Benign prostatic hyperplasia during active surveillance for prostate cancer: is it time to define management strategies?

In recent years, the criteria determining eligibility for active surveillance (AS) for prostate cancer (PCa) patients have evolved considerably. Factors such as disease stage, PSA values, core involvement at biopsies, Gleason Score (GS), and comprehensive risk score classifications [1, 2] have been reassessed to expand the cohort of patients suitable for AS. Despite this broader eligibility, more than 40% of patients with low-risk disease are treated immediately in the United States (U.S.), leading to an increased number of patients receiving unnecessary treatment [3]. Historically, the implementation of AS within the U.S. has been predominantly associated with academic institutions, with lower adoption rates in community-based urology practices. However, recent trends indicate a substantial and rapid expansion in the utilization of AS across a broader spectrum of healthcare institutions, leading to significant increase of active monitoring among the U.S. population diagnosed with PCa [4, 5].

Interestingly, the broader eligibility criteria have not only resulted in an increased number of patients choosing AS, but also extended the period during which individuals commit to this management strategy. This paradigm shift has consequently led to a rise in the incidence of symptomatic benign prostatic hyperplasia (BPH) among patients in AS, a condition that typically emerges around the age of 40 and becomes progressively more common thereafter [6]. Currently, there are no specific recommendations regarding the management of patients developing moderate to severe LUTS secondary to BPH requiring surgery during AS, what the preferred surgical intervention should be, and what are the potential implications on the subsequent management of PCa.