Clinical-Prostate cancer
Management of prostate cancer after holmium laser enucleation of the prostate

https://doi.org/10.1016/j.urolonc.2020.11.003Get rights and content

Highlights

  • HoLEP is effective in treating LUTS from prostatic disease.

  • Greater than 10% of HoLEP patients will have incidental CaP.

  • Further study is necessary to determine whether HoLEP provides oncologic benefit.

Abstract

Introduction

Holmium laser enucleation of the prostate (HoLEP) is effective in treating lower urinary tract symptoms from prostatic disease. We investigate the role of HoLEP in the management of patients with benign prostatic hypertrophy (BPH) and prostate cancer (CaP).

Methods

Retrospective review of data regarding all patients undergoing HoLEP at a single institution was performed. Pre- and postoperative PSA, multiparametric MRI, and pathology results were analyzed for those with CaP identified prior to or incidentally at HoLEP.

Results

From February 2016 to February 2020, 201 patients underwent HoLEP. Twelve patients had CaP diagnosed before HoLEP: 6 patients with GG1 are on active surveillance (AS), 3 of 4 intermediate-risk patients are on AS and 1 received treatment for disease progression, and both high-risk CaP patients achieved symptomatic benefit from HoLEP and are receiving systemic therapy for CaP. Twenty-one patients (11.1%) with incidentally detected CaP at HoLEP remain on AS or watchful waiting based on clinical scenario.

Conclusion

Screening for CaP in HoLEP candidates with PSA and MRI is recommended given that >10% will have incidental CaP. After HoLEP for BPH/LUTS, patients with CaP can be surveilled with PSA and/or MRI. Further investigation is warranted to determine the durability of success of these approaches.

Introduction

Holmium Laser Enucleation of the Prostate (HoLEP) is an endoscopic surgical technique typically employed for treatment of benign prostatic hypertrophy (BPH). While the mainstays of treatment for BPH remain medical management and a host of surgical options, including transurethral resection of prostate (TURP) and ablative procedures, HoLEP is an excellent option, particularly for large glands (>80 ml) and those having median lobes [1]. For those situations in which TURP will be particularly challenging, HoLEP is a less invasive alternative to open or robotic simple prostatectomy [2,3].

Active surveillance (AS) as a therapeutic option for patients with favorable-risk prostate cancer (CaP) is being utilized more commonly [4,5]. Factors that influence the decision to pursue AS include the patient's life expectancy, comorbidities, extent and grade of cancer, and personal preferences [6]. How lower urinary tract symptoms (LUTS) and bother from BPH/LUTS factor into treatment decisions for localized CaP remain unclear. Moreover, the exact role of endoscopic management on CaP outcomes has yet to be defined, particularly given the range of endoscopic techniques for BPH. Among these techniques, HoLEP and TURP may remove tissue containing CaP that might otherwise remain in situ without intervention for LUTS.

Multiparametric magnetic resonance imaging (mpMRI) can assess prostatic anatomy, intraprostatic and extraprostatic CaP [7,8]. mpMRI is being used, along with PSA, physical exam, and prostate biopsy, in the AS of CaP. The role of mpMRI and PSA in the surveillance of patients with incidental or localized CaP treated with HoLEP is unknown at present. In addition, it remains unclear how the removal of prostatic tissue with HoLEP impacts management of localized CaP. We report the outcomes of patients with CaP diagnosed prior to or at the time of HoLEP, in which surveillance has been performed with PSA and mpMRI (Fig. 1).

Section snippets

Methods

An institutional database of HoLEP cases was used to identify all patients undergoing this procedure (February 1, 2016–February 28, 2020). Included were all 201 patients who underwent HoLEP for BPH/LUTS. IRB approval was obtained for retrospective analysis (SH-IRB#2020-167). Patients undergoing other treatments for LUTS, including holmium laser ablation, photoselective vaporization, and TURP were excluded from the analysis. Retrospective chart review of these patients was completed looking for

Results

From 2016 to 2020, 201 HoLEP cases were performed. Median age was 70 years, pretreatment PSA was 3.5 ng/ml, and prostate volume was 79 cm3. Median AUA-SS was 23 out of 35 and postvoid residual was 146 ml, including 15 patients unable to void or with postvoid residual >999 ml. Of the 201 HoLEP patients, 33 were diagnosed with CaP. Two patients were diagnosed with chronic lymphocytic leukemia that was present in the prostatic tissue from HoLEP. Each of these patients is being followed by a

Discussion

CaP is the second most common cancer occurring in men, with an overall incidence of about 17%, and BPH is even more common, with 50% of men ages 51 to 60 having LUTS. [11] Management of LUTS is always considered in the treatment of CaP, and similarly, CaP is also a consideration whenever LUTS are present. HoLEP is an effective method for treatment of refractory LUTS caused by BPH in a minimally invasive setting [12]. In comparisons with TURP and simple prostatectomy, benefits of HoLEP are the

Conclusion

HoLEP is an excellent approach for relief of LUTS in men with significant BPH and CaP; surveillance without further intervention appears reasonable for those with favorable-risk CaP. Further study will be necessary to determine whether HoLEP provides oncologic benefit to these men.

Conflicts of Interest

The authors have no conflicts of interest.

Acknowledgments

The corresponding author would like to thank the Betz Family Endowment for Cancer Research for their continued support. Funding was provided in part by the Spectrum Health Foundation. The corresponding author would like to thank Sabrina Noyes for manuscript preparation and submission.

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    These authors contributed equally to the writing of this manuscript.

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