Incidence, predictive factors and oncological outcomes of incidental prostate cancer after endoscopic enucleation of the prostate: a systematic review and meta-analysis

Introduction: This systematic review aims at reporting the incidence, predictive factors, and the oncological outcomes of incidental prostate cancer (IPCa) in men who underwent endoscopic enucleation of prostate (EEP). Methods: A literature search was performed using the following Medical Subject Heading (MeSH) terms and keywords: “Prostatic Neoplasms”, “Prostate Cancer”, “Transurethral Resection of Prostate”, “Prostate resection”, “Prostate enucleation”. Meta-analysis was performed if there were two or more studies reporting the same outcome under the same definition. In case of insufficient data, results were presented in a narrative manner. Results: Sixty-one studies were included in qualitative synthesis and 55 were included in meta-analysis. The pooled IPCa rate was 0.08 (95% CI 0.073–0.088). Increasing age, higher preoperative serum prostate-specific antigen (PSA) level, higher preoperative PSA density (PSAD), smaller prostate volume, higher postoperative PSA velocity and lower enucleated prostate weight, were reported to have significant correlation with IPCa. In BPH patients, the mean pre-operative and post-operative PSA levels were 5.58 ± 1.48 ng/dL and 1.06 ± 0.27 ng/dL, respectively. In patients with IPCa, the mean pre-operative and post-operative PSA levels were 7.72 ± 2.90 ng/dL and 2.77 ± 1.66 ng/dL, respectively. The mean percentage PSA reduction was 82.0% ± 1.8% for BPH patients and 68.2% ± 12.1% for IPCa patients. IPCa was most commonly managed by active surveillance (68.7%). Conclusions: The pooled incidence of IPCa after EEP was 8%. An absolute post-operative PSA level of < 2.0 and a percentage PSA reduction of > 70% should be expected in BPH patients after EEP.