Urethral realignment with maximal urethral length and bladder neck preservation in robot-assisted radical prostatectomy: Urinary continence recovery.

PURPOSE:To evaluate early recovery of urinary continence after robot-assisted radical prostatectomy (RARP) with urethral realignment using bladder neck preservation (BNP) and maximal urethral length preservation (MULP). METHODS:Patients who underwent RARP between 2014 and 2017 owing to prostate cancer with a Gleason score ≤ 7 (3+4), ≤ cT2c stage, and prostate-specific antigen level < 20 ng/ml were investigated. Patients with tumors of the bladder neck or apex on magnetic resonance imaging were excluded. A total of 266 patients underwent the operation using the standard method between 2014 and 2015 (group 1), while 305 patients underwent urethral realignment between 2016 and 2017 (group 2). Continence was defined as wearing no pad or one security pad. RESULTS:The continence rates immediately after Foley catheter removal, at 2 weeks, and at 1, 3, 6, and 12 months after operation in group 2 were 46.9%, 63.0%, 73.4%, 90.1%, 94.8%, and 98.7%, respectively. The continence rate at 1 month in group 2 was significantly higher than that in group 1 (65.4% versus 73.4%, p = 0.037). The multivariate regression analysis showed that age and surgical method were factors affecting early continence recovery. The positive surgical margin rates were 18.0% and 14.8% in groups 1 and 2, respectively (p = 0.288). Biochemical recurrence occurred in 14.7% and 8.2% in groups 1 and 2, respectively (p = 0.015). CONCLUSION:Urethral realignment using BNP and MULP resulted in rapid continence recovery and good oncological results after RARP in young patients with a Gleason score ≤ 7 and organ-confined disease

Clinical significance and predictors of oncologic outcome after radical prostatectomy for invisible prostate cancer on multiparametric MRI

Abstract Background The objective of our study was to evaluate the clinical significance of invisible prostate cancer (iPCa) on multiparametric magnetic resonance imaging (mpMRI) by analyzing clinical parameters and oncologic outcomes. Methods We retrospectively reviewed the records of patients treated with radical prostatectomy (RP) from 2010 to 2015 at our institution. Before RP, all patients were confirmed to have prostate cancer based on prostate biopsy. We excluded patients who underwent neoadjuvant therapy. Additionally, we excluded patients who had incomplete mpMRI based on PI-RADS (Prostate Imaging Reporting and Data System). iPCa was defined as having no grade 3 or higher region of interests using a scoring system established by PI-RADS without limitations on interpretation from mpMRI by radiologists. We selected patients with iPCa using this protocol. We analyzed data using univariate and multivariate cox regression analysis, logistic analysis, Kaplan-Meier curves, and receiver operator characteristic curves to predict biochemical recurrence (BCR). Results A total of 213 patients with iPCa were selected according to the patient selection protocol. Among them, pathological findings showed that Gleason score (GS) G6, G7 and ≥ G8 were present in 115 cases (54.0%), 78 cases (36.6%), and 20 cases (9.4%), respectively. Further, extracapsular extension (ECE), positive surgical margins (PSM), and lymphovascular invasion (LVI) were present in 28 (13.1%), 18 (8.5%), and 3 cases (1.4%), respectively. Seminal vesicle invasion (SVI) was observed in one case (0.5%). During a median follow-up time of 51 months, BCR was observed 29 cases. Adverse pathology (AP) was defined as GS ≥8, ECE, SVI and LVI. AP and prostate specific antigen (PSA) were significantly associated with BCR. Moreover, PSA > 6.2 ng/ml was suggested as a cut-off value for predicting BCR. Conclusions In our results, cases of iPCa had clinically significant PCa, and AP and poor prognosis were also observed in some. Additionally, we found that PSA is the most clinically reliable predictor of oncologic outcome. We suggest that active treatment and diagnosis should be considered for patients with iPCa with PSA > 6.2 ng/ml

Clinical significance of multiparametric MRI and PSA density as predictors of residual tumor (pT0) following radical prostatectomy for T1a-T1b (incidental) prostate cancer.

PurposeThe aim of this study was to evaluate predictors of residual tumor and clinical prognosis in T1a-T1b (incidental) prostate cancer by analysis of specimens from men undergoing surgery for benign prostatic hyperplasia.Materials and methodsWe retrospectively reviewed medical records of incidental prostate cancer patients who had undergone radical prostatectomy. Patients whose tumor statuses were further confirmed by prostate biopsy, or who had used androgen deprivation therapy before radical prostatectomy, were excluded. Clinical and pathological parameters were analyzed to evaluate residual tumor and clinical prognosis. We used univariate and multivariate logistic regression analyses, as well as receiver operator characteristics, to predict residual tumor (pT0).ResultsThe final analysis included 95 patients. Among these patients, 67 (70.53%) exhibited residual tumor, whereas 28 (29.47%) did not (pT0). Pathology findings showed that 44 (65.67%), 16 (23.88%), and 7 patients (10.45%) exhibited Gleason scores of G6, G7, and ≥G8, respectively. Fifty-seven and 10 patients exhibited pathologic T stages T2 and T3, respectively. Mean follow-up duration was 70.26 (±34.67) months. Biochemical recurrence was observed in 11 patients; none were pT0 patients. Multivariate logistic regression showed that low prostate-specific antigen density after benign prostatic hyperplasia surgery and invisible lesion on multiparametric magnetic resonance imaging were significantly associated with pT0. Additionally, a combination of these factors showed an increase in the diagnostic accuracy of pT0, compared with mpMRI alone (AUC 0.805, 0.767, respectively); this combination showed sensitivity, specificity, and positive predictive values of 71.6%, 89.3%, and 94.1%, respectively.ConclusionOur results suggest that patients with incidental prostate cancer who have both prostate-specific antigen density ≤0.08 after benign prostatic hyperplasia surgery as well as invisible cancer lesion on multiparametric magnetic resonance imaging should be considered for active surveillance

