Nerve-sparing robotic-assisted radical prostatectomy: how I do it after 15. 000 cases

ABSTRACT Introduction: Over the years, since Binder and Kramer described the first Robotic-assisted Radical Prostatectomy (RARP) in 2000, different Nerve-sparing (NS) techniques have been proposed by several authors (1). However, even with the robotic surgery advantages, functional outcomes following RARP, especially erection recovery, still challenge surgeons and patients (2, 3). In this scenario, we have described different ways and grades of neurovascular bundle preservation (NVB) using the prostatic artery as a landmark until our most recent technique with lateral prostatic fascia preservation and modified apical dissection (4-6). In this video compilation, we have illustrated the anatomical and technical details of different grades of NVB preservation. Surgical technique: After the anterior and posterior bladder neck dissection, we lift the prostate by the seminal vesicles to access the posterior aspect of the prostate. Then, we incise the Denonvilliers layers and work between an avascular plane to release the posterior NVB from 5 to 1 and 7 to 11 o'clock positions on the right and left sides, respectively6. In sequence, we access the prostate anteriorly by incising the endopelvic fascia bilaterally (close to the prostate) until communicating the anterior and posterior planes. Finally, we control the prostatic pedicles with Hem-o-lok clips and then proceed for the apical dissection preserving the maximum amount of urethra length and periurethral tissues. Considerations: Potency recovery following radical prostatectomy remains a challenge due to its multifactorial etiology. However, basic concepts for nerve-sparing are crucial to achieving optimal outcomes, such as minimizing the amount of traction used on dissection, avoiding excessive cautery, and neural preservation based on anatomical landmarks (arteries and planes of dissection).

Neurovascular bundle preservation in robotic-assisted radical prostatectomy: How I do it after 15. 000 cases

ABSTRACT Despite the neuroanatomy knowledge of the prostate described initially in the 1980's and the robotic surgery advantages in terms of operative view magnification, potency outcomes following robotic-assisted radical prostatectomy still challenge surgeons and patients due to its multifactorial etiology. Recent studies performed in our center have described that, in addition to the surgical technique, some important factors are associated with erectile dysfunction (ED) following robotic-assisted radical prostatectomy (RARP). These include preoperative Sexual Health Inventory for Men (SHIM) score, age, preoperative Gleason score, and Charlson Comorbidity Index (CCI). After performing 15,000 cases, in this article we described our current Robotic-assisted Radical Prostatectomy technique with details and considerations regarding the optimal approach to neurovascular bundle preservation.

Available evidence on HIFU for focal treatment of prostate cancer: a systematic review

ABSTRACT Purpose: Prostate cancer (PCa) is the second most common oncologic disease among men. Radical treatment with curative intent provides good oncological results for PCa survivors, although definitive therapy is associated with significant number of serious side-effects. In modern-era of medicine tissue-sparing techniques, such as focal HIFU, have been proposed for PCa patients in order to provide cancer control equivalent to the standard-of-care procedures while reducing morbidities and complications. The aim of this systematic review was to summarise the available evidence about focal HIFU therapy as a primary treatment for localized PCa. Material and methods: We conducted a comprehensive literature review of focal HIFU therapy in the MEDLINE database (PROSPERO: CRD42021235581). Articles published in the English language between 2010 and 2020 with more than 50 patients were included. Results: Clinically significant in-field recurrence and out-of-field progression were detected to 22% and 29% PCa patients, respectively. Higher ISUP grade group, more positive cores at biopsy and bilateral disease were identified as the main risk factors for disease recurrence. The most common strategy for recurrence management was definitive therapy. Six months after focal HIFU therapy 98% of patients were totally continent and 80% of patients retained sufficient erections for sexual intercourse. The majority of complications presented in the early postoperative period and were classified as low-grade. Conclusions: This review highlights that focal HIFU therapy appears to be a safe procedure, while short-term cancer control rate is encouraging. Though, second-line treatment or active surveillance seems to be necessary in a significant number of patients.

