Impact of nerve sparing in robot-assisted radical prostatectomy on the risk of positive surgical margin and biochemical recurrence.

OBJECTIVES: Nerve sparing may increase positive surgical margin rate during radical prostatectomy. Our objective was to analyze the positive surgical margin rate and location as well as its impact on biochemical recurrence according to nerve sparing procedure in robot-assisted radical prostatectomy. METHODS: We included 814 patients treated with robot-assisted radical prostatectomy between 2009 and 2021, and evaluated the impact of nerve sparing on positive surgical margin and biochemical recurrence using logistic regression and Cox models. RESULTS: Unilateral nerve sparing and bilateral nerve sparing were performed in 152 (18.6%) cases and 118 (14.5%) cases, respectively. On multivariable analysis, in addition to nerve sparing, bilateral nerve sparing, but not unilateral nerve sparing was associated with an increased risk of positive surgical margin compared with non-nerve sparing. Positive surgical margin at any location increased the risk of biochemical recurrence. During unilateral nerve sparing, positive surgical margin in nerve sparing side, but not in non-nerve sparing side was associated with increased risk of biochemical recurrence on multivariate analysis. CONCLUSIONS: Taken together, surgeons need to notice an increased risk of biochemical recurrence associated with positive surgical margin when performing nerve sparing in robot-assisted radical prostatectomy, and then need to choose the patients suitable for nerve sparing.

Super-veil nerve-sparing extraperitoneal pure single-port robotic-assisted radical prostatectomy on da Vinci Si robotic system.

OBJECTIVES: To investigate the safety profile and short-term outcome of super-veil nerve-sparing extraperitoneal single-port robotic-assisted radical prostatectomy (espRARP) on da Vinci Si platform. METHODS: From December 2018 to March 2021, 106 consecutive patients with treatment-naive prostate cancer were prospectively included. espRARP was performed on da Vinci Si surgical platform. Operative time, estimated blood loss, Clavien-Dindo complication classification, continence, potency recovery, quality-of-life scores, and postoperative prostate-specific antigen (PSA) were documented. RESULTS: Patients aged 52-79 years (mean ± SD, 64.8 ± 6.15 yrs), with a median PSA of 9.2 ng/ml (IQR: 6.70, 16.83) and median prostate volume of 31.9 ml (IQR: 30.01, 38.54). 95.28% (101/106) were clinically localized. All patients underwent espRARP successfully with no open conversions. Operative time was 94.2 ± 30.26 min with an estimated blood loss of 68.5 ml (range, 50-120 ml). No Grade III complications or above were documented. Positive surgical margin was 17.9% (19/106). Median pain score at discharge was 0 (IQR: 0, 1.75) without use of opioid narcotics. Postoperative length of stay was 3 days (IQR: 1, 3), in which 28 patients were discharged within 24 h. Instant, 1-, 3-, and 6 month continence recovery was 18.9, 45.3, 79.2, 93.4, and 96.4%, respectively. Of the 43 patients who received nerve-sparing procedures, 13 (30.23%) resumed potency 6 months postoperatively. 12 month biochemical recurrence-free survival was 92.77% (77/83). CONCLUSIONS: Extraperitoneal single-port robotic-assisted radical prostatectomy is a safe and feasible technique. Combined with super-veil nerve-sparing procedures, it may provide satisfactory outcome in short-term functional recovery.

Toggling Technique Allows Retrograde Early Release to Facilitate Neurovascular Bundle Sparing During Robot-Assisted Radical Prostatectomy: A Propensity Score-Matching Study.

