Lymph Nodes Invasion of Marcille's Fossa Associates with High Metastatic Load in Prostate Cancer Patients Undergoing Extended Pelvic Lymph Node Dissection: The Role of "Marcillectomy".

INTRODUCTION: To assess the incidence of malignancy involvement of lymph nodes (LNs) in Marcille's fossa in patients undergoing robot assisted radical prostatectomy (RARP) and extended pelvic lymph nodes dissection (ePLND) for prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS: Between January 2014 and December 2017, details of patients who underwent RARP and ePLND were prospectively analysed. All the nodal packets were dissected separately, grouped into left and right nodes and submitted in separate packages to dedicated pathologist. RESULTS AND LIMITATIONS: Two hundred and twenty-one patients underwent ePLND and RARP in the study period. In aggregate, Marcille's LNs involvement was found in 5 (2.3%) of patients, 2 on the left side and 3 on the right side. Per cent of positive cores and Gleason at biopsy are clinical predictors of LNs invasion; moreover, in the surgical specimen, seminal vesicle invasion and high-grade cancer were factors related to loco-regional metastases. CONCLUSIONS: Marcille's nodes involvement is associated to contemporarily multiple LN metastases in other template locations in high-risk PCa patients. The Marcille's lymphadenectomy would be recommended when planning an ePLND in high-risk PCa.

Positive Association between Preoperative Total Testosterone Levels and Risk of Positive Surgical Margins by Prostate Cancer: Results in 476 Consecutive Patients Treated Only by Radical Prostatectomy.

OBJECTIVE: To evaluate preoperative total testosterone (TT) as a predictor of positive surgical margins (PSM) in prostate cancer (PCA). PATIENTS AND METHODS: During the period from November 2014 to July 2017, preoperative TT was measured in 476 PCA patients undergoing only radical prostatectomy (RP) and including all risk classes. Surgical margins were stated negative, focal positive (single and less than 1 mL), and multifocal positive (more than 1). The risk of TT and clinical factors associated with the risk of PSM (focal or multifocal versus negative) was evaluated by the multinomial logistic regression model. RESULTS: Overall, PSM were detected in 149 cases (31.3%), which included 99 patients with focal cancer invasion (20.8%) and 50 subjects with multifocal cancer invasion (10.5%). In univariate analysis, PSM associated with higher median levels of TT and prostate-specific antigen than controls. Multifocal PSM associated with higher rates of high-risk PCA (42%) than focal (22.2%) or control cases (18.3%). In multivariate analysis, TT was the only independent factor positively associated with the risk of focal PSM when compared to controls (OR 1.002; p = 0.035). TT (OR 1.003; p = 0.002) and high-risk PCA (OR 1.002; p = 0.047) were independent factors, which positively associated with the risk of multifocal PSM when compared to controls. Risk models were computed. CONCLUSIONS: In a large and contemporary cohort of patients elected to primary RP, TT was an -independent positive factor associated with the risk of focal and multifocal PSM. TT associated with aggressive PCA biology.

Inverse Association of Prostatic Chronic Inflammation among Prostate Cancer Tumor Grade Groups: Retrospective Study of 738 Consecutive Cases Elected to a First Random Biopsy Set.

OBJECTIVES: The study aimed to evaluate associations of prostatic chronic inflammation (PCI) with prostate cancer (PCA) grade groups by the International Society of Urological Pathology (ISUP). METHODS: The study evaluated retrospectively 738 cases. The patient population was sampled into 3 groups collecting cases without and with PCA including subjects with lSUP grade group 1 and grade groups 2-5. RESULTS: PCI was assessed in 185 patients (25.1%) and PCA in 361 patients (48.9%) of whom 188 (25.5%) had ISUP grade and 173 (23.4%) had ISUP groups 2-5 tumors. PCI inversely related to ISUP groups (p < 0.0001). In multivariate analysis, the risk of ISUP grade group 1 PCA compared to negative cases associated positively with age (OR 1.042; p = 0.001) but inversely with total prostate volume (TPV; OR 0.965; p < 0.0001) and PCI (OR 0.314; p < 0.0001). Intermediate-high grade tumors associated positively with age (OR 1.065; p < 0.0001), prostate specific antigen (OR 1.167; p < 0.0001), and abnormal digital rectal examination (OR 2.251; p < 0.0001) but inversely with TPV (OR 0.921; p < 0.0001) and PCI (OR 0.106; p < 0.0001). CONCLUSIONS: PCI decreased the risk of PCA among ISUP tumor grade groups.

