Patient experience and satisfaction after same-day discharge radical prostatectomy using a personalized, digital perioperative programme.

PURPOSE: To assess the patient experience and satisfaction after the implementation in routine of a personalized, digital programme before and after same-day discharge (SDD) robot-assisted radical prostatectomy (RARP). METHODS: The study is a pre/post-interventional, multi-surgeon, unicentre, prospective study. All consecutive patients undergoing SDD RARP were included during a 6-month period. After a pre-interventional assessment of the satisfaction rate (n = 26), all patients (n = 46) were introduced to the Betty. Care platform and followed the BETTY COACHING programme which included a specific radical prostatectomy module. The primary endpoint was patient satisfaction 6 weeks after SDD RARP. Secondary endpoints were hospital stay, readmission and complications rates, unplanned visits, and remote monitoring data. RESULTS: Median age and PSA were 66 years and 7.0 ng/ml. Lymph node-dissection and nerve-sparing procedures were performed in 41.3 and 87.0% of patients, respectively. Median operative time and blood loss were 80 min and 150 ml, respectively. The 90-day rates of unplanned visits, readmission and complications were improved after the digital tool implementation (2.2, 2.2, and 8.7%, respectively). Mean satisfaction score was 9.6 out of 10 (8.0 before implementation). Median duration of pain was 2 days after discharge, with median pain intensity of 2/10. Median duration of daily active use of remote monitoring was 34 days. The urinary continence rate was 91.3% 6 weeks after surgery in the postinterventional cohort. CONCLUSIONS: The implementation of a personalized, surgery-specific, digital programme combining prehabilitation, patient education, rehabilitation, patient-reported outcome measurement and remote monitoring, improves patient experience and satisfaction and could help promoting early discharge even after a major surgery.

From an On-site Program to a Mobile App for Prehabilitation and Rehabilitation for Robotic Radical Prostatectomy: Lessons Learned from 5 Years of Experience, the COVID-19 Outbreak, and Comparison with Nationwide Data.

Prehabilitation programs play a key role in optimizing patient experiences and outcomes after surgery. However, there are few data on robot-assisted radical prostatectomy, and prehabilitation programs may be challenging to launch and maintain over time for every patient. Here we report our 5-yr experience of an on-site prehabilitation program and its impact on patient and hospital outcomes. During the study period, we observed continuous improvements in the same-day discharge rate (from 0% to 26.4%), hospital stay (from 3 to 0.9. d), costs (-63%), days out of hospital within 30 d after surgery in our center, and in comparison to contemporary nationwide data. However, despite these advantages, maintenance and diffusion of this program could be challenging owing to the absence of incentive support and lack of human resources. This led us to develop two free-access mobile apps, available on the app stores for both patients and surgeons, that include checklists, remote monitoring, and multiple educational materials aimed at simplifying the widespread use of optimized perioperative pathways. PATIENT SUMMARY: We found that a prehabilitation program before surgery can help in optimizing patient outcomes after robot-assisted removal of the prostate. We translated this program into a mobile app available for every patient.

Cohort profile: COBLAnCE: a French prospective cohort to study prognostic and predictive factors in bladder cancer and to generate real-world data on treatment patterns, resource use and quality of life.

