HoLEP Feasible for BPH Patients With Low-risk Prostate Cancer

BOSTON—For obstructive benign prostatic hyperplasia (BPH) patients with concurrent low risk T1a or b prostate cancer (PCa), holmium laser enucleation of the prostate (HoLEP) appears to be safe and effective, according to new study findings presented at the American Urological Association 2017 annual meeting.

Kristian Stensland, MD, of Lahey Clinic Foundation in Burlington, Massachusetts, and colleagues reviewed data on 7 patients (aged 54 to 72) with enlarged prostates, bothersome lower urinary tract symptoms (LUTS), and concurrent Gleason 3+3 PCa in a maximum of 20% of not more than 3 biopsy cores and who underwent HoLEP by a single surgeon. Clinicians counseled patients that HoLEP could treat their LUTS along with unknown cancerous tissue. After HoLEP, patients still needed to be monitored for PCa on an active surveillance protocol. If the HoLEP specimen turned out to contain PCa with higher-risk pathology, more aggressive cancer-specific measures would be advised.

The HoLEP procedure was well-tolerated, according to the investigators. None of the patients needed a transfusion or reoperation. Hematocrits decreased by a mean of 3.8 points after surgery. Five patients had preoperative retention requiring a Foley catheter or clean intermittent catheterization. Patients had a median of 1 full day in the hospital and 19 hours of catheterization. In addition, over 4 to 24 months of follow-up, none of the men developed stricture, bladder neck contracture, or incontinence.

During HoLEP, an average of 48.8 g of prostate tissue was removed. For 3 of 7 patients, the specimen contained Gleason 3+3 PCa. Two patients who had magnetic resonance imaging of the prostate within 2 years of HoLEP displayed no suspicious lesions. One patient was found to have 3+4 PCa on biopsy in 2017 and underwent robot-assisted laparoscopic prostatectomy without complications.

Patients’ average urinary flow rates improved with HoLEP from 8.6 to 17 mL/sec. Post-void residual urine volume (PVR) lessened from 176 to 26 mL, on average, or, in some cases, remained low. PSA also decreased significantly from 5.7 ng/mL before HoLEP to a nadir of 1.3 ng/mL afterward.

“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,” Dr Stensland told Renal & Urology News. “We stress that HoLEP is not a definitive procedure for prostate cancer. It is a procedure that relieves lower urinary tract symptoms and is well tolerated. This pilot study supports the idea that men with active surveillance eligible prostate cancer can consider management of their lower urinary tract symptoms with HoLEP instead of more invasive radical prostatectomy.”

The investigators encouraged future studies with longer follow-up to better understand PCa outcomes with HoLEP and identify best practices. Such findings also would have implications for continued active surveillance of PCa. They noted that the study does not reflect the general population of men who have LUTS without PCa.

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Stensland K, Pelzman D, Robertson C, et al. HoLEP in patients with low risk prostate cancer is safe and effective. [abstract] J Urol 2017;197(4S):e12-e13. Poster presented at the American Urological Association 2017 annual meeting in Boston on May 12, 2017. Poster MP 02-08.