Clinical Factors Predicting Tumour Upgrading in Patients Under Active Surveillance and Elected to Active Treatment after Disease Reclassification or Progression.

OBJECTIVES: To evaluate clinical factors associated with tumour upgrading (UPG) in low-intermediate risk patients who progressed while under active surveillance (AS) and underwent delayed radical prostatectomy. MATERIAL AND METHODS: The evaluated factors included prostate specific antigen (PSA), prostate volume, PSA density and number of biopsy positive cores (BPC). Multivariate logistic regression by the forward step Wald procedure was used. RESULTS: The study evaluated 24 patients who had UPG in 13 cases (54.2%). Independent factors associated with tumour UPG included PSA (OR 2.1; p = 0.047) and BPC (OR 2; p = 0.042). CONCLUSIONS: Clinical factors associated with UPG were identified in patients who were under AS for with low-intermediate risk disease. Preoperative PSA levels and number of BPC were independent factors associated with UPG in a contemporary cohort of patients who progressed under AS and underwent delayed active treatment.

Low-Risk Prostate Cancer and Tumor Upgrading to Higher Patterns in the Surgical Specimen. Analysis of Clinical Factors Predicting Tumor Upgrading to Higher Gleason Patterns in a Contemporary Series of Patients Who Have Been Evaluated According to the Modified Gleason Score Grading System.

OBJECTIVE: To identify clinical factors associated with prostate cancer (PCA) upgrading to higher patterns of the surgical specimen in low-risk PCA. MATERIALS AND METHODS: We evaluated the records of 438 patients. The multinomial logistic regression model was used. RESULTS: Low-risk PCA included 170 cases (38.8%) and tumor upgrading was detected in 111 patients (65.3%) of whom 72 (42.4%) had pathological Gleason patterns (pGP) = 3 + 4 and 39 (22.9%) pGP >3 + 4. Prostate-specific antigen (PSA) and proportion of positive cores (P+) were independent predictors of tumor upgrading to higher patterns. The main difference between upgraded cancers related to PSA and to P+ >0.20. The population was stratified into risk classes by PSA ≤5 µg/l and P+ ≤0.20 (class A), PSA >5 µg/l and P+ ≤0.20 (class B), PSA ≤5 µg/l and P+ >0.20 (class C) and PSA >5 µg/l and P+ 0.20 (class D). Upgrading rates to pGP >3 + 4 were extremely low in class A (5.1%), extremely high in D (53.8%). CONCLUSIONS: Low-risk PCA is a heterogeneous population with significant rates of undetected high-grade disease. Significant clinical predictors of upgrading to higher patterns include PSA and P+, which identify a very high-risk class that needs repeat biopsies in order to reclassify tumor grade.

The preoperative serum ratio of total prostate specific antigen (PSA) to free testosterone (FT), PSA/FT index ratio, and prostate cancer. Results in 220 patients undergoing radical prostatectomy.

OBJECTIVES: To evaluate associations of preoperative total prostate specific antigen (PSA) to free testosterone (FT), the PSA/FT index ratio, with features of pathology prostate cancer (PCA) and to investigate its prognostic potential in clustering the PCA population. PATIENTS AND METHODS: After excluding criteria, the records of 220 patients who underwent radical prostatectomy (RP) were retrospectively reviewed. Serum samples of PSA, total testosterone (TT) and FT were collected at 8.00 A.M., one month after biopsies and before RP. The PSA/FT ratio was computed in the population of patients who were clustered in groups according to ranking intervals of the PSA/FT ratio which identified at least 4 clusters which were coded as A, B, C, and D. The independent associations of the PSA/FT index ratio were assessed by statistical methods and a two-sided P < 0.05 was considered to indicate statistical significance. RESULTS: TT correlated to FT which was a significant predictor of PSA in the population of patients who were subsequently clustered, according to increasing interval values of the PSA/FT index ratio, in groups that showed a stronger linear association of FT with PSA. The PSA/FT index ratio significantly associated with pathology features of prostate cancer such as pathology Gleason score (pGS), invasion of the seminal vesicles (pT3b), proportion of positive cores (P+) and proportion of cancer involving the volume of the prostate. In the population of patients, TT, PSA/FT index ratio and P+ independently associated with pGS ≥ 7 and pT3b; moreover, the odds ratio (OR) of the PSA/FT index ratio resulted 9.11 which was stronger than TT (OR = 1.11) and P+ (OR = 8.84). In the PCA population, TT, PSA/FT index ratio and P+ also independently associated with pT3b PCA; interestingly, the OR of PSA/FT index resulted 54.91 which was stronger than TT (OR = 1.31) and P+ (26.43). CONCLUSIONS: Preoperative PSA/FT index ratio is an independent strong factor which directly associates with aggressive features of pathology PCA; moreover, it might express prognostic potential for clustering the patient population in risk classes. Confirmatory studies are required.

