Evaluation of factors associated with the detection of incidental prostate cancer after open prostatectomy for benign prostatic hyperplasia

Predictive factors of incidental prostate cancer in patients undergoing surgery for presumed benign prostatic hyperplasia: an updated systematic review and meta-analysis

Purpose

We aimed to identify the clinical predictors of incidental prostate cancer (IPCa) after surgery for presumed benign prostatic hyperplasia (BPH).

Methods

The literature was comprehensively searched using PubMed, Web of Science, Embase, and Cochrane databases in December 2024. We used pooled standardized mean difference (SMD) and odds ratio (OR) to describe the correlation between relevant risk factors and IPCa.

Results

Twenty-one studies included 10,842 patients that were available for further analysis. After BPH surgery, 957 patients were histopathologically diagnosed with IPCa. The IPCa rate was 8.83%. Most importantly, our results identified that IPCa was significantly associated with age (pooled SMD = 0.36, P < 0.001), body mass index (BMI) (pooled SMD = 0.23, P < 0.001), preoperative prostate-specific antigen (pre-PSA) (pooled SMD = 0.43, P < 0.001), preoperative prostate-specific antigen density (pre-PSAD) (pooled SMD = 0.62, P = 0.028), resected prostate weight (pooled SMD = -0.22, P < 0.001), preoperative treatment with 5-alpha reductase inhibitors (5αRIs) (yes/no) (pooled OR = 0.60, P < 0.001), family history (yes/no) (pooled OR = 3.81, P = 0.029), digital rectal examination (DRE) findings (abnormal/normal) (pooled OR = 5.15, P < 0.001), and transrectal ultrasonography (TRUS) findings (abnormal/normal) (pooled OR = 2.92, P < 0.001). Additionally, sensitivity and subgroup analyses indicated that our findings were reliable and robust. However, we found no significant associations between IPCa and prostate volume, preoperative negative prostate biopsy, smoking history, history of hypertension, history of diabetes, history of dyslipidemia, and abnormal magnetic resonance imaging findings (all P > 0.05).

Conclusions

Age, BMI, pre-PSA, pre-PSAD, resected prostate weight, preoperative treatment with 5αRIs, family history, abnormal DRE findings, and abnormal TRUS findings are independent factors predicting IPCa following BPH surgery. Before BPH surgery, factors such as age, BMI, pre-PSA, and pre-PSAD should be considered to assess the risk of IPCa. For high-risk patients, more detailed imaging and needle biopsy are recommended before surgery to avoid missed diagnosis. In the future, more large-scale and well-designed studies are needed to validate our results further.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42025631346.

Safety and feasibility of En-bloc holmium laser enucleation for very large prostates (> 200 cc) with trainee involvement

Objectives

To evaluate the safety and feasibility of "en-bloc" Holmium Laser Enucleation of the Prostate (HoLEP) with trainee involvement in patients with prostates larger than 200 cc.

Patients and Methods

A retrospective analysis was conducted on patients undergoing HoLEP using the "en-bloc" technique for prostate sizes > 200 cc between July-2017 and December-2023 at an academic teaching hospital. Perioperative data was collected, including patient demographics, clinical parameters, operative details and functional outcomes. Patients who continued to experience incontinence at 1 year were further followed up at 2 years to update their continence status. Sub-group analysis was performed to compare outcomes between patients with preoperative prostate size of 200-300 cc and > 300 cc.

Results

The analysis included 89 patients with a mean age of 73.12 ± 8.10 years. Preoperative prostate weight ranged from 200 to 401 cc with a median of 245 cc, and median PSA was 7.71 ng/ml. Median operative time was 218.5 minutes, and median enucleated prostate volume was 164.2 cc. Median postoperative PSA was 0.4 [0.21-0.78] ng/ml. At 1-year follow-up, mean IPSS was 1 ± 2.4, Qmax was 27.03 ± 11.57 ml/s and PVR was 21.6 ± 28.6 ml. Postoperative complications included blood transfusion (5.6%), acute renal injury (4.5%), urinary tract infection (2.2%), postoperative urinary retention (2.2%) and urethral stricture (5%). Although transient urinary incontinence was noted in 41.6% at 1-3-months, complete continence was achieved in 83.3% and 96.3% at 1 and 2 years postoperatively, respectively. Subgroup analysis showed significant differences in operative time and enucleated weight between prostates 200-300 cc and > 300 cc, but no significant differences in postoperative IPSS, PVR or Qmax at 3-months.

Conclusion

"En-bloc" HoLEP is a feasible and safe procedure for prostates larger than 200 cc, demonstrating favourable perioperative and functional outcomes despite the extended operative times and involvement of trainees.

Incidence and associated factors for incidental prostate cancer among patients who underwent surgery for benign prostatic hyperplasia: first report from Somalia

BACKGROUND

The incidence rate of incidental prostate cancer (IPC) differs significantly among the reported studies in the relevant literature. There is a scarcity of studies regarding IPC reported from Sub-Saharan African Countries, including Somalia. The present is the first study that evaluates the incidence and associated factors for IPC among patients who had surgery for benign prostatic hyperplasia at a tertiary hospital in Somalia.

METHOD

This retrospective study reviewed the data of 538 patients with benign prostate hyperplasia, 464 patients who underwent transurethral resection of the prostate (TURP), and 74 patients with open prostatectomy (OP) over 5 years. A binary logistic regression model was used to investigate the association between perioperative factors such as age, prostate volume, total prostate-specific antigen (TPSA) levels, type of surgery, specimen weight, and the finding of IPC.

RESULTS

IPC was detected in 17.6%, 18.3% of TURP, and 13.5% of OP patients (p = 0.002). The mean age of the patients was 71.82 ± 7.4; IPC patients had a significantly higher mean age than the BPH group (74 ± 10.9 vs. 71.3 ± 10.8, p < 0.001). Sixty-two percent of the patients were T1b, while 57.8% had ISUP grade groups 1 and 2. Patients with T1a had significantly higher International Society of Urological Pathology (ISUP) grades 1 and 2 than those with T1b (69.4% in T1a vs. 50.8% in T1b, p < 0.001). Increased age, higher TPSA levels, low prostate volume, and specimen weight were independently associated with the finding of incidental prostate carcinoma (OR 1.978, 95% CI 0.95-1.60, P < 0.04; OR 1.839, 95% CI 0.99-2.02, P < 0.001; OR 1.457, 95% CI 0.7102.99, P < 0.001, OR 0.989, 95% CI 1.07-2.94, P = 0.01). IPC was most commonly managed by active surveillance (54.7%), followed by androgen deprivation therapy in 28.4%. The overall survival rate for a 5-year follow-up in the entire cohort was 79%. The cancer-specific mortality was 8.4%.

CONCLUSION

The study findings revealed a higher incidence and cancer-specific mortality rate of incidental prostate carcinoma. T1b stage, higher ISUP grade, older age, and higher preoperative TPSA were significantly associated with the overall mortality and cancer-specific mortality rate. More than half of the cases were managed by active surveillance, and it is a safe management strategy, particularly in low-income countries like Somalia.