Multiparametric MRI may Help to Identify Patients With Prostate Cancer in a Contemporary Cohort of Patients With Clinical Bladder Outlet Obstruction Scheduled for Holmium Laser Enucleation of the Prostate (HoLEP)

Abstract

Objective: To investigate the value of standard [digital rectal examination (DRE), PSA] and advanced (mpMRI, prostate biopsy) clinical evaluation for prostate cancer (PCa) detection in contemporary patients with clinical bladder outlet obstruction (BOO) scheduled for Holmium laser enucleation of the prostate (HoLEP).Material and Methods: We retrospectively analyzed 397 patients, who were referred to our tertiary care laser center for HoLEP due to BOO between 11/2017 and 07/2020. Of those, 83 (20.7%) underwent further advanced clinical PCa evaluation with mpMRI and/or prostate biopsy due to elevated PSA and/or lowered PSA ratio and/or suspicious DRE. Logistic regression and binary regression tree models were applied to identify PCa in BOO patients.Results: An mpMRI was conducted in 56 (66%) of 83 patients and revealed PIRADS 4/5 lesions in 14 (25%) patients. Subsequently, a combined systematic randomized and MRI-fusion biopsy was performed in 19 (23%) patients and revealed in PCa detection in four patients (5%). A randomized prostate biopsy was performed in 31 (37%) patients and revealed in PCa detection in three patients (4%). All seven patients (9%) with PCa detection underwent radical prostatectomy with 29% exhibiting non-organ confined disease. Incidental PCa after HoLEP (n = 76) was found in nine patients (12%) with advanced clinical PCa evaluation preoperatively. In univariable logistic regression analyses, PSA, fPSA ratio, and PSA density failed to identify patients with PCa detection. Conversely, patients with a lower International Prostate Symptom Score (IPSS) and PIRADs 4/5 lesion in mpMRI were at higher risk for PCa detection. In multivariable adjusted analyses, PIRADS 4/5 lesions were confirmed as an independent risk factor (OR 9.91, p = 0.04), while IPSS did not reach significance (p = 0.052).Conclusion: In advanced clinical PCa evaluation mpMRI should be considered in patients with elevated total PSA or low fPSA ratio scheduled for BOO treatment with HoLEP. Patients with low IPSS or PIRADS 4/5 lesions in mpMRI are at highest risk for PCa detection. In patients with a history of two or more sets of negative prostate biopsies, advanced clinical PCa evaluation might be omitted.

Incidental prostate cancer after holmium laser enucleation of the prostate—A narrative review

“…One compared HoLEP with both OP and TURP (Capogrosso et al, 2018). Regarding the quality of the studies, 52.6% of our studies were adequate/fair (Capogrosso et al, 2018;He et al, 2020;Herlemann et al, 2017;Kim et al, 2014;Martos et al, 2021;Nunez et al, 2011;Otsubo et al, 2015;Rivera et al, 2014;Rosenhammer et al, 2018b;Tominaga et al, 2019), 36.8% good Elkoushy et al, 2015;Ohwaki et al, 2017;Porreca et al, 2019Porreca et al, , 2020Rosenhammer et al, 2018a;Wenzel et al, 2021) and 10.6% strong quality (Bhojani et al, 2015;Magistro et al, 2020).…”

“…In their study investigating the value of mpMRI and prostate biopsy in diagnosing PCa in patients scheduled for HoLEP, Wenzel et al reported iPCa in 9 (11.8%) patients with no previous PCa diagnosis who had undergone HoLEP (Wenzel et al, 2021). In their study, they reported that Prostate Imaging-Reporting and Data System 4 and five lesions detected via mpMRI before HoLEP function as independent predictors of PCa (OR: 9.91, p = 0.04).…”

“…Three studies compared HoLEP with TURP (He et al, 2020;Herlemann et al, 2017;Rosenhammer et al, 2018a) and another compared HoLEP with OP (Rosenhammer et al, 2018b). Instead of drawing comparisons with other treatment approaches, other studies reported HoLEP's oncological and functional outcomes (Nunez et al, 2011;Rivera et al, 2014;Tominaga et al, 2019), the role of imaging modalities in detecting iPCa (Kim et al, 2014;Porreca et al, 2019Porreca et al, , 2020Wenzel et al, 2021), the predictive factors of iPCa after HoLEP (Bhojani et al, 2015;Elkoushy et al, 2015;Ohwaki et al, 2017) and the role of PSA kinetics in detecting iPCa after HoLEP Magistro et al, 2020;Martos et al, 2021;Otsubo et al, 2015). We collated iPCa after HoLEP management strategies from the studies we reviewed, and summarise them below.…”

Incidental detection of localized prostate cancer with low PSA by computed tomography scan: A report of two cases

“…PCa can also be incidentally diagnosed after transurethral resection 13 or holmium laser enucleation of prostate for BPH. It might be also diagnosed by imaging technick for BPH, 14 other diseases 15 or imaging of metastatic disease in low PSA prostate cancer 4–6 …”

Editorial Comment to Detection rate and variables associated with incidental prostate cancer by holmium laser enucleation of the prostate

“…Considering the role of MRI to detect to predict IPCa after HoLEP, Wenzel et al . demonstrated that Prostate Imaging‐Reporting and Data System (PI‐RADS) 4 and 5 lesions detected by multiparametric MRI (mpMRI) prior HoLEP could be independent predictors of IPCa (OR 9.91, P = 0.04) 4 . This finding suggested that clinicians can consider mpMRI before HoLEP as a worthwhile option to detect IPCa.…”