Saline-assisted fascial exposure (SAFE) technique to improve nerve-sparing in robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: To provide a summary of our initial experience and assess the impact of the Saline-Assisted Fascial Exposure (SAFE) technique on erectile function (EF), urinary continence, and oncological outcomes after Robot-Assisted Laparoscopic Radical Prostatectomy (RALP). PATIENTS AND METHODS: From January 2021 to July 2022, we included patients with a baseline Sexual Health Inventory for Men (SHIM) score of ≥17 and a high probability of extracapsular extension (ECE), ranging from 21% to 73%, as per the Martini et al. nomogram. A propensity score matching was carried out at a ratio of 1:2 between patients who underwent RALP + SAFE (33) and RALP alone (66). The descriptive statistical analysis is presented. The SAFE technique was performed using two approaches, transrectal guided by micro-ultrasound or transperitoneal. Its principle entails a low-pressure injection of saline solution in the periprostatic fascia to achieve an atraumatic dissection of the neural hammock. Potency was defined as a SHIM score of ≥17 and continence as no pads per day. RESULTS: At follow-up intervals of 6, 13, 26, and 52 weeks, the SHIM score differed significantly between the two groups, favouring the RALP + SAFE (P = 0.01, P < 0.001, P < 0.001, and P = 0.01, respectively). These results remained significant when the mean SHIM score was assessed. As shown by the cumulative incidence curve, EF rates were higher in the RALP + SAFE compared to the RALP alone group (log-rank P < 0.001). The baseline SHIM and use of the SAFE technique were independent predictors of EF recovery. CONCLUSIONS: The use of the SAFE technique led to better SHIM scores at 6, 13, 26, and 52 weeks after RALP in patients at high risk of ECE who underwent a partial NS procedure.

Optimum threshold of the 4Kscore for biopsy in men with negative or indeterminate multiparametric magnetic resonance imaging.

Objective: The study aims to identify the optimal 4Kscore thresholds to determine the need for a prostate biopsy when multiparametric magnetic resonance imaging (MRI) (mpMRI) is negative or indeterminate. Materials and methods: We analysed retrospective data from men in eight different institutions who underwent an mpMRI, 4Kscore and prostate biopsy for evaluation of prostate cancer. We selected men with a negative (PIRADS ≤2) or indeterminate (PIRADS 3) mpMRI. 4Kscore values were categorized into ranges of 1-7, 8-19, 20-32 and greater than 32. We evaluated the proportion of men with grade group 2 or higher (GG2+) cancer in groups defined by PIRADS and 4Kscore. We also evaluated the number of biopsies avoided and GG2+ cancer missed in each group reported depend on 4Kscore cutoff points. Results: Among 1111 men who had an mpMRI, 4Kscore and biopsy, 625 of them had PIRADS ≤3 on mpMRI: 374 negative (PIRADS ≤2) and 251 indeterminate (PIRADS 3). In men with a negative mpMRI, we found a 4Kscore cut-point of 33 resulted in an increased risk of GG2+ cancer on biopsy. In patients with an equivocal lesion on mpMRI, men with a 4Kscore cutoff ≥8 had a greater risk of GG2+ cancer on biopsy. Decision curve analysis supported the proposed cut-points in each mpMRI group. Conclusions: In men with negative and indeterminate mpMRI, we found the best 4Kscore threshold to determine the need for biopsy to be 33 and 8 respectively. Future prospective studies in independent populations are needed to confirm these findings.

A multi-institutional study of 1,111 men with 4K score, multiparametric magnetic resonance imaging, and prostate biopsy.

