Holmium Laser Enucleation of the Prostate Provides Similar Incidental Prostate Cancer Detection Rates as Open Prostatectomy: A Matched Pair Analysis

Incidental prostate carcinoma after single-port robot-assisted simple prostatectomy: a multi-institutional report (SPARC)

BACKGROUND

Single-port robot-assisted simple prostatectomy is a minimally invasive alternative for patients with large benign prostatic hyperplasia with severe symptoms and/or failure of medical treatment. In recent literature, the rate of incidental prostate cancer after simple prostatectomy ranges from 1.8% to 13.0%. Our objective is to report the rate of incidental prostate cancer after single-port robot-assisted simple prostatectomy and to compare our findings to other approaches.

METHODS

A Single-Port Advanced Research Consortium [SPARC] multi-institutional retrospective analysis of all initial consecutive single-port robot-assisted simple prostatectomy cases performed from 2019 to 2023 by eleven surgeons from six centers. Our primary outcome was the rate of incidental prostate cancer in adenoma specimens. We used descriptive statistics to analyze the data.

RESULTS

A total of 235 cases were performed successfully without conversions or additional ports. Eleven patients (4.6%) were found to have incidental prostate cancer on pathological analysis. The median percentage of tissue involved by the tumor was 5%. The overall rate of clinically significant prostate cancer was 2.1%. Most cases were Gleason Grade Group 1 (55%). Those with Grade Group ≤3 were subsequently managed with active surveillance with a median follow-up of 17 months. A patient with Gleason Grade Group 4 underwent an uncomplicated multi-port robot-assisted radical prostatectomy with satisfactory functional and oncological outcomes.

CONCLUSIONS

Initial multi-institutional experience with single-port robot-assisted simple prostatectomy showed an incidental prostate cancer rate of 4.6%, comparable to MP, laparoscopic, and open techniques.

Perioperative Rates of Incidental Prostate Cancer after Aquablation and Holmium Laser Enucleation of the Prostate

INTRODUCTION

Aquablation and holmium laser enucleation of the prostate (HoLEP) have evolved as established therapeutic options for men with benign prostatic obstruction (BPO). We sought to compare the rates of incidental prostate cancer (iPCa) after aquablation and HoLEP.

METHODS

At our center, between January 2020 and November 2022, 317 men underwent aquablation, and 979 men underwent HoLEP for BPO. Histopathological assessment of resected tissue was conducted in all cases. If iPCa was detected, the Gleason score and percentage of affected tissue were assessed. Differences in important predictive factors for prostate cancer between study groups were accounted for by additional matched pairs analysis (with matching on age ± 1 year; PSA ± 0.5 ng/mL; and prostate volume ± 5 mL).

RESULTS

Histopathology revealed iPCas in 60 patients (4.6%): 59 (6.03%) after HoLEP and 1 (0.3%) after aquablation (p = 0.001). Of 60 of incidental cancers, 11 had a Gleason score ≥7 (aquablation: 1/1 [100%]; HoLEP: 10/59 [16.9%]). The aquablation and HoLEP study groups differed in patient age, preoperative PSA, and prostate volume. Therefore, matched pairs analysis (aquablation: 132 patients; HoLEP: 132 patients) was conducted to improve comparability. Also after the matching procedure, significantly fewer iPCas were diagnosed after aquablation than HoLEP (aquablation: 0 [0%]; HoLEP: 6 [4.5%]; p = 0.015).

CONCLUSION

Significantly fewer iPCas were identified after aquablation than HoLEP procedures. Histopathologic assessment of tissue after aquablation is feasible and may lead to the diagnosis of clinically significant iPCa. Therefore, histopathologic examination of the aquablation resective tissue should not be omitted.

Single-port Transvesical Robot-Assisted Simple Prostatectomy: Surgical Technique and Clinical Outcomes

BACKGROUND

Surgical management of large prostatic adenomas can be performed via open, endoscopic, or robotic approaches. A low-profile single-port (SP) robot was built to work in confined areas (ie, the bladder) and regionalize surgery.

