Introduction: The management of men with incidentally discovered T1a and T1b prostate cancer (PCa) diagnosed after a bladder outlet procedure is well established, and rarely requires intervention. The surgical treatment of men with significantly enlarged, symptomatic glands who are on active surveillance (AS) for low risk prostate cancer is not well defined. Men are often advised to undergo radical prostatectomy, to treat both pathologies simultaneously. We report our experience with the use of Holmium Laser Enucleation of the Prostate (HoLEP) for large prostates in men on AS for PCa.
Methods: Men on AS for low risk (Gleason Grade Group 1, GG1) PCa who underwent HoLEP between 2013-2019 were identified from a prospectively maintained institutional database. Data regarding preoperative cancer workup, perioperative outcomes, and preoperative/postoperative voiding parameters were analyzed along with postoperative surveillance for PCa including Prostate-specific antigen (PSA) nadir, PSA at last follow-up, and post-procedure multiparametric Magnetic Resonance Imaging (mpMRI) or prostate biopsy.
Results: Nineteen men met inclusion criteria. Mean preoperative max flow (mL/s), postvoid residual (cc), and size (cc) on transrectal ultrasound (TRUS) were 7.9, 156, and 99, respectively. Men had a mean preoperative PSA (ng/ml) of 8.6 with an average of 2 biopsies. Mean resected tissue weight was 66gms with a postoperative flow of 20.8 mL/s and significantly decreased residual of 23cc. 5/19 men had prostate adenocarcinoma in pathology specimen (all GG1). Postoperative PSA nadir was 1.3 at 6.6mos with a PSA of 1.6 at last follow up (20mos). Five men underwent mpMRI with identification of a PIRADs 5 lesion in 1 patient who subsequently underwent a negative fusion biopsy. Three men underwent post-HoLEP TRUS biopsies with 1 undergoing radical prostatectomy for progression of disease to Gleason 4+3=7 (GG3). Radical prostatectomy proceeded without complication, with an undetectable PSA at last follow up.
Conclusions: Men on AS for low risk PCa can safely undergo HoLEP with significant improvement in voiding parameters. Such an approach prioritizes their more pressing problem, which is obstructive voiding. Postoperative monitoring with PSA and mpMRI can detect disease progression requiring definitive treatment. Further research is needed to define optimal surveillance strategy and long-term cancer-specific outcomes. Source of
