Comparison of Four Validated Nomograms (Memorial Sloan Kettering Cancer Center, Briganti 2012, 2017, and 2019) Predicting Lymph Node Invasion in Patients with High-Risk Prostate Cancer Candidates for Radical Prostatectomy and Extended Pelvic Lymph Node Dissection: Clinical Experience and Review of the Literature.

BACKGROUND: The indication for extended pelvic lymph node dissection (ePLND) at the time of radical prostatectomy (RP) is based on nomograms predicting the risk of lymph node invasion (LNI). However, limited data are available on the comparison of these predictive models in high-risk prostate cancer (PC) patients. Therefore, we compared the accuracy of the most used nomograms (MSKCC, Briganti 2012, 2017, and 2019) in the setting of high-risk PC patients submitted to ePLND. METHODS: 150 patients with high-risk PC disease treated from 2019 to 2022 were included. Before RP + ePLND, we assessed the MSKCC, Briganti 2012, 2017, and 2019 nomograms for each patient, and we compared the prediction of LNI with the final histopathological analysis of the ePLND using pathologic results as a reference. RESULTS: LNI was found in 39 patients (26%), and 71.3% were cT2. The percentage of patients with estimated LNI risk above the cut-off was significantly higher in pN+ cases than in pN0 for all Briganti nomograms. The percentage of patients at risk of LNI, according to Briganti Nomogram (2012, 2017, and 2019), was significantly higher in pN+ cases than in pN0 (p < 0.04), while MSKCC prediction didn't vary significantly between pN0 and pN+ groups (p = 0.2). All nomograms showed high sensitivity (Se > 0.90), low specificity (Sp < 0.20), and similar AUC (range: 0.526-0.573) in predicting pN+. Particularly, 74% of cases patients with MSKCC estimated risk > 7% showed pN0 compared to 71% with Briganti 2012 > 5%, 69% with Briganti 2017 > 7%, and 70% with Briganti 2019 > 7%. CONCLUSIONS: Despite the high-risk disease, in our patients treated with ePLND emerges a still high number of pN0 cases and a similar low specificity of nomograms in predicting LNI.

Influence of operative time and blood loss on surgical margins and functional outcomes for laparoscopic versus robotic-assisted radical prostatectomy: a prospective analysis.

INTRODUCTION: The aim of this article was to analyze whether operative time and blood loss during radical prostatectomy (RP) can significantly influence surgical margins (SM) status and post-operative functional outcomes. MATERIAL AND METHODS: We prospectively analyzed prostate cancer (PC) patients undergoing RP, using robot-assisted (RARP) or laparoscopic (LRP) procedures. Blood loss was defined using the variation in hemoglobin (Hb, g/dl) values from the day before surgery and no later than 4 hours after surgery. RESULTS: From a whole population of 413 cases considered for RP, 67% underwent LRP and 33.0% RARP. Positive SM (SM+) were found in 33.9% of cases. Mean surgical operative time was 172.3 ±76 min (range 49-485), whereas blood loss was 2.3 ±1.2 g/dl (range 0.3-7.6). Operative time and blood loss at RP were not significantly correlated (r = -0.028275; p = 0.684). SM+ rates significantly (p = 0.002) varied by operative time; a higher SM+ rate was found in cases with an operative time <120 min (41.2%) and >240 min (53.4%). The risk of SM+ significantly increased 1.70 and 1.94 times in cases with an operative time <120 min and >240 min, respectively, independently to the surgical approach. The rate of erectile disfunction (ED) varied from 22.4% to 60.3% between <120 min and >240 min procedures (p = 0.001). According to blood loss, SM+ rates slightly but significantly (p = 0.032) varied; a higher rate of SM+ was found in cases with a Hb variation between 2-4 g/dl (35.9%). CONCLUSIONS: Independently to the surgical approach, operative time, more than blood loss at RP, represents a significant variable able to influence SM status and post-operative ED.

Removing the urinary catheter on post-operative day 2 after robot-assisted laparoscopic radical prostatectomy: a feasibility study from a single high-volume referral centre.

