Introduction: The aim of this study was to report our experience doing holmium laser enucleation of the prostate (HoLEP) to patients with high prostate-specific antigen (PSA) and negative prostatic biopsy. 

Methods: We conducted a retrospective study of all patients that had HoLEP because of refractory bladder outlet obstruction. The study included all patients with high PSA and negative prostatic biopsy.

Results: Thirty-one patients were identified. The mean age was 74 years. The mean preoperative PSA and PSA density were 8 ng/ml and 0.08 ng/ml/g, respectively. The mean prostate volume and resected weight were 106 cc and 72 g, respectively. The mean three-month postoperative PSA and the mean PSA reduction were 4.6 ng/ml and 79%, respectively. Prostate cancer was diagnosed in 27 patients (87%) with HoLEP; of these, 14 patients had 3+3, 11 had 3+4, and two patients had 4+5 prostate cancer. Thirteen patients with 3+3 prostate cancer were enrolled into active surveillance (AS) and 11 of them had repeat prostatic biopsy within a year of diagnosis showing stable disease or no evidence of cancer. One patient with 3+3 prostate cancer chose radical prostatectomy (RP). Eleven patients had 3+4 prostate cancer; of these, four chose AS and showed no warning criteria of progression to the current time. Three patients had RP and four patients had radiotherapy. Two patients had 4+5 prostate cancer and that was followed by computed tomography and bone scan showing a metastatic disease. The other four patients included one diagnosed with benign prostatic hyperplasia, two with high-grade prostatic intraepithelial neoplasia, and one with atypical small acinar proliferation. Prostate biopsy after six months identified prostate cancer in two of them, including 3+3 prostate cancer in one patient managed by AS and 4+5 in the second one managed by radiotherapy.

Conclusions: Prostatic biopsy can be very challenging for prostate cancer diagnosis in men with a markedly large prostate. HoLEP has a high degree of reliability to diagnose prostate cancer in men with a large prostate and negative prostatic biopsy. Prostatic volume reduction with HoLEP increases the diagnostic yield of further prostatic biopsies to men with persistently high PSA.