Incidental prostate cancer after transurethral resection of the prostate: analysis of incidence and risk factors in 458 patients.

BACKGROUND: The aim of this study is to evaluate the incidence and risk factors of incidental prostate cancer (IPCA) in a contemporary cohort of lower urinary tract symptoms (LUTS) patients who underwent trans-urethral resection of the prostate (TURP). METHODS: A series of 458 consecutive patients who underwent TURP were evaluated between January 2016 to June 2018. Evaluated factors included age (years), Body Mass Index (BMI; kg/square meters), treatment with inhibitors of 5-alpha reductase, previous prostate biopsies, basal prostate specific antigen (PSA) levels (ng/mL), serum leukocyte count (×109/L), weight of resected prostate tissue (grams), grade and stage of IPCA. The multivariate logistic regression model evaluated associations of significant clinical factors with the risk of IPCA. RESULTS: Overall, IPCA was detected in 30 of 454 patients (6.6%). A mean of 21.8 g of tissue was resected. The mean number of positive chips was 5.6 (mean percentage 3.9%) with tumor grade group 1 in 22 cases (73.4%) and tumor stage cT1a in 23 patients (76.7%). On multivariate analysis, independent factors that were positively associated with the risk of IPCA were BMI (odds ratio, OR=1.121; P=0.017) and leukocyte count (OR=1.144; P=0.027). CONCLUSIONS: In a contemporary cohort of patients undergoing TURP for the treatment of LUTS, the risk of IPCA was not negligible with a rate of being 6.6%. BMI and serum leukocyte count were found to be independent factors that were positively associated with the risk of IPCA.

Prostate-specific antigen levels and proportion of biopsy positive cores are independent predictors of upgrading patterns in low-risk prostate cancer.

BACKGROUND: The aim of this study is to evaluate clinical factors associated with the risk of tumor upgrading patterns in low risk prostate cancer (PCA) patients undergoing radical prostatectomy. METHODS: In a period running from January 2013 to December 2016, 245 low risk patients underwent RP. Patients were classified into three groups, which included case with pathology grade group one (no upgrading pattern), two-three (intermediate upgrading pattern), and four-five (high upgrading pattern). The association of factors with the upgrading risk was evaluated by the multinomial logistic regression model. It was used a receiver operating characteristic (ROC) curve and area under the curve (AUC) analysis to assess the efficacy of predictors. RESULTS: Overall, tumor upgrading was detected in 158 patients (67.3%). Tumor upgrading patterns were absent in 80 patients (32.7%), intermediate in 152 cases (62%) and high in 13 subjects (5.3%). Median prostate specific (PSA) levels and proportion of biopsy positive core (BPC) were higher in patients with intermediate (PSA=6 ng/mL; BPC=0.28) and high (PSA=8.9 ng/mL; BPC=0.33) than those without (PSA=5.7 ng/mL; BPC=0.17) and the difference was significant (PSA: P=0.002; BPC: P=0.001). When compared to not upgraded cases, higher BPC proportions were independent predictors of intermediate upgrading patterns (odds ratio, OR=36.711; P<0.0001; AUC=0.613) while higher PSA values were independent predictors of high upgrading patterns (OR=2.033, P<0.0001; AUC=0.779). CONCLUSIONS: PSA and BPC were both independent predictors of tumor upgrading in low risk PCA. BPC associated with the risk of intermediate tumor upgrading patterns, but showed a low discrimination power. PSA associated with high upgrading patterns and showed a fair discrimination power in the model. Tumor upgrading risk patterns should be evaluated in low risk PCA patients before treatment.