Should obesity be associated with worse urinary continence outcomes after robotic-assisted radical prostatectomy? a propensity score matching analysis

ABSTRACT Purpose: To analyze the association between obesity and urinary incontinence rate in men submitted to robot-assisted radical prostatectomy (RARP) in a high-volume cancer center. Materials and Methods: We reported 1.077 men who underwent RARP as the primary treatment for localized prostate cancer from 2013 to 2017. Patients were classified as non-obese (normal BMI or overweight) or obese men (BMI ≥30kg/m2). They were grouped according to the age, PSA level, D'Amico risk group, Gleason score, ASA classification, pathological stage, prostate volume, salvage/adjuvant radiotherapy, perioperative complications, and follow-up time. Urinary continence was defined as the use of no pads. For the analysis of long-term urinary continence recovery, we conducted a 1:1 propensity-score matching to control confounders. Results: Among the obese patients, mean BMI was 32.8kg/m2, ranging 30 - 45.7kg/m2. Only 2% was morbidly obese. Obese presented more comorbidities and larger prostates. Median follow-up time was 15 months for the obese. Complications classified as Clavien ≥3 were reported in 5.6% of the obese and in 4.4% of the non-obese men (p=0.423). Median time for continence recovery was 4 months in both groups. In this analysis, HR was 0.989 for urinary continence recovery in obese (95%CI=0.789 - 1.240; p=0.927). Conclusions: Obese can safely undergo RARP with similar continence outcomes comparing to the non-obese men when performed by surgeons with a standardized operative technique. Future studies should perform a subgroup analysis regarding the association of obesity with other comorbidities, intending to optimize patient counseling.

Pelvic lymph node dissection in high-risk prostate cancer

ABSTRACT Introduction: The therapeutic role of pelvic lymph node dissection (PLND) in prostate cancer (PCa) is unknown due to absence of randomized trials. Objective: to present a critical review on the therapeutic benefits of PLND in high risk localized PCa patients. Materials and Methods: A search of the literature on PLND was performed using PubMed, Cochrane, and Medline database. Articles obtained regarding diagnostic imaging and sentinel lymph node dissection, PLND extension, impact of PLND on survival, PLND in node positive "only" disease and PLND surgical risks were critically reviewed. Results: High-risk PCa commonly develops metastases. In these patients, the possibility of presenting lymph node disease is high. Thus, extended PLND during radical prostatectomy may be recommended in selected patients with localized high-risk PCa for both accurate staging and therapeutic intent. Although recent advances in detecting patients with lymph node involvement (LNI) with novel imaging and sentinel node dissection, extended PLND continues to be the most accurate method to stage lymph node disease, which may be related to the number of nodes removed. However, extended PLND increases surgical time, with potential impact on perioperative complications, hospital length of stay, rehospitalization and healthcare costs. Controversy persists on its therapeutic benefit, particularly in patients with high node burden. Conclusion: The impact of PLND on biochemical recurrence and PCa survival is unclear yet. Selection of patients may benefit from extended PLND but the challenge remains to identify them accurately. Only prospective randomized study would answer the precise role of PLND in high-risk pelvis confined PCa patients.

The comparison of survival between active surveillance or watchful waiting and focal therapy for low-risk prostate cancer: a real-world study from the SEER database / 亚洲男科学杂志(英文版)

