Introduction: The American Society of Anesthesiologists Physical Status classification system (ASA-PS) score is a common and validated risk stratification of patients undergoing surgical procedures. In addition to the benign prostatic hyperplasia (BPH) prevalence in the aging population, there has been an increase in age and medical comorbidities in patients requiring BPH surgery. The role of ASA related to postoperative complications in patients undergoing holmium laser enucleation of the prostate (HoLEP) has not been described.
Methods: A review of our institutional database was performed of patients undergoing HoLEP from July 2018-December 2020. Patients were stratified based on ASA score of 1&2 and 3&4, which was assigned by a staff anesthesiologist. Pre-operative, perioperative and complication data was analyzed using SAS analytics software.
Results: Of 472 patients undergoing HoLEP, 320 (67.8%) were ASA3-4. There was a statistically significant difference found for higher age (72.3±9.8 vs 69.1±9.0years, p<0.001), higher body mass index (BMI) (29.0±5.9 vs 27.3±4.2, p=.004), and higher use of antiplatelet/anticoagulant medications (31.4% vs 3.6%, p<0.001) in the ASA 3-4 group. Otherwise, there was no significant difference between preoperative prostate volume (p=0.158), pre-operative catheter dependent urinary retention (p=0.538) or prior BPH surgical therapy (p=0.880). Intraoperatively, there was no difference in enucleation time (52.76±24.8 vs 54.16±23.7min, p=0.587), OR specimen weight (70.24±58.5 vs 81.53±65.9, p=0.094) or perioperative medical events prolonging hospital stay (3.4% vs 0%, p=0.201). Despite no difference in intraoperative complications, there were higher postoperative complications in the ASA 3-4 group (20.9% vs 12.5%, p=0.03). There was not a difference in Clavien =3 complications (p=0.068) or bleeding-related complications (p=.24). ASA 3-4 patients had statistically similar outcomes to their lower ASA counterparts in post-operative international prostate symptom score (IPSS) (p=0.159) and post void residual (p=0.297).
Conclusions: HoLEP is feasible in patients who are ASA 3-4. The high-risk cohort had equivalent post-operative outcomes but increased rate of low grade (Clavien =2) complications. Patients with an ASA score 3 or 4 should be counseled regarding a higher rate of low-grade post-operative complications.
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