BACKGROUND: This study aimed to present the surgical facilitation of neurovascular bundle (NVB) sparing using the toggling technique (30° lens down/up switching) and to evaluate erectile dysfunction (ED) recovery after robot-assisted radical prostatectomy (RARP). METHODS: We assessed 144 patients (group with toggling, n = 72; group without toggling, n = 72) who underwent RARP with bilateral NVB sparing using propensity score matching. Inclusion criteria were ≥ 1 year follow-up and preoperative potency as per the Sexual Health Inventory for Men (SHIM) questionnaire (≥ 17 points). Recovery of ED after RARP was defined as return to baseline sexual function or self-assessment regarding successful intercourse. The subjective surgeon's nerve sparing (SNS) score and tunneling success rates were used to evaluate surgical facilitation. The recovery rate of ED between the groups was analyzed using Kaplan-Meier analysis. RESULTS: A better ED recovery trend was confirmed according to the SNS score (R² = 0.142, P = 0.004). In the analysis of NVB sparing ease, the toggling group showed higher SNS scores (on right/left side: P = 0.011 and < 0.001, respectively) and overall tunneling success rates (87% vs. 74%, P = 0.001) than the group without toggling. Overall, ED recovery rates were 82% (59/72) and 75% (54/72) in the groups with and without toggling, respectively, at the 1-year follow-up (P = 0.047), and the toggling group showed a faster ED recovery rate at 3 months (47% vs. 35%, P = 0.013). In a specific analysis of the potent cohort (< 60 years, bilateral full NVB spared, SHIM score ≥ 22), the ED recovery rate reached 87% (14/16) in the toggling group. CONCLUSION: The retrograde early release with the toggling technique improves the facilitation of NVB sparing, leading to improved ED recovery.

Impact of mpMRI targeted biopsy on intraoperative nerve-sparing (NeuroSAFE) during robot-assisted laparoscopic radical prostatectomy.

BACKGROUND: The aim of our study was to evaluate the impact of prostate biopsy technique (transrectal ultrasound (US)-prostate biopsy (PBx) versus multiparametric magnetic resonance imaging (mpMRI) targeted prostate biopsy (MRI-PBx) on intraoperative nerve-sparing and the rate of secondary neurovascular-bundle resection (SNR) in patients undergoing robot-assisted laparoscopic radical prostatectomy (RARP). A real-time investigation with a frozen-section examination (NeuroSAFE) microscopically excluded or confirmed prostate cancer invasion of the nerve structures resulting in preservation of the neurovascular bundle or SNR. Additionally, we analyzed risk factors related to SNR, such as longer operation time and postoperative complications. METHODS: The total study cohort was stratified according to non-nerve-sparing versus nerve-sparing RARP. Patients with nerve-sparing approach were then stratified according to biopsy technique (PBx vs. MRI-PBx). Further, we compared PBx versus MRI-PBx according to SNR rate. RESULTS: We included a total of 470 consecutive patients, who underwent RARP for PCa at our institution between January 2016 and December 2019. Patients with a preoperative MRI-PBx had a 2.12-fold higher chance of successful nerve-sparing (without SNR) compared to patients with PBx (p < 0.01). Patients with preoperative MRI-PBx required 73% less intraoperative SNR compared to patients with PBx (p < 0.0001). Prior MRI-PBx is thus a predictor for successful nerve-sparing RARP approach. CONCLUSION: Preoperative MRI-PBx led to better oncological outcomes and less SNR. Young patients with good erectile function could benefit from a preoperative MRI-PBx before nerve-sparing RARP.

An Algorithm to Personalize Nerve Sparing in Men with Unilateral High-Risk Prostate Cancer.

PURPOSE: Current guidelines do not provide strong recommendations on preservation of the neurovascular bundles during radical prostatectomy in case of high-risk (HR) prostate cancer and/or suspicious extraprostatic extension (EPE). We aimed to evaluate when, in case of unilateral HR disease, contralateral nerve sparing (NS) should be considered or not. MATERIALS AND METHODS: Within a multi-institutional data set we selected patients with unilateral HR prostate cancer, defined as unilateral EPE and/or seminal vesicle invasion (SVI) on multiparametric (mp) magnetic resonance imaging (MRI), or unilateral International Society of Urologic Pathologists (ISUP) 4-5 or prostate specific antigen ≥20 ng/ml. To evaluate when to perform NS based on the risk of contralateral EPE, we relied on chi-square automated interaction detection, a recursive machine-learning partitioning algorithm developed to identify risk groups, which was fit to predict the presence of EPE on final pathology, contralaterally to the prostate lobe with HR disease. RESULTS: A total of 705 patients were identified. Contralateral EPE was documented in 87 patients (12%). Chi-square automated interaction detection identified 3 groups, consisting of 1) absence of SVI on mpMRI and index lesion diameter ≤15 mm, 2) index lesion diameter ≤15 mm and contralateral ISUP 2-3 or index lesion diameter >15 mm and negative contralateral biopsy or ISUP 1, and 3) SVI on mpMRI or index lesion diameter >15 mm and contralateral biopsy ISUP 2-3. We named those groups as low, intermediate and high-risk, respectively, for contralateral EPE. The rate of EPE and positive surgical margins across the groups were 4.8%, 14% and 26%, and 5.6%, 13% and 18%, respectively. CONCLUSIONS: Our study challenges current guidelines by proving that wide bilateral excision in men with unilateral HR disease is not justified. Pending external validation, we propose performing NS and incremental NS in case of contralateral low and intermediate EPE risk, respectively.

