Incidental prostate cancer following surgery for benign prostatic hyperplasia: a cohort study

Incidental prostate cancer (iPCa) remains a clinically relevant diagnosis in men undergoing surgery for benign prostatic hyperplasia (BPH). This study aimed to determine the incidence, characterize pathological features, and identify preoperative predictors of iPCa.

We conducted a retrospective cohort study of 735 men undergoing BPH surgery between November 2020 and December 2024. Demographic, clinical, surgical, and pathological variables were analyzed. Predictors of iPCa were evaluated using logistic regression; discrimination was assessed by ROC curves and Youden-optimized cut-offs.

The incidence of iPCa was 5.6%. Among iPCa cases, 48.8% were ISUP 1, while 17.1% corresponded to high-grade tumors (ISUP ≥4). Patients with iPCa had significantly higher PSA (4.8 vs 1.9 ng/mL), higher PSA density (PSAD 0.099 vs 0.029 ng/mL/cmÑ), and smaller prostates (47 vs 66 mL) (all p<0.001). In multivariable analysis including age and PSAD, only PSAD remained independently associated with iPCa (per 0.01 ng/mL/cmÑ increase). PSAD discriminated iPCa better than PSA (AUC 0.86 vs 0.80). A PSAD threshold around 0.15 ng/mL/cmÑ provided balanced performance (sensitivity ≈0.82; specificity ≈0.78). At a median follow-up of 24 months, most patients were managed conservatively (active surveillance or watchful waiting) with favorable short-term biochemical control; a minority required systemic therapy (hormonotherapy), and cancer-specific mortality was low.

iPCa occurred infrequently after BPH surgery, although higher-grade tumors were still observed. PSA density was the strongest preoperative predictor and should be integrated into risk stratification before BPH surgery.