Multi-institutional evaluation of prostate specific antigen dynamics after simple prostatectomy

Men remain at risk for prostate cancer after simple prostatectomy (SP). However, prostate cancer (PCa) screening after SP is challenging given the lack of data directing PSA surveillance and what PSA values should trigger further investigation in this setting. This study aimed to compare initial postoperative PSA measurements and PSA kinetics after SP in patients with benign pathology (benign prostate hyperplasia; BPH) to those with prostate cancer. We performed a retrospective review of all simple prostatectomies performed at two tertiary care centers in the United States between 2014 and 2022. Baseline patient demographics, oncologic diagnosis and treatment history, and preoperative and postoperative PSA values were collected. Records were divided into groups based on malignancy status (BPH alone vs. diagnosis of PCa). A total of 296 patients were identified with a history of simple prostatectomy and both pre- and postoperative PSA testing: 235 patients had no prostate cancer diagnosis and 61 had a history of prostate cancer (27 had known PCa prior to RASP, 34 had an incidental diagnosis of PCa from surgical pathologic specimen). There was no difference in preoperative PSA between the groups (9.6 ng/mL vs. 10.6 ng/mL, p = 0.12). Patients with BPH had an initial postoperative PSA value of 0.72 ng/mL compared to 1.37 ng/mL in those with cancer (p < 0.01). PSA was reduced by 89% in BPH compared to 78% in the malignant cohort (p < 0.01). PSA velocity after surgery was significantly elevated in those with underlying PCa (0.40 ng/mL/year vs. 0.004 ng/mL/year for men with BPH; p < 0.01). 21% of patients (13/61) in the malignant cohort had a PSA > 2 ng/mL after surgery compared to 4% (10/235) of patients in the benign cohort. For patients undergoing a simple prostatectomy, initial postoperative PSA checked at 3 months as well as postoperative PSA velocity may help to identify those at risk for PCa. Given these findings, the authors use an initial postoperative PSA above 1 to trigger further PCa screening, but a larger study with power to make a formal cutoff value is required.