The indwelling urinary catheter (UC) is a significant bother for men after radical prostatectomy (RP) and should be removed as soon as possible without jeopardizing the outcome. Our aim was to assess the feasibility and safety of its removal on postoperative day (POD) 2 after robot-assisted laparoscopic RP (RALP). A consecutive series of patients undergoing RALP for localized prostate cancer (PCa) were prospectively enrolled. Inclusion criteria were: no bladder-neck reconstruction, watertight urethrovesical anastomosis at 150 ml filling, ≤ 200 ml of intraoperative bleeding, ≤ 80 ml of fluid from the drain on POD 1, clear urine from the UC on POD 2. Patients were discharged on POD 2. Continence was assessed at catheter removal and 1, 3 and 6 months after surgery. Urethrovesical anastomosis was performed with a standard technique on 3 layers. Sixty-six patients were enrolled. The UC was removed on POD 2 in all the cases and 96.4% of the patients were discharged on POD 2. Re-catheterization was needed 16 times and it was always performed easily. Twenty-four complications were reported by 20 patients, mostly Clavien-Dindo (CD) grade II; 2 CD IIIB complications were observed. No anastomotic strictures were diagnosed. At catheter removal, 29% of the patients were completely continent, 41% at 1 month, 67% at 3 months and 92% at 6 months. In selected patients, removing the UC 48 h after RALP is feasible and safe and has no negative impact on continence if compared with the best international standards.

Prostate-specific Antigen Density Is a Good Predictor of Upstaging and Upgrading, According to the New Grading System: The Keys We Are Seeking May Be Already in Our Pocket.

OBJECTIVE: To analyze the performance of prostate-specific antigen density (PSAD) as a predictor of upstaging and prognostic grade group (PGG) upgrading. MATERIALS AND METHODS: We retrospectively evaluated data on men with prostate cancer (PCa) treated with robot-assisted laparoscopic radical prostatectomy (RALP) at our center in 2014-2015. Preoperative PSAD was calculated. Bioptic and pathologic PGGs were also considered in the analysis. We defined upgrading as any increase in PGG after RALP; upstaging was the pathologic diagnosis of a clinically unsuspected stage ≥3a PCa. RESULTS: Data on 379 patients were analyzed. Upgrading was found in 41.4% of the patients; 29% of the patients were upstaged. On multivariable analysis, core involvement and PSAD were found to be predictors of upgrading (odds ratio [OR] 1.017, 95% confidence interval [CI] 1.001-1.034, P = .039; and OR 3.638, 95% CI 1.084-12.207, P = .001, respectively). Furthermore, core involvement and PSAD were predictors of upstaging (OR 1.020, 95% CI 1.020-1.034, P = .003; and OR 5.656, 95% CI 1.285-24.894, P = .022, respectively). PSAD showed areas under the curve of 0.712 (95% CI 0.645-0.780, P = .000) and 0.628 (95% CI 0.566-0.689, P = .000) for the prediction of upgrading and upstaging, respectively. In a subpopulation of 90 patients theoretically eligible for active surveillance, 14% were found upstaged and 17% were upgraded. PSAD showed areas under the curve of 0.894 (95% CI 0.808-0.97, P = .000) and 0.689 (95% CI 0.539-0.840, P = .021) for the prediction of upgrading and upstaging, respectively. CONCLUSION: PSAD is a valuable predictor of upgrading and upstaging in men with PCa who were candidates for surgery and is accurate in selecting patients for AS.

Monopolar Transurethral Enucleation of Prostatic Adenoma: Preliminary Report.

OBJECTIVE: To describe preliminary results of our monopolar transurethral enucleation of prostatic adenoma (mTUEPA). MATERIALS AND METHODS: A consecutive series of male patients treated with mTUEPA, a retrograde enucleation of the prostatic adenoma performed by means of a standard monopolar resectoscope, were prospectively enrolled. Symptoms, uroflowmetry parameters, and post-voiding residual were assessed at baseline and at 1, 6, and 12 months postoperatively. Prostate volume was evaluated at baseline by means of transrectal ultrasound. Antiplatelet and anticoagulant drugs were stopped at least 1 week before the operation. RESULTS: Forty-seven patients were enrolled. Mean preoperative prostate volume was 64.9 ± 28.5 g. When assessed at baseline, the mean total International Prostatic Symptoms Score was 15.2 ± 3.9, peak flow rate (Qmax) was 8.4 ± 2.9 mL/s and the post-voiding residual was 103.2 ± 90.6 mL. Four weeks after surgery, patients reported a mean International Prostatic Symptoms Score of 5.3 ± 3. This lower urinary tract symptoms relief was further maintained at 6 and 12 months after surgery. A significant postoperative improvement in uroflowmetry parameters was described, being the 6 and 12 months mean Qmax of 23.4 ± 10.6 mL/s and 18.8 ± 9.2 mL/s, respectively (P < .001). Overall, 14 postoperative complications were reported by 13 of 47 (27.6%) patients: most of them were minor complications (Clavien-Dindo Grade I-II), whereas 1 patient reported capsule perforation during surgery, requiring interruption of the procedure and its further completion (Clavien-Dindo IIIb). CONCLUSION: mTUEPA is a safe and effective technique, merging the principles of laser enucleation and the advantages of mechanical enucleation with standard monopolar transurethral resection of the prostate equipment.

