What is the best time for postoperative radiation therapy in pN1 prostate cancer?

We retrospectively compared long-term biochemical recurrence rates (BCR) in pN1 PCa patients that underwent adjuvant radiotherapy (aRT) vs. no aRT/early salvage (esRT) after robot-assisted radical prostatectomy and extended pelvic lymphadenectomy. All PCa pN1 M0 patients treated at a single high-volume center between 2010 and 2020 were analyzed. Patients with <10 LNs yield, or >10 positive LNs, or persistently detectable PSA after RARP were excluded. Kaplan-Meier (KM) plots depicted BCR rates. Multivariable Cox regression models (MCRMs) focused on predictors of BCR. The cumulative incidence plot depicted BCR rates after propensity score (PS) matching (ratio 1:1). 220 pN1 patients were enrolled, 133 (60.4%) treated with aRT and 87 (39.6%) with no-aRT/esRT. aRT patients were older, with higher rates of postoperative ISUP grade group 4-5, and higher rates of pT3b stage. The actuarial BCR was similar (aRT 39.8% vs. no-aRT/esRT 40.2%; p=1). Median time to BCR was 62 vs. 38 months in aRT vs. no-aRT/esRT patients (p=0.001). In MCRMs, patients managed with no-aRT/esRT were associated with higher rates of BCR over time (hazard ratio [HR]: 3.27, p<0.001). ISUP grade group 5 (HR: 2.18, p<0.01) was an independent predictor of BCR. In PS-matched cumulative incidence plots, the BCR rate was significantly higher in the aRT group (76.4 vs. 40.4%; p<0.01). Patients managed with no-aRT/esRT experienced BCR approximately two years before the aRT group. Despite, the important BCR benefit after aRT, this treatment strategy is underused in daily practice.

Pathological findings at radical prostatectomy of biopsy naïve men diagnosed with MRI targeted biopsy alone without concomitant standard systematic sampling.

OBJECTIVES: To test international society of urological pathology grade group (ISUP GG) concordance rates between multiparametric magnetic resonance imaging (mpMRI) targeted biopsies (TB) vs. standard systematic biopsies (SB) and radical prostatectomy (RP) specimens, in biopsy naïve patients. MATERIALS AND METHODS: This retrospective single center study included 80 vs. 500 biopsy naïve patients diagnosed with TB vs. SB and treated with RP between 2015 and 2018. First, we compared ISUP GG concordance rates and the percentages of undetected clinically significant prostate cancer (csPCa: ISUP GG  ≥ 3), between TB vs. SB and RP. Second, multivariable logistic regression models tested predictors of concordance rates before and after 1:3 propensity score (PS) matching. Third, among TB patients, univariable logistic regression models tested variables associated with ISUP GG concordance at RP. RESULTS: Overall, ISUP GG concordance rates were, respectively, 55 vs. 41.4% for TB vs. SB (P = 0.02). However, no differences in concordance rates were observed in patients with biopsy ISUP GG1 (31 vs. 33.9% for TB vs. SB; P = 0.8). Moreover, 15 vs. 18.8% csPCa were missed by TB vs. SB, respectively (P = 0.4). In multivariable logistic regression models, TB were associated with higher concordance rates before (odds ratio [OR]: 1.13; P = 0.04) and after 1:3 PS matching (OR: 1.15; P 0.03), compared to SB. In TB patients, age (OR: 0.98; P = 0.04), maximum cancer core involvement (MCCI; OR: 1.02; P = 0.02) and maximum cancer core length (MCCL; OR: 1.01; P = 0.07) were associated with ISUP GG concordance. Moreover, a trend for lower concordance rates was observed with higher PSA-D (OR: 0.77; P = 0.1). Finally, intermediate lesion location at mpMRI was associated with lowest concordance rates (44%). CONCLUSION: In biopsy naïve patients treated with RP, TB achieved higher rates of ISUP GG concordance, but same percentages of csPCa missed, compared to SB. Moreover, only patients with ISUP GG ≥2, but not patients with ISUP GG1, exhibited higher concordance rates. Finally, age, MCCI, MCCL, PSA-D, and lesion location were associated with concordance between TB and RP.

Impact of Surgical Experience on Radiation Exposure during Retrograde Intrarenal Surgery: A Propensity-Score Matching Analysis.

BACKGROUND: The impact of surgical experience on radiation exposure (RE) during endourological procedures has been poorly investigated. OBJECTIVE: To assess the impact of surgical experience on fluoroscopy time (FT) and RE during retrograde intrarenal surgery (RIRS). DESIGN, SETTING, AND PARTICIPANTS: The study included 140 patients who underwent RIRS performed either by a senior surgeon (expertise of >100 RIRSs) (group A) or by two junior residents (expertise of <15 RIRSs) (group B) between January 2016 and May 2018. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We tested the hypothesis that surgical experience had a limited impact on RE during RIRS. To adjust for potential baseline confounders, propensity-score matching was performed. Descriptive statistics and linear regression models tested the association between clinical variables and FT and patients' effective doses. RESULTS AND LIMITATIONS: There was no significant difference between the two groups for baseline, intraoperative, and postoperative characteristics. Overall FT (p=0.97) and effective dose (p=0.79) did not differ between groups. A statistically significant association was found between male sex (all p<0.03), stone burden (all p<0.001), operative time (all p<0.003), and postoperative double-J placement (all p<0.02) with both FT and effective dose. Linear multivariable analysis revealed that body mass index was significantly associated with effective dose (p=0.002). Similarly, longer operative time (all p<0.03) and double-J placement (all p<0.04) were significantly associated with increased FT and effective dose. CONCLUSIONS: Surgical experience has a limited impact on FT and RE during RIRS. Longer operative time and double-J placement were associated with increased FT and effective dose. PATIENT SUMMARY: In this study, we assessed whether surgical experience affects fluoroscopy time and patient's effective dose during retrograde intrarenal surgery (RIRS). We found that radiation exposure (RE) was not affected by surgeon's experience and that the standardisation of the surgical technique at the beginning of the learning curve of young surgeons may represent the key factor in reducing RE during RIRS.

Robotic Retroperitoneal Lymph Node Dissection in Advanced Stage Disease.

OBJECTIVES: The current report describes the feasibility of robotic retroperitoneal lymph node dissection (RRPLND), including some technical tricks for port placement for both right- and left-sided surgery. METHODS: Patients with advanced stage retroperitoneal disease underwent RRPLND using the 4-arm da Vinci Si Surgical System (Intuitive Surgical, Inc.). In both cases, the field of dissection was an ipsilateral template for lymph node dissection. RESULTS: RRPLND in such configuration was safe and effective in both cases. The illustrated port placement with perpendicular docking of the robot allowed for a wide range of motion with limited external clashing, providing sufficient space for the assistant surgeon. The operative time was 300 min (including docking and console time), with no perioperative complications and short hospital stay. CONCLUSION: The port configuration for right- or left-sided unilateral template RRPLND was feasible, permitting a wide range of motion for the robotic arms and thus facilitating an efficient and safe dissection.