OBJECTIVE: Prostate magnetic resonance imaging (MRI) and biomarkers are often used in conjunction to enhance the selection process for prostate biopsy. However, the optimal sequence of ordering these tests has not been established. A comprehensive evaluation was conducted on a large multi-institutional cohort of patients who underwent MRI, 4K score, and biopsy of the prostate to examine the impact of utilizing both tests vs. either test alone and to determine if the order in which these tests are administered affects the ability to detect clinically significant prostate cancer (csCaP). METHODS AND MATERIALS: We evaluated men from 8 different institutions who were referred for prostate cancer evaluation and underwent MRI, 4K score test, and prostate biopsy. The primary outcome was the presence of csCaP, defined as grade group 2 or higher cancer on a biopsy of the prostate. We used logistic regression, calibration plots, and decision curve analysis to evaluate using a 4K score or MRI alone vs. both tests together for detecting csCaP. In addition, we evaluated several strategies using one or both tests for selecting men for biopsy and compared them based on the proportion of biopsies avoided and the csCaP's missed. RESULTS: Among the 1,111 men who formed the final cohort, 553 (49.8%) had prostate cancer, and 353 (31.8%) had csCaP. We found that using MRI and 4K score together had better discrimination, calibration, and a higher clinical utility on decision curve analysis compared to using either test individually. Using both tests together resulted in fewer biopsies avoided and missed cancers compared to using either test alone. Strategies that sequence MRI and 4K score tests resulted in the largest biopsy reduction, with no appreciable difference between starting with an MRI vs. a biomarker. CONCLUSIONS: We found that using both an MRI and 4K score together was superior to using either test alone but found no appreciable difference between starting with an MRI vs. starting with a 4K score. Prospective studies are needed to identify the best strategy to sequence MRI and biomarkers in the evaluation of csCaP.

'Stealth' Prostate Tumors.

BACKGROUND: The aim of this study was to determine the false negative rates of prebiopsy magnetic resonance imaging (MRI) and MRI-ultrasound (US) 12-core systematic prostate biopsy (PBx) by analyzing radical prostatectomy specimens. METHODS: This retrospective study included 3600 prostate cancer (PCa) patients who underwent robot-assisted laparoscopic radical prostatectomy. Based on comparison of lobe-specific data on final pathology with preoperative biopsy and imaging data, the study population was subdivided into group I-contralateral (CL) benign PBx (n = 983), group II-CL and/or bilateral (BL) non-suspicious mpMRI (n = 2223) and group III-CL benign PBx + non-suspicious mpMRI (n = 688). This population was studied for the presence of PCa, clinically significant PCa (csPCa), extracapsular extension (ECE) (pathological stage pT3), positive frozen section and final positive surgical margin (PSM) in the CL lobe. Descriptive statistics were performed. RESULTS: In subgroups I, II and III, PCa was respectively detected in 21.5%, 37.7% and 19.5% of cases, and csPCa in 11.3%, 16.3% and 10.3% of cases. CL pT3 disease was seen in 4.5%, 4% and 5.5%, and CL surgical margins and/or frozen section analysis were positive in 6%, 7% and 5% of cases in subgroups I, II and III, respectively. CONCLUSIONS: There are still significant rates of false negatives in the standard care diagnostics of PCa. Further strategies are required to improve the accuracy of diagnosis and determination of tumor location.

Robot-assisted simple prostatectomy for prostates greater than 100 g.

PURPOSE: Efforts are ongoing to treat severe benign prostatic hyperplasia as traditional endoscopic treatment options are often difficult to perform and associated with significant complications. This manuscript highlights our initial experience of robot-assisted simple prostatectomy [RASP] with minimum a year follow-up. We also compared our outcomes with published literature. METHODS: After an Institution Review Board approval, we gathered data of 50 cases of RASP between Jan 2014 and May 2021. Patients with prostate volume > 100 cc [calculated from magnetic resonance imaging (MRI)] and prostate biopsy confirmed benign prostate were candidates for RASP. Patients underwent RASP via transperitoneal route either by suprapubic or trans-vesical approach. Preoperative demographics, peri-operative parameters and post-operative parameters such as hospital stay, catheter removal, urinary continence and uroflow were recorded in standard database and presented as descriptive statistics. RESULTS: Patients presented with a baseline median International Prostate Symptom Score (IPSS) of 23 (inter-quartile range (IQR) 21,25) and a median PSA of 7.7 ng/ml (IQR 6.4,8.7). Median preoperative prostate volume was 167 ml (IQR, 136,198 ml). Median console time was 118 min, and median estimated blood loss was 148 ml (IQR 130, 167 ml). None of our cohort needed intraoperative transfusion, conversion to open surgery or developed any complications. Median time to Foley removal was 10 days (IQR 8,12). Significant drop in the IPSS score and improvement in Qmax was noted over the period of follow-up. CONCLUSION: RASP is associated with considerable improvements in urinary symptoms. However, comparative studies with endoscopic treatment options of large prostatic adenomas are warranted and ideally include cost analysis of different procedures.