The learning curve for laparoscopic radical prostatectomy: an international multicenter study.

PURPOSE: It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy. MATERIALS AND METHODS: We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation. RESULTS: Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve. CONCLUSIONS: The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.

Intraoperative frozen section in laparoscopic radical prostatectomy: impact on cancer control.

BACKGROUND: Intraoperative Frozen Section (IFS) with further tissue resection in case of positive margins has been proposed to decrease positive surgical margins rate during radical prostatectomy. There are a few reports on the benefits of this potential reduction of positive margins (PSM). OBJECTIVE: The aim of this study is to assess the oncological advantages of PSM rate reduction with the use of IFS and additional tissue excision in case of PSM. DESIGN, SETTING AND PARTECIPANTS: 270 patients undergoing laparoscopic radical prostatectomy were included in a prospective study, to evaluate the results of further tissue excision in case of PSM at IFS. Median age was 65 yrs. Median PSA was 7.0 ng/ml. INTERVENTION: The prostate was extracted during the operation. IFS was performed in all patients on the prostate surface, at the base, the apex and along the postero-lateral aspect of the gland. In case of PSM additional tissue was excised from the site of the prostatic bed corresponding to the surgical margin. MEASUREMENTS: Endpoint was biochemical recurrence-free survival. RESULTS AND LIMITATIONS: PSM were found in 67 patients (24.8%). With additional tissue resection, PSM rate dropped from 24.8% to 12.6%. Decreased PSM after further resection didn't improve biochemical-free survival. Patients with initial PSM at IFS rendered negative with further resection, had similar results if compared to patients with margins still positive, and worse results if compared to patients with negative margins (NSM). Biochemical recurrence rate was 2.95% at 58 months in 203 patients with NSM, 15.1% at 54 months in 33 patients with PSM at IFS that were rendered negative after further resection, and 11.7% at 67 months in 34 patients with still PSM after additional resection. These results were confirmed also according to: stage, nerve-sparing procedure, Gleason score. CONCLUSIONS: Our data don't support IFS during radical prostatectomy to improve biochemical-free survival.

A new technique for laparoscopic vesicourethral anastomosis: preliminary report.

OBJECTIVES: To introduce a new and easy technique to perform laparoscopic vesicourethral anastomosis with a single-suture, single-knot, running procedure. METHODS: We have performed 350 laparoscopic radical prostatectomies. In a prospective study, we evaluated a new anastomosis technique in 50 consecutive cases. A multiple knot is prepared at 4 cm from the end of a suture. Then the running suture is started at the bladder neck at 4 o'clock. The posterior plate is maintained open for the first throws, and the suture is pulled only after the third passage at the bladder neck. Then the running suture is completed clockwise and finally tied to the 4-cm tail. RESULTS: Use of this technique in 50 patients was compared with use of a double running suture in 50 other patients. The 2 groups were comparable. The new procedure was related to a decreased anastomotic time, without complications, with no leak at catheter removal at postoperative day 5 or 6. CONCLUSIONS: The experience with this original anastomosis is still preliminary, but the results are very promising, and we would like to propose it to laparoscopic urologists.

Bladder-sparing therapy for muscle-infiltrating bladder cancer.

Radical cystectomy is the treatment of choice for nonmetastatic, muscle-infiltrating bladder cancer. Several researchers have proposed the use of a bladder-sparing approach in carefully selected patients. Strict selection criteria and close follow-up are needed for bladder-preservation protocols. Although repeated transurethral resection of bladder tumors or partial cystectomy might be offered to high-risk patients, combined protocols with transurethral resection of bladder tumors and chemotherapy, with or without additional radiotherapy, seem to provide the best results, with 5-year survival rates of about 50%. Even if the chance of preserving the bladder is appealing, and despite evidence of some promising results, these protocols should still be considered investigative because, as yet, there are no randomized trials available that compare cystectomy with bladder-sparing surgery.

Contribution of the MR spectroscopic imaging in the diagnosis of prostate cancer in the peripheral zone.