To reduce treatment-related side effects in low-risk prostate cancer (PCa), both focal therapy and deferred treatments, including active surveillance (AS) and watchful waiting (WW), are worth considering over radical prostatectomy (RP). Therefore, this study aimed to compare long-term survival outcomes between focal therapy and AS/WW. Data were obtained and analyzed from the Surveillance, Epidemiology, and End Results (SEER) database. Patients with low-risk PCa who received focal therapy or AS/WW from 2010 to 2016 were included. Focal therapy included cryotherapy and laser ablation. Multivariate Cox proportional hazards models were used to compare overall mortality (OM) and cancer-specific mortality (CSM) between AS/WW and focal therapy, and propensity score matching (PSM) was performed to reduce the influence of bias and unmeasured confounders. A total of 19 292 patients with low-risk PCa were included in this study. In multivariate Cox proportional hazards model analysis, the risk of OM was higher in patients receiving focal therapy than those receiving AS/WW (hazard ratio [HR] = 1.35, 95% confidence interval [CI]: 1.02-1.79, P = 0.037), whereas no significant difference was found in CSM (HR = 0.98, 95% CI: 0.23-4.11, P = 0.977). After PSM, the OM and CSM of focal therapy and AS/WW showed no significant differences (HR = 1.26, 95% CI: 0.92-1.74, P = 0.149; and HR = 1.26, 95% CI: 0.24-6.51, P = 0.782, respectively). For patients with low-risk PCa, focal therapy was no match for AS/WW in decreasing OM, suggesting that AS/WW could bring more overall survival benefits.

Follicle-stimulating hormone (FSH) levels prior to prostatectomy are not related to long-term oncologic or cardiovascular outcomes for men with prostate cancer / 亚洲男科学杂志(英文版)

Prior research suggests a link between circulating levels of follicle-stimulating hormone (FSH) and prostate cancer outcomes. FSH levels may also explain some of the observed differences in cardiovascular events among men treated with gonadotropin-releasing hormone (GnRH) antagonists compared to GnRH agonists. This study evaluates the association between preoperative FSH and long-term cardiovascular and oncologic outcomes in a cohort of men with long follow-up after radical prostatectomy. We performed a cohort study utilizing an institutional biobank with annotated clinical data. FSH levels were measured from cryopreserved plasma and compared with sex steroids previously measured from the same samples. Differences in oncologic outcomes between tertiles of FSH levels were compared using adjusted cox regression models. Major adverse cardiovascular events (MACE) were similarly assessed using hospital admission diagnostic codes. A total of 492 patients were included, with a median follow-up of 13.1 (interquartile range: 8.9-15.9) years. Dehydroepiandrosterone sulfate (DHEA-S) levels, but not other androgens, negatively correlated with FSH levels on linear regression analysis (P = 0.03). There was no association between FSH tertile and outcomes of biochemical recurrence, time to castrate-resistant prostate cancer, or time to metastasis. MACEs were identified in 50 patients (10.2%), with a mean time to first event of 8.8 years. No association with FSH tertile and occurrence of MACE was identified. Our results do not suggest that preoperative FSH levels are significantly associated with oncologic outcomes among prostate cancer patients treated with radical prostatectomy, nor do these levels appear to be predictors of long-term cardiovascular risk.

68Ga-PSMA ligand PET/CT integrating indocyanine green-guided salvage lymph node dissection for lymph node metastasis after radical prostatectomy / 亚洲男科学杂志(英文版)

To efficiently remove all recurrent lymph nodes (rLNs) and minimize complications, we developed a combination approach that consisted of 68Gallium prostate-specific membrane antigen (PSMA) ligand positron emission tomography (PET)/computed tomography (CT) and integrated indocyanine green (ICG)-guided salvage lymph node dissection (sLND) for rLNs after radical prostatectomy (RP). Nineteen patients were enrolled to receive such treatment. 68Ga-PSMA ligand PET/CT was used to identify rLNs, and 5 mg of ICG was injected into the space between the rectum and bladder before surgery. Fluorescent laparoscopy was used to perform sLND. While extensive LN dissection was performed at level I, another 5 mg of ICG was injected via the intravenous route to intensify the fluorescent signal, and laparoscopy was introduced to intensively target stained LNs along levels I and II, specifically around suspicious LNs, with 68Ga-PSMA ligand PET/CT. Next, both lateral peritonea were exposed longitudinally to facilitate the removal of fluorescently stained LNs at levels III and IV. In total, pathological analysis confirmed that 42 nodes were rLNs. Among 145 positive LNs stained with ICG, 24 suspicious LNs identified with 68Ga-PSMA ligand PET/CT were included. The sensitivity and specificity of 68Ga-PSMA ligand PET/CT for detecting rLNs were 42.9% and 96.6%, respectively. For ICG, the sensitivity was 92.8% and the specificity was 39.1%. At a median follow-up of 15 (interquartile range [IQR]: 6-31) months, 15 patients experienced complete biochemical remission (BR, prostate-specific antigen [PSA] <0.2 ng ml-1), and 4 patients had a decline in the PSA level, but it remained >0.2 ng ml-1. Therefore, 68Ga-PSMA ligand PET/CT integrating ICG-guided sLND provides efficient sLND with few complications for patients with rLNs after RP.

