Holmium Laser Enucleation of the Prostate Is Safe in Patients with Prostate Cancer and Lower Urinary Tract Symptoms

Abstract

Objective:

To evaluate the outcome of holmium laser enucleation of the prostate (HoLEP) in the known presence of prostate cancer (PCa) and concomitant lower urinary tract symptoms (LUTS).

Patients and Methods:

We retrospectively identified 62 patients who underwent HoLEP for LUTS in the known presence of PCa at our center. Perioperative data were assessed including complications, functional outcomes, and quality of life (QoL). Giving respect to different disease characteristics, patients were stratified according to treatment strategy setting into palliative (I), radiation (II), and surveillance (III) groups and compared accordingly.

Results:

Median follow-up (FU) of the entire study cohort was 27 months (range 2–65 mos). Medians of functional parameters (International Prostate Symptom Score): 18.5 vs 4.5, QoL: 4 vs 1, maximal flow rate: 9.0 vs 18.8 mL/s and residual urine: 100 vs 0 mL, all P<0.05) improved significantly in all groups. Perioperative complications were low and without any statistically significant difference between the groups. Postoperatively, voiding was successful in 90.3% of all patients; at last FU, 17% had some degree of urinary incontinence. Treatment strategy groups showed comparable functional outcomes after HoLEP.

Conclusion:

In the presence of PCa and LUTS, HoLEP represents a feasible, safe, and effective treatment option for patients unfit or without indication for radical prostatectomy. This applies as well in a palliative situation of advanced, obstructive PCa as for patients with LUTS who are scheduled for radiation therapy or surveillance in presumably indolent disease.

Introduction

Holmium laser enucleation of the prostate (HoLEP) is a prostate size independent transurethral surgical procedure recommended by the European Association of Urology guidelines for the management of benign prostatic obstruction (BPO).^1

–4 Compared with transurethral resection of the prostate (TURP) and simple open prostatectomy, HoLEP is associated with less perioperative morbidity and at least similar functional outcome.^5,6 Lasting results have been published up to 5 and 6 years^5,7 and have probably contributed to the complete enucleation of the adenoma following the anatomic plane between adenoma and surgical capsule.

Despite the specific advantages of HoLEP, however, there are no data published about the use of HoLEP in the known presence of prostate cancer (PCa) and concomitant lower urinary tract symptoms (LUTS). On the other hand, following the Surveillance Epidemiology and End Results registry database, we know that 9.3% (n=2742/29,371) of all PCa patients undergo TURP,⁸ mostly for palliation or in a multimodal concept with curative intent before external beam radiation therapy (RT), particularly when radical prostatectomy (RP) is not accepted or contraindicated. In these patients, TURP is associated with worse functional outcome and a significant proportion of treatment failure and incontinence.^9,10 A complete enucleation of the adenoma during HoLEP¹ may avoid higher rates of postoperative urinary retention and reoperation as described for pTURP by Crain and colleagues¹⁰ who performed a “channel” TURP.

To address the feasibility of HoLEP and its potential benefits in patients with biopsy proven PCa, we retrospectively analyzed 62 consecutive HoLEP patients concerning outcome, complications, and survival. Giving consideration to the heterogeneous presentation of patients with PCa and LUTS, regarding extent of disease, prognosis, and treatment strategies, we retrospectively stratified patients in three groups: I, palliative patients; II, patients before curative RT; III, patients under surveillance.

Unlike other laser prostatectomy approaches,^11,12 to the best of our knowledge, so far no data have been published about HoLEP in such a specific clinical setting.

Patients and Methods

Data acquisition

HoLEP was introduced at the urology department of the University Medical Center Hamburg in October 2006. Since then and until January 2012, all patients with known biopsy proven PCa before undergoing HoLEP were identified from our prospective HoLEP database. All patients were operated on by three experienced endourologic surgeons (SA, FC, RH).

Patients' baseline characteristics such as age, prostate-specific antigen (PSA), prostate volume (estimated by transrectal ultrasonography), clinical stage, Gleason score of prostate biopsy, International Prostate Symptom Score (IPSS), quality of life (QoL) from urinary symptoms (according to the last question of IPSS, [0 indicating highest, 6 indicating worst QoL]), maximal urinary flow rate (Qmax) and postvoid residual (PVR) urine were assessed.