PURPOSE: To establish the additional value of 3D magnetic resonance spectroscopy (3D-MRS) imaging to endorectal MR imaging in the diagnosis of prostrate cancer in the peripheral zone. MATERIALS AND METHODS: MR imaging and MRS imaging were performed in 79 patients with suspicion of prostate cancer on the basis of digital rectal exploration, transrectal ultrasound and PSA level. All the examinations were performed with 1.5 T MR scan using an endorectal coil (transverse and coronal FSE T2-weighted sequences, axial SE T1-weighted and PRESS 3D CSI). MR examinations have been evaluated by two Radiologists blind of the clinical data in a "per patients" analysis. MR imaging and MRS imaging findings were compared with the result of histological data from radical prostatectomy in 53 patients and biopsy in 17 patients. RESULTS: Nine patients (11.4%) were excluded because of serious artefacts in the MR spectrum. The reported values of sensitivity, specificity, PPV and NPV for MR imaging alone were respectively 84%, 50%, 76% and 63% (LR+ 1.7; LR- 0.3). Instead the reported values of sensitivity, specificity, PPV and NPV for the combination of MR imaging to MRS imaging were respectively 89%, 79%, 89% and 79% (LR+ 4.28; LR- 0.14). We found an incremental benefit of MRS imaging to MR imaging for tumour diagnosis although these results did not show statistically significant differences. CONCLUSIONS: The MRS imaging improves the accuracy of the endorectal MR imaging in the diagnosis of prostate cancer.

The incidence of prostate cancer in men with prostate specific antigen greater than 4.0 ng/ml: a randomized study of 6 versus 12 core transperineal prostate biopsy.

PURPOSE: The prostate cancer detection rate in patients with elevated prostate specific antigen (PSA) increases with extended needle biopsy protocols. Transperineal biopsy under transrectal ultrasound guidance is rarely reported, although notable cancer diagnoses are obtained with this technique. We describe the results of 6 and 12 core transperineal biopsy. MATERIALS AND METHODS: A total of 214 patients with PSA greater than 4.0 ng/ml were prospectively randomized to undergo 6 or 12 core transperineal biopsy. Each group of 107 patients was comparable in terms of clinical characteristics. The procedure was performed on an outpatient basis using local anesthesia. Specimens were obtained with a fan technique with 2 puncture sites slightly above the rectum (1 per lobe) under transrectal ultrasound guidance. Cores were taken from all peripheral areas, including the far lateral aspect of the prostate. RESULTS: The overall cancer detection rate was 38% and 51% for 6 and 12 core biopsy, respectively. In patients with PSA between 4.1 and 10 ng/ml the cancer detection rate was 30% and 49% for 6 and 12 core biopsy, respectively. CONCLUSIONS: The 12 core transperineal prostate biopsy is superior to 6 core biopsy. The technique provides optimal prostate cancer diagnosis. About half of the patients with PSA greater than 4.0 ng/ml and a slightly lower percent with PSA between 4.1 and 10 ng/ml have prostate cancer.

Prostate cancer: evaluation with endorectal MR imaging and three-dimensional proton MR spectroscopic imaging.

PURPOSE: To establish the additional value of MR Spectroscopy (3D CSI MRS Three-dimensional Chemical Shift Imaging Magnetic Resonance Spectroscopy) to endorectal MR in the diagnosis and grading of prostate cancer. MATERIALS AND METHODS: MR and 3D CSI MR spectroscopy were performed in 53 patients with suspicion of prostate cancer on the basis of rectal exploration and/or transrectal ultrasound and/or the PSA levels. All the examinations were performed with a 1.5 T imager using an endorectal coil. We acquired axial and coronal T2-weighted FSE sequences, axial T1-weighted SE sequences and PRESS 3D CSI (Point Resolved Spectroscopy 3D Chemical Shift Imaging) sequences localized on the axial T2 images so as to include the prostatic gland while excluding the periprostatic fat. The MR examinations were evaluated by two radiologists unaware of the clinical data, transrectal ultrasound findings, PSA levels and histological findings. The MR and 3D CSI MRS findings were compared with the biopsy findings in 22 cases and with material obtained from laparoscopic prostatectomy in 31 cases. RESULTS: The histological examination revealed adenocarcinoma in 37 cases, prostatitis in 2 cases and no alterations in the remaining 14 cases. The morphologic MR scan showed a sensitivity of 76%, a specificity of 56%, an accuracy of 70%, a PPV of 80% and a NPV of 50%. By combining MR and 3D CSI MRS we obtained a sensitivity of 95%, a specificity of 81%, an accuracy of 91%, a PPV of 92% and a NPV of 87%. Elevated choline concentrations were found both in tumours with a low Gleason score (18 cases) and in those with a high Gleason score (19 cases); instead we found markedly reduced (n=9) or absent (n=4) citrate only in the tumours with a high Gleason score, while we found normal citrate levels in the 18 tumours with a low Gleason score. CONCLUSIONS: The 3D CSI MRS improved the reliability of endorectal MR in the diagnosis and characterisation of prostatic cancer. Moreover, the 3D CSI MRS findings demonstrated a linear correlation with tumour grade.