Complete androgen blockade vs. medical castration alone as adjuvant androgen deprivation therapy for prostate cancer patients following radical prostatectomy: a retrospective cohort study / 中华医学杂志(英文版)

BACKGROUND@#Till date, the optimal treatment strategy for delivering adjuvant androgen deprivation therapy (ADT) in localized and locally advanced prostate cancer (PCa), as a lower stage in PCa progression compared with metastatic PCa, is still unclear. This study compares the efficacy of castration alone with complete androgen blockade (CAB) as adjuvant ADT in patients with localized and locally advanced PCa undergoing radical prostatectomy (RP).@*METHODS@#Patients diagnosed with PCa, without lymph node or distant metastasis, who received RP in West China Hospital between January 2009 and April 2019, were enrolled in this study. We performed survival, multivariable Cox proportional hazard regression, and subgroup analyses.@*RESULTS@#A total of 262 patients were enrolled, including 107 patients who received castration alone and 155 patients who received CAB. The survival analysis revealed that there was no significant difference between the two groups (hazard ratios [HR] = 1.07, 95% confidence intervals [95% CI] = 0.60-1.90, P = 0.8195). Moreover, the multivariable Cox model provided similarly negative results before and after adjustment for potential covariant. Similarly, there was no significant difference in the clinical recurrence between the two groups in both non-adjusted and adjusted models. Furthermore, our subgroup analysis showed that CAB achieved better biochemical recurrence (BCR) outcomes than medical castration alone as adjuvant ADT for locally advanced PCa (P for interaction = 0.0247, HR = 0.37, 95% CI = 0.14-1.00, P = 0.0497).@*CONCLUSION@#Combined androgen blockade achieved better BCR outcomes compared with medical castration alone as adjuvant ADT for locally advanced PCa without lymph node metastasis.

Relationship between recovery of urinary continence after laparoscopic radical prostatectomy and preoperative/postoperative membranous urethral length / 北京大学学报(医学版)

OBJECTIVE@#To evaluate the relationship between recovery of urinary continence after laparoscopic radical prostatectomy (LRP) and preoperative/postoperative membranous urethral length (MUL) on magnetic resonance imaging.@*METHODS@#We retrospectively analyzed 69 patients with pathologic confirmed prostate carcinoma who underwent laparoscopic radical prostatectomy. Preoperative MUL was defined as the distance from the apex of prostate to the level of the urethra at penile bulb on the coronal image. Postoperative MUL was defined as the distance from the bladder neck to the level of the urethra at the penile bulb on the coronal image. MUL-retained rate was defined as the percentage of postoperative MUL to preoperative MUL. All patients received extraperitoneal LRP. Patients reported freedom from using safety pad (0 pad/d) were defined as urinary continence. Multivariate Logistic regression analyses were used to identify independent predictors of early continence recovery after LRP. Kaplan-Meier analyses and log-rank test were used to compare time to continence recovery between the groups.@*RESULTS@#For all the 69 patients, the average age was (71.4±8.6) years. The prostate specific antigen before biopsy was (23.40±30.31) μg/L, and the mean preoperative prostatic volume by magnetic resonance imaging was (39.48±22.73) mL. The mean preoperative MUL was (13.0±3.3) mm, the mean postoperative MUL was (12.3±3.4) mm, and the mean MUL-retained rate was 93.9%±6.2%. The continence rate for all the patients after LRP was 57.9% and 97.1% in three months and one year, respectively. The patients achieving early continence recovery had significant smaller prostatic volume (P=0.028), longer preoperative MUL and postoperative MUL (P < 0.001). Multivariate Logistic regression analyses revealed postoperative MUL (P < 0.001) were predictors of continence recovery after LRP. Kaplan-Meier analyses and Log-rank test revealed that preoperative MUL (≥14 mm vs. < 14 mm, P < 0.001) and postoperative MUL (≥13 mm vs. < 13 mm, P < 0.001), MUL-retained rate (< 94% vs. ≥94%, P < 0.001) were all significantly associated with continence recovery.@*CONCLUSION@#Post-operative MUL was independently predictors of early continence recovery after LRP. Preoperative MUL, postoperative MUL and MUL retained rate were significantly associated with recovery of urinary continence.

