Enucleation: The OG of Focal Therapy

How to cite:Sobol I. Enucleation: The OG of Focal Therapy. Grand Rounds in Urology. October 2025. Accessed Apr 2026. https://grandroundsinurology.com/enucleation-the-og-of-focal-therapy/

Summary

Ilya Sobol, MD, Assistant Professor of Urology, Eastern Virginia Medical School, Norfolk, Virginia, explains how enucleation occupies a unique position in managing men who simultaneously face elevated prostate-specific antigen (PSA), benign prostatic hyperplasia (BPH), and possible or known prostate cancer. He begins by describing the challenge of interpreting PSA when both disease states contribute to its production. He notes that peripheral zone PSA output is relatively constant, but transition zone PSA varies widely depending on stromal or glandular predominance. Enucleation removes this variability, resulting in a stable PSA baseline. 

He proposes a strategic approach that begins with the question of whether the patient would be a surgical candidate if clinically significant cancer were found. For patients who are poor candidates for radical prostatectomy but have substantial lower urinary tract symptoms (LUTS) and rising PSA, enucleation may clarify the disease state while curing BPH. He describes how holmium laser enucleation of the prostate (HoLEP) functions as a megabiopsy because it removes the entire transition zone for pathological evaluation. He notes a strong durability of symptom relief and the ability to restore spontaneous voiding in many men with atonic bladders.

Dr. Sobol reviews cancer distribution patterns, showing that most tumors arise in the peripheral zone, while a minority originate in the transition zone. This informs the interpretation of residual PSA and further evaluation after enucleation. He presents clinical scenarios in which enucleation clarifies management. Outcomes include reassurance and continuation of surveillance when the PSA normalizes, identification of focal therapy candidates when cancer remains but the tumour volume decreases, and improved preparation for radiation when enucleation resolves severe LUTS in men with high-risk disease. He emphasizes that enucleation prevents unnecessary procedures by delivering pathology, PSA clarity, and symptom control in a single intervention.

Frontiers in Oncologic Prostate Care and Ablative Local Therapy (FOCAL) is an outstanding program on prostate imaging, transperineal interventions, and ablative treatments for prostate cancer and benign prostatic hyperplasia. Bringing together community-based, academic, and industry partners, FOCAL offers lectures by world-renowned faculty and hands-on training workshops on in-office transperineal interventions, fusion-guided prostate ablation and state-of-the-art BPH management with novel technologies.