Preoperative Stating of Pelvic Lymph Nodes in Prostate Cancer Patients via Endorectal Magnetic Resonance Imaging.

BACKGROUND/AIM: The aim of this study was to evaluate the diagnostic sensitivity, specificity and accuracy of endorectal magnetic resonance imaging (e-MRI), as a preoperative staging modality in the diagnosis of lymph node metastasis (LNM) in patients with prostate cancer (PCa). PATIENTS AND METHODS: Retrospectively, we analyzed data from N=168 patients who underwent radical prostatectomy (RP) between 2004 and 2013 at two tertiary medical centres. Prior to RP all patients underwent an e-MRI. Inclusion criteria were: PSA levels >20 ng/ml or Gleason score >7. Examinations were performed on a closed 1.0-T system combined with an endorectal body phased-array coil, imaging results were correlated with histopathology. RESULTS: 10.7% (N=18 patients) had histologically-proven LNM. e-MRI was true-positive in N=6 (33.3%) and false-negative N=12 patients (66.6%). N=150 (89.3%) patients without LNM e-MRI were true-negative in 96% and false-positive in 4%. Sensitivity was 96%, specificity was 33%, accuracy was 64.5%. CONCLUSION: e-MRI can be considered a useful preoperative staging modality in diagnosis of LNM.

The Value of Endorectal Magnetic Resonance Imaging of the Prostate in Improving the Detection of Anterior Prostate Cancer.

BACKGROUND/AIM: The diagnosis of anterior prostate cancer (APC) is troublesome due to its anatomical location. Patients with an APC often require multiple sets of biopsies until diagnosis is made. The objective of this study is to examine if endorectal magnetic resonance imaging (e-MRI) of the prostate could improve the detection of APC. PATIENTS AND METHODS: A retrospective review of 412 patients records with a clinical suspicion of prostate cancer (PCa) (prostate-specific antigen (PSA) levels >4 ng/ml or a suspicious finding on digital rectal examination (DRE)) who underwent conventional e-MRI (e-cMRI) and functional e-MRI (e-fMRI) of the prostate and subsequent prostate biopsy from April 2004 to July 2010 was conducted. All patients had a history of at least one prior negative set of prostate biopsy. Sixty-five percent (N=268) of patients' images were considered suspicious for PCa of which 53 (12.8%) cases were considered to be suspicious for APC (defined as the presence of PCa anterior to the urethra). All patients underwent an 18-core transrectal ultrasonography (TRUS)-guided biopsy of the peripheral zone and an additional 3-core TRUS-targeted biopsy anterior to the urethra. RESULTS: The median age and median PSA levels of the patients was 68.9 (range=56-72) years and 12.7 ng/ml (range=6.4-21.3), respectively. DRE was only positive in 6 patients (11.4%). The overall PCa detection rate was 90.5%. APC was detected through the targeted cores in 48 patients (90.5%). Seven patients (13.2%) exhibited a PCa of the peripheral zone as well. e-MRI-positive predictive value was 90.5%. CONCLUSION: e-MRI of the prostate has a high predictive value in detecting APC. Patients with a constant increase of PSA levels, negative DRE findings and prior negative sets of prostate biopsy are ideal candidates for e-MRI of the prostate and subsequent TRUS-targeted biopsies of possible suspicious anterior gland sites.

Is an Extended Prostate Biopsy Scheme Associated with an Improvement in the Accuracy Between the Biopsy Gleason Score and Radical Prostatectomy Pathology? A Multivariate Analysis.