Salvage Retzius sparing robotic assisted radical prostatectomy: the first brazilian experience

ABSTRACT Introduction: Salvage Radical Prostatectomy after radiation therapy is challenging and associated with high rates of serious complications (1, 2). The novel Retzius-Sparing RARP (RS-RARP) approach has shown excellent continence outcomes (3, 4). Purpose: To describe step-by-step our Salvage Retzius-Sparing RARP (sRS-RARP) operative technique and report feasibility, safety and the preliminary oncological and continence outcomes in the post-radiation scenario. Materials and Methods: Twelve males presenting local prostate cancer recurrence after radiotherapy that underwent sRS-RARP were included. All patients performed preoperative multiparametric MRI and PSMA-PET. Surgical technique: 7cm peritoneum opening at Douglas pouch, Recto-prostatic space development, Seminal vesicles and vas deferens isolation and section, Extra-fascial dissection through peri-prostatic fat, Neurovascular bundle control, Bladder neck total preservation and opening, Anterior dissection at Santorini plexus plane, Apex dissection with urethra preservation and section, Prostate release, Vesicouretral modified Van Velthoveen anastomosis, Rocco Stitch, Oncological and continence outcomes reported with minimum 1-year follow-up. Results: Ten patients had previously received external beam radiation (EBR) whereas two received previous brachytherapy plus EBR. At 1, 3 and 12 months after surgery, 25%, 75% and 91.6% of the men used one safety pad or less, respectively. No major complications or blood transfusions were reported. Final pathology reported pT2b 41.6%, pT2c 33.3% and pT3a 25%, positive surgical margins 25%, positive lymph nodes were not found, biochemical recurrence 16.6%. Conclusion: Salvage Retzius-Sparing Robotic Assisted Radical Prostatectomy approach appears to be technically feasible and oncologically safe with potential to provide better continence outcomes.

Role of salvage lymph node dissection in patients previously treated for prostate cancer: systematic review

ABSTRACT Prostate cancer is the most common invasive cancer in men. Radical prostatectomy (RP) is a definitive treatment option, but biochemical recurrence can reach 40%. Salvage lymphadenectomy is a relatively recent approach to oligometasis and has been rapidly diffused primarily due to improvement in imaging diagnosis and results showing possibly promising therapy. A systematic literature review was performed in March 2020, according to the PRISMA statement. We excluded studies with patients with suspicion or confirmation of visceral and / or bone metastases. A total of 27 articles were included in the study. All studies evaluated were single arm, and there were no randomized studies in the literature. A total of 1,714 patients received salvage lymphadenectomy after previous treatment for localized prostate cancer. RP was the most used initial therapeutic approach, and relapses were based on PET / CT diagnosis, with Coline-11C being the most widely used radiopharmaceutical. Biochemical response rates ranged from 0% to 80%. The 5 years - Free Survival Biochemical recurrence was analyzed in 16 studies with rates of 0% up to 56.1%. The articles do not present high levels of evidence to draw strong conclusions. However, even if significant rates of biochemical recurrence are not evident in all studies, therapy directed to lymph node metastases may present good oncological results and postpone the onset of systemic therapy. The long-term impact in overall survival and quality of life, as well as the best strategies for case selection remains to be determined.

