Prostate specific antigen (PSA) screening for prostate cancer has recently been challenged due to poor sensitivity. A number of conditions elevate PSA besides prostate cancer with benign prostatic hypertrophy (BPH) being most common. The objective of this study was to assess the positive predictive value (PPV) of PSA and PSA density (PSAD) for prostate cancer risk following Holmium laser enucleation of the prostate (HoLEP).

An institutional IRB-approved database of HoLEP surgeries performed at Indiana University from 1999 to 2018 was queried to identify 1147 patients with post-HoLEP PSA data. 55 post-HoLEP biopsies were recorded. Demographics, PSA, prostate volume, and oncologic details were analyzed. The primary outcome was biopsy proven prostate cancer.

55 patients underwent “for cause” transrectal ultrasound prostate biopsy following HoLEP. Cancer was identified in over 90% of those biopsied. Men with PSA above 1 at time of biopsy had a 94% probability of cancer detection and 80% risk of clinically significant disease. PSAD above 0.1 was associated with a 95% risk of cancer and 88% risk of clinically significant cancer. A PSA greater than 5.8 or PSAD greater than 0.17 was universally associated with biopsy proven cancer.

Post HoLEP PSA and PSAD have high PPV for prostate cancer risk. Thresholds for biopsy should be lower than for non-HoLEP patients. HoLEP patients with PSA above 1 or PSAD above 0.1 have higher likelihoods of harboring clinically significant disease and should undergo biopsy. Referring physicians should be aware of these significant risk shifts.

The Journal of urology. 2019 Sep 05 [Epub ahead of print]

Zain A Abedali, Adam C Calaway, Tim Large, James E Lingeman, Matthew J Mellon, Ronald S Boris

Department of Urology, Indiana University School of Medicine, Indianapolis, Indiana.