Extended pelvic lymph node dissection at the time of robot-assisted radical prostatectomy: Impact of surgical volume on efficacy and complications in a single-surgeon series

INTRODUCTION: We assessed the impact of surgical volume on perioperative outcomes and complications of robotic extended pelvic lymph node dissection (ePLND). METHODS: From November 2008 to October 2012, a total of 233 consecutive patients with intermediate- or high-risk clinically localized prostate cancer underwent robot-assisted radical prostatectomy (RARP) and ePLND by a single, experienced open and laparoscopic surgeon. Data were prospectively collected. Complications were classified according to the Modified Clavien System. Complications potentially related to ePLND were documented. The minimum follow-up was 3 months. To evaluate the impact of surgical volume on the results, 4 patient subgroups (subgroup 1: cases 1-59; 2: 60-117; 3: 118-175; 4: 176-233) were compared using the Chi-squared and Kruskal-Wallis tests. RESULTS: The mean (range) operative time for ePLND was 79 minutes (range: 48-144), with a steady performance over time (p = 0.784). The count of resected lymph nodes plateaued after 60 procedures (mean [range]: 13 [range: 6-32], 15 [range: 7-34], 17 [range: 8-41], 16 [range: 8-42] in Groups 1 to 4, respectively, p = 0.001). Tumour lymph node involvement was 12% in Groups 1 and 2, 7% in Group 3 and 9% in Group 4 (p = 0.075). Overall, 115 complications were reported in 98/233 patients (42%), with a significant decrease after 175 cases (p = 0.028). In Group 4, 3 patients reported an ePLND-related bleeding requiring open revision. Lymphoceles were detected in 10/233 patients (4.2%) and 1 patient (1.7%) in each of the Groups 2 to 4 required a percutaneous drainage. CONCLUSIONS: A surgeon with extensive experience is expected to achieve a safe learning curve for ePLND during RARP. A learning curve of 60 cases is suggested for optimal lymph node yield

Unexpected discovery of surgical gauze during a robotic radical prostatectomy identified as a capturing lymph node on magnetic resonance

Multiparametric magnetic resonance, plays a crucial role in several steps of the management of prostate cancer. Various factors could alter the interpretation and reduce the accuracy of MR. Among these the group of the retained surgical items, can produce serious implications for the health of patient, as well as medical-legal consequences. Here we report the case of a patient, with a prostate tumor, who performed a mp-MRI of the prostate, where it was reported as collateral finding, compatible thesis with lymphadenopathy. During robotic assisted radical prostatectomy, was found a gauze, which persisted asymptomatic, retained after a previous right inguinal hernioplast

Diagnostic value of qualitative and strain ratio elastography in the differential diagnosis of non-palpable testicular lesions

The purpose of this study was to evaluate prospectively the accuracy of qualitative and strain ratio elastography (SE) in the differential diagnosis of non-palpable testicular lesions. The local review board approved the protocol and all patients gave their consent. One hundred and six patients with non-palpable testicular lesions were consecutively enrolled. Baseline ultrasonography (US) and SE were correlated with clinical and histological features and ROC curves developed for diagnostic accuracy. The non-palpable lesions were all ≤1.5 cm; 37/106 (34.9%) were malignant, 38 (35.9%) were benign, and 31 (29.2%) were non-neoplastic. Independent risk factors for malignancy were as follows: size (OR 17.788; p = 0.002), microlithiasis (OR 17.673, p < 0.001), intralesional vascularization (OR 9.207, p = 0.006), and hypoechogenicity (OR, 11.509, p = 0.036). Baseline US had 89.2% sensitivity (95% CI 74.6-97.0) and 85.5% specificity (95% CI 75.0-92.8) in identifying malignancies, and 94.6% sensitivity (95% CI 86.9-98.5) and 87.1% specificity (95% CI 70.2-96.4) in discriminating neoplasms from non-neoplastic lesions. An elasticity score (ES) of 3 out of 3 (ES3, maximum hardness) was recorded in 30/37 (81.1%) malignant lesions (p < 0.001). An intermediate score of 2 (ES2) was recorded in 19/38 (36.8%) benign neoplastic lesions and in 22/31 (71%) non-neoplastic lesions (p = 0.005 and p = 0.001 vs. malignancies). None of the non-neoplastic lesions scored ES3. Logistic regression analysis revealed a significant association between ES3 and malignancy (χ2 = 42.212, p < 0.001). ES1 and ES2 were predictors of benignity (p < 0.01). Overall, SE was 81.8% sensitive (95% CI 64.8-92.0) and 79.1% specific (95% CI 68.3-88.4) in identifying malignancies, and 58.6% sensitive (95% CI 46.7-69.9) and 100% specific (95% CI 88.8-100) in discriminating non-neoplastic lesions. Strain ratio measurement did not improve the accuracy of qualitative elastography. Strain ratio measurement offers no improvement over elastographic qualitative assessment of testicular lesions; testicular SE may support conventional US in identifying non-neoplastic lesions when findings are controversial, but its added value in clinical practice remains to be proven