Cross-organ sensitization between the prostate and bladder in an experimental rat model of lipopolysaccharide (LPS)-induced chronic pelvic pain syndrome.

BACKGROUND: The aim of the current study was to investigate the effects of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) on bladder function via prostate-to-bladder cross-sensitization in a rat model of lipopolysaccharide (LPS)-induced prostate inflammation. METHODS: Male rats were intraprostatically injected with LPS or saline, serving as control. Micturition parameters were examined in a metabolic cage 10 or 14 days later. Subsequently, to evaluate bladder function, cystometry was performed. Micturition cycles were induced by saline infusion and cholinergic and purinergic contractile responses were measured by intravenous injection with methacholine and ATP, respectively. Thereafter, the prostate and bladder were excised and assessed histopathologically for possible inflammatory changes. RESULTS: Metabolic cage experiments showed increased urinary frequency in rats with LPS-induced CP/CPPS. Cystometry showed a significant increase in the number of non-voiding contractions, longer voiding time and lower compliance in CP/CPPS animals compared to controls. Induction of CP/CPPS led to significantly reduced cholinergic and purinergic bladder contractile responses. Histopathological analysis demonstrated prostatic inflammation in CP/CPPS animals. There were no significant differences between the groups regarding the extent or the grade of bladder inflammation. Prostate weight was not significantly different between the groups. CONCLUSIONS: The present study shows that prostate-to-bladder cross-sensitization can be triggered by an infectious focus in the prostate, giving rise to bladder overactivity and alterations in both afferent and efferent signalling. Future studies are required to fully understand the underlying mechanisms.

[Recent advances in high-risk prostate cancer surgery]. / Nouveautés dans la chirurgie des cancers de la prostate localisés de haut risque.

The management of high-risk prostate cancer has greatly evolved in recent years. Advances in imaging helps to better define the actual aggressiveness of the disease, to plan the surgical procedure, and to improve the prognostic evaluation of this high-risk of recurrence disease. The information obtained by MRI and by targeted biopsies improves management before surgery. Advances in nuclear medicine and generalization of PSMA-PET scans are beginning to improve the initial stage of diagnosis, thanks to a better detection of lymph node and distant metastases. The oncological interest of these new imaging techniques, which then influence the therapeutic plan, remains to be defined. The curative impact of an extensive lymph node dissection, as currently recommended, remains to be proved, and recently published randomized trials do not provide firm conclusions. The new hormone therapies pave the way for an intensification of perioperative systemic treatment, with a significant action on the tumor tissue, but an impact on survival, which remains to be defined in the context of ongoing randomized trials.

Use of intraoperative fluorescence to enhance robot-assisted radical prostatectomy.

Robot-assisted radical prostatectomy has become the standard of care for the removal of localized prostate cancer. Positive outcomes depend upon the precise removal of the prostate and associated tissue without damage to nearby structures. This process can be aided by fluorescence-guided surgery to enhance the visual contrast between different structures. Here the authors have conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify ten investigations into the use of fluorescence-guided surgery in robot-assisted radical prostatectomy. These studies used fluorescent tracers to identify structures, including the prostate, neurovascular bundle and lymph nodes. These studies demonstrate the safe and effective use of fluorescence-guided surgery in robot-assisted radical prostatectomy and pave the way for further developments in this field.

Anorectal application of 5% lidocaine cream reduces pain prior to periprostatic nerve block during transrectal ultrasound guided prostate biopsy: Randomized, prospective controlled study.