OBJECTIVE

To describe the novel SP transvesical (TV) robot-assisted simple prostatectomy (RASP) and report clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

SP TV RASP cases were performed in an academic hospital by two surgeons from 2019 to 2023. A total of 117 cases were performed, and data from patients with at least 12 mo of follow-up were analyzed. The inclusion criterion was severe obstructive urinary symptoms or catheter-dependent urinary retention due to large prostates with volume >80 ml.

SURGICAL PROCEDURE

The procedure consisted of two main steps through a single 3-cm suprapubic incision: first, enucleation of the adenoma, and second, a 360° bladder mucosal flap reconstruction. No drains or continuous bladder irrigation was used routinely.

MEASUREMENTS

Intraoperative parameters, pre- and postoperative uroflowmetry, and 1-yr clinical outcomes were assessed. We used descriptive statistics to analyze the data.

RESULTS AND LIMITATIONS

All procedures were completed successfully without additional ports or conversions. The median console time and estimated blood loss were 107 min and 100 ml, respectively. Transfusion rate was 0%. Intraoperative complications included two suspected air emboli attributed to high insufflation pressures. There were no major postoperative complications. In total, 95.8% were discharged within the first 24 h, with a median length of stay and pain score of 5 h and 3/10, respectively. There was persistent improvement in the median International Prostate Symptom Score and flow rate after 1 yr. The median Sexual Score Inventory for Men score was 20 at 12 mo. Our study is limited by its retrospective nature and cohort size.

CONCLUSIONS

SP TV RASP is a feasible alternative for the management of severe benign prostatic hyperplasia that promotes fast recovery and demonstrates 1-yr improvement in urinary function.

PATIENT SUMMARY

Single-port transvesical robot-assisted simple prostatectomy is a minimally invasive alternative for the treatment of large benign prostatic growth. A single robotic arm goes through a small incision in the skin and bladder to extract the obstructive prostatic tissue. Afterward, reconstruction of the area is done to decrease bleeding and improve postoperative symptoms. We found that patients recover quickly and have excellent clinical results with a low risk of complications.

Current Trends in Incidence and Management of T1a and T1b Prostate Cancer

Prostate cancer (PCa) identified incidentally (iPCa) after surgical treatment for symptomatic benign prostatic hyperplasia (BPH) causing lower urinary tract symptoms (LUTS) is considered low risk by the most current guidelines. Management protocols for iPCa are conservative and are identical to other prostate cancers classified as having favorable prognoses. The objectives of this paper are to discuss the incidence of iPCa stratified by BPH procedure, to highlight predictors of cancer progression, and to propose potential modifications to mainstream guidelines for the optimal management of iPCa. The correlation between the rate of iPCa detection and the method of BPH surgery is not clearly defined. Old age, small prostate volume, and high pre-operative prostate-specific antigen (PSA) are associated with an increased likelihood of detecting iPCa. PSA and tumor grade are strong predictors of cancer progression and can be used along with magnetic resonance imaging (MRI) and potential confirmatory biopsies to determine disease management. In instances that iPCa requires treatment, radical prostatectomy (RP), radiation therapy, and androgen deprivation therapy all have oncologic benefits but may be associated with increased risk after the BPH surgery. It is advised that patients with low to favorable intermediate-risk prostate cancer undergo post-operative PSA measurement and prostate MRI imaging before electing to choose between observation, surveillance without confirmatory biopsy, immediate confirmatory biopsy, or active treatment. Subdividing the binary T1a/b cancer staging into more categories with ranging percentages of malignant tissue would be a helpful first step in tailoring the management of iPCa.

Is the systematic histological analysis of benign prostatic hyperplasia surgical specimen always necessary?

INTRODUCTION

After most surgical management of benign prostatic hyperplasia (BPH), the resected tissue undergoes a histological examination. This examination is performed for the risk of finding an incidental prostate cancer (iPCa). The improvement of prostate cancer detection in the past few years decreased the global iPCa rate. This raises the question of the real benefit for all patients of a systematic histological analysis. The aim of our study was to evaluate the iPCa detection rate on a large contemporary cohort of patients treated for BPH, and to define predictive factors of iPCa detection.

