Outcomes of Active Treatment for Localised Prostate Cancer After Holmium Laser Enucleation of the Prostate: A Systematic Review and Meta-analysis.

Background and objective: Holmium laser enucleation of the prostate (HoLEP) is a common surgical management option for localised prostate cancer (PCa). This review aims to ascertain the safety, and functional and pathological outcomes of active treatments (radical prostatectomy [RP], radiotherapy [RT], and focal therapy) for localised PCa after HoLEP. Methods: A systematic review and meta-analysis (PROSPERO registration: CRD42024562687) was conducted, searching the Ovid (Medline) and Embase (Elsevier) databases until October 2024. Comparative and noncomparative studies providing data on patients who underwent HoLEP and subsequent treatment modalities for PCa were included if these reported post- or intraoperative complications, pathological findings, and oncological or functional outcomes. Key findings and limitations: Of the 1567 studies identified, 22 were included. Patients with a history of HoLEP who had undergone RP did not have significantly worse erectile function rates or pathological outcomes than those without prior surgery for benign prostatic hyperplasia. However, HoLEP patients had higher intraoperative complication (odds ratio [OR] 10.78 [95% confidence interval {CI} 2.98-39.03]) and urethrovesical anastomosis leakage (OR 7.15 [95% CI 1.83-27.89]) rates, as well as lower urinary continence rates (OR 0.44, 95% CI 0.30-0.67). Continence rate was lower with RP than with RT (OR 0.15 [95% CI 0.05-0.42]). Limitations were scarcity of relevant studies (especially for treatments other than RP), their predominantly observational and retrospective nature, and their small sample sizes. Conclusions and clinical implications: The findings from this meta-analysis should be considered for patient counselling and management decisions, bearing in mind that patients with prior HoLEP who undergo RP have more intraoperative complications and urethrovesical anastomotic leaks and an increased postoperative incontinence rate. Our findings also highlight the need for further prospective comparative research to evaluate the oncological outcomes of these interventions. Patient summary: We investigated the outcomes in patients treated for localised prostate cancer following previous holmium laser enucleation of the prostate (HoLEP). We found that patients treated with radical prostatectomy after HoLEP have favourable pathological and erectile function outcomes. Intraoperative complication and urinary incontinence rates are, however, higher than in patients without prior surgery for benign prostatic hyperplasia.