Side-specific, Microultrasound-based Nomogram for the Prediction of Extracapsular Extension in Prostate Cancer.

Background: Prediction of extracapsular extension (ECE) is essential to achieve a balance between oncologic resection and neural tissue preservation. Microultrasound (MUS) is an attractive alternative to multiparametric magnetic resonance imaging (mpMRI) in the staging scenario. Objective: To create a side-specific nomogram integrating clinicopathologic parameters and MUS findings to predict ipsilateral ECE and guide nerve sparing. Design setting and participants: Prospective data were collected from consecutive patients who underwent robotic-assisted radical prostatectomy from June 2021 to May 2022 and had preoperative MUS and mpMRI. A total of 391 patients and 612 lobes were included in the analysis. Outcome measurements and statistical analysis: ECE on surgical pathology was the primary outcome. Multivariate regression analyses were carried out to identify predictors for ECE. The resultant multivariable model's performance was visualized using the receiver-operating characteristic curve. A nomogram was developed based on the coefficients of the logit function for the MUS-based model. A decision curve analysis (DCA) was performed to assess clinical utility. Results and limitations: The areas under the receiver-operating characteristic curve (AUCs) of the MUS-based model were 81.4% and 80.9% (95% confidence interval [CI] 75.6, 84.6) after internal validation. The AUC of the mpMRI-model was also 80.9% (95% CI 77.2, 85.7). The DCA demonstrated the net clinical benefit of the MUS-based nomogram and its superiority compared with MUS and MRI alone for detecting ECE. Limitations of our study included its sample size and moderate inter-reader agreement. Conclusions: We developed a side-specific nomogram to predict ECE based on clinicopathologic variables and MUS findings. Its performance was comparable with that of a mpMRI-based model. External validation and prospective trials are required to corroborate our results. Patient summary: The integration of clinical parameters and microultrasound can predict extracapsular extension with similar results to models based on magnetic resonance imaging findings. This can be useful for tailoring the preservation of nerves during surgery.

A SelectMDx/magnetic resonance imaging-based nomogram to diagnose prostate cancer.

BACKGROUND: 70%-80% of prostate cancer (PCa) biopsies performed in the US annually may be unnecessary. Specific antigen testing (PSA) and tans rectal ultrasound (TRUS) are imprecise predictive methods for risk of PCa. Novel strategies are critical to guide biopsy decision-making. AIM: We assessed the utility and accuracy of combining Select MDx and multiparametric magnetic resonance imaging (mpMRI) scores for predicting risk of PCa. METHODS AND RESULTS: Our study was conducted at Mount Sinai hospital at Urology department in New York City from January 2020 to April 2021. Total 129 men performed select MDx test. Indications for prostate biopsy were high-risk Select MDx score, suspicious DRE, PI-RADS scores 3/4/5 on mpMRI, or any combination of these. Fifty-one percentage of 129 patients underwent systemic or combined systemic and MRI/US (ultrasound) fusion biopsy; All men underwent 3 T MRI of Prostate w/wo contrast using standard protocols prior to biopsy. A single surgeon performed prostate biopsies. Gleason score ≥3 + 3 on biopsy is defined as outcome. Descriptive statistics were calculated as cross tables. Binary logistic regression model is used to determine the outcome. The nomogram was based on the coefficients of the logit function. ROCs were plotted and decision curve analysis was performed. Using both high-risk Select MDx and PI-RADS scores of 4/5, 87% of biopsies could have been avoided, while detecting 64% of PCa and missing 36%. If biopsies were performed on men with positive Select MDx or PI-RADS 4/5 results, 16% of biopsies could have been avoided while detecting all PCa. Combining these scores improved specificity and accuracy for the detection of PCa over either used alone. Study limitations include limited sample size, sole institution study, and risk or overfitting for the proposed model which may limit generalizability. CONCLUSION: Combining SelectMDx and mpMRI PI-PADS scores of 4/5 may be useful for PCa biopsy decision-making.