PATIENTS AND METHODS

We retrospectively analyzed the medical charts of all consecutive patients who underwent surgical treatment for BPH in our academic center from 2012 to 2018. Patients with prostate cancer diagnosed before surgery were not included. All the resected tissue underwent standard histopathological examination. iPCa was defined by any grade or stage of prostate cancer identified on the resected tissue by the histological examination. The following variables were analyzed using an uni- and multi-variable logistic regression as potential risk factors of iPCa: age, total PSA, PSA density (PSAd), prostate volume, technique used, weight of resected tissue and use of 5ARI medication.

RESULTS

1045 patients were included in the study. Of them, 439 (42.0%), 206 (19.7%) and 400 (38.3%) underwent HoLEP, OP and TURP, respectively. iPCa was diagnosed in 94 (9.0%) of the 1045. Among them 15 (1.4%) were clinically significant (ISUP score ≥ 2). The multivariable logistic regression analysis identified age (p = 0.03) and PSA density (p < 0.001) as independent predictive factors for the detection of iPCa. Using the median of age and PSAd, we identified a population with 0% of iPCa in our cohort (age < 70 year-old and PSAd < 0.05 ng/mL/mL).

CONCLUSION

The global iPCa rate was 9% in this contemporary large cohort of patients who underwent surgical treatment for BPH, with 1.4% of clinically significant cancer. Age and PSAd were independent predictive factors to find iPCa. Patients younger than 70 with a PSAd < 0.05 ng/mL/mL had 0% of iPCA in our cohort. In this specific population, we could probably avoid a systematical histological examination of the resected tissue.

Comparison of the efficacy and safety of transurethral laser versus open prostatectomy for patients with large-sized benign prostatic hyperplasia: A meta-analysis of comparative trials

PURPOSE

The selection of open prostatectomy (OP) over transurethral laser surgery is controversial for large volume prostates. Thus, we aim to compare the efficacy and safety of transurethral laser versus OP, and provide the latest evidence of clinical practice for large-sized benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

This meta-analysis used Review Manager V5.3 software and the systematic literature search of Cochrane Library, Embase, PubMed, and Web of Science datasets was performed for citations published from 2000 to 2020 that compared transurethral laser with OP for the treatment of large BPH. Variables of interest assessing the two techniques included clinical characteristics, and the perioperation-, effectiveness-, and complication-related outcomes.

RESULTS

The meta-analysis included twelve studies containing 1,514 patients, with 792 laser and 722 OP. The transurethral laser group was associated with shorter hospital stay and catheterization duration, and less hemoglobin decreased in the perioperative variables. There was no significant difference in the international prostate symptom score, post-void residual urine volume, maximum flow rate, and quality of life score. Transurethral laser group had a significantly lower incidence of blood transfusion than OP group (odds ratio, 0.10; 95% confidence interval, 0.05 to 0.19; p<0.001; I²=8%), and no statistical differences were found with respect to the other complications.

CONCLUSIONS

Both OP and transurethral laser prostatectomy are effective and safe treatments for large prostate adenomas. With these advantages of less blood loss and transfusion, and shorter catheterization time and hospital stay, laser may be a better choice for large BPH.

Incidental prostate cancer after holmium laser enucleation of the prostate-A narrative review

Prostate cancer can be detected incidentally after surgical therapy for benign prostatic obstruction such as holmium laser enucleation of the prostate (HoLEP), thus called incidental prostate cancer (iPCa). We aimed to review the studies on iPCa detected after HoLEP and investigate its prevalence. A detailed search of original articles was conducted via the PubMed-MEDLINE, Web of Science, Wiley Online Library and Cochrane Library databases in the last 10 years up to 1 May 2021 with the following search string solely or in combination: "prostate cancer", "prostate carcinoma", "holmium laser enucleation of the prostate" and "HoLEP". We identified 19 articles to include in our analysis and divided them into six main categories: HoLEP versus open prostatectomy and/or transurethral resection of the prostate in terms of iPCa, oncological and functional outcomes, the role of imaging modalities in detecting iPCa, predictive factors of iPCa, the role of prostate-specific antigen kinetics in detecting iPCa and the management of iPCa after HoLEP. We found that the iPCa after HoLEP rate ranges from 5.64% to 23.3%. Functional and oncological outcomes were reported to be encouraging. Oncological treatment options are available in a wide range.

