Does mechanical morcellation of large glands compromise incidental prostate cancer detection on specimen analysis? A pathological comparison with open simple prostatectomy

The Role of Morcellation in En Bloc Resection of Large Bladder Tumors

Background/Objectives: Conventional transurethral resection of bladder tumor (TURBT) for non-muscle invasive bladder cancer (NMIBC) is usually performed in a piecemeal manner, leading to difficulties in accurate pathological assessment. En bloc resection of bladder tumor (ERBT) has been developed to address these limitations, offering improved specimen quality. So far, ERBT has been restricted to small bladder tumors due to difficulties in en bloc extraction of large ones (>3 cm). Recently, the morcellation technique has been proposed to facilitate the removal of large bladder tumors during ERBT. This narrative review aims to evaluate the feasibility of ERBT with subsequent morcellation for large bladder tumors, focusing on its role in tumor extraction and its impact on pathological assessment. Methods: A comprehensive literature search was conducted across multiple databases to identify studies evaluating the use of morcellation in ERBT for large bladder tumors. Inclusion criteria comprised studies reporting recurrence rates, detrusor muscle (DM) presence in pathological specimens, and perioperative complications. Additionally, we offered uropathologists a questionnaire to gather their perspectives on the use of morcellation following ERBT, focusing on its impact on pathological assessment, margin evaluation, and staging accuracy. Results: While there is limited evidence on the use of morcellation in ERBT for tumors larger than 3 cm and its impact on oncologic outcomes, morcellation has shown potential in facilitating the retrieval of large tumor specimens, ensuring clear resection margins and accurate staging. However, the learning curve for morcellation techniques and the need for specialized equipment may limit widespread adoption. Conclusions: Morcellation in ERBT for large bladder tumors represents a promising advancement in the management of these challenging cases, offering adequate pathological assessment and oncologic outcomes. Pathologists' reviews of morcellated specimens will likely further validate the technique. Continued research and technological innovations are necessary to optimize its implementation in clinical practice.

Predictive factors of incidental prostate cancer in patients undergoing surgery for presumed benign prostatic hyperplasia: an updated systematic review and meta-analysis

Purpose

We aimed to identify the clinical predictors of incidental prostate cancer (IPCa) after surgery for presumed benign prostatic hyperplasia (BPH).

Methods

The literature was comprehensively searched using PubMed, Web of Science, Embase, and Cochrane databases in December 2024. We used pooled standardized mean difference (SMD) and odds ratio (OR) to describe the correlation between relevant risk factors and IPCa.

Results

Twenty-one studies included 10,842 patients that were available for further analysis. After BPH surgery, 957 patients were histopathologically diagnosed with IPCa. The IPCa rate was 8.83%. Most importantly, our results identified that IPCa was significantly associated with age (pooled SMD = 0.36, P < 0.001), body mass index (BMI) (pooled SMD = 0.23, P < 0.001), preoperative prostate-specific antigen (pre-PSA) (pooled SMD = 0.43, P < 0.001), preoperative prostate-specific antigen density (pre-PSAD) (pooled SMD = 0.62, P = 0.028), resected prostate weight (pooled SMD = -0.22, P < 0.001), preoperative treatment with 5-alpha reductase inhibitors (5αRIs) (yes/no) (pooled OR = 0.60, P < 0.001), family history (yes/no) (pooled OR = 3.81, P = 0.029), digital rectal examination (DRE) findings (abnormal/normal) (pooled OR = 5.15, P < 0.001), and transrectal ultrasonography (TRUS) findings (abnormal/normal) (pooled OR = 2.92, P < 0.001). Additionally, sensitivity and subgroup analyses indicated that our findings were reliable and robust. However, we found no significant associations between IPCa and prostate volume, preoperative negative prostate biopsy, smoking history, history of hypertension, history of diabetes, history of dyslipidemia, and abnormal magnetic resonance imaging findings (all P > 0.05).

Conclusions

Age, BMI, pre-PSA, pre-PSAD, resected prostate weight, preoperative treatment with 5αRIs, family history, abnormal DRE findings, and abnormal TRUS findings are independent factors predicting IPCa following BPH surgery. Before BPH surgery, factors such as age, BMI, pre-PSA, and pre-PSAD should be considered to assess the risk of IPCa. For high-risk patients, more detailed imaging and needle biopsy are recommended before surgery to avoid missed diagnosis. In the future, more large-scale and well-designed studies are needed to validate our results further.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42025631346.

En bloc resection of large bladder tumor: is it feasible and reasonable?

