Editorial Comment to Tri-modality therapy with i-125 brachytherapy, external beam radiation therapy, and short-term hormone therapy for high-risk prostate cancer after holmium laser enucleation of the prostate.

The authors described a patient with a history of holmium laser enucleation of the prostate (HoLEP) who underwent low‐dose‐rate (LDR) brachytherapy combined with external beam radiation therapy (EBRT) and hormone therapy for high‐risk prostate cancer (PC).

The transurethral resection (TUR) defect was listed as a relative contraindication for brachytherapy because of increasing technical difficulties of implantation. Recently, some studies have reported the clinical outcomes of the LDR brachytherapy for patients with PC with TUR history. A single‐arm prospective study showed favorable oncological outcomes and acceptable urinary toxicity in patients with low to intermediate‐risk PC. In contrast, a higher frequency of urinary toxicities was observed in patients with TUR history compared with those without it. , Additionally, the presence of a rim of the prostate tissue of at least 1 cm around the urethral defect at the posterolateral side was one of the inclusion criteria for seed implantation.

These reports suggested that LDR brachytherapy is a treatment option even in patients with PC with TUR history if the rim of the prostate tissue remained sufficient for seed implantation; however, the risk of complications is higher than that in patients without TUR history.

In the present case, brachytherapy was performed after HoLEP. The enucleation including HoLEP appears to form larger defects and thinner prostatic rim than conventional TUR. Accordingly, advanced techniques of seed implantation may be required in these cases.

Interestingly, trimodal therapy was performed in the patient had HoLEP history because of high‐risk PC; 6 years of survival time was observed without recurrence and complication. LDR brachytherapy combined with EBRT caused increase of the urinary complications compared with brachytherapy alone.

Before brachytherapy is selected as a curative treatment of PC in patients with prostatic defect, it is necessary to judge whether brachytherapy can be performed by evaluating the residual prostate tissue thickness and careful preplanning with a radiologist. Furthermore, the combined use of perirectal hydrogel spacer can reduce the risk of rectal toxicity.

Conflict of interest

The author declares no conflict of interest.