Technical Tips in Managing Large Median Lobes During Robot-assisted Radical Prostatectomy.

Prostate cancer surgeons are commonly faced by a technically challenging situation dealing with prostate cancer having large median lobes. Patients with large median lobes often have larger prostates, which makes it difficult to visualize anatomical planes during robot-assisted radical prostatectomy (RARP). Herein, we described our experience in dealing with large median lobes during RARP. We have focused on technical tips to avoid complications and facilitate a smooth procedure in patients with large median lobes during RARP. A total of 2671 patients who underwent RARP were divided into two groups based on the presence or absence of a protruded median lobe (PML): group A (2411 patients without a PML) and group B (260 patients with a PML). All patients underwent preoperative magnetic resonance imaging and final intraoperative confirmation for the presence of a PML. Pre-, intra-, and postoperative parameters were compared in two groups using the Student t test and two-proportion t test as appropriate. Patients in group B have statistically significantly higher median prostate-specific antigen (PSA; 7.7 vs 5.8 ng/dl), PSA density (0.17 vs 0.09), and International Prostate Symptom Score (19.5 vs 7.2); longer median console time (114 vs 134 min) and surgery time (145 vs 170 min); and higher blood loss (150 vs 175 ml) than those in group A. There were no statistically significant differences in pathological stages (T2, T3; 87%, 13% vs 88%, 12%) and rates of positive surgical margins (7% vs 8.5%) between groups A and B. Single-center and retrospective design was the major limitation of our study. We conclude that understanding the key steps to facilitate bladder neck dissection is vital to avoid serious intraoperative events and to maximize outcomes. Patient summary: In this report, we looked at our robotic radical prostatectomy cohort with large median lobes. We found that surgery in these patients requires more time and blood loss, but similar cancer control. We conclude that following the key steps are important to avoid complications.

The Mount Sinai Prebiopsy Risk Calculator for Predicting any Prostate Cancer and Clinically Significant Prostate Cancer: Development of a Risk Predictive Tool and Validation with Advanced Neural Networking, Prostate Magnetic Resonance Imaging Outcome Database, and European Randomized Study of Screening for Prostate Cancer Risk Calculator.

Background: The European Association of Urology guidelines recommend the use of imaging, biomarkers, and risk calculators in men at risk of prostate cancer. Risk predictive calculators that combine multiparametric magnetic resonance imaging with prebiopsy variables aid as an individualized decision-making tool for patients at risk of prostate cancer, and advanced neural networking increases reliability of these tools. Objective: To develop a comprehensive risk predictive online web-based tool using magnetic resonance imaging (MRI) and clinical data, to predict the risk of any prostate cancer (PCa) and clinically significant PCa (csPCa) applicable to biopsy-naïve men, men with a prior negative biopsy, men with prior positive low-grade cancer, and men with negative MRI. Design setting and participants: Institutional review board-approved prospective data of 1902 men undergoing biopsy from October 2013 to September 2021 at Mount Sinai were collected. Outcome measurements and statistical analysis: Univariable and multivariable analyses were used to evaluate clinical variables such as age, race, digital rectal examination, family history, prostate-specific antigen (PSA), biopsy status, Prostate Imaging Reporting and Data System score, and prostate volume, which emerged as predictors for any PCa and csPCa. Binary logistic regression was performed to study the probability. Validation was performed with advanced neural networking (ANN), multi-institutional European cohort (Prostate MRI Outcome Database [PROMOD]), and European Randomized Study of Screening for Prostate Cancer Risk Calculator (ERSPC RC) 3/4. Results and limitations: Overall, 2363 biopsies had complete clinical information, with 57.98% any cancer and 31.40% csPCa. The prediction model was significantly associated with both any PCa and csPCa having an area under the curve (AUC) of 81.9% including clinical data. The AUC for external validation was calculated in PROMOD, ERSPC RC, and ANN for any PCa (0.82 vs 0.70 vs 0.90) and csPCa (0.82 vs 0.78 vs 0.92), respectively. This study is limited by its retrospective design and overestimation of csPCa in the PROMOD cohort. Conclusions: The Mount Sinai Prebiopsy Risk Calculator combines PSA, imaging and clinical data to predict the risk of any PCa and csPCa for all patient settings. With accurate validation results in a large European cohort, ERSPC RC, and ANN, it exhibits its efficiency and applicability in a more generalized population. This calculator is available online in the form of a free web-based tool that can aid clinicians in better patients counseling and treatment decision-making. Patient summary: We developed the Mount Sinai Prebiopsy Risk Calculator (MSP-RC) to assess the likelihood of any prostate cancer and clinically significant disease based on a combination of clinical and imaging characteristics. MSP-RC is applicable to all patient settings and accessible online.

