Endogenous Testosterone Recovery after Enucleation for BPH: Clinical Insights into the Concept of "Normal" Testosterone

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BACKGROUND: Lower urinary tract symptoms (LUTS), particularly nocturia, may disrupt sleep and have been hypothesized to suppress the hypothalamic-pituitary-gonadal axis. Although anatomical endoscopic enucleation of the prostate (AEEP) has been associated with increased testosterone in men with low baseline levels, its effect in men with "biochemically normal" preoperative testosterone remains unclear. OBJECTIVES: To evaluate postoperative total testosterone (TT) changes after AEEP and to identify a preoperative TT threshold that predicts clinically meaningful TT elevation. MATERIALS AND METHODS: We conducted a single-center retrospective cohort study of men undergoing AEEP between 2018 and 2021. Of 560 cases, 304 met inclusion criteria. Morning TT was measured preoperatively and 6-12 months postoperatively. Clinically significant TT elevation was defined as a ≥20% increase from baseline. Receiver operating characteristic (ROC) analysis identified the optimal preoperative TT cut-off for predicting TT elevation, and multivariable logistic regression evaluated independent predictors. RESULTS: The mean age was 69.7 years, and 92 of 304 patients (30.3%) achieved postoperative TT elevation. ROC analysis demonstrated moderate discrimination (AUC 0.737; 95% CI 0.678-0.797), with a Youden-optimal TT cut-off of 4.525 ng/mL (sensitivity 72.8%, specificity 64.2%). On bootstrap internal validation, the optimism-corrected AUC was 0.738, and the optimal cut-off varied across resamples (95% range 3.13-5.07 ng/mL), indicating that the threshold is exploratory. Preoperative TT <4.5 ng/mL independently predicted TT elevation (adjusted OR 4.345; 95% CI 2.533-7.453; p < 0.001), as did TT <3.5 ng/mL (adjusted OR 3.682; 95% CI 2.158-6.283; p < 0.001). DISCUSSION: AEEP was associated with meaningful TT increases not only in hypogonadal men but also in those with conventionally normal baseline TT, particularly within the 3.5-4.5 ng/mL range. CONCLUSION: In this uncontrolled cohort, a preoperative TT threshold around 4.5 ng/mL identified men more likely to show postoperative TT elevation; this exploratory finding warrants prospective, controlled validation before the current "normal" TT range is reconsidered.

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