Predictors of Trifecta Achievement After HoLEP (ReMIUS-BPO)

Predictors of Trifecta Achievement After Holmium Laser Enucleation of the Prostate

Holmium laser enucleation of the prostate (HoLEP) is a surgical treatment option for men experiencing bothersome lower urinary tract symptoms due to an enlarged prostate. Researchers predict that specific participant or operator-dependent conditions before or during HoLEP may influence the trifecta outcome, based on similar studies. Therefore, the aim of this study is to understand what these conditions are. Trifecta success indicates a high-quality surgery based on three essential criteria: the treatment's effectiveness, ease of recovery, and the absence of serious side effects. In this study, trifecta is defined as relief from bothersome symptoms validated by international symptom score questionnaires, no urinary incontinence, and no serious events occurring within three months after HoLEP.

Study Overview

• Status: Not yet recruiting
• Conditions: Bladder Outlet Obstruction; Lower Urinary Tract Symptoms (LUTS); Benign Prostatic Enlargement (BPE); Clavien Dindo Surgical Complication Scale; Urinary Incontinence Following Surgical Procedure; Trifecta Achievement; HoLEP
• Intervention / Treatment: Procedure: Transurethral Holmium Laser Enuclation of the Prostate

Detailed Description

This study aims to identify preoperative and perioperative variables influencing trifecta achievement in HoLEP surgery and to determine the predictive value of these variables.

Based on the analysis of the collected data, it is anticipated that one or more variables will show a statistically significant association with trifecta outcomes.

Additionally, the study seeks to evaluate the predictive value of these variables for successfully reaching the trifecta. Based on our analysis of the collected data, we expect that one or more of these variables will show a statistically significant association with trifecta outcomes.

Lower urinary tract symptoms (LUTS) are defined by the International Continence Society (ICS) as a constellation of complaints originating from lower urinary tract organs, such as the bladder, prostate, urethra, adjacent pelvic floor muscles, and distal ureters. A large-scale epidemiological study has shown that the prevalence of LUTS in men over 40 years of age is 62%, increasing with advancing age. LUTS in older men are most commonly attributed to benign prostatic obstruction (BPO), and autopsy series have reported benign prostatic hyperplasia (BPH) histology in 60-80% of cases. All patients who are refractory to medical treatment or present with complications are candidates for surgical therapy.

In selecting the surgical approach, patient comorbidities, bladder neuromuscular function, and prostate volume are key determinants. Transurethral laser enucleation techniques (HoLEP, ThuLEP) are non-inferior to conventional methods in BPO surgery and even demonstrate advantages in patients in whom antiplatelet or anticoagulant therapy cannot be discontinued; accordingly, they have been incorporated into the European Association of Urology guidelines.

"Trifecta" refers to the achievement of three ideal and measurable conditions within a defined perioperative or postoperative period, representing surgical success from both the patient's and the surgeon's perspectives (functional outcomes and complications). As trifecta is a relatively new concept in BPO surgery, there are currently insufficient studies to establish universally accepted criteria. Moreover, because the factors contributing to trifecta achievement and their relative impact remain unclear, this clinical study has been designed.

Following approval by the local ethics committee, data of all patients treated with HoLEP between March 2026 and April 2028 will be prospectively collected.

All male patients with an indication for surgical treatment, and without clinically proven prostate cancer, bladder cancer, or neurogenic LUTS, will be included in the study. Preoperatively, all patients will undergo non-invasive laboratory and imaging evaluations, including complete blood count, routine biochemistry, urinalysis, urine culture, total PSA, uroflowmetry with post-void residual measurement (PVR), and ultrasonography or magnetic resonance imaging when clinically indicated. Standardized international questionnaires will be used for symptom assessment.

Postoperative complications will be classified according to the Clavien-Dindo grading system. All patients will be evaluated postoperatively at 1, 3, 6, and 12 months, and annually thereafter, using uroflowmetry with PVR, total PSA, renal function tests, and international symptom questionnaires.

In our study, trifecta was defined as the simultaneous fulfillment of all of the following criteria at postoperative month 3: absence of complications greater than Clavien-Dindo grade II, absence of urinary incontinence, and at least a 30% reduction in the International Prostate Symptom Score (IPSS).

The primary endpoint of the study was defined as trifecta achievement at postoperative month 3 following HoLEP. To identify factors predicting trifecta success, analyses were planned using a binary outcome (yes/no). The effects of preoperative and perioperative variables on trifecta achievement will be evaluated using logistic regression models. Variables found to be significant in univariable analyses or considered clinically relevant will be included in the multivariable model. Model predictive performance will be assessed using the area under the receiver operating characteristic curve (AUC), and results will be reported as odds ratios (ORs) with 95% confidence intervals (CIs). All statistical analyses will be two-sided, and a p-value <0.05 will be considered statistically significant.

As the study was designed as a multivariable predictive model, the minimum sample size was calculated for multivariable logistic regression using the Riley framework with the pmsampsize package in R Studio (version 4.5.1). Based on the literature, trifecta prevalence was assumed to be 63%, approximately 10 parameters were expected to be included in the model, and a Cox-Snell R² of 0.15 was assumed. Accordingly, the minimum required sample size was calculated as 549 patients. Considering potential missing data and loss to follow-up, a 10% inflation was applied, resulting in a planned target sample size of approximately 604 patients.