PURPOSE: Bladder cancer is a complex disease with a wide range of outcomes. Clinicopathological factors only partially explain the variability between patients in prognosis and treatment response. There is a need for large cohorts collecting extensive data and biological samples to: (1) investigate gene-environment interactions, pathological/molecular classification and biomarker discovery; and (2) describe treatment patterns, outcomes, resource use and quality of life in a real-world setting. PARTICIPANTS: COBLAnCE (COhort to study BLAdder CancEr) is a French national prospective cohort of patients with bladder cancer recruited between 2012 and 2018 and followed for 6 years. Data on patient and tumour characteristics, treatments, outcomes and biological samples are collected at enrolment and during the follow-up. FINDINGS TO DATE: We describe the cohort at enrolment according to baseline surgery and tumour type. In total, 1800 patients were included: 1114 patients with non-muscle-invasive bladder cancer (NMIBC) and 76 patients with muscle-invasive bladder cancer (MIBC) had transurethral resection of a bladder tumour without cystectomy, and 610 patients with NMIBC or MIBC underwent cystectomy. Most patients had a solitary lesion (56.3%) without basement membrane invasion (71.7% of Ta and/or Tis). Half of the patients with cystectomy were stage ≤T2 and 60% had non-continent diversion. Surgery included local (n=298) or super-extended lymph node dissections (n=11) and prostate removal (n=492). Among women, 16.5% underwent cystectomy and 81.4% anterior pelvectomy. FUTURE PLANS: COBLAnCE will be used for long-term studies of bladder cancer with focus on clinicopathological factors and molecular markers. It will lead to a much-needed improvement in the understanding of the disease. The cohort provides valuable real-world data, enabling researchers to study various research questions, assess routine medical practices and guide medical decision-making.

Impact of outcomes and costs for implementation of robotic radical cystectomy with full intracorporeal urinary diversion.

Introduction: Radical cystectomy (RC) remains a surgery with important morbidity despite technical advances. Our aim was to determine the impact on outcomes and costs of robot-assisted radical cystectomy (RARC) with full intracorporeal diversion. Material and methods: We retrospectively included 196 consecutive patients undergone RC for bladder cancer between 2017 and 2022. Comparisons were done between the open radical cystectomy (ORC; n = 166) and RARC with full intracorporeal diversion (n = 30) in the overall cohort and after matched pair analysis. Results: More neobladders were performed in the RARC group (40% vs 18.7%, p = 0.011). Peri-operative parameters continuously improved over time in the RARC cohort despite an increased proportion of elderly patients with higher comorbidity index. RARC patients had lower prolonged stay (33.3% vs 68.3%, p = 0.002), lower grade 1 complication rates (26.7% vs 53.3%, p = 0.016) and blood loss (185 vs 611 ml, p <0.001) than ORC patients. RARC was an independent favorable predictor for prolonged stay (OR 0.199) and complication (OR 0.334). Cost balance favored ORC, with an increase of hospitalization cost at 816 euros for RARC. Conclusions: After matching, RARC with full intracorporeal diversion was associated with improved outcomes and a moderated increase of post-operative costs mainly due to the use of robotic devices.

Same-day discharge surgery for robot-assisted radical prostatectomy in the era of ERAS and prehabilitation pathways: a contemporary, comparative, feasibility study.

PURPOSE: To assess the feasibility of same-day discharge (SDD) after robot-assisted radical prostatectomy (RARP) in the context of enhanced recovery after surgery (ERAS) and prehabilitation pathways. MATERIALS AND METHODS: For 1 year, we prospectively assessed the feasibility of SDD RARP in the context of ERAS and prehabilitation pathways. SDD patients were compared to overnight patients operated during the same period by the same surgeon. Primary outcomes were complication and 90-day readmission rates. RESULTS: Of the overall cohort, 51.9% were discharged home the day of surgery. Both cohorts were comparable in terms of pre-operative and intra-operative characteristics. There was a not significant trend towards shorter operative time in the SDD cohort (93.7 versus 105.2 min, p = 0.077). Mean blood loss was comparable between both cohorts. No significant difference in terms of complication (p = 0.606; 16.0% versus 11.1%) and readmission rates (< 4%) was noted. There was a not significant trend towards faster continence recovery for patients included in the SDD cohort, compared with those in the inpatient cohort. The overall cost per patient was reduced by 10.8% with SDD surgery with no increased cost due to emergency visits or readmissions CONCLUSIONS: Implementation of SDD RARP in the context of ERAS and prehabilitation pathways is safe, reduces cost and does not compromise the post-operative course. Proportion of patients undergoing SDD continuously increased to reach 60% of the surgeon cohort at the end of the study period. The trend suggesting a faster continence recovery after SDD has to be confirmed in a larger cohort.