Anxiety in candidates for radical prostatectomy in a university hospital

SUMMARY OBJECTIVE: Metabolic changes caused by anxiety can interfere in both the surgery itself and the recovery process. One way to reassure the patient is to clarify how the procedure will be performed and discuss the possible complications. This study aimed to investigate the anxiety level of candidates for radical prostatectomy at a university hospital. METHODS: Thirty-four patients with a diagnosis of prostate cancer were studied prospectively. Data collection involved the administration of the Hospital Anxiety and Depression Scale and a radical prostatectomy knowledge test. RESULTS: The results showed that 94.1% of the patients reported having received clarifications from the physician or healthcare team regarding the surgery and 23.5% reported having received information on the probability of a medical error during surgery. The most cited postoperative complications were sexual impotence and urinary incontinence. A significant association was found between the total Hospital Anxiety and Depression Scale score and the complications cited (p=0.0004); patients who marked a larger number of possible complications had a higher Hospital Anxiety and Depression Scale score. CONCLUSION: The present study demonstrates that the explanations given by the multidisciplinary health team are not achieving their maximum potential in terms of lowering patient anxiety.

A novel nomogram provides improved accuracy for predicting biochemical recurrence after radical prostatectomy / 中华医学杂志(英文版)

BACKGROUND@#Various prediction tools have been developed to predict biochemical recurrence (BCR) after radical prostatectomy (RP); however, few of the previous prediction tools used serum prostate-specific antigen (PSA) nadir after RP and maximum tumor diameter (MTD) at the same time. In this study, a nomogram incorporating MTD and PSA nadir was developed to predict BCR-free survival (BCRFS).@*METHODS@#A total of 337 patients who underwent RP between January 2010 and March 2017 were retrospectively enrolled in this study. The maximum diameter of the index lesion was measured on magnetic resonance imaging (MRI). Cox regression analysis was performed to evaluate independent predictors of BCR. A nomogram was subsequently developed for the prediction of BCRFS at 3 and 5 years after RP. Time-dependent receiver operating characteristic (ROC) curve and decision curve analyses were performed to identify the advantage of the new nomogram in comparison with the cancer of the prostate risk assessment post-surgical (CAPRA-S) score.@*RESULTS@#A novel nomogram was developed to predict BCR by including PSA nadir, MTD, Gleason score, surgical margin (SM), and seminal vesicle invasion (SVI), considering these variables were significantly associated with BCR in both univariate and multivariate analyses (P < 0.05). In addition, a basic model including Gleason score, SM, and SVI was developed and used as a control to assess the incremental predictive power of the new model. The concordance index of our model was slightly higher than CAPRA-S model (0.76 vs. 0.70, P = 0.02) and it was significantly higher than that of the basic model (0.76 vs. 0.66, P = 0.001). Time-dependent ROC curve and decision curve analyses also demonstrated the advantages of the new nomogram.@*CONCLUSIONS@#PSA nadir after RP and MTD based on MRI before surgery are independent predictors of BCR. By incorporating PSA nadir and MTD into the conventional predictive model, our newly developed nomogram significantly improved the accuracy in predicting BCRFS after RP.

