Urologic Oncology: Seminars and Original Investigations
Clinical-Prostate cancerManagement of prostate cancer after holmium laser enucleation of the prostate
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.