A prehabilitation programme implemented before robot-assisted radical prostatectomy improves peri-operative outcomes and continence recovery.

OBJECTIVES: To assess the impact of a routine, on-site, 1-day prehabilitation (PreHab) programme on peri-operative and continence recovery after robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: All 303 consecutive RARPs performed between March 2018 and February 2020 since the routine implementation of PreHab were included in our study. PreHab was carried out according to the availability of the 1-day programme before the planned date of surgery (two sessions per month including four patients per session). The PreHab programme was implemented in 165 patients (54.5%). The primary endpoint was continence recovery, strictly defined as no safety pad use at 1 and 6 months. Secondary endpoints were peri-operative variables (blood loss, operating time, length of stay, transfusion, complications, and readmission rates). Comparisons were made according to whether the PreHab pathway was applied or not (PreHab+ vs PreHab-) in univariable and multivariable models. RESULTS: The PreHab pathway was implemented for a stable proportion of patients over time (54.5%). The two cohorts were comparable in terms of preoperative and pathological features (P > 0.05). Length of stay was significantly shorter in the PreHab+ group (1.3 vs 1.9 days; P = 0.001). There was a trend towards fewer complications in the PreHab+ group (P = 0.061). Use of the PreHab pathway was independently correlated with higher continence rates at 1 month (37% vs 60%; P < 0.001) and 6 months (67.4% vs 87.3%; P < 0.001), even after controlling for age, body mass index, prostate volume, type of apical reconstruction, nerve-sparing surgery and lymph node dissection. The main limitation of the study was the absence of randomization. CONCLUSIONS: Our experience demonstrates that the PreHab programme is the major predictor of improved peri-operative outcomes and continence recovery after RARP, with sustainable benefits 6 months after surgery.

First report of testis-sparing surgery for sertoliform cystadenoma: case presentation and review of literature.

INTRODUCTION: Sertoliform cystadenoma is a very rare, benign lesion of the rete-testis difficult to distinguish from other malignancies of the testicle. CASE PRESENTATION: We present the case of a 42-year-old male who presented with a right testicular mass, asymptomatic for 1 year. Clinical examination revealed a palpable, painless, and well-delimited right testicular superior pole nodule. Testicular ultrasound confirmed the nodule, whereas serum tumoral markers were normal. The patient underwent inguinal partial orchiectomy. Intraoperative excisional biopsy and frozen section pathology were performed, reporting undetermined tumoral origin with negative surgical margins. Ischemia time was 12 minutes. The final pathology report showed a Sertoliform cystadenoma of rete testis, with immunomorphology positive for AE1, CK7, and negative surgical margins. CONCLUSION: To our knowledge, this is the first report of testicular sparing surgery for Sertoliform cystadenoma, a very rare benign tumor of rete testis. All previously reported cases were managed by radical inguinal orchidectomy.

The prognostic value of high-grade prostate cancer pattern on MRI-targeted biopsies: predictors for downgrading and importance of concomitant systematic biopsies.

PURPOSE: To assess the proportion and risk factors for downgrading and reclassification to favorable disease in patients having high-grade (HG) prostate cancer (PCa) pattern on magnetic resonance imaging (MRI)-targeted-biopsy (TB). METHODS: From a radical prostatectomy (RP) cohort, we included patients with pre-biopsy positive MRI and HG [defined by Grade Group (GG) ≥ 3] PCa on MRI-TB. All patients also underwent concomitant systematic biopsy (SB). The main endpoints were the rates of downgrading to GG2, overall downgrading, favorable disease (pT2 and GG2) on RP specimens, and biochemical recurrence-free-survival (RFS). We studied the correlations between HG on concomitant SB, final pathological outcomes and biochemical RFS curves. RESULTS: Overall downgrading, downgrading to GG2 disease and favorable disease were noted in 36.2%, 24.1%, and 15.4% respectively. HG on concomitant SB was correlated with pT3-4 disease (p < 0.001), pN1 disease (p < 0.001), positive surgical margins (p = 0.043), PSA recurrence (p = 0.003). In multivariable analysis, the presence of GG4-5 on TB (p = 0.013; OR 0.263) and the presence of HG on concomitant SB (p = 0.010; OR 0.269) were negatively and independently correlated with the risk of downgrading to GG2. The presence of HG on concomitant SB independently predicted RFS with a hazard ratio of 2.173 (p = 0.049; 95% CI 1.005-4.697). CONCLUSIONS: Our data shows that a limited HG restricted to TB can often be associated with a favorable grade in almost a quarter of the cases and downgraded in almost half of the cases. Detailed SB features, mainly the presence of HG on concomitant SB, was associated with a more accurate pathology and oncologic outcomes prediction, pleading for the maintenance of SB in MRI-positive patients.