Intra- and perioperative results including total operative time, enucleation-weight (g), and -speed (tissue-enucleation-weight divided by total operative time (g/min), histopathology of the HoLEP specimen, complications, Qmax and PVR after removal of the catheter were extracted from our database and hospital charts.

Functional results (IPSS), QoL (range 0–6), complications, (re-) interventions, medication, cancer-specific treatment, and current PSA level after discharge were assessed by a self-administered standardized nonvalidated questionnaire and telephone interview in May 2012.

Surgical technique

HoLEP was performed as previously described by Kuntz and associates,¹³ and a 100 W holmium laser power suite (VersaPulse, Lumenis, Yokneam, Israel) was used to perform HoLEP. A morcellation device (VersaCut, Lumenis, Inc., Santa Clara, CA) was used to facilitate retrieval of enucleated tissue.

Definition of complications

Complications were recorded from clinical charts and follow-up (FU) questionnaires and graded according to the Clavien complication grading system.¹⁴ They were further classified as intraoperative, early (≤30 days) and late (>30 days) complications.

Patient stratification

Patients were retrospectively categorized according to treatment strategy:

Palliative group (I): Patients with a high burden of disease, as indicated by high PSA levels >20 ng/mL, high grade PCa on prostate biopsy or locally or systemically advanced or systemic PCa, not suitable for curative treatment options.

Radiation therapy group (II): Patients who underwent RT (72 grey) with curative intent 3 months after HoLEP. RP was denied or not feasible because of age or comorbidity. Indication for HoLEP before RT was based on patient and doctor preference and confirmed for each patient in an interdisciplinary conference (urologist and radio-oncologist).

Surveillance group (III): Patients whose pre- and postoperative tumor characteristic did not indicate definitive PCa treatment. Specifically, patients harboring low-risk PCa and patients with a life expectancy less than 10 years were managed expectantly.

Statistical analysis

Frequencies, proportions, means, medians, and ranges were reported for categorical and continuously coded variables, respectively. The Fisher exact or chi-square test and Kruskal-Wallis test were used to compare proportions and medians. A Student t test was used for comparing means. Kaplan-Meyer analysis was applied to assess differences in overall and cancer-specific survival. All statistical tests were performed two-sided using the SPSS software for Windows (SPSS for Windows, release 20.0). A P value or log rank ≤0.05 was considered statistically significant.

Results

Overall, 62 patients with biopsy proven PCa and clinical LUTS underwent HoLEP at our institution.

Baseline characteristics

PCa was diagnosed at a median of 2.6 months (range 0–143 mos) before HoLEP-surgery (Table 1). The majority of patients presented with clinical stage T₁ (48.4%), M₀ (93.5%), and high-grade PCa (53.5%). Preoperatively, 19 (30.6%) patients underwent androgen deprivation therapy (ADT); 2 (3.2%) patients underwent external RT (72 Gy) and ADT, 7 and 8 years before HoLEP, respectively. All other patients (43/62; 69%) did not undergo medical or invasive cancer-specific treatment before HoLEP. Four (6.5%) of the patients had distant metastases, revealed by bone and computed tomography (CT) scan.

Table 1.

Disease Characteristics of 62 Patients Before and After Palliative Holmium Laser Enucleation of the Prostate, Stratified After Treatment Approach