Association between Incidental Pelvic Inflammation and Aggressive Prostate Cancer.

The impact of pelvic inflammation on prostate cancer (PCa) biology and aggressive phenotype has never been studied. Our study objective was to evaluate the role of pelvic inflammation on PCa aggressiveness and its association with clinical outcomes in patients following radical prostatectomy (RP). This study has been conducted on a retrospective single-institutional consecutive cohort of 2278 patients who underwent robot-assisted laparoscopic prostatectomy (RALP) between 01/2013 and 10/2019. Data from 2085 patients were analyzed to study the association between pelvic inflammation and adverse pathology (AP), defined as Gleason Grade Group (GGG) > 2 and ≥ pT3 stage, at resection. In a subset of 1997 patients, the association between pelvic inflammation and biochemical recurrence (BCR) was studied. Alteration in tumor transcriptome and inflammatory markers in patients with and without pelvic inflammation were studied using microarray analysis, immunohistochemistry, and culture supernatants derived from inflamed sites used in functional assays. Changes in blood inflammatory markers in the study cohort were analyzed by O-link. In univariate analyses, pelvic inflammation emerged as a significant predictor of AP. Multivariate cox proportional-hazards regression analyses showed that high pelvic inflammation with pT3 stage and positive surgical margins significantly affected the time to BCR (p ≤ 0.05). PCa patients with high inflammation had elevated levels of pro-inflammatory cytokines in their tissues and in blood. Genes involved in epithelial-to-mesenchymal transition (EMT) and DNA damage response were upregulated in patients with pelvic inflammation. Attenuation of STAT and IL-6 signaling decreased tumor driving properties of conditioned medium from inflamed sites. Pelvic inflammation exacerbates the progression of prostate cancer and drives an aggressive phenotype.

Robot-assisted vs ultrasonography-guided transversus abdominis plane (TAP) block vs local anaesthesia in urology: results of the UROTAP randomized trial.

OBJECTIVES: To prospectively analyse robotically administered transperitoneal transversus abdominis plane (robot-assisted transversus abdominis plane [RTAP]) compared with both ultrasonography-guided transversus abdominis plane (UTAP) and local anaesthesia (LA) with regard to pain control and narcotic use in patients undergoing robot-assisted prostatectomy (RARP) or robot-assisted partial nephrectomy (RAPN). SUBJECTS/PATIENTS AND METHODS: Patients undergoing RARP or RAPN were randomized in a single-blind 2:2:1 fashion to RTAP:UTAP:LA, with the study powered to evaluate superiority of UTAP to LA and non-inferiority of RTAP to UTAP. We compared time to deliver the block, operating room time, postoperative pain scores using the visual analogue scale, and intra-operative and postoperative analgesia consumption. RESULTS: A total of 143 patients were randomized and received treatment. There was no significant difference in patient baseline characteristics. UTAP did not demonstrate superiority to LA in terms of pain control. RTAP and LA were faster to administer than UTAP (time to perform block 2.5 vs 2.5 vs 6.25 min; P < 0.001). There was no difference in postoperative narcotic, acetaminophen, ketorolac or ondansetron requirements among the three groups (P > 0.05). The study was terminated early due to the unexpected efficacy of LA. CONCLUSION: This study showed that UTAP and RTAP do not provide superior pain control to LA. The efficiency, effectiveness, and ease of administration of LA make it an excellent option for first-line therapy for postoperative analgesia.

