Rates of incidental prostate cancer following HoLEP Can it be predicted preoperatively?

This study aimed to identify preoperative predictors of incidental prostate cancer (iPCa) in patients undergoing holmium laser enucleation of the prostate (HoLEP) for benign prostatic hyperplasia (BPH) and to evaluate subsequent followup strategies.

We retrospectively analyzed 571 patients who underwent HoLEP by a single surgeon between 2020 and 2024 and who attended at least one postoperative followup visit at our tertiary center. Demographic features, preoperative clinical parameters, and pathologic findings were recorded. Treatment decisions following the diagnosis of iPCa were also analyzed. To reduce baseline imbalances and ensure analytical rigor, propensity score matching was performed.

The incidence of iPCa was 7.81%. After propensity score matching, elevated preoperative prostate-specfic antigen (PSA) density was significantly associated with the presence of iPCa (odds ratio [OR] 1.095, 95% confidence interval [CI] 1.04-1.16, p=0.01). In a separate analysis, older age (OR 1.11, 95% CI 1.03-1.19, p=0.005), higher total PSA (OR 1.13, 95% CI 1.04-1.22, p= 0.03), and higher PSA density (0.24 vs. 0.04, p<0.001) were identified as clinically significant factors distinguishing the clinically significant prostate cancer group from the clinically insignificant prostate cancer plus benign group.

PSA density was identified as an independent preoperative predictor of incidental prostate cancer following HoLEP, whereas older age, higher total PSA, and elevated PSA density were found to be clinically significant factors associated with clinically significant cases. In older patients with high PSA density, further evaluation for possible prostate cancer may be considered before HoLEP, particularly if the detection of clinically significant disease would alter the decision to proceed with surgery.