Variable	Overall	Palliative group (I)	Radiation group (II)	Surveillance group (III)	P
Number of patients {%}	62 (100.0)	19 (30.6)	22 (35.5)	21 (33.9)	–
Age					0.1
Mean (median)	73.6 (74)	75.7 (76.5)	72.9 (73)	72.5 (73.5)
Range	53–84	65–84	66–79	53–84
Time PCa Dx to Sx {mo}					0.028
Mean (median)	15.4 (2.6)	42.3 (19.0)	3.4 (2.4)	3.6 (1.7)
Range	0–143	0–143	0–9	0–16
Preoperative ADT					0.003
No	43 (69.4)	9 (47.3)	14 (63.6)	20 (95.2)
Yes	19 (30.6)	10 (52.6)	8 (36.4)	1 (4.8)
PSA preop (ng/mL)					0.9
Mean (median)	16.4 (7.1)	30.8 (7.5)	8.9 (5.5)	11.3 (7.2)
Range	0–185.9	0–185.9	0.2–38.0	0.8–72.3
cT Stage					0.07
cT₁	30 (48.4)	5 (26.3)	13 (59.1)	12 (57.1)
cT₂	24 (38.7)	8 (42.1)	7 (31.8)	9 (42.9)
cT₃	7 (11.3)	5 (26.3)	2 (9.1)	0 (0)
cT₄	1 (1.6)	1 (5.3)	0 (0)	0 (0)
cM Stage					0.008
cM₀	58 (93.5)	15 (78.9)	22 (100)	21 (100)
cM₁	4 (6.5)	4 (21.1)	0 (0)	0 (0)
Biopsy Gleason					0.009
PCa nongraded	4 (6.5)	3 (15.8)	0 (0)	1 (4.8)
Low grade (Gleason ≤6)	25 (40.3)	5 (26.3)	6 (27.3)	14 (66.7)
High grade (Gleason >7)	33 (53.2)	11 (57.9)	16 (72.7)	6 (28.6)
Specimen Gleason					0.041
No PCa within specimen	30 (48.4)	6 (31.6)	13 (59.1)	11 (52.4)
Low grade (Gleason ≤6)	13 (21.0)	2 (10.5)	5 (22.7)	6 (28.6)
High grade (Gleason >7)	19 (30.6)	11 (57.9)	4 (18.2)	4 (19.0)
Time Sx to last FU					0.5
Mean (median)	26.5 (27.0)	25.3 (27.5)	29.5 (27.5)	23.9 (16.0)
Range	2.0–65.0	3.0–61.0	2.0–65.0	5.0–56.0
PSA FU (ng/mL)					0.3
Mean (median)	5.6 (0.6)	14.6 (0.6)	1.9 (0.4)	3.0 (1.0)
Range	0–142.1	0–142.1	0–27.8	0–20
PSA drop (%)					0.6
Mean (Median)	83.5 (94.2)	67.9 (69.5)	90.4 (95.4)	85.7 (92.9)
Range	0–100	0–100	42–100	43–100
ADT at FU					0.005
No	34 (73.9)	5 (45.5)	15 (71.4)	14 (100.0)
Yes	12 (26.1)	6 (54.5)	6 (28.6)	0 (0)

PCa=prostate carcinoma; Dx=diagnosis; Sx=surgery; ADT=androgen deprivation therapy; PSA=prostate-specific antigen; cT=local clinical stage; cM=systemic extent; FU=follow–up.

Giving respect to different PCa disease characteristics, 19 patients (30.6%) were stratified to group I, 22 (35.5%) to group II, and 21 (33.9%) to group III, respectively. Significant differences were observed for median time from PCa diagnosis to therapy (19.0 vs 2.4 vs 1.7, P=0.028) and proportion of patients with preoperative ADT (52.6 vs 36.4 vs 4.8%, P=0.003) between palliative, radiation, and surveillance groups, respectively, reflecting the retrospective stratification of patients (Table 1). Moreover, patients categorized as palliative were less likely to present with nonmetastatic disease (78.9 vs 100, vs 100%, P=0.008), low-grade PCa in the preoperative biopsy (26.3 vs 27.3 vs 66.7%, P=0.009) and in the postoperative HoLEP specimen (10.5 vs 22.7 vs 28.6%, P=0.041). Distribution of median age (74 years), length of FU (27 mos, range 2–65 mos), pre- or postoperative PSA level, PSA drop, or clinical stage were similar across all groups (all P≥0.07, Table 1).

No significant statistical differences between groups were observed considering median prostate size or preoperative voiding symptoms (all P≥0.1, Table 2). Overall, 16 patients in frank urinary retention underwent HoLEP.

Table 2.