AIM: To examine whether an extended prostate biopsy (PB) scheme is associated with an improvement in the accuracy between the PB Gleason score (GS) and radical prostatectomy (RP) pathology and to identify probable preoperative variables that stratified patients likely to harbor significant upgrading (SU). PATIENTS AND METHODS: A retrospective review of 538 patients' records diagnosed with prostate cancer (PCa) who underwent RP and exhibited a SU, at two tertiary medical centers, was conducted. The patients were divided into 3 groups: 194 who underwent a 6-core PB (36%), 156 who underwent a 12-core PB (28.9%) and 188 (34.9%) who underwent an 18-core PB. A multivariate analysis was conducted, including prostate-specific antigen (PSA) level, clinical stage, prostate size and duration from PB to RP. RESULTS: The 6-core group exhibited a 42.7% SU, the 12-core group exhibited a 38.8% SU and the 18-core group exhibited a 14.1% SU. There was a highly significant lower rate of SU in the 18-core than that in the 6-core (p<0.001) and 12-core PB group (p<0.001) but no significant difference in the rate of SU was noted between the 6- and 12-core group (p=0.913). According to the multivariate analysis, only a prostate size of >35 g significantly elevated the probability of SU in the 6-core (p<0.025) and 12-core PB groups (p<0.025), respectively. CONCLUSION: An extended PB scheme is associated with a significant improvement in the accuracy between the PB GS and RP pathology. Prostate size >35 g in patients who undergo a 6- or 12-core PB is the only preoperative variable that stratifies patients likely to harbor SU.

How good is post-biopsy multiparametric magnetic resonance imaging in detecting and characterising the index lesion of localised prostate cancer?

OBJECTIVE: The aim of this study was to evaluate the accuracy of multiparametric endorectal magnetic resonance imaging (mp-MRI) in detecting and characterising the largest tumour lesion, which is defined as the index tumour of prostate cancer. MATERIAL AND METHODS: A total of 55 patients with proven histological prostate cancer underwent post-biopsy MRI at 1.5 T and subsequent radical prostatectomy. The maximum tumour diameter (MTD) of the index lesion was determined independently by MRI and histopathology in a prospective manner. The detection rate of the index lesion, the MTD and volume by pathology, and the pathological tumour (pT) stage were correlated with the MTD by MRI using Pearson's correlation. RESULTS: Pathohistology revealed 158 cancer foci. MRI detected 55 foci. The sensitivity, specificity, accuracy, and negative and positive predictive values of mp-MRI for index lesion detection were 89%, 100%, 90%, 44% and 100%, respectively. Three positive correlations were found: one between the MTD of the index lesion by MRI and the MTD by pathology (Pearson coefficient = 0.890, p < 0.01), a second between the MTD by MRI and the index tumour volume at pathology (Pearson coefficient = 0.786, p < 0.01), and a third between the MTD and the pT stage (Pearson coefficient = 0.678, p < 0.01). CONCLUSION: mp-MRI can accurately detect the index lesion and estimate the TVP of localised prostate cancer.

Robot-assisted radical prostatectomy for the treatment of radiation-resistant prostate cancer: surgical, oncological and short-term functional outcomes.

OBJECTIVE: The objective of this study was to assess the surgical, oncological and short-term functional outcomes in patients undergoing salvage robot-assisted radical prostatectomy (SRARP) for the treatment of radiation-resistant prostate cancer. PATIENTS AND METHODS: The records of 3,500 men who underwent RARP from February 2006 to July 2011 were retrospectively reviewed. All peri- and postoperative data were recorded prospectively in our database. A total of 13 patients (0.37%) who had undergone SRARP for the treatment of radiation-resistant prostate cancer were identified. RESULTS: The primary treatment was external beam radiotherapy in 7 patients (53.8%) and brachytherapy in 6 patients (46.2%). The interval from radiotherapy to biochemical recurrence (BCR) varied from 12 to 108 months (median 48.9). Neurovascular bundle preservation was performed in 3 patients (23.1%). No intraoperative or major complications were encountered. Minor complications were encountered in 4 patients (30.7%). At 12 months, 7 patients were continent (53.8%), 3 exhibited mild incontinence (23.1%) and 3 (23.1%) were incontinent. Regarding potency, none of the patients were potent at 6 months, but 3 patients (23.1%) were potent at 1 year. Regarding BCR, 3 of the patients (23.1%) never reached a prostate-specific antigen nadir of zero, and during the follow-up period only 3 patients (23.1%) exhibited BCR. No disease-specific mortality was evident during follow-up. CONCLUSIONS: Although early in its development, it appears that SRARP is technically feasible and offers satisfactory surgical, oncological and short-term functional outcomes.

