The Impact of Anesthesia-induced Intraoperative Hypotension on Hemostasis During Holmium Laser Enucleation of the Prostate.

OBJECTIVE

To investigate the effect of intraoperative hypotension (IOH) on clinically significant hematuria (CSH) following holmium laser enucleation of the prostate (HoLEP). Benign prostatic hyperplasia (BPH) is a common cause of lower urinary tract symptoms (LUTS) in men. HoLEP has emerged as a superior surgical option due to its hemostatic properties, especially in patients at risk of bleeding. IOH, commonly defined as a >20% reduction in systolic blood pressure (BP) from baseline, is frequent under general anesthesia and may obscure intraoperative bleeding-but its role in CSH is unclear.

METHODS

A retrospective analysis was performed of all HoLEPs conducted by a single surgeon in 2024. The primary outcome was CSH, defined as clot retention, reoperation, management change, or persistent hematuria >1 month. Patients were matched by preoperative prostate volume using coarsened exact matching (CEM). IOH was defined in two ways: (1) mean systolic blood pressure (SBP) > 20% below baseline, and (2) peak intraoperative SBP > 20% below peak 1-year preoperative SBP. Associations were assessed with Wilcoxon Rank Sum and Chi-squared/Fisher's exact tests.

RESULTS

Of 212 patients, 22 developed CSH; 18 were successfully matched to controls. Baseline characteristics were similar. Under the peak definition, enucleation-phase IOH was significantly associated with CSH (OR 3.31; 95% CI 1.13-9.7; P = .029). CSH patients also experienced higher rates of emergency department visits (42% vs 6%) and readmissions (37% vs 3%).

CONCLUSION

Enucleation-phase IOH during HoLEP was associated with increased CSH risk. Optimizing enucleation-phase SBP may reduce postoperative complications. Collaboration between surgical and anesthesia teams is critical to improving safety and outcomes.