Clinical Scorecard: Expert Agreement on Evaluating Apical Mucosal Preservation in Holmium Laser Enucleation of the Prostate (HoLEP): Consequences for Developing Artificial Intelligence Models

At a Glance

Key Highlights

• Transient stress urinary incontinence (TSUI) occurs in up to 44% early post-HoLEP but rates have decreased with improved mucosal preservation techniques.
• Expert urologists showed variable but measurable agreement in visually rating apical mucosal preservation from intraoperative videos using a three-tier scale.
• Reliable expert annotation of mucosal preservation is critical for developing AI models to predict postoperative continence outcomes.

Guideline-Based Recommendations

Diagnosis

• Use intraoperative video assessment to evaluate apical mucosal preservation after HoLEP.
• Exclude patients with confounding factors such as urethral strictures, neurogenic bladder, bladder tumors, pelvic radiation history, or pre-existing incontinence when assessing continence outcomes.

Management

• Adopt surgical techniques emphasizing apical mucosal preservation to reduce early postoperative urinary incontinence.
• Standardize HoLEP laser settings and morcellation techniques to ensure procedural consistency.

Monitoring & Follow-up

• Assess postoperative urinary continence at approximately 6 weeks using patient-reported leakage and pad use.
• Use blinded expert review of surgical videos to classify mucosal preservation for prognostic evaluation.

Risks

• Incomplete or damaged apical mucosa correlates with higher risk of early postoperative urinary incontinence.
• Variability in expert assessment may affect reliability of AI model training and predictions.

Patient & Prescribing Data

Men undergoing en-bloc HoLEP without complicating urological conditions and with available high-quality surgical video and continence follow-up data.

Preservation of apical mucosa during HoLEP is associated with improved early continence; expert consensus on mucosal preservation rating is necessary to develop AI tools for intraoperative assessment.

Clinical Best Practices

• Perform HoLEP using standardized en-bloc technique with consistent laser settings and morcellation devices.
• Exclude patients with confounding urological conditions when evaluating continence outcomes.
• Use a three-tiered scale (completely preserved, partially preserved, not preserved) for apical mucosal preservation assessment.
• Employ blinded, independent expert review of intraoperative videos to reduce bias.
• Develop AI models based on reliable expert annotations to predict postoperative continence and guide surgical technique improvements.

References

• 1. HoLEP as treatment for BPH
• 2. Rates of transient stress urinary incontinence post-HoLEP
• 3-5. Technical modifications reducing incontinence
• 6. Randomized trial comparing en-bloc and lobe-by-lobe techniques
• 7,8. AI in surgical step recognition
• 9,10. AI applications in urology
• 11. Importance of reliable expert labeling in AI
• 12. Standardized en-bloc HoLEP technique
• 13. Interpretation of Cohen’s Kappa
• 14. Fleiss’ multi-rater Kappa