Prostate MRI percentage tumor involvement or "PI-RADS percent" as a predictor of adverse surgical pathology.

BACKGROUND: This study assesses magnetic resonance imaging (MRI) prostate % tumor involvement or "PI-RADs percent" as a predictor of adverse pathology (AP) after surgery for localized prostate cancer (PCa). Two separate variables, "All PI-RADS percent" (APP) and "Highest PI-RADS percent" (HPP), are defined as the volume of All PI-RADS 3-5 score lesions on MRI and the volume of the Highest PI-RADS 3-5 score lesion each divided by TPV, respectively. METHOD: An analysis was done of an IRB approved prospective cohort of 557 patients with localized PCa who had targeted biopsy of MRI PIRADs 3-5 lesions followed by RARP from April 2015 to May 2020 performed by a single surgeon at a single center. AP was defined as ISUP GGG ≥3, pT stage ≥T3 and/or LNI. Univariate and multivariable analyses were used to evaluate APP and HPP at predicting AP with other clinical variables such as Age, PSA at surgery, Race, Biopsy GGG, mpMRI ECE and mpMRI SVI. Internal and External Validation demonstrated predicted probabilities versus observed probabilities. RESULTS: AP was reported in 44.5% (n = 248) of patients. Multivariable regression showed both APP (odds ratio [OR]: 1.10, 95% confidence interval [CI]: 1.04-1.14, p = 0.0007) and HPP (OR: 1.10; 95% CI: 1.04-1.16; p = 0.0007) were significantly associated with AP with individual area under the operating curves (AUCs) of 0.6142 and 0.6229, respectively, and AUCs of 0.8129 and 0.8124 when incorporated in models including preoperative PSA and highest biopsy GGG. CONCLUSIONS: Increasing PI-RADS Percent was associated with a higher risk of AP, and both APP and HPP may have clinical utility as predictors of AP in GGG 1 and 2 patients being considered for AS. PATIENT SUMMARY: Using PIRADs percent to predict AP for presurgical patients may help risk stratification, and for low and low volume intermediate risk patients, may influence treatment decisions.

Nomogram Predicting Adverse Pathology Outcome on Radical Prostatectomy in Low-Risk Prostate Cancer Men.

OBJECTIVE: To develop and validate a prediction model to predict the risk of adverse pathology outcome on final pathology in low-risk prostate cancer (PCa) men. MATERIALS AND METHODS: This study was a monocentric retrospective analysis of 426 men who underwent radical prostatectomy (RP) for low-risk PCa. The validation cohort included 103 men from another hospital. Adverse pathology outcome was defined either by upgrading on RP Gleason Score (GS) (from GS 3+3 to GS ≥ 3+4 with Gleason pattern 4 ≥ 10%) or a non-organ confined disease (pathologic stage ≥ pT3a). Multivariable logistic regression analysis was performed to build nomogram for predicting adverse pathology outcome. Nomogram validation was performed by calculating the area under receiver operating characteristic curves (AUC) and comparing nomogram-predicted probabilities with actual rates of adverse pathology outcome in the external cohort. The Kaplan-Meier method was used to estimate and compare the biochemical recurrence-free survival rates between the two groups. RESULTS: Of 426 men in the development cohort, 45.7% showed adverse pathology outcome on RP. Age, body mass index, prostate specific antigen density, history of prior negative biopsy, magnetic resonance imaging prostate imaging reporting and data system score 4-5 and percentage of positive biopsies were significant predictors in multivariate analysis. A nomogram was constructed with an area under curve of 87%. There was agreement between predicted and actual rates of adverse pathology outcome in the validation cohort. The 5-year biochemical recurrence-free survival rates in patients with and without adverse pathology outcome was 70% and 98%, respectively. CONCLUSION: This novel nomogram would help identify low-risk PCa men at risk of adverse pathology outcome and can be relevant for treatment decision-making.

Development and External Validation of a Prediction Model to Identify Candidates for Prostate Biopsy.

