Presented by: Nicholas Dean MD
Northwestern University

Introduction

HoLEP is associated with advantages over minimally invasive prostate therapies (MIST) for BPH. One advantage of HoLEP is the ability to remove prostate tissue for accurate pathologic assessment. Intra-operative assessment of tissue dissection during enucleation may also allow the experienced surgeon to predict the presence or absence of incidental PCa at time of HoLEP. We aimed to assess the accuracy of intra-operative surgeon detected incidental PCa at time of HoLEP.

Materials

A single surgeon (AEK) maintained a prospective BPH database at Northwestern Hospital from Jan 2021 to present. From April 2022 to present the surgeon has been recording if they believe cancer is visually detected during enucleation immediately after the procedure. Variables collected included patient demographics, surgeon visualization of cancer at time of the procedure, and final HoLEP pathology. Patients with a prior diagnosis of PCa on active surveillance were excluded from our analysis. Statistical analysis was performed with SPSS.

Results

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We identified 217 patients without a history of PCa who underwent HoLEP between April to Oct 2022. Incidental PCa was identified in 13.4% of men on final pathology (29/217) and 55.2% were diagnosed with grade group(GG)1 (n=16), 34.4% GG2 (n=10), and 10.3% GG3-5 (n=3) disease. The surgeon intra-operatively determined the correct status of PCa on final pathology in 81.2% (176) of patients. Overall surgeon detection of PCa had a sensitivity of 37.5%, specificity of 92%, PPV of 51.7%, and a NPV of 86.7%. The surgeon correctly identified all patients with incidental GG3-5 PCa (n=3) and incidental urothelial cancers involving the prostate (n=2). Patients thought to have cancer at time of HoLEP with benign final pathology had higher rates of pre-operative indwelling catheters (56.3% versus 25.5%, p <0.01), but no differences in prior biopsies, prostatitis, or 5ARI use (all p>0.05).

Conclusion

High grade PCa, as well as urothelial cancer can accurately be identified at time of HoLEP; however, low grade cancers cannot reliably be detected.  If the surgeon believes they visualize cancer at time of HoLEP, thorough pathologic evaluation is needed to differentiate from catheter related inflammation; however, lack of visualization does not rule out low grade cancer.

Funding

None

Co-Authors

Jenny Guo, MD
Northwestern University

Eric Li, MD
Northwestern University

Perry Xu, MD
Northwestern University

Amy Krambeck, MD
Northwestern University