Same Day Discharge versus Inpatient Surgery for Robot-Assisted Radical Prostatectomy: A Comparative Study.

(1) Background: no study has compared outcomes of same day discharge (SDD) versus inpatient robot-assisted radical prostatectomy (RARP) in homogenous cohorts. Our aim was to compare perioperative outcomes and urinary continence recovery between SDD and inpatient RARP in contemporary, comparable patients. (2) Methods: we included consecutive patients undergoing RARP between 2018 and 2020 (n = 376). Only patients eligible for SDD (no oral anticoagulant, distance home-hospital <150 km) and having >6-month follow-up were included (n = 180). All patients underwent RARP with or without lymph node dissection. Comparisons were performed between SDD (n = 42) and inpatient RARP (n = 138). Primary outcomes were 90-day complication and readmission rates and continence rates at 1 and 6 months. (3) Results: median patient age was 66.7 years. Median duration of surgery and blood loss was 134 min and 200 mL, respectively. Lymph node dissection and nerve-sparing procedures were performed in 76.7% and 82.2% of cases, respectively. Median follow-up was 19.5 months. No difference was seen regarding patient features, peri-operative outcomes, and pathology parameters between both groups. The proportion of SDD RARP was stable over time (23.5%). The 90-day unplanned visits, readmission and complication rates were 9.5%, 7.1%, and 19.0% in SDD patients versus 14.5% (p = 0.407), 10.1% (p = 0.560), 28.3% (p = 0.234) for inpatient RARP, respectively. Trends favoring SDD were not statistically significant. Continence rates at 1-(p = 0.589) and 6-months (p = 0.674) were comparable between SDD and inpatient RARP. The main limitation was the lack of randomization. (4) Conclusions: this multi-surgeon comparative study confirms the safety of routine SDD RARP in terms of perioperative and functional outcomes. Trends favoring SDD in terms of complications, emergency visits and readmission have to be confirmed.

MRI Characteristics Accurately Predict Biochemical Recurrence after Radical Prostatectomy.

BACKGROUND: After radical prostatectomy (RP), biochemical recurrence (BCR) is associated with an increased risk of developing distant metastasis and prostate cancer specific and overall mortality. METHODS: The two-centre study included 521 consecutive patients undergoing RP for positive pre-biopsy magnetic resonance imaging (MRI) and pathologically proven prostate cancer (PCa), after which a combination scheme of fusion-targeted biopsy (TB) and systematic biopsy was performed. We assessed correlations between MRI characteristics, International Society of Urological Pathology (ISUP) grade group in TB, and outcomes after RP. We developed an imaging-based risk classification for improving BCR prediction. RESULTS: Higher Prostate Imaging and Reporting and Data System (PI-RADS) score (p = 0.013), higher ISUP grade group in TB, and extracapsular extension (ECE) on the MRI were significantly associated with more advanced disease (pTstage), higher ISUP grade group (p = 0.001), regional lymph nodes metastasis in RP specimens (p < 0.001), and an increased risk of recurrence after surgery. A positive margin status was significantly associated with ECE-MRI (p < 0.001). Our imaging-based classification included ECE on MRI, ISUP grade group on TB, and PI-RADS accurately predicted BCR (AUC = 0.714, p < 0.001). This classification had more improved area under the curve (AUC) than the standard d'Amico classification in our population. Validation was performed in a two-centre cohort. CONCLUSIONS: In this cohort, PI-RADS score, MRI stage, and ISUP grade group in MRI-TB were significantly predictive for disease features and recurrence after RP. Imaging-based risk classification integrating these three factors competed with d'Amico classification for predicting BCR.