PURPOSE: Prostate biopsies are associated with infectious complications and approximately 80% are either benign or clinically insignificant prostate cancer. Our aim is to develop and independently validate prediction model to avoid unnecessary prostate biopsies by predicting clinically significant prostate cancer (csPCa) Materials and Methods: Retrospective analysis of single-center cohort (Mount Sinai Hospital, NY) of 1632 men who underwent systematic or combined systematic and Magnetic Resonance Imaging (MRI)/ultrasound fusion targeted prostate biopsy between 2014-2020. External cohort (University of Miami) included 622 men that underwent biopsy. Outcome for predicting csPCa was defined as International Society of Urologic Pathology (ISUP) Gleason grade ≥ 2 on biopsy. Multivariable logistic regression analysis was performed to build nomogram using coefficients of logit function. Nomogram validation was performed in external cohort by plotting receiver operating characteristics (ROC). We also plotted decision curve analysis (DCA) and compared nomogram-predicted probabilities with actual rates of csPCa probabilities in external cohort. RESULTS: Of 1632 men, 43% showed csPCa on biopsy. PSA density, prior negative biopsy, and Prostate Imaging and Reporting Data System (PI-RADS) scores 3, 4, and 5 were significant predictors for csPCa. ROC for prediction of csPCa was 0.88 in external cohort. There was agreement between predicted and actual rate of csPCa in external cohort. DCA demonstrated net benefit using the model. Using the prediction model at threshold of 30, 35% of biopsies and 46% of diagnosed indolent PCa could be avoided, while missing 5% of csPCa. CONCLUSION: Using our prediction model can help reduce unnecessary prostate biopsies with minimal impact on csPCa detection rates.

Current strategies to improve erectile function in patients undergoing radical prostatectomy - preoperative scenario.

Radical prostatectomy (RP) is a common procedure for localized and locally advanced prostate cancer (PCa). Despite advances in the technique with the introduction of robotic surgery, erectile dysfunction (ED) remains a major drawback. Therefore, a personalized evaluation that considers the patient's expectations and cultural background, baseline erectile function (EF), health status, and tumoral extension is important to optimize outcomes. Since EF has a tremendous impact on the quality of life of the patient and the intimate partner, it is timely to review multidisciplinary approaches to be implemented in the preoperative setting. Here we propose various strategies divided into two main categories, namely, comprehensive preoperative planning and prehabilitation (Figure 1.).

Current strategies to improve erectile function in patients undergoing radical prostatectomy - postoperative scenario.

In order to optimize functional outcomes following radical prostatectomy (RP), early rehabilitation programs should be stablished in the clinical practice. A multidisciplinary approach to assess the patient's mental, physical and social well-being are as important as the implementation of pharmacological and mechanical interventions. In current article of the seminar, we focus on strategies to improve erectile function (EF) after surgery. These strategies have been grouped into 4 main categories: pharmacologic and mechanical interventions, psychosocial interventions, hormonal assessment and a final section dedicated to strategies under research.

Current strategies to improve erectile function in patients undergoing radical prostatectomy-intraoperative scenario.

Results after radical prostatectomy (RP) are generally judged by complete removal of the cancer, return of urinary control, and the ability to have intercourse. Given the complexity of the anatomy of the prostate and its relationship to the surrounding nerves, muscles, and fascia, RP is considered a challenging and technically demanding surgery. Here we propose multiple intraoperative strategies to optimize oncological and functional outcomes.

The Role of 3D Models Obtained from Multiparametric Prostate MRI in Performing Robotic Prostatectomy.

Background: Multiparametric prostate MRI (mpMRI) can provide important information for surgical planning, yet its interpretation is not immediate and imaging consultation at the time of surgery can result in interruptions and delay. The use of three-dimensional (3D) models based on mpMRI might obviate these issues. We aimed to evaluate the role of the prospective integration of 3D models from mpMRI in the robotic console in reducing the rate of positive surgical margins (PSMs). Materials and Methods: PSMs at our center are evaluated intraoperatively using the Neurovascular Structure Adjacent Frozen Section Examination method. Based on the rate of PSMs on frozen section during the year before the implementation of 3D models during surgery (22.5%), we estimated that 151 subjects were needed to detect a statistically significant difference of at least 40%. Patients with biopsy-proven prostate cancer (PCa) who received a 3T mpMRI at our institution and had a PIRADS ≥3 on mpMRI were included. Results: One hundred fifty-one patients were included. Overall, 17 (11.3%) patients had a PSM, 6 (35%) of them had PSM in an area where the mpMRI did not demonstrate any lesions. The rates of PSMs on both frozen (22.5% vs 11.3%) and permanent section (13.1% vs 6.6%) were significantly lower (p ≤ 0.03) compared with the cohort of patients operated during 2018 (n = 358). No significant differences among clinical characteristics were found between the study cohort and the 2018 cohort (all p > 0.05). Conclusions: The use of 3D models at the time of surgery was shown to reduce the PSM rate on both frozen and permanent section. Integrating 3D models in the robotic console could lead to improved PCa outcomes.