Preoperative Data of 62 Patients Undergoing Palliative Holmium Laser Enucleation of the Prostate

Variable	Overall	Palliative group (I)	Radiation group (II)	Surveillance group (III)	P
TRUS (cc)					0.4
Mean (median)	70.5 (67.5)	71.0 (75.0)	65.5 (52.0)	75.0 (68.0)
Range	20.0–157.0	20.0–150.0	20.0–157.0	40.0–137.0
Urinary retention preop	22 (35.5)	10 (52.6)	5 (22.7)	7 (33.3)	0.1
Frank urinary retention at HoLEP	17 (27.4)	8 (42.1)	5 (22.7)	4 (19.0)	0.2
IPSS preop					0.1
Mean (median)	17.5 (18.5)	18.9 (19.5)	14.6 (11)	19.1 (19)
Range	8–31	13–24	8–31	9–29
QoL preop					0.9
Mean (median)	3.7 (4)	3.8 (4)	3.4 (4)	3.8 (4)
Range	1–6	1–6	1–6	1–6
PVR preop (mL)					0.3
Mean (median)	138 (100)	96 (70)	106 (107)	188 (200)
Range	0–500	0–450	0–230	0–500
Qmax preop (mL/s)					0.8
Mean (median)	10.3 (9)	9.1 (9.5)	10.6 (8.8)	10.6 (11.5)
Range	3.7–26.3	3.7–12.3	6.6–26.3	3.7–20.1

TRUS=transrectal ultrasonography; preop=preoperatively; HoLEP=holmium laser enucleation of the prostate; IPSS=International Prostate Symptom Score; QoL=quality of life; PVR=postvoid residual; Qmax=maximal urinary flow rate.

Perioperative results

Immediately after catheter removal after HoLEP, median Qmax and PVR improved statistically significantly when compared with baseline (9.0 vs 18.8 mL/s and 100 vs 0 ml, both P<0.05). No statistically significant differences in postoperative functional outcomes were observed between groups (Table 3). Median enucleation speed (0.6 vs 0.6 vs 0.9 g/min, P=0.011) was significantly higher, however, for patients in the surveillance group compared with their counterparts.

Table 3.

Postoperative Characteristics After Palliative Holmium Laser Enucleation of the Prostate, Stratified After Treatment Approach

Variable	Overall	Palliative group (I)	Radiation group (II)	Surveillance group (III)	P
Number of patients (%)	62 (100.0)	19 (30.6)	22 (35.5)	21 (33.9)
Enucleation weight (g)					0.3
Mean (Median)	41.7 (34.1)	39.4 (33.0)	38.8 (27.3)	46.6 (43.4)
Range	5–121	11–88	5–121	17.6–107.8
Enucleation speed (g/min)					0.01
Mean (median)	0.7 (0.7)	0.6 (0.6)	0.7 (0.6)	0.9 (0.9)
Range	0.1–1.7	0.3–1.4	0.1–1.5	0.4–1.7
IPSS postop					0.047
Mean (median)	6 (4.5)	9.8 (11)	5.9 (5)	3.9 (2.5)
Range	0–22	0–22	0–18	0–12
QoL postop					0.8
Mean (median)	1.7 (1)	2.2 (1.5)	1.5 (1)	1.5 (2)
Range	0–6	0–6	0–4	0–3
PVR postop (mL)					0.1
Mean (median)	18.1 (0)	41.2 (0)	3.8 (0)	19.2 (0)
Range	0–400	0–400	0–50	0–120
Qmax postop (mL/s)					0.8
Mean (median)	20.2 (18.8)	23 (17.8)	20 (20.2)	19.4 (18.3)
Range	1.6–48.9	13.1–35	9.3–31.4	1.6–48.9
Number of pads/d postop					0.033
0	31 (50.0)	6 (31.6)	13 (59.1)	12 (85.7)
1	7 (11.3)	2 (10.5)	5 (22.7)	0
2	5 (10.9)	1 (9.1)	3 (14.3)	1 (7.1)
3	3 (6.5)	2 (18.2)	0 (0)	1 (7.1)
Urge symptoms postop					0.8
No	33 (71.7)	8 (72.7)	14 (66.7)	11 (78.6)
Yes	13 (28.3)	3 (27.3)	7 (33.3)	3 (21.4)
Anticholinergic medication					0.2
No	39 (84.8)	11 (100.0)	15 (71.4)	13 (92.9)
Yes	5 (10.9)	0 (0)	4 (19.1)	1 (7.1)
Discontinued	2 (4.3)	0 (0)	2 (9.5)	0 (0)

IPSS=International Prostate Symptom Score; postop=postoperative; QoL=quality of life; PVR=postvoid residual; Qmax=maximal urinary flow rate.