PURPOSE OF REVIEW

Transurethral resection of bladder tumor (TURBT) remains the basis of bladder tumor diagnosis and an effective means of treating nonmuscle invasive bladder cancer (NMIBC). There are several limitations to this procedure: TURBT may cause free floating of malignant cells in the bladder and as a result re-implantation and early recurrence. Also, it does not allow the pathologist to define the correct spatial orientation of the specimen. The development of en bloc resection of bladder tumor (ERBT) has helped overcome the abovementioned key disadvantages of TURBT. However, many urologists doubt whether this approach is feasible for treating larger tumors.

RECENT FINDINGS

In this review, it is shown that ERBT of large bladder tumor (>3 cm) is in fact a feasible and well tolerated method. Although there is a lack of comparative data proving its advantages over TURBT, en bloc in large tumor seems to result in better local cancer control (due to higher prevalence of detrusor specimen, lower need for re-TURBT), lower rate of relapse outside the resection area (due to lower risk of tumor cells circulation), and higher quality of pathology specimen.

SUMMARY

Despite the skepticism of some surgeons, potential difficulties caused by larger tumor size may be overcome easily, and most agree that tumor size should not limit the implementation of the method in their daily practice.

Incidental prostate carcinoma after single-port robot-assisted simple prostatectomy: a multi-institutional report (SPARC)

BACKGROUND

Single-port robot-assisted simple prostatectomy is a minimally invasive alternative for patients with large benign prostatic hyperplasia with severe symptoms and/or failure of medical treatment. In recent literature, the rate of incidental prostate cancer after simple prostatectomy ranges from 1.8% to 13.0%. Our objective is to report the rate of incidental prostate cancer after single-port robot-assisted simple prostatectomy and to compare our findings to other approaches.

METHODS

A Single-Port Advanced Research Consortium [SPARC] multi-institutional retrospective analysis of all initial consecutive single-port robot-assisted simple prostatectomy cases performed from 2019 to 2023 by eleven surgeons from six centers. Our primary outcome was the rate of incidental prostate cancer in adenoma specimens. We used descriptive statistics to analyze the data.

RESULTS

A total of 235 cases were performed successfully without conversions or additional ports. Eleven patients (4.6%) were found to have incidental prostate cancer on pathological analysis. The median percentage of tissue involved by the tumor was 5%. The overall rate of clinically significant prostate cancer was 2.1%. Most cases were Gleason Grade Group 1 (55%). Those with Grade Group ≤3 were subsequently managed with active surveillance with a median follow-up of 17 months. A patient with Gleason Grade Group 4 underwent an uncomplicated multi-port robot-assisted radical prostatectomy with satisfactory functional and oncological outcomes.

CONCLUSIONS

Initial multi-institutional experience with single-port robot-assisted simple prostatectomy showed an incidental prostate cancer rate of 4.6%, comparable to MP, laparoscopic, and open techniques.

Single-port Transvesical Robot-Assisted Simple Prostatectomy: Surgical Technique and Clinical Outcomes

BACKGROUND

Surgical management of large prostatic adenomas can be performed via open, endoscopic, or robotic approaches. A low-profile single-port (SP) robot was built to work in confined areas (ie, the bladder) and regionalize surgery.

OBJECTIVE

To describe the novel SP transvesical (TV) robot-assisted simple prostatectomy (RASP) and report clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

SP TV RASP cases were performed in an academic hospital by two surgeons from 2019 to 2023. A total of 117 cases were performed, and data from patients with at least 12 mo of follow-up were analyzed. The inclusion criterion was severe obstructive urinary symptoms or catheter-dependent urinary retention due to large prostates with volume >80 ml.

SURGICAL PROCEDURE

The procedure consisted of two main steps through a single 3-cm suprapubic incision: first, enucleation of the adenoma, and second, a 360° bladder mucosal flap reconstruction. No drains or continuous bladder irrigation was used routinely.

MEASUREMENTS

Intraoperative parameters, pre- and postoperative uroflowmetry, and 1-yr clinical outcomes were assessed. We used descriptive statistics to analyze the data.

RESULTS AND LIMITATIONS

All procedures were completed successfully without additional ports or conversions. The median console time and estimated blood loss were 107 min and 100 ml, respectively. Transfusion rate was 0%. Intraoperative complications included two suspected air emboli attributed to high insufflation pressures. There were no major postoperative complications. In total, 95.8% were discharged within the first 24 h, with a median length of stay and pain score of 5 h and 3/10, respectively. There was persistent improvement in the median International Prostate Symptom Score and flow rate after 1 yr. The median Sexual Score Inventory for Men score was 20 at 12 mo. Our study is limited by its retrospective nature and cohort size.

CONCLUSIONS

SP TV RASP is a feasible alternative for the management of severe benign prostatic hyperplasia that promotes fast recovery and demonstrates 1-yr improvement in urinary function.

