radical prostatectomy after partial HOLEP - is it possible?

@spaccer I can't answer the scar tissue question other than scar tissue can be created with treatment from radiation as my radiation oncologist told me I had to use another method of treatment if I ever get a biological re-occurrence.

I too, had a 3+4 Gleason and an 11.2 psa. I had 5 treatments with the Mridian radiation machine which has a built in MRI (vs fused images). The margins treated around the prostate are much less because of the built in MRI (2 mm) vs 3-5 mm with other types of radiation machines. This means less healthy tissue is exposed. If you are thinking of radiation, check out the Mirage randomized trial which showed a significant difference in side effects and toxicity because of the built in MRI.

Here is an article from Urology Times talking about it:
https://www.urologytimes.com/view/mirage-trial-margin-reduction-with-mri-guided-sbrt-reduces-toxicity-vs-ct-guided-sbrt

Yes, but for different reasons. The HOLEP, to my understanding, does not remove the capsule which could be intact or broken, thereby releasing cancerous cells. You need to have that addressed.
Also, if you go the HOLEP route, the remaining prostate tissue is cancerous and must be removed by “morcellating” it, which is the grinding up and suctioning out of tissue - NOT a good idea! In fact, you do not mention when this G3+4 was discovered. If they analyzed ground up bits of gland from the procedure and found them to be cancerous that could be an issue. HOLEP guidelines say to tell your doctor if you have/had prostate cancer (not your job - they should know!).
Morcellation should only be used when no cancer is present. So please do not pursue this option!
First, you need a PSMA to see if there is any spread. Ben’s suggestion for MRIdian is excellent if the disease is still confined to the gland and capsule is intact; you may also consider surgical removal where lymph glands can be analyzed for spread.
Depending on what is found you may need radiation as well. G3+4 in itself is not super bad but if it got out of the gland due to your HOLEP it will need to be treated peripherally as well.
I tell you this because I had Green Light Laser - which uses no morellation - and never had a biopsy first. My PSA was not terribly high and my DRE was completely normal. However, a few years later when my Biopsy revealed G4+3 unfavorable my surgeon said I probably SHOULD have had a biopsy in lieu of the laser surgery (different doc) since the cancer was probably there already and only got worse even though my urination improved greatly after the procedure.
So please get as much info as you can and consult with different docs - surgeons, radiation oncologists - before you move forward. Best
Phil

Thank you for the info. After the HOLEP, my PSA is now 0.35 so I think I have some time to make a decision. My PSA was 5.2 before the HOLEP. I had the HOLEP because I was unable to urinate after a hernia operation. Rather than radiation, I would prefer laser ablation or HIFU.

I had the HOLEP in July, 2024 because I was unable to urinate after a hernia operation in May, 2024. The HOLEP removed the central core of my prostate which left 30 to 40 % of my prostate intact. I had an MRI in December with the following results:
Prostate has been assessed using ACR’s PI-RADS version 2.1.
PI-RADS category 4 suspicious mass, right posterior lateral basilar peripheral zone.
I will get a biopsy on March 12th.
I do not know if morellation was used during my HOLEP. After the operation, I had a catheter in for 9 days. I finally went to the emergency room to have it removed because it had gotten plugged up and I was urinating around the catheter. After the removal, I urinated and a cross section of my prostate came out. This is what was blocking the catheter. I asked my urologist if I this was a concern that a portion of my prostate which was cancerous was in my bladder for that period of time, and he said that it was not a concern. Do members here believe that I should be concerned about this and have an MRI done on my bladder?

Spaccer, I don’t think the bladder is the concern; even if prostate cancer cells were floating around in there you would most probably urinate them out. In any case, those cells wouldn’t cause your bladder to become cancerous, if that is your concern.
But the bigger point in my mind is knowing WHEN you had the G3+4 - before or after the HOLEP?? If you research the contraindications for HOLEP they mention the presence of PCa. That’s a question you have to ask your Urologist.
After your 3/12 biopsy you should probably have a full PSMA PET scan, which may( or hopefully will not) show additional areas of concern.
In my own case the medial lobe of the prostate had grown into the bladder in the form of an elongated polyp. So whenever I began to urinate, the outward flow would push the polyp downward like a flapper valve on the toilet, cutting off the stream. Once it was gone I felt great, but my second urologist thinks that polypoid mass was cancer all along.
You still have to find your true Gleason score within that suspicious area and press for a Decipher Score which indicates how aggressive the cancer might be. Not all G3+4’s are the same so this is an important piece of the treatment planning. Best
Phil

Spaccer, Csn.cancer.org is a good website discussing HOLEP in a forum like we have here. Just type it into the search bar.
There are many instances of cancer being found incidentally after analysis of the morcellated material. Most agree that a repeat of this procedure is not recommended.
Didn’t mean to rock your world or cause alarm; like all surgeries (no matter how “less invasive” they say they are) success or failure is in the hands of the surgeon.
Your prior HOLEP does not subject you to more peril unless your urologist/surgeon botches things badly - then you could have problems, right?
But they did use morcellators for years in women with uterine cancer only to find that they were “seeding” the body cavity with cancer cells. But so far I have not seen any mention of studies in men with PCa so it’s probably not a concern.
You’ll know more after your biopsy. BTW, how old are you? Your age certainly is a factor in planning your treatment of surgery vs radiation. Best
Phil