A Modified Clavien-Dindo Framework and a Heatmap Analysis to Identify Predictors of Complications After Endoscopic Enucleation of the Prostate.
BACKGROUND Holmium laser enucleation of prostate (HoLEP) is a size-independent procedure for benign prostatic obstruction. However, the predictors of various complications are poorly defined in the literature. OBJECTIVE We propose a standardized framework for reporting postenucleation complications using a modified Clavien-Dindo (CD) classification. We aim to identify predictors of postoperative complications following HoLEP within this unified framework, integrating both patient- and procedure-related variables. METHODOLOGY We retrospectively analyzed a prospectively collected database of patients undergoing HoLEP. Complications were stratified according to a modified CD classification framework developed for HoLEP. Predictors were analyzed using multinomial regression, and a heatmap was generated to identify correlations among predictors. RESULTS A total of 855 patients were included in the study. The median prostate volume was 102 cc. Minor complications were seen in 513 patients (60%), most frequently transient incontinence (37.4%). Major complications occurred in 46 patients (5.4%), primarily bladder neck stenosis (2%) and urethral stricture (2%). Multivariate analysis showed that advancing age (odds ratio [OR] 1.03; p = 0.008), recurrent urinary retention (OR 1.60; p = 0.003), elevated body mass index (BMI) (OR 1.04; p = 0.017), Anticoagulation use (OR 1.44; p = 0.029) and longer operative duration (OR 1.004; p = 0.002) were independent predictors of minor complications. Major complications were associated with smaller prostates (OR 0.93, p = 0.016). Spearman's correlation showed that postoperative incontinence was correlated with advanced age (r = 0.090, p < 0.01), high BMI (r = 0.082, p < 0.05), and longer surgical duration (r = 0.119, p < 0.01). Prostate volume was negatively correlated with postoperative inability to void (r = -0.107, p < 0.01), bladder neck stenosis (r = -0.107, p < 0.01), and urethral stricture (r = -0.102, p < 0.01). Gross hematuria was correlated with anticoagulation use (r = 0.101, p < 0.01) and BMI (r = 0.114, p < 0.01), although neither factor predicted major complications. CONCLUSION We proposed a standardized framework for reporting complications following endoscopic enucleation of the prostate. Our study also identified predictors of post-HoLEP major and minor complications.