Positive Association between Preoperative Total Testosterone and Lymph Node Invasion in Intermediate Risk Prostate Cancer.

INTRODUCTION: Prostate cancer (PCa) patients who are classified into the intermediate risk category represent a heterogeneous population needing further preoperative risk assessment. OBJECTIVES: To evaluate clinical total testosterone (TT) associations with lymph node invasion (LNI) in intermediate risk PCa. MATERIAL AND METHODS: Between November 2014 and July 2016, intermediate risk PCa was assessed in 154 patients who underwent extended pelvic lymph node dissection if the risk of LNI was higher than 5%. Clinical factors associated with the risk LNI were investigated by the multinomial logistic regression model. RESULTS: The risk of LNI was assessed higher than 5% in 40.9% of cases of whom 15.5% had LNI. In the multivariate model, the risk of LNI was independently increased by prostate specific antigen (OR = 1.185; p = 0.021) and TT (OR = 1.004; p = 0.036). As a result, TT was an independent factor that associated with LNI because it increased the risk of LNI by 4% for each increment unit of TT. CONCLUSION: Preoperative TT independently increased the risk of LNI in the intermediate risk class of PCa patients elected to radical prostatectomy and extended pelvic lymph node dissection. TT might be a useful preoperative factor for stratifying intermediate risk patients because of the positive association of TT with high grade tumors.

Impact of Combination of Local Anesthetic Wounds Infiltration and Ultrasound Transversus Abdominal Plane Block in Patients Undergoing Robot-Assisted Radical Prostatectomy: Perioperative Results of a Double-Blind Randomized Controlled Trial.

OBJECTIVE: To determinate benefits of the combination of local anesthetic wounds infiltration and ultrasound transversus abdominal plane (US-TAP) block with ropivacaine on postoperative pain, early recovery, and hospital stay in patients undergoing robot-assisted radical prostatectomy (RARP). METHODS: The study is double-blinded randomized controlled trial. Our hypothesis was that the combination of wound infiltration and US-TAP block with ropivacaine would decrease immediate postoperative pain and opioids use. Primary outcomes included postoperative pain and opioids demand during the hospital stay. Secondary outcomes were nausea/vomiting rate, stool passing time, use of prokinetics, length of hospital stay (LOS), and 30-days readmission to the hospital for pain or other US-TAP block-related complications. RESULTS: A total of 100 patients who underwent RARP were eligible for the analysis; 57 received the US-TAP block with 20 mL of 0.35% ropivacaine (US-TAP block group) and 43 did not receive US-TAP block (no-US-TAP group). All the patients received the local wound anesthetic infiltration with 20 mL of 0.35% ropivacaine. US-TAP block group showed a decreased mean Numerical Rating Scale (NRS) within 12 hours after surgery (1.6 vs 2.6; p = 0.02) and mean NRS (1.8 vs 2.7; p = 0.04) with lesser number of patients who used opioid (3.5% vs 18.6%; p = 0.01) during the first 24 hours. Moreover, we found a shorter mean LOS (4.27 vs 4.72, days; p = 0.04) with a lower requirement of prokinetics administration during the hospital stay (21% vs 72%; p < 0.001). No US-TAP block-related complications were reported. CONCLUSION: Combination of anesthetic wound infiltration and US-TAP block with ropivacaine as part of a multimodal analgesic regimen can be safely offered to patients undergoing RARP and extended pelvic lymph node dissection. It improves the immediate postoperative pain control, reducing opioids administration and is associated to a decreased use of prokinetics and shorter hospital stay.

Clinical factors stratifying the risk of tumor upgrading to high-grade disease in low-risk prostate cancer.

PURPOSE: To identify clinical factors stratifying the risk of tumor upgrading to increasing patterns of the tumor grading system in low-risk prostate cancer (PCa). METHODS: We evaluated the records of 438 patients who underwent radical prostatectomy. Associations between clinical factors and tumor upgrading were assessed by the univariate and multivariate multinomial logistic regression model. RESULTS: Low-risk PCa included 170 cases (38.8%) and tumor upgrading was detected in 111 patients (65.3%): 72 (42.4%) had pathology Gleason pattern (pGP) 3 + 4, 27 (15.9%) pGP 4 + 3, and 12 (7.1%) pGP 4 + 4. Prostate- specific antigen (PSA) and proportion of positive cores (P+) were independent predictors of upgrading to high-risk disease. These factors also stratified the risk of tumor upgrading to the increasing patterns of the tumor grading system. The model allowed the identification of pGP 4 + 4. The main difference between high-risk PCa and other upgraded tumors related to PSA load (odds ratio 2.4) that associated with high volume disease in the specimen. CONCLUSIONS: Low-risk PCa is a heterogeneous population with significant rates of tumor upgrading. Significant clinical predictors stratifying the risk of tumor upgrading to increasing patterns of the grading system included PSA and P+. These factors allowed the identification of the subset hiding high-grade disease requiring further investigations before delivering active treatments.