A combination of enhanced recovery after surgery and prehabilitation pathways improves perioperative outcomes and costs for robotic radical prostatectomy.

BACKGROUND: An enhanced recovery after surgery (ERAS) pathway has shown benefit in oncologic surgery. However, literature is scarce regarding the impact of this pathway, alone or combined with prehabilitation (PreHab) programs, on outcomes after robot-assisted radical prostatectomy (RARP). METHODS: Included in this study were 507 consecutive patients undergoing RARP from 2014 to 2019. The primary endpoint was duration of hospital stay. Secondary outcomes included intraoperative blood loss, operative duration, readmission rate, and overall costs. Univariate and multivariate comparisons were performed according to the ERAS and PreHab program status. RESULTS: ERAS patients had shorter hospital stays (P < .001), reduced operative times (P < .001), and decreased blood loss (P < .001) in comparison with non-ERAS patients. Shorter hospital stays were not associated with an increased readmission rate (7.9% [stable over time]; P = .757). Patients from an ERAS-/PreHab- group had a longer hospital stay (4.7 days) than those from an ERAS+/PreHab- group (3.5 days) and those from an ERAS+/PreHab+ group (1.6 days; P < .001). In a multivariate analysis, operative time and perioperative pathway (odds ratio for ERAS, 0.144; P < .001; odds ratio for ERAS and PreHab, 0.025; P < .001) were independently predictive for a prolonged length of stay (P < .001). Costs significantly decreased when ERAS and PreHab pathways were combined. CONCLUSIONS: The implementation of ERAS and PreHab programs significantly changes the postoperative course of patients and may synergistically optimize RARP outcomes. The combination of these pathways improves patient recovery and is associated with reduced lengths of stay, blood loss, operative times, and costs without an increase in the postdischarge readmission rate.

Subsphincteric Anastomosis During Laparoscopic Robot-Assisted Radical Prostatectomy and Its Positive Impact on Continence Recovery.

Introduction: To assess the interest of a new sphincter preserving anastomosis technique for continence recovery after robot-assisted laparoscopic radical prostatectomy (RALP). Materials and Methods: We performed a monocentric single-operator study on 187 consecutive RALP. Patients were divided into two groups: Group 1 (standard anastomosis, until December 2017) and Group 2 (subsphincteric anastomosis [SSA], since January 2018). The SSA consisted in respecting the sphincteric sleeve during the anastomosis suturing only the internal layer of the urethra with the bladder and thereby avoiding the loss of sphincteric length induced by the suture. Pre-, intra-, and postoperative data were prospectively collected and compared. Criteria of continence were as follows: no pad use and complete absence of leakage at catheter removal at 1 month and 1 year. Results: The two groups were comparable in terms of prostate-specific antigen, gland volume, and Gleason score. In Group 2 (SSA), we observed a complete continence recovery in 75.6% at catheter removal (p = 0.0000035), in 82.9% at 1 month (p = 0.000092), and in 97.5% at 1 year (p = 0.028), independently of bladder neck preservation (p = 0.388). There was also a significant difference between the two groups concerning urinary reeducation requirement (p = 0.0006), pad use, and urinary quality of life (p = 0.0000002). No anastomosis complication was reported. Conclusions: The SSA significantly improved the rates of immediate, early, and 1-year continence recovery after RALP. These results need further study among larger numbers of patients.

Survival Outcomes of Patients with Pathologically Proven Positive Lymph Nodes at Time of Radical Cystectomy with or without Neoadjuvant Chemotherapy.