Qualitative assessment of contrast-enhanced ultrasound in differentiating clear cell renal cell carcinoma and oncocytoma

Background: We aimed to assess whether clear cell renal cell carcinoma (ccRCC) can be differentiated from renal oncocytoma (RO) on a contrast-enhanced ultrasound (CEUS). Methods: Between January 2021 and October 2022, we retrospectively queried and analyzed our prospectively maintained dataset. Renal mass features were scrutinized with conventional ultrasound imaging (CUS) and CEUS. All lesions were confirmed by histopathologic diagnoses after nephron-sparing surgery (NSS). A multivariable analysis was performed to identify the potential predictors of ccRCC. The area under the curve (AUC) was depicted in order to assess the diagnostic accuracy of the multivariable model. Results: A total of 126 renal masses, including 103 (81.7%) ccRCC and 23 (18.3%) RO, matched our inclusion criteria. Among these two groups, we found significant differences in terms of enhancement (homogeneous vs. heterogeneous) (p < 0.001), wash-in (fast vs. synchronous/slow) (p = 0.004), wash-out (fast vs. synchronous/slow) (p = 0.001), and rim-like enhancement (p < 0.001). On the multivariate logistic regression, heterogeneous enhancement (OR: 19.37; p = <0.001) and rim-like enhancement (OR: 3.73; p = 0.049) were independent predictors of ccRCC. Finally, these two variables had an AUC of 82.5% and 75.3%, respectively. Conclusions: Diagnostic imaging for presurgical planning is crucial in the choice of either conservative or radical management. CEUS, with its unique features, revealed its usefulness in differentiating ccRCC from RO

Cribriform pattern does not have a significant impact in Gleason Score ≥7/ISUP Grade ≥2 prostate cancers submitted to radical prostatectomy

The aim of this study was to correlate cribriform pattern (CP) with other parameters in a large prospective series of Gleason score ≥7/ISUP grade ≥2 prostate cancer (PC) cases undergoing radical prostatectomy (RP)

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

Simple Summary The indication for ePLND at the time of RP is based on a risk assessment of LNI through validated nomograms such as the MSKCC; Briganti 2012; Briganti 2017 and Briganti 2019. However, in daily practice, a relevant percentage of cases, including those with the high-risk disease, show no LNI at the final histopathological assay pathology (pN0) after ePLND. Furthermore, currently available evidence does not demonstrate the superiority of one nomogram over the others, and there is still lacking data to support the routine use of one predictive model over another, even in more aggressive diseases. Therefore, we evaluated the accuracy of the most used nomograms (MSKCC, Briganti 2012, Briganti 2017, and Briganti 2019) for predicting LNI and compared them in our sub-cohort of high-risk PC patients treated with ePLND. We found that the predictive performance of the four nomograms as well as their ability to avoid unnecessary ePLND, are virtually the same, even in high-risk PC patients. 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

Impact of uni- or multifocal perineural invasion in prostate cancer at radical prostatectomy

Background: Aim of this study was to correlate perineural invasion (PNI) with other clinical-pathological parameters in terms of prognostic indicators in prostate cancer (PC) cases at the time of radical prostatectomy (RP). Methods: Prospective study of 288 consecutive PC cases undergoing RP. PNI determination was performed either in biopsy or in RP specimens classifying as uni- and multifocal PNI. The median follow-up time was 22 (range, 6-36) months. Results: At biopsy PNI was found in 34 (11.8%) cases and in 202 (70.1%) cases at the time of surgery. Among those identified at RP 133 (46.1%) and 69 (23.9%) cases had uni- and multi-PNI, respectively. Presence of PNI was significantly (P<0.05) correlated with unfavorable pathological parameters such higher stage and grade. The percentage of extracapsular extension in PNI negative RP specimens was 18.6% vs. 60.4% of PNI positive specimens. However, the distribution of pathological staging and International Society of Urological Pathology (ISUP) grading did not vary according to whether PNI was uni- or multifocal. The risk of biochemical progression increased 2.3 times in PNI positive cases was significantly associated with the risk of biochemical progression (r=0.136; P=0.04). However, at multivariate analysis PNI was not significantly associated with biochemical progression [hazard ratio (HR): 1.87, 95% confidence interval (CI): 0.68-3.12; P=0.089]. Within patients with intermediate risk disease, multifocal PNI was able to predict cases with lower mean time to biochemical and progression free survival (chi-square 5.95; P=0.04). Conclusions: PNI at biopsy is not a good predictor of the PNI incidence at the time of RP. PNI detection in surgical specimens may help stratify intermediate risk cases for the risk of biochemical progression