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

We aimed to evaluate the incidental prostate cancer (PCa) rate and predictive factors in patients who underwent open prostatectomy (OP) with a pre-diagnosis of benign prostatic hyperplasia (BPH). This study included patients with a pre-diagnosis of BPH, who underwent OP due to symptomatic prostate enlargement. Our database included age, medications, prostate-specific antigen (PSA), free/total PSA ratio, PSA density, digital rectal examination (DRE), prostate volume, serum neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, aspartate aminotransferase/alanine aminotransferase ratio, presence of metabolic syndrome (MetS) and histopathological results after OP. Of the 430 patients that underwent OP, 406 (94.4%) with a benign pathological diagnosis were evaluated as the benign group and 24 (5.6%) detected to have PCa constituted the incidental PCa group. The rate of incidental PCa was much higher in the elderly patients. The cut-off value of age was 71.5 years in the PCa group according to the receiver operating characteristic curve analysis. According to the multivariate analysis, DRE and the presence of MetS were effective in predicting PCa (p < .001 and p = .031, respectively). DRE was found 16 times more effective and MetS was 2.8 times more effective than the other parameters. Our results showed that DRE and the presence of MetS could be useful predictive factors of incidental PCa in OP.

Active Surveillance for Incidental (cT1a/b) Prostate Cancer: Long-Term Outcomes of the Prospective Noninterventional HAROW Study

INTRODUCTION

Optimal treatment for incidental prostate cancer (IPC) after surgical treatment for benign prostate obstruction is still debatable. We report on long-term outcomes of IPC patients managed with active surveillance (AS) in a German multicenter study.

METHODS

HAROW (2008-2013) was designed as a noninterventional, prospective, health-service research study for patients with localized prostate cancer (≤cT2), including patients with IPC (cT1a/b). A follow-up examination of all patients treated with AS was carried out. Overall, cancer-specific, and metastasis-free survival and discontinuation rates were determined.

RESULTS

Of 210 IPC patients, 68 opted for AS and were available for evaluation. Fifty-four patients had cT1a category and 14 cT1b category. Median follow-up was 7.7 years (IQR: 5.7-9.1). Eight patients died of which 6 were still under AS or watchful waiting (WW). No PCa-specific death could be observed. One patient developed metastasis. Twenty-three patients (33.8%) discontinued AS changing to invasive treatment: 12 chose radical prostatectomy, 7 radiotherapy, and 4 hormonal treatment. Another 19 patients switched to WW. The Kaplan-Meier estimated 10-year overall, cancer-specific, metastasis-free, and intervention-free survival was 83.8% (95% CI: 72.2-95.3), 100%, 98.4% (95% CI: 95.3-99.9), and 61.0% (95% CI: 47.7-74.3), respectively. In multivariable analysis, age (RR: 0.97; p < 0.001), PSA density ≥0.2 ng/mL2 (RR: 13.23; p < 0.001), and PSA ≥1.0 ng/mL after surgery (RR: 5.19; p = 0.016) were significantly predictive for receiving an invasive treatment.

CONCLUSION

In comparison with other AS series with a general low-risk prostate cancer population, our study confirmed the promising survival outcomes for IPC patients, whereas discontinuation rates seem to be lower for IPC. Thus, IPC patients at low risk of progression may be good candidates for AS.

Holmium Laser Enucleation of Prostate Within 6 Weeks of Transrectal Ultrasound Guided Prostate Biopsy is Safe and Effective

OBJECTIVE

To evaluate the safety and efficacy of performing Holmium laser enucleation of the prostate (HoLEP) for the treatment of bladder outlet obstruction secondary to an enlarged prostate within 6-weeks of a transrectal ultrasound (TRUS) guided prostate biopsy.