BACKGROUND: To compare overall survival (OS) outcomes in pN1-3 disease at the time of radical cystectomy (RC) for muscle invasive bladder according to the neoadjuvant chemotherapy (NAC) status. MATERIALS AND METHODS: This multicenter study included 450 consecutive patients undergoing RC for muscle-invasive urothelial bladder cancer with pN1-3 pM0 disease from 2010 to 2019. NAC consisted in platinum-based chemotherapy. The primary endpoint was the comparison between NAC and non-NAC in terms of death from any cause. OS was assessed using the Kaplan-Meier method and multivariate Cox proportional hazards regression was used to estimate adjusted hazard ratios. RESULTS: Median age was 69 years. Patients receiving NAC were younger (p = 0.051), and more likely had downstaging to non-muscle invasive disease (10.7% versus 4.3%, p = 0.042). Median OS was 26.6 months. NAC patients had poorer OS compared with those who did receive NAC (Hazard ratio (HR) 1.6; p = 0.019). The persistence of muscle-invasive bladder in RC specimens was also significantly associated with OS (HR 2.40). In the NAC cohort, the two factors independently correlated with OS were the number of positive lymph nodes (p = 0.013) and adjuvant chemotherapy (AC) (HR 0.31; p = 0.015). CONCLUSIONS: Persistent nodal disease in RC specimens after NAC was associated with poor prognosis and lower OS rates compared with pN1-3 disease after upfront RC. In this sub-group of NAC patients, AC was independently associated with better OS.

Intercenter reproducibility of software-based fusion biopsies for grade group prediction when targeting suspicious MRI lesions.

PURPOSE: To assess the intercenter reproducibility of software-based fusion targeted biopsy (TB) for grade-group assessment and pretherapeutic evaluation of highly suspicious MRI lesions. PATIENTS AND METHODS: In this study, were included 380 consecutive patients who underwent radical prostatectomy (RP) after prostate cancer diagnosis and a prebiopsy MRI showing Prostate Imaging-Reporting and Data System (PIRADS) score 4 or 5 lesions. All patients underwent systematic biopsies (SB) combined with software-based fusion TB in the 2 centers. Biopsies were only performed by expert urologists or radiologists in a contemporary time frame. The primary endpoint was the center difference of concordance/upgrading rates between biopsy and RP specimens. RESULTS: Pathological features on biopsy and RP specimens were significantly different among centers with more unfavourable disease in center 1. The rate of TB upgrading was 33.6% in center 1 vs. 35.4% (P = 0.860) in center 2. Grading concordance was also comparable among centers (50.0% vs. 47.1%) as well as the SB upgrading rate. Regression analysis did not find any baseline characteristics (Age, prostate-specific antigen, MRI lesions, center) predictive for TB upgrading. These findings were achieved by using fewer TB per lesion in center 1 (2.3 vs. 5.0, P < 0.001), at the expense of more SB cores (14.4 vs. 8.5, P < 0.001). The influence of MRI characteristics (lesion size and number, PIRADS score) on upgrading rates was consistent among centers. CONCLUSIONS: Software-based fusion TB technique leads to comparable outcomes in terms of grade group prediction accuracy in PIRADS 4 to 5 lesions, insignificant between centers, in spite of different non imaging-based aggressiveness features.

Improvement of the intermediate risk prostate cancer sub-classification by integrating MRI and fusion biopsy features.

