<b><i>Objective:</i></b> The aim of the study was to compare procedural efficacy, early and late functional outcomes in holmium laser enucleation of the prostate (HoLEP) under spinal anesthesia (SA) versus general anesthesia (GA). <b><i>Methods:</i></b> We retrospectively reviewed patients undergoing HoLEP at our institution between 2012 and 2017. Standard pre-, peri-, and postoperative characteristics were compared according to anesthetic technique. Multivariable logistic regression analyses (MVAs) were employed to study the impact of SA on procedural efficacy and postoperative complications. <b><i>Results:</i></b> Our study cohort consisted of 1,159 patients, of whom 374 (32%) underwent HoLEP under SA. While a medical history of any anticoagulation/antiplatelet therapy except low-dose acetylsalicylic acid was significantly more common among patients undergoing GA (16% vs. 10%, <i>p</i> = 0.001), no other significant differences in preoperative characteristics were noted including age, body mass index, American Society of Anesthesiologists Classification (ASA), prostate size, or International Prostate Symptom Score (IPSS), and quality of life scores. Patients under SA exhibited shorter times of enucleation 42 min (interquartile range [IQR]:27–59 vs. 45 min [IQR: 31–68], <i>p</i> = 0.002), and combined time of enucleation/morcellation/coagulation (57 min [IQR: 38–85] vs. 64 min [IQR: 43–93], <i>p</i> = 0.002), as well as fewer complications (Clavien-Dindo ≥3) (12 [3.2%] vs. 55 [7%], <i>p</i> = 0.013). These associations were confirmed in MVA. Patients did not differ significantly with regard to early micturition including post-void residual volume and maximum flow-rate improvement. At a median follow-up of 33 months (IQR: 32–44), patients with SA had a lower IPSS score (median 3 [IQR: 1–6] vs. 4 [IQR: 2–7], <i>p</i> = 0.039). However, no significant differences were observed with respect to any urinary incontinence, urge symptoms, and postoperative pain. <b><i>Conclusion:</i></b> In this large retrospective series, HoLEP under SA was a safe and efficacious procedure with comparable early and long-term functional outcomes.
Patterns and predictors of optimal surgical and functional outcomes after holmium laser enucleation of the prostate (HoLEP): introducing the concept of “trifecta”