Relationships Between Holmium Laser Enucleation of the Prostate and Prostate Cancer - Beyond the Abstract

Prostate cancer (PCa) and Benign prostatic hyperplasia (BPH) are both conditions that increase in prevalence for older men. Therefore, when urologists initially evaluate a patient for BPH and lower urinary tract symptoms (LUTS), they must do their due diligence to ensure that the patient does not have PCa.

However, even among men with no concern for PCa (e.g. normal or low PSA) or men with a negative elevated PSA workup (e.g. normal prostate biopsy or prostate MRI) around 15% of them will be found to have incidental PCa (iPCa) at the time of transurethral surgery for BPH/LUTS. This is concerning because if a patient is diagnosed with clinically significant iPCa, this results in inefficient care and potentially worse outcomes for the patient than if the patient had just undergone definitive treatment for PCa upfront.

Holmium Laser Enucleation of the Prostate (HoLEP) is a size-independent treatment option for BPH/LUTS. Given that interest in prostate enucleation is increasing among the urologic community, we thought a perspective article on the relationships between HoLEP and PCa was timely. Indeed, there are multiple situations where HoLEP and PCa intersect. For example, some patients with biopsy proven PCa and severe BPH/LUTS choose to undergo HoLEP prior to radiation therapy even though HoLEP is not a treatment for PCa to prevent radiation-induced exacerbation of LUTS.

Furthermore, some patients with advanced or metastatic PCa will choose to undergo HoLEP as they are in urinary retention i.e. “palliative HoLEP”. Some patients are found to have clinically significant iPCa despite an appropriate workup for elevated PSA and may require further definitive treatment for PCa after HoLEP. Thus, we review outcomes associated with robotic prostatectomy after HoLEP. Many authors have attempted to identify variables associated with iPCa at the time of HoLEP and, therefore, we review pertinent studies on this topic. Unfortunately, no studies can comment if MRI or prostate biopsy is superior to preventing the detection of iPCa, but this will be an interesting area of future research. Some other patients have no evidence of PCa prior to HoLEP, no iPCa at the time of HoLEP, but still, develop PCa after the surgery. Therefore, we also review studies looking at variables associated with the identification/development of PCa in the post-HoLEP setting.

Much of the literature on these topics is retrospective in nature, but we did a deep dive to summarize the currently available evidence. Lastly, many readers may find our review of the current management pathway utilized at Northwestern University prior to performing HoLEP helpful.

Written by: Matthew Lee, MD, Department of Urology, Ohio State University School of Medicine, Columbus, OH

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