Holmium Laser Enucleation of the Prostate in Men with Refractory Lower Urinary Tract Symptoms on Active Surveillance for Prostate Cancer: An Updated Cohort Analysis
Adam Wiggins, MD, Alireza Moinzadeh, MD, David Canes, MD, Jessica Mandeville, MD.
Lahey Hospital and Medical Center, Burlington, MA, USA.
BACKGROUND: The safety and feasibility of surgical treatment for BPH and lower urinary tract symptoms (LUTS) in men who are concomitantly undergoing active surveillance (AS) for known low-risk prostate cancer (PCa) is not well studied. We previously reported 20 patients with low risk PCa on active surveillance who underwent holmium laser enucleation of the prostate (HoLEP). Herein, we provide an updated and expanded cohort analysis, in hopes of assessing the safety and feasibility of HoLEP in this patient population.
METHODS: Men on AS who underwent HoLEP between 2013 and 2023 were identified. Data was collected and included patient demographics, pre-operative cancer workup, prostate-specific antigen (PSA) levels, perioperative outcomes, and voiding parameters. Postoperative oncologic data was analyzed, including PSA nadir, further imaging results, prostate biopsy (PBx) results, PSA at last follow-up, and ultimate prostate cancer treatment.
RESULTS: Nineteen more men met inclusion criteria for this expanded cohort analysis, for a total of 39 patients. The average patient age was 66 years (std dev = 5.4 years), with a mean Body Mass Index of 28 Kg/m2 (std dev: 9.2 Kg/m2). Most men (97%) were Caucasian. The mean pre-operative maximum flow rate was 8.4 ml/s (std dev = 3.4 ml/sec), with a median post-void residual of 79cc (interquartile range [IQR]: 57 - 269) and a mean prostate size of 101cc (std dev = 32cc). Patients had a median adjusted preoperative PSA of 9.5 ([IQR]: 4.5-13.5) ng/ml. All men had undergone a prior prostate biopsy, with most men having had one core positive for PCa (median 1; [IQR 1-2]. Concerning post-operative oncologic data, the mean resected tissue weight was 79g (Std dev = 43) with improved postoperative flow rate (median improvement = 11 ml/s, [IQR] 6 - 21) and significantly decreased post-void residual (median improvement = 85cc, ([IQR] 35 - 245). A total of 10 (26%) men had PCa in the HoLEP specimen (all Gleason Grade Group 1). The median postoperative PSA nadir was 1ng/ml ([IQR]: 0.5-1.4) at a median of 4 months. At last follow-up (median 17 months, IQR: 4-48), the median postoperative PSA was 1.8 (IQR: 0.5-1.5) ng/ml. Twelve men underwent postoperative multiparametric magnetic resonance imaging (mpMRI) with the identification of a new prostate imaging reporting and data system 5 lesion in four patients, who ultimately underwent prostate biopsy. Of these men, three had progression of disease, of which two decided to undergo treatment.
CONCLUSIONS: This updated and expanded analysis of 7 years of follow up data provides further evidence that, while postoperative monitoring with PSA, mpMRI, and biopsy remains necessary to detect disease progression that may require definitive treatment, men on AS for low-risk PCa can safely and feasibly undergo HoLEP with significantly improved voiding parameters. 
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