Robot-assisted radical prostatectomy in patients with a pathologic prostate specimen weight ≥100 grams versus ≤50 grams: surgical, oncologic and short-term functional outcomes.

INTRODUCTION: The objective of this study is to evaluate the surgical, oncological and short-term functional outcomes in patients with a pathologic prostate specimen weight ≥100 g versus patients with a pathologic prostate specimen weight ≤50 g undergoing robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: The records of 4,000 men who underwent RARP from February 2006 to April 2012 were reviewed retrospectively. A total of 185 men had a pathologic prostate specimen weight ≥100 g (group A). A matched pairs analysis was performed using our database to identify men with a pathologic prostate specimen weight ≤50 g but with equivalent clinicopathologic characteristics to serve as the control group (group B). RESULTS: Our results indicated that although the intraoperative results were more than satisfying in patients with large glands, there is a significant increase in blood loss, operative time needed, increased need for bladder neck reconstruction as well as an increase in intraoperative complications. Nevertheless, patients with large glands exhibit less aggressive tumors, less positive surgical margins and a lower incidence of biochemical recurrence. Regarding functional outcomes, patients with larger glands had no difference regarding continence rates when compared to patients with smaller glands but exhibited significantly lower potency rates. CONCLUSIONS: Although RARP in patients with a pathologic prostate specimen weight ≥100 g is technically challenging, in experienced hands it can be considered a safe procedure with excellent surgical, oncological and functional outcomes. Nevertheless, this conclusion is limited, in that it is from a single institution with a large case volume and may not be reflective of outcomes at centers with smaller volumes and less experience.

Peritoneal dissemination of prostate cancer with the absence of lymph node, skeletal, or visceral metastases in a patient scheduled to undergo robot-assisted radical prostatectomy.

Peritoneal dissemination of prostate cancer (PCa) with the absence of other metastases is extremely rare. Atypical sites of metastatic disease, for example the peritoneum, are only a recognized finding at autopsy. Herein, we report a case of peritoneal dissemination of a PCa, with the absence of lymph node, skeletal, or visceral metastases in a patient scheduled to undergo robot-assisted laparoscopic prostatectomy.

The Prune Belly syndrome: urological aspects and long-term outcomes of a rare disease.

Prune-Belly syndrome is a disorder characterized by the following triad of symptoms: deficiency of the abdominal muscles, malformations of the urinary tract and bilateral cryptorchidism. This study included a total of 16 patients. The findings included clinical characteristics, diagnostics, therapy and long-term clinical outcomes. All patients were asked to complete a questionnaire and, in some cases, were given further examination. All patients were diagnosed with congenital aplasia of the abdominal wall and a variety of urogenital malformations. Cryptorchidism was present in 11 patients (68.8%), malformations of the prostate in 3 (18.8%), urethral malformations in 8 (50%) and mega-ureter in 14 patients (87.5%). A mega-bladder was observed in 13 patients (81.3%). Distinctive renal malformations, such as renal dysplasia, in 3 patients (18.8%) and hydronephrosis in 9 patients (56.3%), respectively. Abdominoplasty was performed on 4 patients (25%). Urethral surgery was performed in 10 patients (62.5%). Seven patients (43.8%) required ureter surgery, most of which involved re-implantation of the ureter and, in some cases, additional ureter modeling. Renal surgery was performed on 5 patients. Four patients with non-functioning kidneys with hydronephrosis underwent a nephrectomy and one patient pyeloplasty. We demonstrate that successful treatment is possible even in cases of serious and complex malformations, such as those of the Prune-Belly syndrome. Treatment must be tailored to the individual patient. The severity of the renal dysplasia is the main prognostic factor.

Surgical and oncological outcomes in patients with a preoperative PSA value <4 ng/ml undergoing robot-assisted radical prostatectomy.

