Preoperative Magnetic Resonance Imaging Findings of the Transition Zone Predict Incidental Prostate Cancer in HoLEP

To assess the effectiveness of magnetic resonance imaging (MRI) of the transition zone (TZ) for predicting incidental prostate cancer (iPCa) detected after holmium laser enucleation of the prostate by comparing cases with and without iPCa.

We retrospectively evaluated 136 patients who underwent holmium laser enucleation for benign prostatic hyperplasia (BPH) between June 2022 and April 2025. After excluding seven patients with biopsy-confirmed prostate cancer, data from 114 patients were analyzed and divided into two groups: iPCa (n=17) and BPH (n=97). The preoperative and postoperative outcomes were compared. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of iPCa. MRI assessment focused exclusively on the TZ according to version 2.1 of the Prostate Imaging-Reporting and Data System (PI-RADS).

MRI-TZ findings of a PI-RADS score of 3 or more were significantly more prevalent in the iPCa group than in the BPH group (64.7% vs. 16.5%, p<0.0001). Univariate analysis identified both positive MRI-TZ findings, a prostate-specific antigen (PSA) level greater than 6.2 ng/ml and TZ-adjusted PSA level greater than 0.18 ng/ml/ml as significant predictors of iPCa. However, multivariate logistic regression identified only positive MRI-TZ findings as an independent predictor of iPCa (odds ratio=8.96, 95% confidence interval=2.68-29.9; p=0.0004). No significant differences in postoperative urinary outcomes were observed between the two groups.

Preoperative positive MRI-TZ findings may predict iPCa in patients undergoing holmium laser prostate enucleation and potentially guide individualized perioperative risk stratification.