INTRODUCTION: Treatment decision-making for intermediate-risk prostate cancer (CaP) is mainly based on grade and tumor involvement on systematic biopsy. We aimed to assess the added value of multi-parametric magnetic resonance imaging (mpMRI) and targeted biopsy (TB) features for predicting final pathology and for improving the well-established favourable/unfavourable systematic biopsy-based sub-classification. MATERIALS AND METHODS: From a prospective database of 377 intermediate risk CaP cases, we evaluated the performance of the standard intermediate risk classification (IRC), and the predictive factors for unfavourable disease on final pathology aiming to build a new model. Overall unfavourable disease (OUD) was defined by any pT3-4 and/or pN1 and/or grade group (GG) ≥ 3. RESULTS: The standard IRC was found to be predictive for unfavourable disease in this population. However, in multivariable analysis regression, ECE on mpMRI and GG ≥3 on TB remained the 2 independent predictive factors for OUD disease (HR = 2.7, P = 0.032, and HR = 2.41, P = 0.01, respectively). By using the new IRC in which unfavorable risk was defined by ECE on mpMRI and/or GG ≥3 on TB, the proportion of unfavorable cases decreased from 62.3% to 34.1% while better predicting unfavorable disease in RP speciments. The new model displayed a better accuracy than the standard IRC for predicting OUD (AUC: 0.66 vs. 0.55). CONCLUSIONS: The integration of imaging and TB features drastically improves the intermediate risk sub-classification performance and better discriminates the unfavourable risk group that could benefit from more aggressive therapy such as neo-adjuvant and/or adjuvant treatment, and the favourable group that could avoid over-treatment. External validation in other datasets is needed.

Assessment of the Minimal Targeted Biopsy Core Number per MRI Lesion for Improving Prostate Cancer Grading Prediction.

BACKGROUND: To study the impact of MRI characteristics and of targeted biopsy (TB) core number on the final grade group (GG) prediction. MATERIALS AND METHODS: The cohort was 478 consecutive patients who underwent radical prostatectomy (RP) after positive mpMRI (multiparametric magnetic resonance imaging) followed by fusion TB. Endpoints were the upgrading and concordance rates between TB and RP specimens. RESULTS: Upgrading rate after TB was 40.6%. Patients with upgrading had lower PIRADS (Prostate Imaging-Reporting and Data System) scores (p < 0.001), smaller lesion size (p = 0.017), fewer TB cores (p < 0.001), and lower TB density (p = 0.015) compared with cases with grade concordance. There was a significant continuous improvement in upgrading rate when TB core number per lesion increased from 56.3% to 25.6% when <2 or ≥5 TB cores were taken, respectively (p = 0.002). The minimal TB number per lesion to reduce upgrading risk to approximately 30%was 4 in PIRADS 3, and 3 in PIRADS 4-5 cases. CONCLUSIONS: Grade group prediction by TB is significantly improved by higher PIRADS score, larger lesion size, and increased TB per lesion. At least four TB cores should be taken in PIRADS 3 score lesions, whereas three cores seem enough in PIRADS 4-5 cases to improve GG prediction and limit upgrading risk.

Impact of MRI and Targeted Biopsies on Eligibility and Disease Reclassification in MRI-positive Candidates for Active Surveillance on Systematic Biopsies.

OBJECTIVE: To assess the impact of concomitant targeted biopsies (TB) for predicting final disease reclassification in MRI-positive low-risk prostate cancer patients eligible for active surveillance (AS) on systematic biopsies (SB). MATERIALS AND METHODS: From a prospective database, we included all prebiopsy MRI-positive men fulfilling AS criteria at diagnosis (Toronto [n = 114], UCSF [n = 82], or PRIAS [n = 60] criteria) on SB. All patients underwent a combination of SB and software-based fusion TB, and an immediate radical prostatectomy. The primary endpoints were the pathologic upgrading and upstaging rates. RESULTS: Biopsy grade group was upgraded to grade group (GG) 2 and to GG≥3 on TB in 65.9%-76.7% and in 12.2-16.7%, respectively. The rate of GG ≥3 in radical prostatectomy specimens varied from 31.6% to 43.3% with no relation between strictest criteria and lower upgrading rates. The proportion of not organ-confined disease (35%-39%) was comparable among the AS cohorts. Negative TB was strongly associated with the absence of final GG ≥3. Tumor grade on TB was significantly correlated with the risk of final GG ≥3 in both Toronto and UCSF cohorts, not in the PRIAS cohort. In the PRIAS cohort, the only independent predictive factor for GG ≥3 disease was the maximal tumor length in any core (P = .034). CONCLUSION: In MRI-positive patients, the risk of disease reclassification was comparable whatever the SB-based AS criteria used. TB were predictive of final upgrading, with a varied impact according to the AS criteria. SB features remained relevant for reclassification prediction even in case of positive TB. The risk of upstaged disease remains important, approximately one third, and neither TB/SB parameters nor MRI findings could accurately predict it.