Eleven of 62 (18.3%) patients died (4 from disease progression); 8.1% (5/62) of the patients were lost to FU. Hence, 46 (74.2%) patients were available for FU analysis. The self-administered questionnaire at FU demonstrated statistically significant improvement of median IPSS and QoL when compared with baseline (18.5 vs 4.5 and 4 vs 1, all P<0.05). Stratified for treatment groups, median IPSS at FU was most favorable (2.5) for the surveillance group vs 5 in the radiation group vs 11 in the palliative group (P=0.047). However, no statistically significant differences were recorded regarding QoL or the prevalence of urge symptoms (all p≥0.2).

Of statistical significance, however, more patients of the surveillance group reported complete urinary continence (UI) (P=0.033, Table 3). Specifically, a total of 85.7% reported being continent, with the use of no pad or a maximum of one protective pad/d. In contrast, eight (17.4%) of the patients reported mild to moderate (predominantly urge) UI 4 to 65 months after HoLEP. More precisely, the use of two or three pads/d was documented by five (10.9%) and three (6.5%) of the patients, respectively. None of the patients needed more than three pads. Of all patients who reported no preoperative use of pads for UI, 30/42 (71.4%) reported complete urinary continence, 4 (9.5%), 5 (11.9%), and 3 (7.1%) reported use of one, two, or three pads, respectively, after HoLEP.

Oncologic findings

In 29/62 patients (46.8%), no PCa was detected within the HoLEP specimen. Downgrading to low-grade PCa was found in five (8.1%) patients with high-grade PCa in the preoperative biopsy, whereas upgrading to high-grade PCa in the HoLEP specimen was found in six (10.5%) of all patients. Grading was concordant in 17 (27.4%) in preoperative biopsy and HoLEP specimen.

At FU, a majority of 42.2% of all patients had PSA levels <0.5 ng/mL. The median relative drop in the PSA levels (comparing pre- and postoperative FU PSA values) was 94.2% (Table 1). Twelve (27.2%) patients were under ADT at FU. Of those, six patients received ADT at FU after RT but not at baseline. In the subgroup of 14 patients who underwent HoLEP without RT or ADT, the median PSA level dropped from 10.4 ng/mL preoperatively to 1.55 ng/mL (-8.2 ng/mL/-86.5%) at a median FU of 14.5 months. New clinical metastases did not develop in any patient after HoLEP. After RT, only two (9.5%) patients showed PSA levels >PSA nadir+ 2 ng/mL, indicating RT failure.

Complications

In all patients, the intraoperative course was uneventful (no clinically relevant capsule perforation, no incomplete enucleation, no surgical reintervention) (Table 4). Postoperatively, clot retention developed in three (4.8%) patients, which was managed conservatively by manual bladder washout. One patient received a blood transfusion for postoperative bleeding. In 56 (90.3%) patients, the catheter was removed successfully on the second postoperative day, according to our standard operating procedure after conventional HoLEP. Because of trial without voiding, six (9.6%) patients needed recatheterization (Table 4); in five of these patients, spontaneous voiding was possible within the first 4 weeks after HoLEP; one patient was lost to FU. Late complications consisted of one urethral stricture (1.6%) and two bladder neck stenosis strictures (3.2%) (Table 4), which necessitated urethrotomy and bladder neck resection, respectively. One of the two patients with bladder neck stenosis had a history of RT. No difference in the complication rate (early and late) was observed between different treatment categories (all P≥0.09, Table 5).

Table 4.