OBJECTIVES: Trans rectal ultrasound guided prostate biopsy with periprostatic nerve block (PPNB) is performed following probe insertion and manipulation leaving these initial maneuvers uncovered in terms of pain control. We evaluated whether topical analgesia reduces pain during early stages of the procedure. PATIENTS AND METHODS: Seven group prospective, randomized controlled study: groups 1-3: nerve block with 5 ml 1% lidocaine bilaterally plus perianal topical application of 10 ml 5% lidocaine cream. Groups 4-6 as in 1-3 plus digital application of 10 ml 5% lidocaine cream internally on rectal walls. For each approach exposure times were 5 (groups 1 and 4), 10 (groups 2 and 5) and 20 (groups 3 and 6) min, respectively. The control group (7) received PPNB only. Patients filled a 0-10 visual analogue scale (VAS) at five points: after probe insertion, during probe manipulation, following PPNB, after prostate biopsies and a global pain estimation. RESULTS: Two hundred and fifty-two patients were enrolled. Significant differences in VAS between all study groups and controls were observed at the pre-biopsy stages of the procedure. In multivariate analysis adjusted for prostate specific antigen, diabetes mellitus status, spinal disease, abnormal digital rectal examination and non- benign prostate hyperplasia histology, significance remained for probe insertion and intra-rectal manipulation. For each exposure time no significant differences were observed between topical application and topical + intra-rectal application. After PPNB, differences between study and control groups disappeared. CONCLUSION: Topical anesthesia significantly reduces pain during early stages of prostate biopsy. Perianal application sufficed whereas intra-rectal application of local anesthetics does not add to pain control. Perianal application for 10 min seems to be optimal.

A systematic review of nerve-sparing surgery for high-risk prostate cancer.

INTRODUCTION: We provide a systematic analysis of nerve-sparing surgery (NSS) to assess and summarize the risks and benefits of NSS in high-risk prostate cancer (PCa). EVIDENCE ACQUISITION: We have undertaken a systematic search of original articles using 3 databases: Medline/PubMed, Scopus, and Web of Science. Original articles in English containing outcomes of nerve-sparing radical prostatectomy (RP) for high-risk PCa were included. The primary outcomes were oncological results: the rate of positive surgical margins and biochemical relapse. The secondary outcomes were functional results: erectile function (EF) and urinary continence. EVIDENCE SYNTHESIS: The rate of positive surgical margins differed considerably, from zero to 47%. The majority of authors found no correlation between NSS and a positive surgical margin rate. The rate of biochemical relapse ranged from 9.3% to 61%. Most of the articles lacked data on odds ratio (OR) for positive margin and biochemical relapse. The presented results showed no effect of nerve sparing (NS) on positive margin (OR=0.81, 0.6-1.09) or biochemical relapse (hazard ratio [HR]=0.93, 0.52-1.64). A strong association between NSS and potency rate was observed. Without NSS, between 0% and 42% of patients were potent, with unilateral 79-80%, with bilateral - up to 90-100%. Urinary continence was not strongly associated with NSS and was relatively good in both patients with and without NSS. CONCLUSIONS: NSS may provide benefits for patients with urinary continence and significantly improves EF in high-risk patients. Moreover, it is not associated with an increased risk of relapse in short- and middle-term follow-up. However, the advantages of using such a surgical technique are unclear.

Association of neurovascular bundle preservation with oncological outcomes in patients with high-risk prostate cancer.

OBJECTIVE: To investigate the oncologic safety of neurovascular bundles (NVB) preservation at radical prostatectomy (RP) in patients with high-risk and/or locally advanced prostate cancer (PCa). MATERIAL AND METHODS: Within a two-institutional high-volume center database we identified patients who harbored high-risk PCa at RP (2000-2017). Only patients with D'Amico high-risk PCa were included. Kaplan-Meier and multivariable Cox regression models tested the effect of NVB preservation on biochemical recurrence (BCR), metastasis and overall survival (OS). Subgroup analyses focused on patients with clinical stage T3 and/or biopsy ISUP grade 5 and pathologic stage T3. RESULTS: Of 4351 patients with D'Amico high-risk, 35.7% vs. 38.0% vs. 26.3% underwent bilateral vs. unilateral vs. no NVB preservation, respectively. At 120 months after RP BCR-free, metastasis-free survival and OS rates were 62.2% vs. 44.3% vs. 27.1% (p < 0.001), 83.7% vs. 66.7% vs. 60.3% (p < 0.001), and 91.8% vs. 87.5% vs. 72.3% (p < 0.001) for bilateral vs. unilateral vs. no NVB preservation, respectively. In multivariable Cox regression models, bilateral and unilateral compared to no NVB preservation did not increase the risk for BCR, metastasis or death in the entire cohort and in subgroups with clinical stage T3 and/or biopsy ISUP grade 5, as well as pathologic stage T3. CONCLUSIONS: NVB preservation was not associated with worse oncological outcome in patients with high-risk and/or locally advanced PCa and may be offered to well-selected patients who are at risk of harboring nonorgan-confined PCa.