Confirmation by Early Oncologic Outcomes After Surgery of the Accuracy of Intermediate-risk Prostate Cancer Classification Based on Magnetic Resonance Imaging Staging and Targeted Biopsy.

Over the past decade, prostate cancer (PCa) diagnosis drastically evolved from systematic biopsies (SBs) to multiparametric magnetic resonance imaging (mpMRI) and targeted biopsy (TB), which have emerged as powerful imaging tools for diagnosis, staging, and preoperative planning. MRI and TB should now be widely adopted for assessing prognosis and be incorporated into predictive models. To date, the standard intermediate risk classification (IRC) defined unfavourable and favourable disease with clinical information and overall biopsy data. Roumiguie et al have proposed a new model based on mpMRI staging and grade group on TB and validated it using radical prostatectomy (RP) pathology (Urol Oncol 2020;38:386-92). The aim of our study was to validate the accuracy of this new IRC with early oncologic outcomes and biochemical recurrence (BCR) after RP. From a prospective database of RP patients with positive prebiopsy mpMRI (Prostate Imaging-Reporting and Data System score ≥3) followed by SB in combination with TB, 454 patients with intermediate-risk PCa were included. Median follow-up was 31.5 mo. The new IRC outperformed the standard IRC in predicting BCR (p = 0.007). The area under the curve was 0.613 for the new MRI- and TB-based IRC versus 0.575 for the standard IRC. This new IRC could optimise the prediction of recurrence risk before treatment decision-making. PATIENT SUMMARY: Outcomes after surgery confirm the accuracy of the new classification of intermediate-risk prostate cancer based on magnetic resonance imaging (MRI) staging and targeted biopsy data. We found that this new classification outperformed the standard classification in predicting biochemical recurrence of cancer for men with positive MRI findings undergoing targeted biopsies.

Performance of systematic, MRI-targeted biopsies alone or in combination for the prediction of unfavourable disease in MRI-positive low-risk prostate cancer patients eligible for active surveillance.

PURPOSE: To assess the upstaging/upgrading rates of low-risk prostate cancer (PCa) according to the biopsy scheme used (systematic (SB), targeted biopsies (TB), or both) in the setting of positive pre-biopsy MRI. PATIENTS AND METHODS: We included 143 consecutive men fulfilling the Toronto University active surveillance (AS) criteria who underwent a pre-biopsy positive MRI, a combination of SB and software-based fusion TB, and a radical prostatectomy, in two expert centres. The primary endpoints were the pathological upgrading and upstaging rates. Overall unfavourable disease (OUD) was defined by any pT3-4 and/or pN1 and/or ≥ GG 3. RESULTS: Using TB alone would have missed 21.7% of cancers including 16.7% of ≥ GG 3. The use of TB was significantly associated with a lower risk of ≥ Grade Group (GG) 3 disease (p < 0.006) in RP specimens. Combination of SB and TB lowered this risk by 39%, compared with TB alone. The biopsy scheme did not affect the upstaging rates which were substantial even in case of combination scheme (from 37 to 46%). OUD was detected in approximately 50% of cases. The presence of high grade on TB was the only independent predictive factor for both ≥ GG 2 (p = 0.015) and ≥ GG 3 (p = 0.023) in RP specimens. CONCLUSIONS: High grade on TB biopsies represented the major predictor of upgrading. Combination of SB and TB better defined the sub-group of patients having the lowest risk of reclassification, compared with TB or SB alone. The risk of non-organ-confined disease remained high, and could not be accurately predicted by MRI or systematic/targeted biopsy features.