A comparison of perioperative outcomes between extraperitoneal robotic single-port and multiport radical prostatectomy with the da Vinci Si Surgical System / 亚洲男科学杂志(英文版)

To evaluate outcomes between extraperitoneal robotic single-port radical prostatectomy (epR-spRP) and extraperitoneal robotic multiport radical prostatectomy (epR-mpRP) performed with the da Vinci Si Surgical System, comparison was performed between 30 single-port (SP group) and 26 multiport (MP group) cases. Comparisons included operative time, estimated blood loss (EBL), hospital stay, peritoneal violation, pain scores, scar satisfaction, continence, and erectile function. The median operation time and EBL were not different between the two groups. In the SP group, the median operation time of the first 10 patients was obviously longer than that of the latter 20 patients (P < 0.001). The median postoperative hospital stay in the SP group was shorter than that in the MP group (P < 0.001). The rate of peritoneal damage in the SP group was less than that in the MP group (P = 0.017). The pain score and overall need for pain medications in the SP group were lower than those in the MP group (P < 0.001 and P = 0.015, respectively). Patients in the SP group were more satisfied with their scars than those in the MP group 3 months postoperatively (P = 0.007). At 3 months, the cancer control, recovery of erectile function, and urinary continence rates were similar between the two groups. It is safe and feasible to perform epR-spRP using the da Vinci Si surgical system. Therefore, epR-spRP can be a treatment option for localized prostate cancer. Although epR-spRP still has a learning curve, it has advantages for postoperative pain and self-assessed cosmesis. In the absence of the single-port robotic surgery platform, we can still provide minimally invasive surgery for patients.

Evaluating continence recovery time after robot-assisted radical prostatectomy / 北京大学学报(医学版)

OBJECTIVE@#To evaluate urinary continence recovery time and risk factors of urinary continence recovery after robot-assisted laparoscopic radical prostatectomy (RARP).@*METHODS@#From January 2019 to January 2021, a consecutive series of patients with localized prostate cancer (cT1-T3, cN0, cM0) were prospectively collected. RARP with total anatomical reconstruction was performed in all the cases by an experienced surgeon. Lymph node dissection was performed if the patient was in high-risk group according to the D'Amico risk classification. The primary endpoint was urinary continence recovery time after catheter removal. Postoperative and pathological variables were analyzed. Continence was rigo-rously analyzed 48 hours, 1 week, 4 weeks, 12 weeks, and 24 weeks after catheter removal. Continence was evaluated by recording diaper pads used per day, and all the patients were instructed to perform the 24-hour pad weight test until full recovery of urinary continence. The patient was defined as continent if no more than one safety pad were needed per day, or no more than 20-gram urine leakage on the 24-hour pad weight test. Time from catheter removal to full recovery of urinary continence was recorded, and risk factors influencing continence recovery time evaluated.@*RESULTS@#In total, 166 patients were analyzed. The mean age of the enrolled patients was 66.2 years, and the median prostate specific antigen (PSA) was 8.51 μg/L. A total of 59 patients (35.5%) had bilateral lymphatic dissection, and 28 (16.9%) underwent neurovascular bundle (NVB) preservation surgery. Postoperative pathology results showed that stage pT1 in 1 case (0.6%), stage pT2 in 77 cases (46.4%), stage pT3 in 86 cases (51.8%), and positive margins in 28 patients (16.9%). Among patients who underwent lymph node dissection, lymph node metastasis was found in 7 cases (11.9%). Median continence recovery time was one week. The number of the continent patients at the end of 48 hours, 1 week, 4 weeks, 12 weeks, and 24 weeks were 65 (39.2%), 32 (19.3%), 34 (20.5%), 24 (14.5%), and 9 (5.4%). Two patients remained incontinent 24 weeks after catheter removal. The continence rates after catheter removal at the end of 48 hours, 1 week, 4 weeks, 12 weeks, and 24 weeks were 39.2%, 58.4%, 78.9%, 93.4%, and 98.8%, respectively. Univariate COX analysis revealed that diabetes appeared to influence continence recovery time (OR=1.589, 95%CI: 1.025-2.462, P=0.038). At the end of 48 hours, 4 weeks, 12 weeks, and 24 weeks after catheter removal, the mean OABSS score of the continent group was significantly lower than that of the incontinent group.@*CONCLUSION@#RARP showed promising results in the recovery of urinary continence. Diabetes was a risk factor influencing continence recovery time. Bladder overactive symptoms play an important role in the recovery of continence after RARP.