Implementation of Intraoperative Frozen Section During Radical Prostatectomy: Short-term Results from a German Tertiary-care Center.

BACKGROUND: Neurovascular bundle (NVB) preservation (NVBP) and surgical margin status are the main intraoperative factors influencing functional and oncologic outcomes in patients with prostate cancer undergoing radical prostatectomy (RP). OBJECTIVE: To test the impact of implementing the intraoperative frozen section technique (IFST) during NVBP on the frequency of NVB procedures and its effect on positive surgical margins (PSMs). DESIGN, SETTING, AND PARTICIPANTS: We relied on an institutional tertiary-care center database to identify patients who underwent RP (January 2014-October 2018). Until October 2017, decision for NVBP was taken based on preoperative magnetic resonance imaging, clinical characteristics, and nomograms, without the IFST. After November 2017, all patients received bilateral NVBP with the IFST, to check for a PSM in the area of the NVB. If a PSM occurred, a secondary resection of the respective NVB was performed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: PSM and NVB procedures were assessed. Subgroup analyses focused on pathologic tumor stages. RESULTS AND LIMITATIONS: Overall, 346 patients were identified. Of these patients, 54.9% (n=190) versus 45.1% (n=156) underwent RP without versus with the IFST. By using the IFST during NVBP, the PSM decreased from 29.5% to 15.4% (p=0.003) in the entire cohort (14.6% vs 8.6% in pT2; 47.1% vs 29.4% in pT3). Conversely, NVBP increased from 55.3% to 95.5% (p<0.001) in the entire cohort (68.9% vs 99.0% in pT2; 39.1% vs 88.2% in pT3). In multivariable logistic regressions, IFST use was an independent predictor of PSMs (odds ratio [OR]: 0.54, 95% confidence interval [CI]: 0.30-0.98; p=0.047) and NVBP (OR: 5.60, 95% CI: 3.10-10.51; p<0.001) after controlling for patient and tumor characteristics. CONCLUSIONS: Implementation of the IFST during NVBP resulted in more frequent NVBP and was associated with a lower PSM, compared with RP without the IFST. Therefore, the IFST should be performed, if available. PATIENT SUMMARY: The intraoperative frozen section technique (IFST) during preservation of neurovascular bundles (NVBP) should be offered to patients who undergo radical prostatectomy. The IFST can reduce positive margin rates and increase the rate of NVBP.

Trends in risk-group distribution and Pentafecta outcomes in patients treated with nerve-sparing, robot-assisted radical prostatectomy: a 10-year low-intermediate volume single-center experience.

PURPOSE: To evaluate the trends in risk-group distribution and Pentafecta outcomes in patients treated with nerve-sparing (NS), robot-assisted radical prostatectomy (RARP) in a single low-intermediate volume prostate cancer (PCa) center over a 10-year period. MATERIALS AND METHODS: We queried a prospectively maintained database for patients who underwent NS RARP between 2009 and 2018 in a low-intermediate volume PCa center. Risk-groups were defined according to the D'Amico classification. Pentafecta outcomes referred to the postsurgical presence of potency and continence, and the absence of biochemical recurrence (BCR), positive surgical margins (PSM), and perioperative complications. The Kruskall-Wallis test, the t test and the Mann-Whitney tests were used when appropriate. RESULTS: 603 patients underwent NS RARP and 484 patients were evaluated for Pentafecta outcomes. Median postsurgical follow-up was 28 months. Overall, 137 (22.7%), 376 (62.3%), and 90 (15%) patients were diagnosed in the low-, intermediate-, and high-risk groups, respectively. Patients undergoing NS RARP shifted from 33 to 20% in the low-risk group, from 52 to 62% in the intermediate-risk group, and from 10 to 13% in the high-risk group. Patients reaching Pentafecta increased from 38 to 44%. No postoperative potency was the main reason for non-achieving Pentafecta (71%). BCR strongly limited Pentafecta achievement in the high-risk group (61%), but not in intermediate (24%) and low-risk (30%) groups. CONCLUSIONS: Low-intermediate volume PCa centers show similar trends to high-volume centers regarding risk group distributions over time in PCa patients undergoing NS RARP. We reported an increase in Pentafecta outcomes achievement over time even for experienced surgeons. Pentafecta outcomes achievement is risk-group dependent.

Athermal versus ultrasonic nerve-sparing laparoscopic radical prostatectomy: a comparison of functional and oncological outcomes.