PATIENT SUMMARY

Single-port transvesical robot-assisted simple prostatectomy is a minimally invasive alternative for the treatment of large benign prostatic growth. A single robotic arm goes through a small incision in the skin and bladder to extract the obstructive prostatic tissue. Afterward, reconstruction of the area is done to decrease bleeding and improve postoperative symptoms. We found that patients recover quickly and have excellent clinical results with a low risk of complications.

Prevalence and risk factors of incidental prostate cancer in certain surgeries for benign prostatic hyperplasia: A systematic review and meta-analysis

BACKGROUND

This study aimed to explore the prevalence and clinical risk factors in patients diagnosed with incidental prostate cancer (IPC) during certain surgeries (transurethral resection of the prostate [TURP], open prostatectomy [OP], and holmium laser enucleation of the prostate [HoLEP]) after clinically suspected benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Literature search of the MEDILINE, Web of Science, Embase, and Cochrane Library databases was performed to identify eligible studies published before June 2021. Multivariate adjusted odds ratios (ORs) and associated 95% confidence intervals (CIs) of the prevalence and clinical risk factors of IPC were calculated using random or fixed-effect models.

RESULTS

Twenty-three studies were included in the meta-analysis. Amongst the 94.783 patients, IPC was detected in 24.715 (26.1%). Results showed that the chance of IPC detection (10%, 95% CI: 0.07-4.00; P<0.001; I2=97%) in patients treated with TURP is similar to that of patients treated with HoLEP (9%, 95% CI: 0.07-0.11; P<0.001; I2=81.4%). However, the pooled prevalence estimate of patients treated with OP was 11% (95% CI: -0.03-0.25; P=0.113; I2=99.1%) with no statistical significance. We observed increased incidence of IPC diagnosis after BPH surgery amongst patients with higher prostate-specific antigen (PSA) level (OR: 1.13, 95% CI: 1.04-1.23; P=0.004; I2=89%), whereas no effect of age (OR: 1.02, 95% CI: 0.97-1.06; P=0.48; I2=78.8%) and prostate volume (OR: 0.99, 95% CI: 0.96-1.03; P=0.686; I2=80.5%) were observed.

CONCLUSIONS

The prevalence of IPC was similar amongst patients undergoing TURP, HoLEP, and OP for presumed BPH. Interestingly, increased PSA level was the only independent predictor of increasing risk of IPC after BPH surgery rather than age and prostate volume. Hence, future research should focus on predictors which accurately foretell the progression of prostate cancer to determine the optimal treatment for managing patients with IPC after BPH surgery.

Is the systematic histological analysis of benign prostatic hyperplasia surgical specimen always necessary?

INTRODUCTION

After most surgical management of benign prostatic hyperplasia (BPH), the resected tissue undergoes a histological examination. This examination is performed for the risk of finding an incidental prostate cancer (iPCa). The improvement of prostate cancer detection in the past few years decreased the global iPCa rate. This raises the question of the real benefit for all patients of a systematic histological analysis. The aim of our study was to evaluate the iPCa detection rate on a large contemporary cohort of patients treated for BPH, and to define predictive factors of iPCa detection.

PATIENTS AND METHODS

We retrospectively analyzed the medical charts of all consecutive patients who underwent surgical treatment for BPH in our academic center from 2012 to 2018. Patients with prostate cancer diagnosed before surgery were not included. All the resected tissue underwent standard histopathological examination. iPCa was defined by any grade or stage of prostate cancer identified on the resected tissue by the histological examination. The following variables were analyzed using an uni- and multi-variable logistic regression as potential risk factors of iPCa: age, total PSA, PSA density (PSAd), prostate volume, technique used, weight of resected tissue and use of 5ARI medication.

RESULTS

1045 patients were included in the study. Of them, 439 (42.0%), 206 (19.7%) and 400 (38.3%) underwent HoLEP, OP and TURP, respectively. iPCa was diagnosed in 94 (9.0%) of the 1045. Among them 15 (1.4%) were clinically significant (ISUP score ≥ 2). The multivariable logistic regression analysis identified age (p = 0.03) and PSA density (p < 0.001) as independent predictive factors for the detection of iPCa. Using the median of age and PSAd, we identified a population with 0% of iPCa in our cohort (age < 70 year-old and PSAd < 0.05 ng/mL/mL).

CONCLUSION

The global iPCa rate was 9% in this contemporary large cohort of patients who underwent surgical treatment for BPH, with 1.4% of clinically significant cancer. Age and PSAd were independent predictive factors to find iPCa. Patients younger than 70 with a PSAd < 0.05 ng/mL/mL had 0% of iPCA in our cohort. In this specific population, we could probably avoid a systematical histological examination of the resected tissue.