BACKGROUND: The objective of this study was to assess the surgical and oncological outcomes in patients with a preoperative prostate specific antigen (PSA) value <4 ng/ml undergoing robot-assisted radical prostatectomy (RARP) for prostate cancer. PATIENTS AND METHODS: The records of 2000 men who underwent RARP from February 2006 to April 2010, were retrospectively reviewed. A total of 169 (8.4%) patients with a preoperative PSA value <4 ng/ml were identified. A comparison was performed between the overall patient cohort and the aforementioned patients. The analyzed parameters included: minor and major postoperative complications, postoperative Gleason score, pathological stage, positive margin status as well as presence of biochemical progression and of disease-specific mortality during the follow-up period. RESULTS: The following results reflect the comparison of the overall cohort of patients vs. the cohort of patients who had a preoperative PSA value <4 ng/ml. A statistical difference of the analyzed parameters was observed in the median PSA value; 10.3 ng/ml (0.3-220 ng/ml) vs. 2.8 ng/ml (0.3-3.9 ng/ml) (p<0.001), in bilateral NVB; 65.7% vs. 85.2% (p<0.001), in Gleason score <7; 42.8% vs. 59.1% (p<0.05), in Gleason score 7; 47.7% vs. 36.6% (p<0.05) and in Gleason score >7 in 9.5% vs. 3.5% (p<0.001). Organ-confined disease was noted in 73.5% vs. 86.3% (p<0.05), extraprostatic extension in 25.2% vs. 13.7% (p<0.05). The percentage of cancer found in the prostate specimen was 16.1% (1-99%) vs. 7.3% (1-96%) (p<0.05) and a positive surgical margin status was encountered in 8.9% vs. 4.7% (p<0.05) of patients. Pelvic lymph node dissection was performed in 1623 patients (81.2%) of the overall cohort out of whom 64 cases (3.2%) were positive for metastasis. In the patient cohort of PSA value <4 ng/ml, pelvic lymph node dissection was performed in 114 patients (67.4%), out of which one case (0.5%) was positive for metastasis (p<0.05). After a median follow-up of 24.2 months (range 3-56 months), 162 patients (95.8%) were free of biochemical progression and no disease-specific mortality was evident. CONCLUSION: RARP in patients with a preoperative PSA value <4 ng/ml is a safe surgical procedure with limited complications and excellent oncological outcome.

Surgical and oncological outcomes in patients with preoperative PSA >20 ng/ml undergoing robot-assisted radical prostatectomy.

BACKGROUND: The objective of this study was to assess the surgical and the oncological outcomes in patients with a preoperative prostate specific antigen (PSA) value >20 ng/ml, undergoing robot-assisted radical prostatectomy (RARP) for prostate cancer. PATIENTS AND METHODS: The records of 2000 men who underwent RARP from February 2006 to April 2010 were retrospectively reviewed. A total of 147 (7.3%) patients with a preoperative PSA value >20 ng/ml were identified. A comparison was performed between the overall patient cohort and the patients with PSA >20 ng/ml. The analyzed parameters included: minor and major postoperative complications, postoperative Gleason score, pathological stage, positive margins and lymph node status, as well as biochemical progression and disease-specific mortality during the follow-up period. RESULTS: The following results reflect the comparison of the overall cohort of patients vs. the cohort of patients who had a preoperative PSA >20 ng/ml. A statistical difference of the analyzed parameters was observed for median PSA value 10.3 ng/ml vs. 34.8 ng/ml (p<0.05), for bilateral neurovascular bundle preservation 65.7% vs. 19.7% (p<0.001), for a Gleason score <7, 42.8% vs. 12.9% (p<0.05) and for a Gleason score >7 in 9.5% vs. 19.7% (p<0.05). Organ-confined disease was noted in 73.5% vs. 31.9% (p<0.05) and extraprostatic extension in 25.2% vs. 86.1% (p<0.05). The percentage of cancer found in the prostate specimen was 16.1% vs. 38.1% (p<0.05) and a positive surgical margin (PSM) status was encountered in 8.9% vs. 33.3% (p<0.05) of patients. Positive lymph nodes were encountered in 3.2% vs. 17.1% of patients (p<0.05). After a median follow-up of 19.6 months (range 3-56 months), 118 patients (80.2%) were free of biochemical progression and no disease-specific mortality was evident. CONCLUSION: Although RARP in patients with preoperative PSA >20 ng/ml is a safe surgical procedure with limited complications, the risk of positive lymph nodes, as well as the PSM status are found to be significantly higher. Patients should be informed of these probable outcomes, as well as for a possible need for adjuvant treatment before undergoing the procedure.

