Prostate‐specific antigen follow‐up and management for patients undergoing holmium laser enucleation of the prostate

Abstract

ObjectivesTo investigate who needs a careful postoperative monitoring for prostate cancer (PCa) after holmium laser enucleation of the prostate (HoLEP). We examined characteristics and oncological outcomes of HoLEP‐related PCa.MethodsPatients who underwent HoLEP during 2002–2017 in a Japanese tertiary center were retrospectively analyzed. Patients were divided into non‐PCa, PCa with HoLEP specimen (PCa‐Ope), and PCa diagnosed during follow‐up (PCa‐Post). Outcomes of all HoLEP‐related PCa were monitored.ResultsOf the total 758, 60 (7.9%) were diagnosed with PCa from resected specimen of HoLEP and 9 (1.2%) were diagnosed postoperatively. Preoperative prostate‐specific antigen (iPSA), postoperative PSA (pPSA), and PSA density were significantly higher in both PCa groups than those in non‐PCa group. While iPSA significantly correlated to prostate volume (PV), pPSA was not associated with PV. A receiver‐operating‐characteristics curve demonstrated that pPSA 1.2 ng/mL achieved the optimal cut‐off (AUC 0.95) for the incidence of PCa‐Post. In addition to the incidence of PCa and iPSA, lower enucleation efficiency (enucleated volume /PV) was significantly associated with pPSA >1.2 ng/mL. Among PCa‐Ope, 51 were Grade Group (GG) ≤2 and 42 were followed‐up with active surveillance, whereas 8 of 9 PCa‐Post were GG ≥3 and 2 progressed to death.ConclusionsPatients undergoing HoLEP are associated with some risk of potential PCa. While oncological outcomes were favorable among PCa‐Ope, postoperative PSA should be carefully monitored even if not diagnosed with PCa with HoLEP specimen. Enucleation efficiency should be also considered not to misread pPSA value.

Editorial comment on Prostate‐specific antigen follow‐up and management for patients undergoing holmium laser enucleation of the prostate

“…They also reported that enucleation efficiency should be more critical than preoperative prostate volume (PV) to consider the pPSA, and lower enucleation efficiency (enucleated volume/PV) was significantly associated with pPSA >1.2 ng/mL, which is an essential perioperative finding because PSA is likely to be elevated because of residual prostate after HoLEP. 1 In other recent reports, Lambert et al demonstrated that 24 (4.2%) out of 773 patients developed postoperative PCa after HoLEP and argued that the pPSA after HoLEP is an independent predictor for future diagnosis of PCa. 2 Closer follow-up and diagnostic investigations to detect postoperative PCa are indicated when pPSA is >1.73 ng/mL (ROC AUC 0.903), specifically within the first year after HoLEP.…”

“…Meanwhile, Ishidoya et al reported that postoperative PCa could be potentially more malignant than most iPCa. 1 Late diagnosis after HoLEP can lead to a poor prognosis of pPCa; therefore, recognizing the risk of pPCa is essential.…”