Patients with low-grade prostate cancer (PCa) on active surveillance are not immune to the impact of lower urinary tract symptoms (LUTS) from benign prostatic hyperplasia (BPH). As utilization of active surveillance has increased over the past two decades, the number of men who can benefit from BPH treatment with a known prostate cancer diagnosis has also grown.^1,2 Although clinical principles guide patient-centered care in this area, there remain little data to support these discussions and treatment decisions. Several important areas include the safety of BPH procedures in this population, outcomes with respect to urinary function, and the impact of BPH treatment on prostate cancer monitoring, follow-up testing, and long-term oncologic outcomes.

From an administrative perspective, Marchioni and colleagues evaluated transurethral outlet procedures in patients with BPH and a known PCa diagnosis using the ACS NSQIP outcome database (N = 34,542; 5.8% PCa).³ Patients were stratified by postoperative diagnosis (PCa vs BPH) and the data showed PCa patients fared slightly worse than BPH patients with increased inpatient time, greater transfusion rates (1.6×), and prolonged operative time for outlet procedures. Importantly, there were no differences in readmission, reoperation, or mortality. It remains unclear how PCa impacted these treatment outcomes, but it is possible that the procedures in the PCa population were done for malignant obstruction—a much more difficult situation to manage and one that may not be as relevant to BPH management during PCa active surveillance considering its typical use in lower-grade disease.

From a clinical perspective, the Canary Prostate Active Surveillance Study database was a prospective, multicenter study of 1501 men with a median follow-up of 6.4 years.⁴ This project aimed to identify the prevalence of LUTS and rates of treatment for men managing PCa with active surveillance. During this period nearly 20% utilized BPH medications and 1.4% had a BPH procedure. Although patients with severe LUTS were most likely to be treated procedurally, this remained relatively infrequent (4.2%) suggesting procedural management may be underutilized in such patients. Otherwise, 34% of patients in the cohort had definitive prostate cancer therapy during follow-up, with approximately half managed with prostatectomy. The authors found an association with worse LUTS and a greater proportion of indolent (Grade Group 1) PCa.

Regarding active surveillance, MRI has become an indispensable tool in prostate cancer management. The prostatic urethral lift (PUL), an option for BPH patients who desire ejaculatory-sparing procedural management, has been widely utilized in recent years. The impact of prior PUL on MRI quality for PCa assessment was evaluated by Benidir and colleagues.⁵ The authors determined that nearly 40% of scans were limited by moderate artifact from the PUL implants, resulting in poor image quality. These impacts were primarily observed in the transition zone, but large portions of the gland were unable to be visualized in certain MRI sequences due to the presence of the metallic implants. As such, caution should be exercised when considering implantable devices for BPH management in the setting of PCa active surveillance.

Oncologic safety and treatment outcomes have been evaluated for 3 major BPH procedures during PCa active surveillance: photovaporization of the prostate (PVP), holmium enucleation of the prostate (HoLEP), and simple prostatectomy. Jibara and colleagues assessed 71 patients at a single center and found urinary function improvements did not differ from patients without known PCa, while 93% remained on active surveillance at 3 years post PVP.⁶ Ultimately, 7 men had PCa treated, and most were treated with external beam radiotherapy (N = 6). This suggests PVP may be a safe and effective approach to BPH in the PCa active surveillance population.

Both HoLEP and simple prostatectomy have fared similarly. Rivera and colleagues evaluated their single-center HoLEP dataset, including 43 patients with PCa prior to HoLEP.⁷ Two patients were intermediate-risk PCa and 1 patient was high risk. Additionally, 2 patients had prostate cancer upgraded after HoLEP (GG1 → GG1 and GG1 → GG5). The 2 patients with intermediate disease remained on AS after surgery, and the high-risk patient had disease progression warranting systemic treatment. Elsaqa and colleagues prospectively evaluated 117 men with over 1 year of follow-up who underwent HoLEP while on PCa active surveillance.⁸ Urinary symptoms improved as expected while 72% of patients remained on active surveillance and 23% went on to radiotherapy for definitive PCa treatment. For patients with intermediate-risk PCa, 41% went on to definitive PCa therapy while 58% remained on AS.⁹ Collectively, HoLEP appears feasible in appropriately selected men with PCa, enabling many to remain on active surveillance, especially in the setting of less aggressive disease.

Managing BPH in patients on PCa active surveillance may improve the sensitivity of PSA testing due to reduced “background noise” from the adenoma that was removed. Livingston and colleagues assessed 92 patients who underwent simple prostatectomy, including 68 patients without cancer and 24 patients who either had known PCa prior to surgery or incidentally found cancer on the surgical specimen.¹⁰ Disease ranged from GG1 to GG5, whereas an initial and subsequently stable PSA around 1 ng/mL was associated with the absence of PCa. Additionally, PSA velocity was substantially lower (0.04 vs 1.4 ng/mL per year) in patients without PCa. While informative, a major gap exists in data regarding PSA changes for patients on AS after BPH treatment. These parameters remain unexplored and an opportunity for future research.

Collectively, BPH treatment in patients who are on PCa active surveillance can achieve expected urinary outcomes, according to existing data. Furthermore, when appropriately selected in the setting of well-defined PCa, treating BPH in patients on active surveillance is likely safe from an oncologic standpoint. The factors related to PCa progression after BPH treatment remain unclear, but are likely related to tumor biology and more aggressive PCa, which are factors unlikely to be impacted by BPH management.