The Impact of Multiparametric Magnetic Resonance Imaging on Treatment Strategies for Incidental Prostate Cancer after Holmium Laser Enucleation of the Prostate

Abstract

Purpose: To investigate the impact of multiparametric magnetic resonance imaging (mpMRI) on treatment strategies for incidental prostate cancer (iPCa) after holmium enucleation of the prostate (HoLEP); Methods: Data from 1781 men who underwent HoLEP for clinical bladder outlet obstruction between September 2009 and March 2022 were reviewed retrospectively. Among patients with confirmed iPCa, those with prostate-specific antigen (PSA) levels < 10 ng/mL and who underwent mpMRI 3 months after HoLEP were included. Pathologic results, including Gleason grade (GG) and tumor volume, were identified. mpMRI was interpreted using the Prostate Imaging Reporting and Data System version 2 (PI-RADSv2). Treatment strategies for iPCa according to GG alone, or according to a combination of Gleason grade and mpMRI, were analyzed and compared. Results: Of 1764 men with serum PSA levels < 10 ng/mL, iPCa was confirmed in 64 (3.6%) after HoLEP. Of the 62 men who underwent mpMRI, the median (IQR) age at the time of HoLEP was 72.5 (66.5-78.0) years. The median PSA level and prostate volume were 3.49 (1.82-5.03) ng/mL and 49.6 (38.5-85.4) cm(3), respectively. The pathologic results of iPCa were as follows: GG1 = 42 (67.7%), GG2 = 13 (21.0%), GG3 = 2 (3.2%), GG4 = 1 (1.6%), and GG5 = 4 (6.5%). Of the patients with GG1 and GG2, 78.6% (33/42) and 53.8% (7/13), respectively, underwent active surveillance (AS). However, of 42 patients with GG1, 27 (64.3%) had a PI-RADSv2 score of 2, and 24 (88.9%) of them underwent AS. Of the 13 patients with GG2, 4 (80%) with a PI-RADSv2 score of 2 underwent AS. All patients with GG 3-5 were clinically expected to have locally advanced PCa and be treated with radiotherapy and/or ADT. Conclusions: For patients with iPCa of GG 1-2 after HoLEP, mpMRI helps to establish a treatment strategy by allowing risk stratification to select those who should be considered for AS or active treatment.