Buccal mucosa urethroplasty in the treatment of bulbar urethral strictures.

OBJECTIVES: To report our 8-year experience with buccal mucosa onlay urethroplasty with the dorsal approach in the treatment of bulbar urethral strictures. The buccal mucosal graft is widely used as an effective option for urethral reconstruction. METHODS: Since June 1994, we have treated 65 patients with bulbar urethral strictures with buccal mucosa urethroplasty. A free graft of buccal mucosa was used as a ventral onlay in 9 patients and as a dorsal onlay in the remaining 56 patients. The bulbar urethra was isolated from the corpora. Endoscopic urethrotomy was performed dorsally. The graft was obtained from the lower lip and sutured to the urethra and corpora cavernosa. A transurethral grooved catheter and suprapubic drainage was maintained for 7 and 14 days, respectively. RESULTS: The median follow-up was 41 months (range 6 to 94). The overall recurrence rate was 3% (2 of 65). One recurrence occurred in a ventral onlay patient and one in a dorsal onlay patient. Minor complications occurred in 9 patients (14%). CONCLUSIONS: Buccal mucosa dorsal onlay urethroplasty is an excellent option for the treatment of bulbar urethral strictures.

Can patient selection for bladder preservation be based on response to chemotherapy?

BACKGROUND: Neoadjuvant chemotherapy for patients with muscle-invasive bladder carcinoma is given to treat micrometastases and to preserve the bladder. The objective of this study was to evaluate the possibility of bladder preservation in patients with muscle-invasive bladder carcinoma who were treated with neoadjuvant methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) chemotherapy. METHODS: One hundred four consecutive patients with T2-T4,N0,M0 transitional cell carcinoma of the bladder were treated with 3 cycles of neoadjuvant M-VAC chemotherapy. After clinical restaging, 52 patients underwent transurethral resection of the bladder (TURB) alone, 13 patients underwent partial cystectomy, and 39 patients underwent radical cystectomy. RESULTS: The median survival for the entire group was 7.49 years (95% confidence interval, 4.86-10.0 years). Forty-nine patients (49%) were T0 at the time of TURB after receiving M-VAC. Thirty-one of 52 patients (60%) who received chemotherapy and underwent TURB alone were alive at a median follow-up of 56 + months (range, 10-160 + months): Twenty-three patients (44%) in that TURB group maintained an intact bladder. Of 13 responding patients with monofocal lesions who underwent partial cystectomy, only 1 patient required salvage cystectomy, and survival generally was good. The 5-year survival rate for this group was 69%. With a long median follow-up of 88 + months (range, 16-158 months), 4 patients (31%) were alive with a functioning bladder. In the radical cystectomy group, the median follow-up was 45 months (range, 4-172 + months), and 15 of 39 patients (38%) patients remained alive. In 77 patients who had their tumors down-staged to T0 or superficial disease, the median follow-up was 63 months (range, 4-172 + months), and the 5-year rate survival was 69%. This is in contrast to a 5-year survival rate of only 26% in 27 patients who failed to respond and had a status >/= T2 after receiving chemotherapy (median follow-up, 31 months; range, 7-156 + months). The median survival for 27 elderly patients (age >/= 70 years; median age, 73 years; range, 70-82 years) was 90 months (7.5 years). For elderly patients who underwent TURB and partial cystectomy, the 5-year survival rate was 67% with a 109-month (9-year) median survival; 47% of patients preserved their bladders intact. The median follow-up of the living elderly patients was 61 months (range, 20-120 + months). CONCLUSIONS: Bladder sparing in selected patients on the basis of response to neoadjuvant chemotherapy is a feasible approach that should be confirmed in prospective, randomized trials. Selected elderly patients are candidates for this approach.

Which urethroplasty for which results?

PURPOSE OF REVIEW: Urethral surgery is rapidly changing because of developments in techniques. The aim of this paper is to provide an update and a review of the most significant surgical options and their outcomes in the treatment of urethral strictures. RECENT FINDINGS: Indications and results of anastomotic repair, pedicled flap, free graft and complex urethral reconstruction are reported. New trends such as dorsal urethroplasty and the use of buccal mucosa are reviewed. SUMMARY: Most urethral strictures can be managed successfully by urethral surgery. A wide spectrum of effective procedures is available. To obtain optimal results, adequate knowledge and experience of the most common techniques are required.