scholarly journals Multiparametric MRI may Help to Identify Patients With Prostate Cancer in a Contemporary Cohort of Patients With Clinical Bladder Outlet Obstruction Scheduled for Holmium Laser Enucleation of the Prostate (HoLEP)

2021 ◽  
Vol 8 ◽  
Author(s):  
Mike Wenzel ◽  
Maria N. Welte ◽  
Lina Grossmann ◽  
Felix Preisser ◽  
Lena H. Theissen ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Logistic Regression ◽  
Prostate Biopsy ◽  
Bladder Outlet Obstruction ◽  
Tertiary Care ◽  
Digital Rectal Examination ◽  
Outlet Obstruction ◽  
Holmium Laser ◽  
Laser Enucleation ◽  
Holmium Laser Enucleation

Objective: To investigate the value of standard [digital rectal examination (DRE), PSA] and advanced (mpMRI, prostate biopsy) clinical evaluation for prostate cancer (PCa) detection in contemporary patients with clinical bladder outlet obstruction (BOO) scheduled for Holmium laser enucleation of the prostate (HoLEP).Material and Methods: We retrospectively analyzed 397 patients, who were referred to our tertiary care laser center for HoLEP due to BOO between 11/2017 and 07/2020. Of those, 83 (20.7%) underwent further advanced clinical PCa evaluation with mpMRI and/or prostate biopsy due to elevated PSA and/or lowered PSA ratio and/or suspicious DRE. Logistic regression and binary regression tree models were applied to identify PCa in BOO patients.Results: An mpMRI was conducted in 56 (66%) of 83 patients and revealed PIRADS 4/5 lesions in 14 (25%) patients. Subsequently, a combined systematic randomized and MRI-fusion biopsy was performed in 19 (23%) patients and revealed in PCa detection in four patients (5%). A randomized prostate biopsy was performed in 31 (37%) patients and revealed in PCa detection in three patients (4%). All seven patients (9%) with PCa detection underwent radical prostatectomy with 29% exhibiting non-organ confined disease. Incidental PCa after HoLEP (n = 76) was found in nine patients (12%) with advanced clinical PCa evaluation preoperatively. In univariable logistic regression analyses, PSA, fPSA ratio, and PSA density failed to identify patients with PCa detection. Conversely, patients with a lower International Prostate Symptom Score (IPSS) and PIRADs 4/5 lesion in mpMRI were at higher risk for PCa detection. In multivariable adjusted analyses, PIRADS 4/5 lesions were confirmed as an independent risk factor (OR 9.91, p = 0.04), while IPSS did not reach significance (p = 0.052).Conclusion: In advanced clinical PCa evaluation mpMRI should be considered in patients with elevated total PSA or low fPSA ratio scheduled for BOO treatment with HoLEP. Patients with low IPSS or PIRADS 4/5 lesions in mpMRI are at highest risk for PCa detection. In patients with a history of two or more sets of negative prostate biopsies, advanced clinical PCa evaluation might be omitted.

scholarly journals Introduction of a New Score to Assess Surgical Efficiency in Holmium Laser Enucleation of the Prostate

2020 ◽  
Vol 104 (11-12) ◽  
pp. 914-922
Author(s):  
Bernd Rosenhammer ◽  
Maximilian Schönhärl ◽  
Roman Mayr ◽  
Marco J. Schnabel ◽  
Maximilian Burger ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Quality Control ◽  
Logistic Regression ◽  
Clinical Practice ◽  
Laser Energy ◽  
Learning Curves ◽  
Holmium Laser ◽  
Surgical Experience ◽  
Laser Enucleation ◽  
Holmium Laser Enucleation

<b><i>Introduction:</i></b> While holmium laser enucleation of the prostate (HoLEP) is accepted as safe and efficient, a long learning curve is considered the main reason for its slow adoption in clinical practice. So far, no standardized and easy-to-use parameter has been implemented to measure surgical experience or efficiency which could be useful for training and quality control purposes. The aim of the present study was to evaluate the learning curves of 2 HoLEP beginners and to identify applicable efficiency outcome measures as well as potentially complicating factors in performing HoLEP. <b><i>Patients and Methods:</i></b> A total of 594 patients treated by HoLEP between September 2016 and May 2019 were enrolled. The procedures were initially performed by 1 HoLEP expert (reference surgeon); over time, 2 further surgeons were trained. Baseline characteristics, enucleation weight, morcellation and enucleation time, laser energy usage, and postoperative results were recorded prospectively. The learning curves of the 2 novices were analyzed and compared to the reference surgeon. Logistic regression analyses were performed to identify predictors for postoperative grade ≥2 complications. <b><i>Results:</i></b> Median enucleation ratio and complication rates did not significantly alter along the learning curves. Median enucleation speed and laser energy application of the 2 novices significantly improved with growing experience. Combining these variables, we introduced the “HoLEP efficiency score” (HES) which demonstrated the most appropriate value to reflect the surgical experience and efficiency. The median HES for the reference surgeon was 82.8 min kJ/g. For the 2 novices, a drop from 130 and 124.4 min kJ/g by −57 and −30%, respectively, was observed. Among several tested clinical parameters, the presence of prostate cancer (<i>p</i> = 0.047) and the surgical caseload (<i>p</i> &#x3c; 0.001) influenced the HES. On multivariable logistic regression, American Society of Anesthesiologists score and prostate cancer were independent predictors for grade ≥2 complications (<i>p</i> = 0.002, odds ratio [OR] 2.042 and <i>p</i> = 0.038, OR 1.940). <b><i>Conclusion:</i></b> We introduce the HES as an objective and measurable tool to quantify surgical efficiency. In clinical practice, the HES may find application in training and quality control purposes as well as in comparing surgical modifications and hardware. Patients with prostate cancer seem to be more challenging cases and have a higher risk for complications, and may preferably be treated by experienced surgeons.

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