PURPOSE: Many urologists emphasize the concept of heat-related damage suggesting the avoidance of any energy to perform nerve-sparing radical prostatectomy. At our institution, both athermal and ultrasonic dissection have been used over the last years to perform a nerve-sparing laparoscopic radical prostatectomy (NSLRP). In this study, we compare functional and oncological outcomes of the two procedures. METHODS: All charts from patients undergoing NSLRP between January 2009 and June 2015 were reviewed. The International Index of Erectile Function (IIEF-5) was recorded preoperatively and 3, 12 and 24 months after surgery; continence was recorded at 3 and 12 months; PSA was recorded at last follow-up. Uni- and multivariate analyses were performed to assess the association of variables with functional and oncological outcomes. RESULTS: Ultrasonic NSLRP was used for 120 patients, while athermal NSLRP on 111. The impact of the cutting technique on erection recovery was different at 3 months, favoring athermal dissection (p = 0.002); however, significance was lost at 12 (p = 0.09) and 24 (p = 0.14) months. Continence recovery was comparable at 3 (p = 0.1) and 12 (p = 0.2) months; the rate of positive surgical margins and PSA recurrence were also similar (p = 0.2 and p = 0.06, respectively). At univariate analysis, age, Gleason sum, nerve-sparing laterality, and extension (intra- vs interfascial) were associated with overall erection recovery; only age and nerve-sparing laterality were independent predictors. Age and preoperative TRUS prostate volume were associated with continence recovery, both at uni- and multivariate analysis. CONCLUSIONS: The use of an ultrasonic device compared to athermal dissection during NSLRP does not affect long-term potency, nor continence and early biochemical recurrence.

Perineural invasion in prostate needle biopsy: Prognostic value on radical prostatectomy and active surveillance.

PURPOSE: The aim of this study was to evaluate the clinical impact of perineural invasion (PNI) in prostate biopsy in patients submitted to radical prostatectomy and on active surveillance (AS). MATERIALS AND METHODS: We performed a single center, retrospective, cohort study on patients diagnosed with clinically localized prostate cancer and submitted to radical prostatectomy between January 2010 and December 2016. We evaluated clinical and anatomopathological characteristics from the biopsy and radical prostatectomy specimen and correlated with biochemical recurrence (BCR) using a survival analysis. We also evaluated the impact of PNI in patients with criteria for active surveillance. RESULTS: The cohort analyzed consists of 107 patients, with a mean age of 63.1 years and a mean PSA prior to biopsy of 7.8 ng/ml. In prostate biopsy, 66.4% of the patients had a Gleason score of 6, 30.9% had a Gleason score of 7, and 2.7% had a Gleason score of 8 or higher, with PNI being detected in 57 (53.3%) of the patients. Regarding the anatomopathological characteristics of the surgical specimen, invasion of the seminal vesicles was observed in 6.5%, lymph nodes involvement in 9.3% and positive surgical margins in 27.1% of the cases. During follow-up, BCR was recorded in 24.3% of cases. Clinicopathological features were stratified according to the presence or absence of PNI, with statistical significance in relation to the Gleason Score (p = 0.001), pathologic T stage (p = 0.001), D'Amico risk (p = 0.002) and upstaging of the Gleason score (p = 0.045). The survival analysis revealed a relationship between PNI and BCR (hazard ratio = 2.98; 95% CI: 1.36-6.58; p = 0.007). Regarding the men potentially eligible for AS, the presence of PNI on the biopsy presented a significant relation with Gleason upgrade (p = 0.004) and extraprostatic extension (p = 0.017). CONCLUSIONS: The presence of PNI in prostate biopsy is related to adverse anatomopathological factors, being a potential predictor of BCR and have a possible role in the selection of patients for AS.

Apical peri-prostatic nerve block versus intra-rectal xylocaine gel for trans- rectal ultrasound guided prostate biopsy among Nigerian patients: A prospective randomized study.

