Measuring the length of a patient’s membranous urethra before holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia could help predict if they will experience urinary incontinence after the procedure, according to a new study presented at the European Association of Urology (EAU) 2026 Annual Meeting.

The approach could help guide preprocedural counseling and planning, said Jeremy Lai, MD, urologist at Northwestern Medicine Central DuPage Hospital in Winfield and Delnor Hospital in Geneva, Illinois, who was not involved with the study. For instance, a man with a shorter membranous urethra may require more intensive pelvic floor physical therapy before HoLEP than one with a longer membranous urethra — the short section of urethra between the prostate and the penis which is surrounded by muscles to help regulate urination.

Although HoLEP is an effective treatment for patients with benign prostatic hyperplasia, some men experience urinary incontinence after the procedure. One recent meta-analysis found as many as 12% of patients experienced incontinence after the intervention, with that risk decreasing as time went on. Previous research has found a link between a shorter membranous urethra and incontinence after radical prostatectomy for prostate cancer, Lai said, but the relationship is unclear in cases of benign prostatic hyperplasia.

In the new study, Nick Lee, MD, urology resident at the University of Montreal, Montreal, Québec, Canada, and his colleagues set out to explore whether measuring the membranous urethra in preprocedural MRIs could help pinpoint who may be at risk for urinary incontinence.

The investigators retrospectively collected data, including preoperative characteristics, perioperative details, and urinary incontinence outcomes, from 147 patients who underwent HoLEP for benign prostatic hyperplasia at their institution between 2018 and 2024.

They found that the median membranous urethral length was 8.2 mm (interquartile range, 6.1-11.0). The incidence of post-op stress urinary incontinence decreased as time went on, with nearly 50% of patients experiencing incontinence at 1 month, dropping to only 10% at 6 months.

When the investigators compared membranous urethral length to incidence of urinary incontinence, they found longer lengths were significantly associated with lower odds of incontinence. They saw this association as early as 1 month (odds ratio [OR], 0.86; 95% CI, 0.77-0.96; P = .009), becoming more pronounced at 3 months (OR, 0.77; 95% CI, 0.65-0.91; P = .002) and 6 months (OR, 0.65; 95% CI, 0.49-0.87; P = .004).

The Utility of Predicting Incontinence

Predicting which patients may be at risk for postoperative urinary incontinence could play a part in preprocedural counseling and surgical decisions, according to the investigators. Lai agreed. 

“Maybe if we knew of a shorter membranous urethral length beforehand, that could shape our counseling and spur patients with shorter length to be more proactive and consistent with their pre-op and post-op pelvic exercises,” Lai said. “Alternatively, we could possibly send these short patients for formal pelvic floor physical therapy before surgery, which is what we routinely do for prostate cancer patients before their prostatectomy.”

However, length measurement before benign prostatic hyperplasia may not be straightforward, he said. Although men with prostate cancer usually have an MRI that can provide the reading, those with benign prostatic hyperplasia may not undergo a preprocedural scan.

“It’s not something we routinely look at for this patient population, even though as the study suggests, it would intuitively make sense,” Lai said.

Adding an MRI prior to HoLEP would present additional costs and time commitments for patients, Lai said, and he questioned if those costs “would be worth it given our counseling and expectations around pre-operative patient exercises already.”

Other questions remain, according to John Thomas Wei, MD, David A. Bloom Professor of Urology at the University of Michigan Medical School in Ann Arbor, Michigan. Specifically, how did the researchers measure urinary incontinence, he asked, and what was the cutoff for long vs short membranous urethral length?

Lai said further study should be multicenter to account for variations in measurement. “It’s actually not hard for different people to measure the same object on imaging and get measurements that vary by 1-2 mm, or possibly even more,” he said.

But when it comes to measuring membranous urethral length, there may be another option other than MRI, Lai said. Cystoscopy could be an in-office alternative that many patients with benign prostatic hyperplasia may already be receiving and is easier to schedule and preform. “Comparing cystoscopy measured membranous urethral length and MRI membranous urethral length and then extrapolating that to incontinence could be an interesting next study,” he said.

Lai reported having no relevant financial conflicts of interest. 

Meaghan Lee Callaghan is a science journalist based outside of New York City. Her work has appeared in Audubon, Infectious Disease Special Edition, Popular Science, and Scientific American, among other places.