Impact of Holmium Laser Enucleation of the Prostate on Active Surveillance for Prostate Cancer in Patients With Lower Urinary Tract Symptoms.

Abstract

Background: Active surveillance (AS) is a recommended strategy for low- or favorable intermediate-risk prostate cancers (PCa), avoiding more invasive treatments. However, the concurrent development of symptomatic benign prostatic hyperplasia (BPH) may necessitate holmium laser enucleation of the prostate (HoLEP). This study aims to evaluate the impact of HoLEP on patients under AS for PCa.

Methods: Medical records of patients under AS for PCa diagnosed between 2010 and 2023 were retrospectively reviewed. Patients with a life expectancy of more than 10 years and a follow-up of at least 1 year were included. Functional and oncological outcomes, as well as follow-up data (PSA levels, PSA density (PSA-D), mpMRI, prostate biopsies), were collected. Patients who underwent HoLEP were compared to those who did not. The primary endpoint was discontinuation of AS.

Results: A total of 310 patients under AS were included, of whom 62 (20%) underwent HoLEP. Prostate volume was higher in the HoLEP group than in the non-operated group (70 vs. 50 g, p < 0.0001), and PSA density was lower (0.09 vs. 0.12 p < 0.0001). The median enucleated volume was 62 mL (IQR 34-85). Grade group (GG) 1 and 2 prostate cancer was identified in enucleated pathology in 17 (27%) and 3 (5%) patients, respectively. No patient had a GG lesion ≥ 3 on the enucleated pathology. The rate of AS discontinuation was 18% in the HoLEP group vs. 56% in the control group (p < 0.01). Multivariate analysis identified HoLEP as a protective factor for continued AS (HR = 0.231; p < 0.0001). At last follow-up, PSA and PSA density were significantly lower in the HoLEP group (2 vs. 7.7 p < 0.0001 and 0.06 vs. 0.14 p < 0.0001, respectively).

Conclusion: Performing HoLEP in patients under AS for PCa with LUTS due to BPH may reduce the risk of deferred prostate cancer treatment, without altering oncological outcomes or future treatment options. HoLEP significantly impacts AS parameters, modifying patient monitoring. Further studies are needed to confirm these findings and establish appropriate follow-up protocols.

Trial registration: CNIL number 24-5016.