Relationship between prostate apex depth and early recovery of urinary continence after laparoscopic radical prostatectomy / 北京大学学报(医学版)

OBJECTIVE@#To evaluate the relationship between recovery of urinary continence after laparoscopic radical prostatectomy (LRP) and preoperative prostate apex depth (PAD) on magnetic resonance imaging (MRI).@*METHODS@#We retrospectively analyzed 184 patients with pathologic confirmed prostate carcinoma who underwent LRP in Department of Urology, Peking University Third Hospital. All the patients received MRI examination before surgery. Membranous urethral length (MUL) was defined as the distance from the apex of prostate to the level of the urethra at penile bulb on the coronal image. PAD was defined as the distance from the apex of prostate to the suprapubic ridge line on sagittal MRI. PAD ratio (PADR) was defined as PAD/pubic height. All the patients received extraperitoneal LRP. The patients' reporting freedom from using safety pad (0 pad/d) were defined as urinary continence. Univariate and multivariate regression analyses were used to identify independent predictors of early continence recovery after LRP. Kaplan-Meier analyses and log-rank test were used to compare time to continence recovery between the groups.@*RESULTS@#For all the 184 patients, the average age was (69.0±7.7) years, the ave-rage mass index(BMI) was (25.07±3.29) kg/m2, and the pre-biopsy PSA was (16.80±21.99) g/L. For all the patients who underwent MRI preoperatively, the mean PV was (39.35±25.25) mL and the mean MUL was (14.0±3.7) mm. The mean PAD was (24.52±4.97) mm and the mean PADR was 0.70±0.14. The continence rate for all the patients after LRP was 62.0% and 96.2% in three months and one year. The patients achieving early continence recovery had significant smaller PV (P=0.049), longer MUL (P < 0.001) and higher PADR (P=0.005). Multivariate analysis revealed MUL (P < 0.001) and PADR (P=0.032) were predictors of continence recovery after LRP. Kaplan-Meier analyses and Log-rank test revealed that MUL (≥14 mm vs. < 14 mm, P < 0.001) and PADR (≥0.70 vs. < 0.70, P < 0.001), PV(< 50 mL vs. ≥50 mL, P=0.001) were all significantly associated with continence recovery.@*CONCLUSION@#MUL and PADR are independent predictors of early continence recovery after LRP. MUL, PADR and PV are significantly associated with recovery of urinary continence.

Detecting and grading prostate cancer in radical prostatectomy specimens through deep learning techniques

OBJECTIVES: This study aims to evaluate the ability of deep learning algorithms to detect and grade prostate cancer (PCa) in radical prostatectomy specimens. METHODS: We selected 12 whole-slide images of radical prostatectomy specimens. These images were divided into patches, and then, analyzed and annotated. The annotated areas were categorized as follows: stroma, normal glands, and Gleason patterns 3, 4, and 5. Two analyses were performed: i) a categorical image classification method that labels each image as benign or as Gleason 3, Gleason 4, or Gleason 5, and ii) a scanning method in which distinct areas representative of benign and different Gleason patterns are delineated and labeled separately by a pathologist. The Inception v3 Convolutional Neural Network architecture was used in categorical model training, and a Mask Region-based Convolutional Neural Network was used to train the scanning method. After training, we selected three new whole-slide images that were not used during the training to evaluate the model as our test dataset. The analysis results of the images using deep learning algorithms were compared with those obtained by the pathologists. RESULTS: In the categorical classification method, the trained model obtained a validation accuracy of 94.1% during training; however, the concordance with our expert uropathologists in the test dataset was only 44%. With the image-scanning method, our model demonstrated a validation accuracy of 91.2%. When the test images were used, the concordance between the deep learning method and uropathologists was 89%. CONCLUSION: Deep learning algorithms have a high potential for use in the diagnosis and grading of PCa. Scanning methods are likely to be superior to simple classification methods.