Complications According to the Clavien Grading System of 62 Patients Undergoing Palliative Holmium Laser Enucleation of the Prostate

Complication grade	Overall	Early (0–30 d)	Late (>30 d)
G I	9 (14.5)	9 (14.5)	0
Obstruction (Catheter)	6 (9.7)	6 (9.7)
Bleeding (Clot retention)	3 (4.8)	3 (4.8)
G II	1 (1.6)	1 (1.6)	0
Bleeding (Transfusion)	1 (1.6)	1 (1.6)
G III	3 (4.8)	0	3 (4.8)
Urethral stricture (UTI)	1 (1.6)		1 (1.6)
BN obstruction (TUR)	2 (3.2)		2 (3.2)
G IV	0	0	0
G V	0	0	0
Any complication	13 (20.1)	10 (16.1)	3 (4.8)

G=grade; UTI=urethrotomia interna; BN=bladder neck; TUR=transurethral resection of the bladder neck.

Table 5.

Intraoperative and Postoperative Complications of 62 Patients Undergoing Palliative Holmium Laser Enucleation of the Prostate, Stratified After Treatment Approach

Variable	Overall	Palliative group (I)	Radiation group (II)	Surveillance group (III)	P
Number of patients (%)	62 (100.0)	19 (30.6)	22 (35.5)	21 (33.9)
No. complications					0.2
Overall	13	7 (53.8)	2 (15.4)	4 (30.8)
No. complications					0.09
Grade I	9	5 (55.5)	1 (11.1)	3 (33.3)
No. complications					0.3
Grade II	1	1 (100)	0	0
No. complications					0.9
Grade III	3	1 (33.3)	1 (33.3)	1 (33.3)

Discussion

To the best of our knowledge, there are no valid data available in the context of PCa, LUTS, and HoLEP. This void accounts for palliative situations, but also for patients with clinical LUTS and less advanced PCa, scheduled for RT or PCa surveillance patients with bladder outlet obstruction. First, our results show that independent of prostate size, HoLEP is feasible in patients with biopsy proven PCa in palliative patients as well as patients with less advanced PCa, scheduled for RT or PCa surveillance patients with bladder outlet obstruction. The intraoperative course was uneventful, and a low rate of postoperative complication was observed, not exceeding those so far reported for standard HoLEP.^7,15 The rate of grade III complications (three reoperations; 4.8%) seems moderate compared with other reports for palliative TURP by Marszalek and associates⁹ and Crain and colleagues¹⁰ with postoperative failure of voiding in 36% to 42%, need of repeated TURP in 25% to 29%, and permanent incontinence in 10%.^9,10

To minimize adverse events, many surgeons prefer to perform a channel TURP in patients with PCa and LUTS.^9,10,16 The palliative character of the procedure might have discouraged surgeons from a complete resection down to the capsule of the prostate, because it is postulated for a proper resection in patients with BPO.¹⁷ By this minimal TURP, intraoperative safety might be increased, but mostly at the costs of deteriorated functional outcome and overall morbidity.^5,10 It is certainly a reasonable concept in PCa patients with advanced, metastatic disease, reduced general conditions and life expectancy. A complete enucleation of the obstructing tissue, however, as achieved by HoLEP or OP instead of palliative TURP could be of even more benefit in such a patient cohort, because it might provide longer lasting relief of LUTS.

The extent of tissue ablation achieved by HoLEP is demonstrated by a PSA drop of −86% (10.4 ng/mL preoperatively to 1.55 ng/mL) in a subgroup of 14 patients who underwent HoLEP without RT or ADT (data not shown), and previous studies have demonstrated that HoLEP removes significantly more tissue compared with TURP.¹⁸ Interestingly, all reoperations in our patients were because of typical late complications such as urethral stricture and bladder neck stricture and not from persistent LUTS.

In more than 50% of all patients with biopsy proven PCa, no further histopathologic evidence of PCa was found in the enucleated specimen. These results are in accordance with the findings of Bach and coworkers,¹⁹ who reported cancer detection after palliative TURP of 54% in patients with PCa. From the histopathologic point of view, these findings reflect that most carcinomas do not originate from the transitional zone of the prostate, but from the periphery.

Moreover, the rate of complications did not differ between palliative, RT, and surveillance patients. Despite similar mean enucleation weights, however, the enucleation velocity in the palliative group was significantly slower compared with patients of the RT or surveillance group. More extended local disease causing partly impaired identification of anatomic planes might have hindered straightforward enucleation of the prostatic lobes. This is intuitively reflected by the histopathologic findings of the HoLEP specimen revealing PCa invasion in two-thirds of the palliative patients, whereas in the majority of the RT and surveillance groups, no PCa was found.

