To investigate the effect of intraoperative hypotension (IOH) on clinically significant hematuria (CSH) following holmium laser enucleation of the prostate (HoLEP). Benign prostatic hyperplasia (BPH) is a common cause of lower urinary tract symptoms (LUTS) in men. HoLEP has emerged as a superior surgical option due to its hemostatic properties, especially in patients at risk of bleeding. IOH, commonly defined as a >20% reduction in systolic blood pressure (BP) from baseline, is frequent under general anesthesia and may obscure intraoperative bleeding—but its role in CSH is unclear.

A retrospective analysis was performed of all HoLEPs conducted by a single surgeon in 2024. The primary outcome was CSH, defined as clot retention, reoperation, management change, or persistent hematuria >1 month. Patients were matched by preoperative prostate volume using coarsened exact matching (CEM). IOH was defined in two ways: (1) mean systolic blood pressure (SBP) > 20% below baseline, and (2) peak intraoperative SBP > 20% below peak 1-year preoperative SBP. Associations were assessed with Wilcoxon Rank Sum and Chi-squared/Fisher’s exact tests.

Of 212 patients, 22 developed CSH; 18 were successfully matched to controls. Baseline characteristics were similar. Under the peak definition, enucleation-phase IOH was significantly associated with CSH (OR 3.31; 95% CI 1.13-9.7; P = .029). CSH patients also experienced higher rates of emergency department visits (42% vs 6%) and readmissions (37% vs 3%).

Enucleation-phase IOH during HoLEP was associated with increased CSH risk. Optimizing enucleation-phase SBP may reduce postoperative complications. Collaboration between surgical and anesthesia teams is critical to improving safety and outcomes.