Perioperative Rates of Incidental Prostate Cancer after Aquablation and Holmium Laser Enucleation of the Prostate

Abstract

Introduction: Aquablation and holmium laser enucleation of the prostate (HoLEP) have evolved as established therapeutic options for men with benign prostatic obstruction (BPO). We sought to compare the rates of incidental prostate cancer (iPCa) after aquablation and HoLEP.

Methods: At our center, between January 2020 and November 2022, 317 men underwent aquablation, and 979 men underwent HoLEP for BPO. Histopathological assessment of resected tissue was conducted in all cases. If iPCa was detected, the Gleason score and percentage of affected tissue were assessed. Differences in important predictive factors for prostate cancer between study groups were accounted for by additional matched pairs analysis (with matching on age ± 1 year; PSA ± 0.5 ng/mL; and prostate volume ± 5 mL).

Results: Histopathology revealed iPCas in 60 patients (4.6%): 59 (6.03%) after HoLEP and 1 (0.3%) after aquablation (p = 0.001). Of 60 of incidental cancers, 11 had a Gleason score ≥7 (aquablation: 1/1 [100%]; HoLEP: 10/59 [16.9%]). The aquablation and HoLEP study groups differed in patient age, preoperative PSA, and prostate volume. Therefore, matched pairs analysis (aquablation: 132 patients; HoLEP: 132 patients) was conducted to improve comparability. Also after the matching procedure, significantly fewer iPCas were diagnosed after aquablation than HoLEP (aquablation: 0 [0%]; HoLEP: 6 [4.5%]; p = 0.015).

Conclusion: Significantly fewer iPCas were identified after aquablation than HoLEP procedures. Histopathologic assessment of tissue after aquablation is feasible and may lead to the diagnosis of clinically significant iPCa. Therefore, histopathologic examination of the aquablation resective tissue should not be omitted.

Keywords: Aquablation; Holmium enucleation of the prostate; Incidental prostate cancer; Prostate cancer.

Fig. 1.

Study flow diagram.

Fig. 2.

Histological images of iPCa. a HoLEP: benign histology (hematoxylin/eosin staining, magnification ×40). b Aquablation: benign histology (hematoxylin/eosin staining, magnification ×40). c HoLEP: iPCa, Gleason score 6 = 3 + 3 (hematoxylin/eosin staining, magnification ×100). d HoLEP: iPCa, Gleason score 7a = 3 + 4 (hematoxylin/eosin staining, magnification ×20). e Aquablation: iPCa, Gleason score 8 = 4 + 4 (hematoxylin/eosin staining, magnification ×200). f Aquablation: iPCa, Gleason score 8 = 4 + 4 (PSAP immunohistochemistry, magnification ×200).