Second, functional results (IPSS, QoL, PVR, Qmax) after HoLEP improved statistically significantly compared with baseline, similar to the results after HoLEP in patients with BPO^15,20 and showed only minor differences according to treatment group. Despite no significant preoperative differences, however, patients in a palliative setting complain about more LUTS at FU according to the IPSS score when compared with their counterparts. This observation is in accordance with a study by Crain and colleagues¹⁰ who observed higher postoperative IPSS scores after TURP in patients with PCa compared to those with BPO.

Despite the overall encouraging functional results, a significant proportion of patients complained about postoperative urge symptoms (28.9%) and UI (17.4%) with the daily use of two to three urinary pads. Interestingly, prevalence of urge symptoms was highest in patients after RT (33%), and UI was most reported in palliative patients (27.3%). Differences between the groups probably failed to reach significant levels because of the small sample size of the groups. The linkage of PCa RT and urgency is well described,^21
–23 and post- and preoperative RT may also have affected urinary function after HoLEP.

Furthermore, patient age is one of the most important risk factors in male UI.^24,25 In a comparable cohort of patients, Marszalek and associates⁹ report about 11% of all patients complaining about incontinence after palliative TURP. The mean age of 74 years in our study cohort was higher than in most other studies investigating incontinence after transurethral procedures.

External sphincter anatomy and function may be modified in patients with PCa and, because of the retrospective nature of the study, we cannot discriminate between pure urge incontinence or mixed incontinence because of external sphincter deficiency from invasion of PCa or iatrogenic injury during HoLEP. In patients with clinical sphincter invasion, however, a “palliative channel HoLEP” can be considered with enucleation of the middle lobe and one side lobe limiting the risk of stress UI. This concept was, meanwhile, performed successfully in two selected cases with sphincter invasion, not included in the present study. Recently, the authors have switched one patient referred for palliative HoLEP to palliative channel TURP in which a CT scan demonstrated a high probability of urinary sphincter (confirmed by a sclerotic sphincter appearance in urethroscopy) and ureteral orifice invasion. Resection of a ureteral orifice is a clear limitation of palliative HoLEP and a “pro” for palliative TURP.

In the current series of 62 consecutive HoLEP patients, however, the intraoperative course was uneventful, and complete enucleation was possible in all patients. Unfortunately, because HoLEP has virtually replaced TURP in our institution since 2006, no cohort of palliative TURP patients was available to examine comparative safety and efficacy. In this sense, a preferably randomized, controlled, multicenter trial comparing safety, efficacy, and oncologic outcome of HoLEP and TURP is warranted.

Major drawbacks are represented by the retrospective character of the study (case series), limited number of patients, and acquisition of FU data based on a standardized self-administered questionnaire. This study, however, is the first ever reported about HoLEP in the setting of biopsy proven prostate cancer and LUTS. Taken together, our data show that HoLEP in patients with biopsy proven PCa seems a feasible, effective, and safe transurethral minimally invasive alternative to TURP. It provides a low complication rate, encouraging functional outcome, and significant improvement of QoL in palliative, surveillance, and even patients after subsequent RT. Patients, however, need to be informed about risk of postoperative urgency and UI, foremost when combined with RT.

Conclusion

HoLEP represents a feasible, safe, and effective minimally invasive surgical treatment in patients with PCa undergoing palliation, definitive RT, or surveillance. A multicenter, randomized, controlled trial comparing safety, efficacy, and oncologic outcome of HoLEP and TURP is warranted.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

References

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Holmium Laser Enucleation of the Prostate Is Safe in Patients with Prostate Cancer and Lower Urinary Tract Symptoms—A Retrospective Feasibility Study

Abstract

Objective:

Patients and Methods:

Results:

Conclusion:

Introduction

Patients and Methods

Data acquisition

Surgical technique

Definition of complications

Patient stratification

Statistical analysis

Results

Baseline characteristics

Perioperative results

Oncologic findings

Complications

Discussion

Conclusion

Footnotes

Disclosure Statement

Abbreviations Used

References