AIMS: This study compared the analgesic effect of apical peri-prostatic block with that of intra-rectal xylocaine gel for trans-rectal ultrasound guided prostate biopsy (TRUS-PBx) in Nigeria. METHODS: This is a prospective randomized comparative study carried out over one year in University of Benin Teaching Hospital, Edo State, Nigeria. The participants were randomized into two groups; Group A had 10 mls of intra-rectal xylocaine gel instillation while Group B had apical infiltration of 10 mls of 1% xylocaine all before TRUS-PBx. RESULT: There was a statistically significant difference in the mean pain score during and one hour after TRUS-PBx between Group A and Group B of the study population respectively (p < 0.0001). Those that had intra-rectal xylocaine gel (Group A) had more pain during and after biopsy. There was no difference in the mean pain score during probe insertion between the two groups (p = 0.952). CONCLUSION: This study demonstrated the superiority of apical peri-prostatic nerve block over intra rectal xylocaine gel instillation during TRUS-PBx with respect to its anesthetic efficacy. Therefore, centers providing TRUS-PBx in Nigeria should consider apical peri-prostatic nerve block as their mode of anesthesia for the procedure due to its efficacy and high safety profile.

Impact of biopsy perineural invasion on younger prostate cancer patients after radical prostatectomy.

OBJECTIVES: To identify the potential indicators for higher-risk disease and poor outcome in younger prostate cancer (PCa) patients (age ≤ 50) who had undergone radical prostatectomy (RP) in the prostate-specific antigen (PSA) era. MATERIALS AND METHODS: A total of 186 PCa cases of age ≤ 50 who underwent RP between 2003 and 2010 at our center were included for study. High-risk disease after RP was defined as cases with pre-PSA ≥ 20 ng/ml and/or Gleason score (GS) ≥ 4 + 3 and/or pT stage ≥ 3. The poor outcome group was defined as cases with biochemical recurrence (BCR) and/or metastasis (Mets) and/or all-cause death. Multivariate logistic regression models were performed to identify independent risk factors for both high-risk disease and poor outcome. RESULTS: Among 186 younger PCa patients aged ≤ 50, 36 cases (19.5%) had high-risk disease and 24 cases (12.9%) had poor outcome. The presence of biopsy perineural invasion (BxPNI) was significantly associated with high-risk disease and showed a trend to correlate with worse outcome in univariate analysis. On multivariate logistic regression analysis, BxPNI was shown to be a significant independent risk factor with covariate of D'Amico for poor outcome (p = 0.047) and an independent risk factor with covariate of BxGPC for high-risk PCa excepting the variables to define high-risk disease (p = 0.013). Prognostically, cases with BxPNI showed a poor BCR-free survival in univariate analysis but did not reach significance (p = 0.063). CONCLUSION: Our results show that BxPNI could be considered as a risk classification factor to identify the best candidates among younger PCa patients for further treatment and may also be used for developing active surveillance (AS) selection criteria for younger PCa patients.

Detrusorrhaphy and Intrafascial Nerve-Sparing During Robot-Assisted Radical Prostatectomy on Recovery of Continence and Potency: Surgical Feasibility, One-Year Functional and Oncologic Outcomes.

PURPOSE: To report the 1-year functional outcomes, oncologic outcomes, and postoperative complications in patients who underwent modified robot-assisted radical prostatectomy (RARP) procedures for achieving early recovery of continence and potency postoperatively. MATERIALS AND METHODS: This study included 165 patients who underwent RARP. Overall, 98 patients underwent RARP using our modified detrusorrhaphy and intrafascial nerve-sparing techniques (group 1) and 67 underwent standard RARP (group 2). Continence and potency rates were assessed at 1 week, 1, 3, 6, and 12 months after RARP. Oncologic outcomes comprised positive surgical margins (PSMs) and biochemical recurrence (BCR) rate. RESULTS: The continence rates were 61.2% and 6.0%, 72.5% and 11.9%, 79.6% and 20.9%, 91.8% and 58.2%, and 97.9% and 74.6% at 1 week, 1, 3, 6, and 12 months in group 1 and 2, respectively. The potency rates were 66.3% and 11.9%, 78.6% and 38.8%, 85.7% and 50.8%, 92.9% and 70.2%, and 95.9% and 79.1% at 1 week, 1, 3, 6, and 12 months in group 1 and 2, respectively. Overall postoperative complication rates (< 10%) were similar between the  groups. The PSMs rate was 17.4% and 16.4% in the two groups. The rate of PSMs in the cohort of patients with stage pT2 disease decreased to 13.6% and 12.5% in groups 1 and 2,  respectively. BCR rate was 5.1% and 6.0% in groups 1 and 2, respectively. CONCLUSION: The use of detrusorrhaphy and intrafascial nerve-sparing techniques is safe and feasible, with our results demonstrating early return to continence and potency. Further studies should be conducted.