysis**} & \multicolumn{2}{c}{**Multivariate Analysis**} \\ \cline{2-4}  & \(p\)**-Value** & \(p\)**-Value** & **OR (95\% CI)** \\ \hline Age (years) & _0.008_ * & 0.20 & 1.09 (0.95–1.24) \\ Serum PSA (ng/mL) & 0.61 & 0.64 & 1.08 (0.95–1.24) \\ Prostate volume (mm\({}^{3}\)) & _0.012_ * & _0.01_* & 1.05 (1.01–1.10) \\ Previous alpha-blockers (yes vs. no) & 0.51 & 0.99 & 1.04 (0.01–433.54) \\ Qmax (mL/s) & 0.49 & 0.64 & 1.05 (0.85–1.30) \\ PVR (mL) & 0.91 & 0.35 & 0.99 (0.97–1.01) \\ IPSS (total score) & _<0.001_ * & _0.001_ * & 1.60 (1.20–2.12) \\ IEF-5 (total score) & 0.667 & 0.49 & 1.08 (0.85–1.39) \\ Operative time (min) & 0.83 & 0.06 & 0.98 (0.96–1.00) \\ DaE (kJ) & 0.44 & 0.43 & 1.00 (0.99–1.02) \\ Catheterization (hours) & 0.41 & 0.06 & 2.72 (0.96–7.67) \\ \hline \hline \end{tabular}  
* UI: urinary incontinence; Qmax: maximum flow rate; PVR: post-void residual; IPSS: International Prostate Symptom Score; IEF-5: International Index of Erectile Function 5-item; DaE: delivered amount of energy; OR: Odds Ratio; *: significant value.  
\end{table} 
Table 5: Univariate and multivariate analyses (logistic regression) predicting UI at one month with preoperative variables.