Clinically Significant Prostate Cancer in Patients Undergoing Holmium Laser Enucleation of Prostate for Benign Hyperplasia: A Preoperative Nomogram and a Postoperative Surveillance Protocol.

PURPOSE: Despite appropriate preoperative evaluation, some patients are diagnosed with clinically significant prostate cancer after Holmium laser enucleation of the prostate. Postoperative screening is challenging due to unreliable thresholds and nomograms. We developed a preoperative nomogram to predict clinically significant prostate cancer and a postoperative decision matrix for risk stratification. The secondary aim was to validate existing risk calculators.

MATERIALS AND

METHODS

A retrospective cohort of 857 patients was analyzed, of whom 773 were eligible. The primary outcome was the detection of clinically significant prostate cancer (csPCa) at 1 year postoperatively. A multivariate Cox regression analysis was performed. Performance was assessed with time-dependent receiver operating characteristic analysis, calibration plots, and decision curve analysis (DCA). Prostate Cancer Prevention Trial 2.0 and Memorial Sloan Kettering Cancer Center calculators were validated in 100 randomly selected patients. Postoperative surveillance used nadir prostate-specific antigen (PSA) and prostate-specific antigen reduction ratio (PRR).

RESULTS

csPCa was identified in 30 patients (3.9%). Independent predictors were age (hazard ratio [HR] 1.08, p = 0.001), PSA density (HR 1.54, p = 0.003), and family history (HR 5.62, p = 0.007). The area under the curve was 0.71 at 1 year for the preoperative model. DCA showed clinical utility above 5%. Standard calculators overpredicted risk (8.8% and 38.2% vs observed 2%). For postoperative surveillance, nadir PSA 1 ng/mL and PRR 50% cutoffs had negative predictive value of 97.9% and 98.4%, respectively.

CONCLUSIONS

We developed a preoperative nomogram for predicting csPCa within 1 year postoperatively. The postoperative surveillance decision matrix enables risk-adapted follow up.