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HoLEP in Patients with Low Risk Prostate Cancer is Safe and Effective
Kristian Stensland, MD, Daniel Pelzman, BS, Alireza Moinzadeh, MD, David Canes, MD, Jessica Mandeville, MD.
Lahey Hospital and Medical Center, Burlington, MA, USA.

BACKGROUND: When a man with otherwise surveillance-appropriate low risk prostate cancer has significantly bothersome BPH in a large gland, this typically tips the scales in favor of treatment with standard of care, either radical prostatectomy or radiation therapy. However this presumes the prostate cancer is the more threatening of his coexisting conditions. Incidentally discovered (T1a/b) prostate cancer following Holmium Laser Enucleation of the Prostate (HoLEP) is a well known phenomenon. However, performing HoLEP in the setting of a prostate cancer harboring gland has not yet been described. Herein, we describe outcomes of HoLEP in a select cohort of patients with significant lower urinary symptoms, and known low risk prostate cancer.
METHODS: Data were collected retrospectively on patients undergoing HoLEP by a single surgeon. A select group of well informed patients with large symptomatic glands and low risk cancer were carefully counseled that HoLEP was an option to address the obstructive BPH, would unpredictably remove the cancer (all, part, or none), emphasizing they were not undergoing a cancer operation, and that HoLEP would be followed by continued surveillance. Pre- and post-operative clinical factors, and operative and hospital stay data were collected.
RESULTS: In total, 7 men were included. All men had Gleason 3+3 cancer in at most 20% of at most 3 cores on biopsy. Other preoperative characteristics are described in Table 1. All men tolerated the procedure well without intraoperative complications. The mean amount of tissue removed was 48.8g. Mean pre- to post-op hematocrit drop was 3.8 points; no patients required transfusion or reoperation. Median length of hospital stay was 24.5 hours, and median length of catheterization was 19 hours. On final pathology, 3 of 7 of patients had cancer in the specimen, all of which were Gleason 3+3. Postoperatively patients recovered well. At postoperative visits, all flow rates improved, PVR improved or remained appropriately low, and PSA significantly decreased in all patients (Table 1). By the time of most recent follow-up, no patient had developed stricture, bladder neck contracture, urge or stress incontinence, or required reoperation. Median time from surgery to last follow-up was 4 months (range 4-24 months). Notably, 2 patients had prostate MRI within 2 years of HoLEP, neither of which showed suspicion for prostate cancer.
CONCLUSIONS: We have offered HoLEP judiciously to select patients on surveillance for low risk prostate cancer and significant symptomatic BPH, a complex and increasingly common scenario, with acceptable short term outcomes. Further investigations into long-term cancer-specific outcomes, as well as strategies for continued surveillance in these patients, will be crucial in order to further evaluate and refine this new approach.
Pre- and Post-operative Characteristics
Factor
Age in Years (median, [range])64 [54-72]
Preop PSA (median, [range])5.7 [4.1-10.9]
Post PSA Nadir (median, [range])1.3 [0.7-2.6]
Preop TRUS Size (mean, [range])94.5 [37-220]
Preop PVR (mean, [range])176 [0-600]
Postop PVR (mean, [range])26 [0-78]
Preop Flow Rate (mean, [range])8.6 [1-11]
Postop Flow Rate (mean, [range])17 [10-26]
Preop Retention Requiring Foley or CIC (n)5


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