Robotic-assisted radical prostatectomy in men ≥75 years of age. Surgical, oncological and functional outcomes.

BACKGROUND: The aim of this study is to evaluate the surgical, the oncological and the functional outcomes in men ≥75 years of age undergoing robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: The records of N=2000 men who underwent RARP from February 2006 to April 2010 were retrospectively reviewed. A total of 45 patients who were ≥75 years of age were indentified. A comparison was performed between the overall patient cohort and the aforementioned patients. The analyzed parameters included: minor and major postoperative complications, postoperative Gleason score, pathological stage, positive-margin status, continence and potency in 12 months, disease-specific mortality and presence of biochemical progression at the follow-up period. RESULTS: The following results reflect the comparison of the overall cohort of patients vs. the cohort of patients who were ≥75 years of age. A statistical difference of the analyzed parameters was observed only minor complications 11.4% vs. 15.5% (p<0.05), neurovascular bundle (NVB) preservation 65.7% vs. 51.1% (p<0.05) and potency after 12 months 66.2% vs. 39.6% (p<0.001). Major complications were noted in 1.3% vs. 2.2% of cases. A Gleason score <7 was noted in 42.8% vs. 37.3%, a Gleason score 7 in 47.7% vs. 51.1% and a Gleason score >7 in 9.5% vs. 11.6%. Organ-confined disease was noted in 73.5% vs. 68.8%, extraprostatic extension in 25.2% vs. 31.2% and positive surgical margin status was encountered in 8.9% vs. 11.1% of cases. At 12 months, 92.8% vs. 86.9% of patients were continent and 66.2% vs. 39.6% were potent. After a median follow-up of 17.2 months no disease-specific mortality was evident and 95.5% were free of biochemical progression in the cohort of patients who were ≥75 years of age. CONCLUSION: Our findings suggest that RARP in patients ≥75 years of age is a safe surgical procedure with limited complications, excellent oncologic and continence outcomes as well as acceptable potency outcomes. Nevertheless, RARP should be limited to a selected cohort of patients with a good overal health status and an individual life expectancy of more than 10 years in order for the oncological advantages of surgery to be achieved.

Robotic-assisted radical prostatectomy in men ≤50 years of age. Surgical, oncological and functional outcomes.

BACKGROUND: The aim of this study was to evaluate the surgical, oncological and functional outcomes in men ≤50 years of age treated with robot-assisted laparoscopic radical prostatectomy (RARP). PATIENTS AND METHODS: The records of 2000 men who underwent RARP from February 2006 to April 2010 were retrospectively reviewed. A total of 68 patients who were ≤50 years of age were indentified. A comparison was performed between the overall patient cohort and the aforementioned patients. The analyzed parameters included: minor and major postoperative complications, postoperative Gleason score, pathological stage, positive margin status, continence and potency 12 months after treatment and presence of biochemical progression and disease-specific mortality during the follow-up period. RESULTS: The following results reflect the comparison of the overall cohort of patients vs. the cohort of patients who were ≤50 years of age. A statistical difference of the analyzed parameters was observed in prostate weight 56.1 g vs. 31.4 g (p<0.05), in bilateral neurovascular bundle (NVB) preservation 65.7% vs. 92.6% (p<0.05), and in oncological and functional outcomes. Organ-confined disease was noted in 73.5% vs. 78.5% (p<0.05), extraprostatic extension in 25.2% vs. 21.5% (p<0.05) and positive surgical margins were encountered in 8.9% vs. 5.8% (p<0.05). A Gleason score <7 was noted in 42.8% vs. 54.4% (p<0.05), a Gleason score 7 in 47.7% vs. 41.2% (p<0.05) and a Gleason score >7 in 9.5% vs. 4.4% (p<0.05). At 12 months, 92.8% vs. 95.5% were continent and 66.2% vs. 93.7% (p<0.001) were potent. After a median follow-up of 17.8 months, 97.1% patients of the ≤50 years patient cohort were free of biochemical progression and no disease-specific mortality was evident. CONCLUSION: Our findings suggest that RARP in patients ≤50 years of age is a safe surgical procedure with limited complications and excellent oncologial and functional outcomes. Although the preservation of the NVB in such patients is preferable, this can be performed without compromising the radical nature of cancer surgery.

