Proportional median-lobe burden and early urinary incontinence after HoLEP: An anatomical hypothesis

Early urinary incontinence after holmium laser enucleation of the prostate (HoLEP) affects postoperative counseling, recovery expectations, and perceived procedural success. Current risk stratification relies mainly on patient- and procedure-level variables, including age, prostate size, operative time, specimen weight, and surgeon experience. This article hypothesizes that proportional median-lobe burden, defined as the median lobe-to-total prostate volume ratio, may be associated with urinary incontinence within 30 days after catheter removal. The rationale concerns the relative distribution of tissue at the vesicoprostatic junction rather than gland size alone. Differences in proximal dissection and postoperative cavity geometry are possible anatomical correlates requiring direct measurement; their contribution to leakage has not been demonstrated. Any association may instead reflect baseline patient characteristics, distal sphincter anatomy, operative complexity, or surgeon-related factors. The proposal does not establish a second continence mechanism or a causal interaction between proximal geometry and distal sphincter function. Prospective evaluation should establish the reproducibility of a prespecified MRI-based definition, distinguish leakage subtypes, and compare the ratio with absolute median-lobe and total prostate volumes. Baseline-adjusted association analyses should be distinguished from exploratory analyses incorporating operative variables and from assessments of predictive performance. Clinical use would require external validation and evidence of incremental predictive value.