MATERIALS AND METHODS

We performed a retrospective review of patients who underwent a HoLEP at our institution, excluding any patients with a confounding urologic history and compared patients who underwent a TRUS-guided 6- or 12-core prostate biopsy, and then underwent a HoLEP within 6 weeks (study group) with all other patients (control group). Our primary outcomes were enucleation efficiency (EE) and perioperative complication rate. Our secondary outcomes included postoperative drop in hemoglobin, duration of catheterization, length of hospital stay, voiding metrics at 1 and 6 months and rate of incidental prostate cancer diagnosed on histopathological examination of prostate specimens after HoLEP. To test for differences between the study and control groups, we performed independent sample t-test (2-tailed) and chi-square tests for quantitative and qualitative variables, respectively. P values of < 0.05 were considered statistically significant.

RESULTS

552 patients met inclusion criteria and 84 patients underwent prostate biopsy within a period of 45 days prior to HoLEP. Enucleation efficiency was higher in the study group (P = 0.00). There was no significant difference between the 2 groups regarding perioperative complications, postoperative voiding outcomes, or rate of incidental prostate cancer detection.

CONCLUSIONS

TRUS prostate biopsy performed within 6 weeks of HoLEP does not negatively impact operative difficulty or treatment outcome.

Transurethral laser versus open simple prostatectomy for large volume prostates: a systematic review and meta-analysis of randomized controlled trials

The benefit of transurethral laser prostatectomy over open simple prostatectomy (OSP) is controversial in aged symptomatic benign prostatic hyperplasia (BPH) patients with large volume prostates, and the aim of this study is to compare the safety and efficiency of these two methods. Meta-analysis was applied using the Review Manager V5.3 software and the retrieved randomized controlled clinical trials (RCTs) comparing transurethral laser prostatectomy with OSP were analyzed for the treatment of large volume prostates from 2000 to 2019 in PubMed, Web of Science, Cochrane, and EMBASE datasets. Five RCTs assessing transurethral laser prostatectomy versus OSP were considered suitable for this meta-analysis, which included a total of 448 patients, with 232 patients undergoing laser and 216 patients undergoing OSP. Compared with OSP, although transurethral laser prostatectomy required a longer operative time (weighted mean difference (WMD) 27.49 mins; 95% confidence interval (CI) 16.54-38.44; P < 0.00001) and obtained a less resected prostate weight (WMD - 11.72 g; 95% CI - 21.75 to - 1.70; P = 0.02), patients undergoing laser prostatectomy benefited from significantly less hemoglobin decline (- 0.97 g/dL; 95% CI - 1.31 to - 0.64; P < 0.00001), shorter time of catheterization (WMD - 3.67 days; 95% CI - 5.60 to - 1.75; P = 0.0002), shorter length of hospital stay (WMD - 4.75 days; 95% CI - 6.57 to - 2.93; P < 0.00001), and less blood transfusion (odds ratio 0.10; 95% CI 0.03 to 0.35; P = 0.0003). During postoperative follow-up, no significant difference was observed between the two groups in IPSS, QoL, Q_max, and PVR. Both transurethral laser prostatectomy and OSP are safe and effective for large prostates that require prostate resection. Taking into account of less blood loss, shorter catheterization time and hospital stay, and less blood transfusion, transurethral laser prostatectomy may be a better treatment for patients with large prostates.

Changes in serum PSA after endoscopic enucleation of the prostate are predictive for the future diagnosis of prostate cancer

PURPOSE

After Endoscopic Enucleation of the Prostate (EEP) for benign prostatic obstruction (BPO), men remain at risk for prostate cancer (PCa). Significant PSA changes occur after enucleation, which interfere with later screening for PCa. It remains unclear which patients need further diagnostic investigations for PCa after EEP. The goal of this study was to identify an independent predictor for PCa diagnosis after Holmium Laser Enucleation of the Prostate (HoLEP) in patients whose HoLEP resection specimen did not show PCa.

METHODS

Data of 773 patients who underwent HoLEP for BPO between 2010 and 2018 in a referral center were analyzed. Exclusion criteria were PCa detection in the HoLEP specimen or absence of post-operative PSA values. Patients were divided in a PCa group and Control group depending on whether or not PCa was detected during follow-up after HoLEP. The predictive value for future diagnosis of PCa of different forms of PSA-change after HoLEP was analyzed by multivariate Cox regression and ROC analysis.

