Prevalence and Factors Associated With Incidental Prostate Cancer After Benign Prostatic Hyperplasia Surgery: A Five-Year Retrospective Study in Addis Ababa, Ethiopia

Abstract Background Incidental prostate cancer (IPC), defined as cancer unexpectedly identified on histopathology after surgery for presumed benign prostatic hyperplasia (BPH), has been widely studied internationally, but data from sub-Saharan Africa remain scarce, and none exist from Ethiopia. This study examined the prevalence, predictors, clinicopathological features, and management of IPC among patients undergoing transurethral resection of the prostate (TURP) or transvesical prostatectomy (TVP) for presumed BPH. Methods This retrospective cross-sectional study included 239 patients who underwent TURP or TVP for presumed BPH at MCM Comprehensive Specialized Hospital, Addis Ababa, Ethiopia, between January 2021 and December 2025. Sociodemographic, clinical, laboratory, and procedural data were abstracted from medical records. Bivariable comparisons used chi-square or Fisher's exact tests and t-tests or Mann–Whitney U tests, as appropriate; univariable and multivariable logistic regression estimated crude and adjusted odds ratios (AORs) with 95% confidence intervals (CIs). Model fit and discrimination were assessed, and sensitivity analyses examined robustness to prostate-specific antigen (PSA) transformation and influential observations Results IPC was identified in 23 of 239 patients (9.6%), with no significant difference by procedure (TURP 11.1% vs. TVP 8.2%, p = 0.445). Patients with IPC had significantly higher rates of hypertension (47.8% vs. 26.4%, p = 0.030), hydronephrosis (39.1% vs. 14.4%, p = 0.006), acute kidney injury (39.1% vs. 8.3%, p < 0.001), and higher PSA and PSA density (both p < 0.001). On multivariable analysis, preoperative PSA (AOR = 1.25 per ng/mL, 95% CI: 1.14–1.38), diabetes mellitus (AOR = 5.28, 95% CI: 1.64–16.95), and hydronephrosis (AOR = 3.92, 95% CI: 1.29–11.94) were independently associated with IPC; age was not (AOR = 1.19 per decade, p = 0.459). The model showed good discrimination (area under the curve [AUC] = 0.838) and calibration (Hosmer–Lemeshow p = 0.162), with findings robust across sensitivity analyses. Among IPC cases, 95.7% had International Society of Urological Pathology (ISUP) Grade Group ≥ 2, yet no patient received active surveillance, radical prostatectomy, radiotherapy, or documented staging investigation; management was uniformly based on androgen deprivation. Conclusions IPC affected nearly 1 in 10 men undergoing BPH surgery, with PSA, diabetes mellitus, and hydronephrosis independently associated with it; PSA density > 0.15 had 90% specificity but only 48% sensitivity. Most cases were clinically significant, yet none received staging or definitive local therapy, highlighting the need for structured incidental-cancer care pathways in similar resource-limited settings.