Identification of the metabolic signatures of prostate cancer by mass spectrometry-based plasma and urine metabolomics analysis

OBJECTIVE

Prostate cancer (PCa) is one of the most commonly diagnosed cancers among men which is associated with profound metabolic changes. Systematic analysis of the metabolic alterations and identification of new biomarkers may benefit PCa diagnosis and a deep understanding of the pathological mechanism. The purpose of this study was to determine the metabolic features of PCa.

METHODS

Plasma and urine metabolites from 89 prostate cancer (PCa) patients, 84 benign prostatic hyperplasia (BPH) patients, and 70 healthy males were analyzed using LC-MS/MS and GC-MS. The Orthogonalised Partial Least Squares Discriminant Analysis (OPLS-DA) was used to find the significantly changed metabolites. The clinical value of the candidate markers was examined by receiver operating characteristic curve analysis and compared with prostate-specific antigen (PSA).

RESULTS

Multivariate statistical analyses found a series of altered metabolites, which related to the urea cycle, tricarboxylic acid cycle (TCA), fatty acid metabolism, and the glycine cleavage system. Plasma Glu/Gln showed the highest predictive value (AUC = 0.984) when differentiating PCa patients from healthy controls, with a higher sensitivity than PSA (96.6% vs. 94.4%). Both Glu/Gln and PSA displayed a low specificity when differentiating PCa patients from BPH patients (<53.2%), while the combination of Glu/Gln and PSA can further increase the diagnostic specificity to 66.9%.

CONCLUSIONS

The present study showed the metabolic features of PCa, provided strong evidence that the amide nitrogen and the energy metabolic pathways could be a valuable source of markers for PCa. Several candidate markers identified in this study were clinically valuable for further assessment.

En bloc GreenLight laser enucleation of the prostate (GreenLEP): An in-depth look at the anatomical endoscopic enucleation of the prostate using a 532-nm lithium triborate laser

GreenLight laser enucleation of the prostate (GreenLEP) is an alternative endoscopic enucleation of the prostate (EEP) technique for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic obstruction (BPO). GreenLEP is an 'en bloc' EEP technique to remove the transitional zone tissue in one piece. The procedure is a combination of laser enucleation and blunt gentle mechanical dissection using the tip of the resectoscope. The advantage of mechanical dissection is that it allows for better visualisation of the capsule and in some cases makes the dissection a little faster. This procedure is performed with a 532-nm lithium triborate laser (GreenLight™ XPS 180 W generator, AMS), a 2090 side-firing fibre and a Piranha™ morcellator (Richard Wolf GmbH). We offer a review of the evolution of the technique including the most important technical aspects, complications, advantages/disadvantages, tips and tricks and a visual step by step guide to perform the GreenLEP technique. GreenLEP is one of the latest energy sources reported in the armamentarium of EEP techniques for the treatment of BPO. GreenLEP has previously demonstrated its feasibility, safety and similar short- to mid-term functional outcomes compared to surgical gold standards in the literature.

Accuracy of the preoperative PSA level for predicting clinically significant incidental transitional zone-prostate cancer before endoscopic enucleation of very large adenoma

OBJECTIVE

To analyse the accuracy of high preoperative PSA levels for predicting transitional zone incidental PCa (TZ-PCa) in men with very large prostates.

MATERIALS AND METHODS

Perioperative data from 375 consecutive patients who underwent endoscopic enucleation of the prostate (EEP) for benign prostatic obstruction between July 2013 and December 2018 were retrospectively reviewed. Patients were stratified into three groups according to the preoperative PSA level: low-PSA (< 4 ng/mL), intermediate-PSA (4 ≤ PSA < 10 ng/mL) and high-PSA (≥ 10 ng/mL). Men in each group were propensity score matched by age, 5α-reductase inhibitor (5-ARI) use, prostate volume and mpMRI. The TZ-PCa incidence rate was retrospectively compared by preoperative PSA level in a propensity score model including all predetermined variables.

RESULTS

Age, prostate volume, 5-ARI use were similar between patient groups. The median PSA levels in the low-, intermediate- and high-PSA groups were 3 [2.3; 3.4], 6.6 [5.3; 8.1] and 12.7 [11; 16.7] ng/mL, respectively. The median prostate volume was > 100 grams in all groups (108, 105 and 120 cc, respectively). The T1a-Gleason 6 incidental TZ-PCa rate was statistically comparable between the three groups (3.4, 5.1 and 8.6% in the low-, intermediate- and high-PSA groups, respectively). The detection rate of clinically significant TZ-PCa was low for preoperative PSA levels > 4 ng/mL (1.7%); with no difference between the intermediate- and high-PSA groups.

CONCLUSION

In men with large glands, the clinically significant incidental TZ-PCa detection rate was similar regardless of the preoperative PSA level stratum. Such details may help with patient counselling during BPH surgical management.