• Study Type: Interventional
• Enrollment (Estimated): 604
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Murat Gulsen Assistant Professor, MD; Phone Number: +905062357421; Email: mglotr@gmail.com

Study Locations

• Turkey (Türkiye)
  • Samsun, Turkey (Türkiye)
    • Ondokuz Mayis University, Samsun
    • Contact: Murat Gulsen Assistant Professor, MD; Phone Number: +905062357421; Email: mglotr@gmail.com

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• All male patients aged ≥ 40 years who are candidates for surgical treatment for BPO.
• Ability to provide informed consent, when required.

Exclusion Criteria:

• Clinically proven active condition(s) that require another intervention other than BPO surgery, such as lower urinary tract malignancy, urethral stricture, or neurogenic lower urinary tract symptoms.
• History of previous surgery for BPO, urethral stricture, or prostate cancer.
• Incomplete baseline or procedural data.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: HoLEP; Only arm is the participants who are eligible to undergo HoLEP. Single arm, determination of predictors of the trifecta.	Procedure: Transurethral Holmium Laser Enuclation of the Prostate; HoLEP, En-bloc or tri-lobar technique.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Trifecta achievement three months after HoLEP	Achievement of all three of the following criteria, three months after HoLEP: At least a 30% reduction in International Prostate Symptom Score (IPSS); Absence of major complications (no Clavien-Dindo grade > II),; No urinary incontinence	From enrollment to the three months after the intervention for each participant.

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Length of Hospital Stay After the Intervention	Duration of hospitalization following the intervention. Unit: days	Perioperative/Periprocedural
Change in peak urinary flow rate (Qmax)	Difference in maximum urinary flow rate measured by uroflowmetry compared to baseline. Unit: mL/s	Starting one month after the intervention and continuing for one year after the intervention, with multiple measurements.

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Bladder Voiding Efficiency (BVE)	Bladder voiding efficiency, defined as the ratio of voided volume to total bladder capacity. Ratio (unitless)	From enrollment to the three months after the intervention.
Enucleation-Volume Ratio	Enucleation-volume ratio, defined as the ratio of enucleated adenoma weight to pre-operatively measured prostate volume. Ratio (unitless).	Perioperative/Periprocedural

Collaborators and Investigators

• Sponsor: Ondokuz Mayıs University
• Investigators: Principal Investigator: Murat Gulsen, MD, Ondokuz Mayıs University

Publications and helpful links

General Publications

• Grosso AA, Amparore D, Di Maida F, de Cillis S, Cocci A, Di Dio M, Russo GI, Cimino S, Quara A, Salvi M, Fiori C, Mari A, Porpiglia F, Minervini A, Tuccio A. Comparison of perioperative and short-terms outcomes of en-bloc Holmium laser enucleation of the prostate (HoLEP) and robot-assisted simple prostatectomy: a propensity-score matching analysis. Prostate Cancer Prostatic Dis. 2024 Sep;27(3):478-484. doi: 10.1038/s41391-023-00743-6. Epub 2023 Oct 19.
• Bove AM, Brassetti A, Ochoa M, Anceschi U, D'Annunzio S, Ferriero M, Tuderti G, Misuraca L, Mastroianni R, Cartolano S, Torregiani G, Lombardo R, De Nunzio C, Simone G. Robotic simple prostatectomy vs HOLEP, a 'multi single-center' experiences comparison. Cent European J Urol. 2023;76(2):128-134. doi: 10.5173/ceju.2023.204. Epub 2023 Apr 17.
• Grosso AA, Di Maida F, Nardoni S, Salvi M, Giudici S, Lambertini L, Cadenar A, Tellini R, Cocci A, Mari A, Minervini A, Tuccio A. Patterns and Predictors of Optimal Surgical and Functional Outcomes after Holmium Laser Enucleation of the Prostate (HoLEP): Introducing the Concept of "Trifecta". World J Mens Health. 2023 Jul;41(3):603-611. doi: 10.5534/wjmh.220042. Epub 2023 Jan 1.

Study record dates

Study Major Dates

• Study Start (Estimated): January 30, 2026
• Primary Completion (Estimated): April 26, 2028
• Study Completion (Estimated): July 31, 2028

Study Registration Dates

• First Submitted: January 28, 2026
• First Submitted That Met QC Criteria: February 18, 2026
• First Posted (Actual): February 24, 2026

Study Record Updates

• Last Update Posted (Actual): February 24, 2026
• Last Update Submitted That Met QC Criteria: February 18, 2026
• Last Verified: January 1, 2026

More Information

Terms related to this study

• Keywords: HoLEP Trifecta; HoLEP Symptomatic Relief; HoLEP Predictive Factors
• Additional Relevant MeSH Terms: Urogenital Diseases; Male Urogenital Diseases; Urologic Diseases; Female Urogenital Diseases; Female Urogenital Diseases and Pregnancy Complications; Urological Manifestations; Urinary Bladder Diseases; Urethral Diseases; Urethral Obstruction; Pathological Conditions, Signs and Symptoms; Signs and Symptoms; Lower Urinary Tract Symptoms; Urinary Bladder Neck Obstruction
• Other Study ID Numbers: MIUS.2026.001

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Individual participant data (IPD) will not be shared due to privacy concerns and data protection regulations, including the Turkish Personal Data Protection Law (KVKK). Only aggregated, de-identified results will be reported in publications and presentations.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No