Preoperative magnetic resonance imaging findings in the transition zone predict incidental prostate cancer in holmium laser enucleation of the prostate

Background: To assess the effectiveness of magnetic resonance imaging (MRI) of the transition zone (TZ) for predicting incidental prostate cancer (iPCa) detected after holmium laser enucleation of the prostate (HoLEP) by comparing cases with and without iPCa. Methods: We retrospectively evaluated 136 patients who underwent HoLEP for benign prostatic hyperplasia (BPH) between June 2022 and April 2025. After excluding seven patients with biopsy-confirmed prostate cancer, data from 114 patients were analyzed and divided into two groups: iPCa (n = 17) and BPH (n = 97). The preoperative and postoperative outcomes were compared. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of iPCa. MRI assessment focused exclusively on the TZ according to the Prostate Imaging-Reporting and Data System (PI-RADS) version 2.1. Results: MRI-TZ findings (PI-RADS score of 3 or more) were significantly more prevalent in the iPCa group than in the BPH group (64.7% vs. 16.5%, p < 0.0001). Univariate analysis identified both MRI-TZ findings and prostate-specific antigen (PSA) levels greater than 6.2 ng/mL and TZ-adjusted PSA levels (PSAD-TZ) greater than 0.18 ng/mL/mL as significant predictors of iPCa. However, multivariate logistic regression identified only MRI-TZ findings as an independent predictor of iPCa (odds ratio, 8.96; 95% confidence interval: 2.68–29.9; p = 0.0004). No significant differences in postoperative urinary outcomes were observed between the two groups. Conclusion: Preoperative MRI-TZ findings may predict iPCa in patients undergoing HoLEP and potentially guide individualized perioperative risk stratification.