Predictive Factors and Oncologic Outcome of Downgrade to Pathologic Gleason Score 6–7 after Radical Prostatectomy in Patients with Biopsy Gleason Score 8–10

Gleason score (GS) 8&#8211;10 is associated with adverse outcomes in prostate cancer (PCa). However, biopsy GS (bGS) may be upgraded or downgraded post-radical prostatectomy (RP). We aimed to investigate predictive factors and oncologic outcomes of downgrade to pathologic GS (pGS) 6&#8211;7 after RP in PCa patients with bGSs 8&#8211;10. We retrospectively reviewed clinical data of patients with bGS &#8805; 8 undergoing RP. pGS downgrade was defined as a pGS &#8804; 7 from bGS &#8805; 8 post-RP. Univariate and multivariate cox regression analysis, logistic regression analysis, and Kaplan&#8211;Meier curves were used to analyze pGS downgrade and biochemical recurrence (BCR). Of 860 patients, 623 and 237 had bGS 8 and bGS &#8805; 9, respectively. Post-RP, 332 patients were downgraded to pGS &#8804; 7; of these, 284 and 48 had bGS 8 and bGS &#8805; 9, respectively. Prostate-specific antigen (PSA) levels; clinical stage; and adverse pathologic features such as extracapsular extension, seminal vesicle invasion and positive surgical margin were significantly different between patients with pGS &#8804; 7 and pGS &#8805; 8. Furthermore, bGS 8 (odds ratio (OR): 0.349, p &lt; 0.001), PSA level &lt; 10 ng/mL (OR: 0.634, p = 0.004), and &#8804;cT3a (OR: 0.400, p &lt; 0.001) were identified as significant predictors of pGS downgrade. pGS downgrade was a significant positive predictor of BCR following RP in patients with high bGS (vs. pGS 8, hazard radio (HR): 1.699, p &lt; 0.001; vs. pGS &#8805; 9, HR: 1.765, p &lt; 0.001). In addition, the 5-year BCR-free survival rate in patients with pGS downgrade significantly differed from that in patients with bGS 8 and &#8805; 9 (52.9% vs. 40.7%, p &lt; 0.001). Among patients with bGS &#8805; 8, those with bGS 8, PSA level &lt; 10 ng/mL, and &#8804;cT3a may achieve pGS downgrade after RP. These patients may have fewer adverse pathologic features and show a favorable prognosis; thus we suggest that active treatment is needed in these patients. In addition, patients with high-grade bGS should be managed aggressively, even if they show pGS downgrade

Effect of prostate gland weight on the surgical and oncological outcomes of extraperitoneal robot-assisted radical prostatectomy

Abstract Background Robot-assisted radical prostatectomy (RARP) is performed by urologists as one of the surgical procedures for treating prostate cancer. Numerous studies have been published with regard to the impact of prostate weight on performing RARP but were limited by the insufficient number of patients and use of the transperitoneal approach. This study aimed to determine the effect of prostate gland weight on the surgical and short-term oncological outcomes of RARP using the extraperitoneal approach. Methods In total, 1168 patients who underwent extraperitoneal RARP (EP-RARP) performed by a single surgeon at Yonsei University Severance Hospital between May 2009 and May 2016 were included in the study. The patients were divided into 4 groups according to the prostate weight measured by transrectal ultrasonography preoperatively. Intraoperative and postoperative outcomes were analyzed retrospectively. One-way analysis of variance and the chi-square test were used in the statistical analyses. Results Age, the Gleason score, clinical stage, and pathological stage were significantly different. Patients with a larger prostate size had a longer console time and higher estimated blood loss (P  75 g, and if appropriate management is implemented for blood loss intraoperatively, EP-RARP can be performed regardless of the prostate size

Clinical Significance of Multiparametric Magnetic Resonance Imaging as a Preoperative Predictor of Oncologic Outcome in Very Low-Risk Prostate Cancer

Currently, multiparametric magnetic resonance imaging (mpMRI) is not an indication for patients with very low-risk prostate cancer. In this study, we aimed to evaluate the usefulness of mpMRI as a diagnostic tool in these patients. We retrospectively analyzed the clinical and pathological data of individuals with very low-risk prostate cancer, according to the NCCN guidelines, who underwent mpMRI before radical prostatectomy at our institution between 2010 and 2016. Patients who did not undergo pre-evaluation with mpMRI were excluded. We analyzed the factors associated with biochemical recurrence (BCR) using Cox regression model, logistic regression analysis, and Kaplan&ndash;Meier curve. Of 253 very low-risk prostate cancer patients, we observed 26 (10.3%) with BCR during the follow-up period in this study. The median follow-up from radical prostatectomy was 53 months (IQR 33&ndash;74). The multivariate Cox regression analyses demonstrated that the only factor associated with BCR in very low-risk patients was increase in the pathologic Gleason score (GS) (HR: 2.185, p-value 0.048). In addition, multivariate logistic analyses identified prostate specific antigen (PSA) (OR: 1.353, p-value 0.010), PSA density (OR: 1.160, p-value 0.013), and suspicious lesion on mpMRI (OR: 1.995, p-value 0.019) as the independent preoperative predictors associated with the pathologic GS upgrade. In our study, the pathologic GS upgrade after radical prostatectomy in very low-risk prostate cancer patients demonstrated a negative impact on BCR and mpMRI is a good prognostic tool to predict the pathologic GS upgrade. We believe that the implementation of mpMRI would be beneficial to determine the treatment strategy for these patients