Prostate-specific antigen associates with extensive lymph node invasion in high-risk prostate cancer.

OBJECTIVE: To evaluate clinical predictors of lymph node invasion (LNI) in patients with high-risk prostate cancer undergoing radical prostatectomy (RP) with extended pelvic lymph node dissection (ePLND). METHODS: A contemporary cohort of 116 patients, who underwent ePLND during RP, was retrospectively evaluated. Patients were classified into 3 groups including cases without LNI (group 1), with 1 to 3 positive nodes (group 2; limited LNI), and with more than 3 positive nodes (group 3; extensive LNI). The multinomial logistic regression model (multivariate analysis) evaluated the risk of LNI. RESULTS: Overall, 30 patients (25.9%) had LNI, which was limited in 17 cases (14.7%) and extensive in 13 subjects (11.2%). Median prostate-specific antigen (PSA) was higher in cases with limited (11.4 ng/mL) or extensive (23.5 ng/mL) LNI than cases without (7.3 ng/mL) and the difference was significant ( p <.0001). Median proportion of biopsy-positive cores was higher in limited (0.64) or extensive (0.54) LNI than cases without (0.34) and the difference was significant ( p < .0001). The distribution of other factors did not show any significant difference among the groups. On multivariate analysis, only higher values of PSA significantly affected the odds of extensive LNI when compared to cases without (odds ratio, 1.054; p = .005); PSA showed a fair discrimination power (area under the curve 0.792). CONCLUSION: PSA was the only independent predictor of extensive LNI and could be an important preoperative factor for stratifying high-risk patients.

Associations of Transitional Zone Volume with Intraprostatic Chronic Inflammation and Prostate Cancer Risk in Patients Undergoing a First Random Biopsy Set.

OBJECTIVES: To investigate associations of the transitional zone volume (TZV) with intraprostatic chronic inflammatory infiltrate (CII) and prostate cancer (PCa) risk in patients undergoing a first random biopsy set. MATERIALS AND METHODS: The study included a homogenous population of 596 patients. The volume of the prostate and TZV were separately measured. Independent associations were investigated by multivariate logistic regression analysis. RESULTS: The median TZV was 18 ml, CII was detected in 157 cases (26.3%), and PCa was present in 292 patients (49%). TZV was the only independent clinical factor associated with CII risk (OR = 1.014). After correcting for CII (OR = 0.276; p < 0.0001), independent factors associated with PCa risk included age (OR = 1.066), prostate specific antigen (OR = 1.177), TZV (OR = 0.919), and an abnormal digital rectal exam (OR = 2.024). CONCLUSION: In a patient population undergoing a first random prostate biopsy set because of suspected cancer, independent associations were detected among TZV, CII, and PCa. The association between TZV and CII was direct, but the relation between TZV and PCa was inverse. The measurement of the volume of the transitional zone was a useful parameter for evaluating chronic intraprostatic inflammation and PCa risk.

Preoperative Plasma Levels of Total Testosterone Associated with High Grade Pathology-Detected Prostate Cancer: Preliminary Results of a Prospective Study in a Contemporary Cohort of Patients.