Technical advances in nerve-sparing and continence preservation.

PURPOSE OF REVIEW: Urinary incontinence and erectile dysfunction are common after radical prostatectomy. These side effects greatly impact patients' quality of life. Therefore, surgical techniques and technology tools are constantly being developed to optimize trifecta outcomes. Here we focus on advances in nerve-sparing (NS) and continence preservation. RECENT FINDINGS: New surgical techniques dedicated to preservation rather than reconstruction have been developed to improve urinary continence (UC) and NS. On the other hand, intraoperative assessment of prostatic and periprostatic structures has shown promising outcomes toward NS whereas avoiding omission of extracapsular extension (ECE). Likewise, neural regeneration strategies are under research to improve return of erectile function and UC. SUMMARY: Superb outcomes after Robot-Assisted Radical Prostatectomy require a proper balance between NS and risk of ECE. Detailed anatomic knowledge together with an accurate surgical planning are cornerstone for tailoring the approach in each case.

Clinical Utility of Negative Multiparametric Magnetic Resonance Imaging in the Diagnosis of Prostate Cancer and Clinically Significant Prostate Cancer.

BACKGROUND: Multiparametric magnetic resonance imaging (MRI) is increasingly used to diagnose prostate cancer (PCa). It is not yet established whether all men with negative MRI (Prostate Imaging-Reporting and Data System version 2 score <3) should undergo prostate biopsy or not. OBJECTIVE: To develop and validate a prediction model that uses clinical parameters to reduce unnecessary prostate biopsies by predicting PCa and clinically significant PCa (csPCa) for men with negative MRI findings who are at risk of harboring PCa. DESIGN SETTING AND PARTICIPANTS: This was a retrospective analysis of 200 men with negative MRI at risk of PCa who underwent prostate biopsy (2014-2020) with prostate-specific antigen (PSA) >4 ng/ml, 4Kscore of >7%, PSA density ≥0.15 ng/ml/cm3, and/or suspicious digital rectal examination. The validation cohort included 182 men from another centre (University of Miami) with negative MRI who underwent systematic prostate biopsy with the same criteria. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: csPCa was defined as Gleason grade group ≥2 on biopsy. Multivariable logistic regression analysis was performed using coefficients of logit function for predicting PCa and csPCa. Nomogram validation was performed by calculating the area under receiver operating characteristic curves (AUC) and comparing nomogram-predicted probabilities with actual rates of PCa and csPCa. RESULTS AND LIMITATIONS: Of 200 men in the development cohort, 18% showed PCa and 8% showed csPCa on biopsy. Of 182 men in the validation cohort, 21% showed PCa and 6% showed csPCa on biopsy. PSA density, 4Kscore, and family history of PCa were significant predictors for PCa and csPCa. The AUC was 0.80 and 0.87 for prediction of PCa and csPCa, respectively. There was agreement between predicted and actual rates of PCa in the validation cohort. Using the prediction model at threshold of 40, 47% of benign biopsies and 15% of indolent PCa cases diagnosed could be avoided, while missing 10% of csPCa cases. The small sample size and number of events are limitations of the study. CONCLUSIONS: Our prediction model can reduce the number of prostate biopsies among men with negative MRI without compromising the detection of csPCa. PATIENT SUMMARY: We developed a tool for selection of men with negative MRI (magnetic resonance imaging) findings for prostate cancer who should undergo prostate biopsy. This risk prediction tool safely reduces the number of men who need to undergo the procedure.