Effect of prior HoLEP procedure on multiparametric MRI accuracy in detection of prostate cancer

The objective of this study is to evaluate whether prior Holmium laser enucleation of the prostate (HoLEP) affects the diagnostic accuracy of multiparametric prostate MRI (mpMRI) with PI-RADS scoring for detecting clinically significant prostate cancer (csPCa) on biopsy.

We queried the Northwestern Electronic Data Warehouse for all patients who underwent mpMRI followed by prostate biopsy. Demographic information, mpMRI data including PI-RADS score and biopsy data including Gleason grade (GG) were collected. Patients were stratified based on prior HoLEP and highest PI-RADS score of index lesion on MRI. The outcome of interest was detection of csPCa (GG ≥ 2) on biopsy. Logistic regression was performed to assess the impact of prior HoLEP on the detection of csPCa at time of biopsy.

A total of 8937 patients met inclusion criteria, of which 97 patients (1.1%) had prior HoLEP. HoLEP specimen revealed benign pathology in 38 patients (39.2%), GG1 in 32 patients (33.0%), GG2 in 25 patients (25.8%) and GG3 in 2 patients (2.1%). Average time from HoLEP to mpMRI was 11.5 months. The post-HoLEP group had lower prostate volumes (median 25.0 vs. 47.0 cc; p < 0.001) and PSA density (median 0.06 vs. 0.12 ng/ml²; p < 0.001). Rates of csPCa detection based on highest PI-RADS score were comparable between control and HoLEP groups. Prior HoLEP did not significantly affect the detection of csPCa on multivariable analysis adjusting for age, race, PI-RADS, family history of PCa, and PSA density (OR = 0.97; 95% CI: 0.60-1.57).

PI-RADS remains a reliable predictor of csPCa after HoLEP despite anatomic alterations. mpMRI should continue to guide biopsy and risk stratification in this population, though larger validation is warranted.