OBJECTIVES: To investigate the associations, if any, between preoperative plasma levels of total testosterone (TT) and pathology Gleason score (pGS) in a contemporary cohort of prostate cancer (PCa) patients. MATERIALS AND METHODS: Between November 2014 and June 2015, plasma levels of TT were measured in 142 patients who underwent radical prostatectomy. Exclusion criteria were as follows: 5α-reductase inhibitors, LH-releasing hormone analogues, or testosterone replacement treatment. The entire cohort, assessed by continuous and categorical variables, was classified into two groups according to the pGS that included low-intermediate (pGS 6-7) and high grade (pGS > 7) cases. TT was evaluated as a continuous variable. RESULTS: The cohort included 128 cases. High grade PCa was detected in 28 (21.8%) patients. Median plasma levels of both TT and prostate specific antigen (PSA) were significantly higher in these cases. In the clinical multivariate model, independent and positive predictors of pGS > 7 were TT (p = 0.041; OR = 1.004), PSA (p = 0.006; OR = 1.191), and bGS > 6 (p = 0.004; OR = 5.0); that is, a single unit increase in TT plasma levels increases the odds of having high grade PCa by 4%. CONCLUSION: In a contemporary cohort of patients, preoperative plasma levels of TT directly and independently associated with high grade PCa. High baseline plasma levels of TT might have clinical applications for managing PCa. New and well designed prospective studies dealing with this subject are required.

Simultaneous Measurements of Follicle Stimulating Hormone and Total Testosterone and Associations in Clinically Localized Prostate Cancer.

OBJECTIVES: To evaluate the potential relations of simultaneous measurements of basal levels of follicle stimulating hormone (FSH) and total testosterone (TT) in clinically localized prostate cancer (PCa). MATERIALS AND METHODS: The study included 126 patients who had simultaneous measurements of prostate specific antigen (PSA), FSH, and TT before undergoing radical prostatectomy for clinically localized PCa. Correlations and independent associations between clinical and pathological factors were investigated by statistical methods. RESULTS: The tumor volume (TV) was directly correlated to PSA and TT which was inversely related to FSH. Moreover, it was independently associated with both PSA and TT. In a multivariate linear regression model, FSH and TV were simultaneous independent factors associated with TT, and the association was inverse in the former and direct in the latter. In the patient population, the subset with FSH levels above the third quartile was related to lower median levels of TT that were associated with high grade cancer showing a lower TV. In localized PCa, basal levels of TT were associated with tumor parameters and inversely related to FSH levels, and the subset FSH levels above the third quartile were related to lower TT levels that were associated with high grade cancers showing a lower tumor load. CONCLUSION: Preoperative TT was associated with tumor parameters and inversely related to FSH levels. Patient with increased FSH levels was related to lower levels of TT, which was associated with high grade cancer.

Robotic assisted radical prostatectomy accelerates postoperative stress recovery: Final results of a contemporary prospective study assessing pathophysiology of cortisol peri-operative kinetics in prostate cancer surgery.

OBJECTIVE: To investigate the effects of prostate cancer (PCa) surgery on the stress system and to identify potential independent factors associating with stress recovery. METHODS: The design of the study was prospective and PCa surgery included robot assisted radical prostatectomy (RARP) or retropubic radical prostatectomy (RRP). Between February 2013 to December 2014, 315 consecutive patients were evaluated. The effects of PCa surgery on the stress system were measured by cortisol serum levels before and after surgery on postoperative day (POD) 0, 1, 3, 5 and 45. Cortisol variations in the population and subpopulation (RARP vs. RRP) of patients were investigated by statistical methods. Factors associating with stress recovery were assessed by simple linear regression (SLR) and multiple linear regression (MLR) analysis. RESULTS: RARP was performed in 75.9% of cases. In the patient population, there were wide serum cortisol perioperative variations. PCa surgery triggered the stress system which immediately (POD 0) responded by cortisol overproduction which induced the negative feedback mechanism that started on POD 1, continued on POD 3, was still ongoing on POD 5 and completely settled on POD 45 (stress recovery). In the subpopulation of patients, significantly lower cortisol serum levels were detected on POD 3-5 in RARP cases in whom cortisol levels were close to preoperative levels (stress recovery) on POD 5. Independent predictive factors of serum cortisol on POD 5 (stress recovery) were preoperative cortisol (p = 0.02), cortisol levels on POD 3 (p < 0.0001) and RARP (p = 0.03) in which the association was negative (stress recovery faster than RRP). CONCLUSION: Our study shows that PCa surgery immediately (POD 0) triggers the stress system which respond by overproduction of cortisol which induces the negative feedback mechanism that starts on POD 1, is still ongoing on POD 5, but is completely settled on POD 45. Moreover, after surgical trauma, our study gives evidence that the RARP procedure associates with stress recovery faster than RRP. Further confirmatory studies are required.