Surgical, oncologic, and short-term functional outcomes in patients undergoing robot-assisted prostatectomy after previous transurethral resection of the prostate.

PURPOSE: The objective of this study was to assess the surgical, oncologic, and short-term functional outcomes of patients with a history of transurethral resection of the prostate (TURP) who underwent robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: The records of 2000 men who underwent RALP from February 2006 to April 2010 were retrospectively reviewed. A total of 80 men had undergone TURP before RALP. A match-paired analysis was performed using our database to identify 80 additional men without a history of TURP with equivalent clinicopathologic characteristics to serve as a control group (non-TURP group). The parameters compared included patient preoperative clinicopathologic characteristics, intraopeoperative characteristics, postoperative oncologic characteristics, minor and major postoperative complications, continence, and potency. RESULTS: The mean time between TURP and RALP was 3.6 months (3-6 months). Regarding preoperative characteristics, a statistical difference was only observed regarding preoperative patient potency in the TURP vs non-TURP group. Regarding intraopeoperative characteristics, a statistical difference was observed regarding the need for bladder neck reconstruction and skin-to-skin operative time. Regarding postoperative pathologic characteristics, the positive surgical margin rate was not significant when the two groups were compared. The continence and potency rates in 12 months were similar (87.5%/91.25%) and (70.3%/86.5%) for both patient cohorts. CONCLUSION: Although the procedure is technically more demanding, exhibits a prolonged operative time and time interval before continence and potency returns, it can be safely performed without compromising functional results as well as the radical nature of cancer surgery.

Urethral diverticulum with massive lithiasis presenting as a scrotal mass.

Urethral diverticula in men are uncommon clinical entities. Their clinical manifestations include urinary tract infection, hematuria, irritative or obstructive voiding symptoms, ventral bulging and displacement of the penile shaft. Male urethral diverticulum with massive lithiasis presenting as a scrotal mass with stress urinary incontinence as the main symptom is extremely rare. Herein, we present such a case.

Inapparent tumor on endorectal multimodality magnetic resonance imaging of prostate: should we perform a biopsy?

OBJECTIVES: To examine whether one could spare patients with a clinical suspicion of prostate cancer (PCa) but inapparent tumor on multimodality endorectal magnetic resonance imaging (e-MRI) of the prostate from undergoing prostate biopsy. METHODS: A total of 109 patients with a clinical suspicion of PCa underwent conventional and functional e-MRI of the prostate and subsequently prostate biopsy. The inclusion criteria were prostate-specific antigen level>4 ng/mL or a suspicious finding on digital rectal examination. The images were interpreted by a highly experienced radiologist and were considered negative for PCa in all cases. Regardless of the negative findings, all patients underwent an 18-core prostate biopsy. Functional e-MRI included contrast-enhanced e-MRI and diffusion-weighted imaging. The examinations were performed on a closed 1.0-T system combined with an endorectal body phased-array coil. The clinicopathologic parameters of the patients included age, prostate-specific antigen level, digital rectal examination findings, PCa detection rate, clinically significant PCa detection rate, high-grade PCa detection rate, and e-MRI specificity. RESULTS: The median age of the patients was 67.4 years, and the median prostate-specific antigen level was 12.9 ng/mL. The digital rectal examination findings were positive in 42 patients (38.5%) and negative in 67 patients (61.5%). Overall, PCa was detected in 19.2% of patients, with 47.6% cases defined as clinically significant and 38.1% as high grade. Overall, the e-MRI specificity was 80.8%. CONCLUSIONS: The results of our study have shown that the absence of tumor on e-MRI scans of patients with a clinical suspicion of PCa does not rule out the probability of clinically significant and high-grade PCa, making prostate biopsy mandatory for these patients as well.