RESULTS

Overall, 24 (4.2%) patients developed PCa after HoLEP. At 5 year follow-up, the PCa-free survival rate was 85%. First post-operative PSA was an independent predictor of PCa diagnosis after HoLEP (HR 1.106, 95% CI 1.074-1.139, p < 0.001, ROC AUC 0.903) with an optimal cut-off value of 1.73 ng/ml (sensitivity 83.3%, specificity 82.3%).

CONCLUSIONS

For patients who underwent HoLEP for BPO, post-operative PSA after HoLEP is an independent predictor for future PCa diagnosis. When PSA is > 1.73 ng/ml within the first year after HoLEP, rigorous follow-up and diagnostic investigations for PCa are indicated.

Incidental prostate cancer after transurethral resection of the prostate: analysis of incidence and risk factors in 458 patients

BACKGROUND

The aim of this study is to evaluate the incidence and risk factors of incidental prostate cancer (IPCA) in a contemporary cohort of lower urinary tract symptoms (LUTS) patients who underwent trans-urethral resection of the prostate (TURP).

METHODS

A series of 458 consecutive patients who underwent TURP were evaluated between January 2016 to June 2018. Evaluated factors included age (years), Body Mass Index (BMI; kg/square meters), treatment with inhibitors of 5-alpha reductase, previous prostate biopsies, basal prostate specific antigen (PSA) levels (ng/mL), serum leukocyte count (×10⁹/L), weight of resected prostate tissue (grams), grade and stage of IPCA. The multivariate logistic regression model evaluated associations of significant clinical factors with the risk of IPCA.

RESULTS

Overall, IPCA was detected in 30 of 454 patients (6.6%). A mean of 21.8 g of tissue was resected. The mean number of positive chips was 5.6 (mean percentage 3.9%) with tumor grade group 1 in 22 cases (73.4%) and tumor stage cT1a in 23 patients (76.7%). On multivariate analysis, independent factors that were positively associated with the risk of IPCA were BMI (odds ratio, OR=1.121; P=0.017) and leukocyte count (OR=1.144; P=0.027).

CONCLUSIONS

In a contemporary cohort of patients undergoing TURP for the treatment of LUTS, the risk of IPCA was not negligible with a rate of being 6.6%. BMI and serum leukocyte count were found to be independent factors that were positively associated with the risk of IPCA.

Favorable long-term oncological and urinary outcomes of incidental prostate cancer following holmium laser enucleation of the prostate

The aim of the present study was to investigate the impact of incidental prostate cancer (IPCa), which was diagnosed by holmium laser enucleation of the prostate (HoLEP), on long-term oncological and functional outcomes. A total of 482 patients who underwent HoLEP for benign prostatic hyperplasia (BPH) between 2008 and 2016 at our institution were retrospectively reviewed. We defined IPCa as prostate cancer (PCa) according to the enucleated tissue of transitional zone. Therefore, 64 patients were excluded for the following reasons: Prostate-specific antigen (PSA) ≥4.0 ng/ml and no prostate biopsy (n=46); and PSA ≥4.0 ng/ml and diagnosed with PCa by prostate biopsy performed during HoLEP (n=18). Notably, 418 patients were included in the study and divided into two groups: The BPH group and the IPCa group. For 5 years, postoperative PSA and functional outcomes were evaluated. Of 418 patients, 25 (6%) were diagnosed with IPCa by HoLEP, 21 patients (84%) had a Gleason score ≤6 and 5 patients (20%) received adjuvant therapy for PCa following HoLEP. No significant differences were observed between groups for preoperative PSA, PSA density, or urinary and sexual function outcomes; however, age at the time of HoLEP significantly differed between groups (71.7 vs. 75.5 years, P=0.026). Long-term (5-year) urinary outcomes demonstrated sustained improvement. Postoperative PSA increased gradually in the IPCa group (3-year, P=0.033; 4-year, P=0.037); International Index of Erectile Function 5 conversely decreased (5-year, P=0.068). According to the present results, if standard PSA screening and prostate biopsy are performed, watchful waiting for IPCa is feasible, and IPCa does not impact on 5-year urinary outcomes.