Predictors of positive surgical margins after laparoscopic robot assisted radical prostatectomy

Anatomic Factors Associated with Complications After Radical Prostatectomy: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

The role of anatomical factors in predicting outcomes after radical prostatectomy (RP) remains unclear. This review aims to evaluate the impact of various anatomical factors on the perioperative outcomes of patients undergoing RP for localized prostate cancer (PCa).

METHODS

A comprehensive literature search was conducted through January 2024 using the PubMed/Medline, Embase, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. Data were extracted and pooled for a meta-analysis, with outcomes including operative time, blood loss, transfusion rates, overall complications, and positive surgical margins (PSMs). Heterogeneity was assessed using Cochrane Q test, and subgroup analyses were conducted to explore the influence of surgical approach.

KEY FINDINGS AND LIMITATIONS

A total of 91 studies met our inclusion criteria. Among the anatomical factors, prostate volume (PV), prostate weight, and median lobe (ML) were suitable for the meta-analysis. Larger prostates were associated with increased operative time, blood loss, and complication rates, but with fewer PSMs (all p < 0.05). ML presence was not associated with a higher risk of complications. Heterogeneity was high across studies (Cochrane Q tests <0.05), reflecting inconsistent definitions and methods. In subgroup analyses, the open approach was associated with a longer operative time than robotic surgery for large prostates (p = 0.03) and a lower PSM rate (p < 0.001).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Anatomical factors, particularly PV, play a significant role in RP outcomes. Larger prostates are associated with higher complication rates but fewer PSMs. Further research with standardized outcome measures is necessary to clarify these relationships and guide clinical decision-making.

PATIENT SUMMARY

In this study, we examined how a patient's individual anatomy might affect the results of prostate surgery for cancer. We found that larger prostates tend to lead to longer surgeries and increased blood loss, but these also have a lower risk of leaving cancer cells behind. These findings could help doctors in better planning surgeries and improving patient outcomes.

Effects of Bony Pelvic and Prostate Dimensions on Surgical Difficulty of Robot-Assisted Radical Prostatectomy: An Original Study and Meta-analysis

BACKGROUND

Due to the deep location of the prostate within the pelvic cavity, procedures of robot-assisted radical prostatectomy (RARP) might be challenged by the prostate size and the limited pelvic cavity space. This study aimed to investigate the roles of bony pelvic and prostate dimensions in RARP procedures by an original study coupled with a meta-analysis.

METHODS

In the original study, patients undergoing multiport RARP between 2021 and 2022 were consecutively assessed. The associations of anatomic features with operative time (OT), estimated blood loss (EBL), and positive surgical margin (PSM) were evaluated using linear and logistic regression analyses as well as restricted cubic spline (RCS) analysis. Based on machine-learning algorithms, this study established predictive models for surgical difficulty and interpreted the model using SHapley Additive exPlanation (SHAP). In the meta-analysis, three databases were searched for eligible studies. Quantitative syntheses were subsequently performed.

RESULTS

Overall, 219 patients were enrolled in the original study. Prostate volume (PV) and the prostate volume-to-pelvic cavity index (PCI) ratio (PV-to-PCI ratio) were significantly associated with longer OT (P < 0.05). In the RCS models, U-shaped associations were observed between the prostate anteroposterior diameter (PAD) and OT, and between the prostate height (PH) and EBL, and an L-shaped association was observed between the anteroposterior diameter of the pelvic inlet (API) and EBL. The XGBoost model was superior to the logistic regression model in predicting prolonged OT. The meta-analysis demonstrated that greater PV was significantly associated with longer OT (β = 0.20; 95% confidence interval [CI] 0.12-0.27; odds ratio [OR] = 1.05; 95% CI 1.00-1.11), and a smaller PV could increase the risk of PSM (OR = 0.82; 95% CI 0.77-0.88).

CONCLUSIONS

A large prostate within a narrow and deep pelvis might suggest increased surgical difficulty of RARP. The size of the pelvic inlet also had a great impact on RARP. For PAD and PH, there seemed to be an optimal range with the lowest surgical difficulty. Machine-learning models based on the XGBoost algorithm could be successfully applied to predict the surgical difficulty of RARP.

Prediction of extracapsular extension of prostate cancer by MRI radiomic signature: a systematic review

The objective of this review is to survey radiomics signatures for detecting pathological extracapsular extension (pECE) on magnetic resonance imaging (MRI) in patients with prostate cancer (PCa) who underwent prostatectomy. Scientific Literature databases were used to search studies published from January 2007 to October 2023. All studies related to PCa MRI staging and using radiomics signatures to detect pECE after prostatectomy were included. Systematic review was performed according to Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA). The risk of bias and certainty of the evidence was assessed using QUADAS-2 and the radiomics quality score. From 1247 article titles screened, 16 reports were assessed for eligibility, and 11 studies were included in this systematic review. All used a retrospective study design and most of them used 3 T MRI. Only two studies were performed in more than one institution. The highest AUC of a model using only radiomics features was 0.85, for the test validation. The AUC for best model performance (radiomics associated with clinical/semantic features) varied from 0.72-0.92 and 0.69-0.89 for the training and validation group, respectively. Combined models performed better than radiomics signatures alone for detecting ECE. Most of the studies showed a low to medium risk of bias. After thorough analysis, we found no strong evidence supporting the clinical use of radiomics signatures for identifying extracapsular extension (ECE) in pre-surgery PCa patients. Future studies should adopt prospective multicentre approaches using large public datasets and combined models for detecting ECE.

CRITICAL RELEVANT STATEMENT

The use of radiomics algorithms, with clinical and AI integration, in predicting extracapsular extension, could lead to the development of more accurate predictive models, which could help improve surgical planning and lead to better outcomes for prostate cancer patients.

PROTOCOL OF SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021272088. Published: https://doi.org/10.1136/bmjopen-2021-052342 .

KEY POINTS

Radiomics can extract diagnostic features from MRI to enhance prostate cancer diagnosis performance. The combined models performed better than radiomics signatures alone for detecting extracapsular extension. Radiomics are not yet reliable for extracapsular detection in PCa patients.

Multimodal radiomics based on 18F-Prostate-specific membrane antigen-1007 PET/CT and multiparametric MRI for prostate cancer extracapsular extension prediction

OBJECTIVES

To compare the performance of the multiparametric magnetic resonance imaging (mpMRI) radiomics and 18F-Prostate-specific membrane antigen (PSMA)-1007 PET/CT radiomics model in diagnosing extracapsular extension (EPE) in prostate cancer (PCa), and to evaluate the performance of a multimodal radiomics model combining mpMRI and PET/CT in predicting EPE.

METHODS

We included 197 patients with PCa who underwent preoperative mpMRI and PET/CT before surgery. mpMRI and PET/CT images were segmented to delineate the regions of interest and extract radiomics features. PET/CT, mpMRI, and multimodal radiomics models were constructed based on maximum correlation, minimum redundancy, and logistic regression analyses. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) and indices derived from the confusion matrix.

RESULTS

AUC values for the mpMRI, PET/CT, and multimodal radiomics models were 0.85 (95% CI, 0.78-0.90), 0.73 (0.64-0.80), and 0.83 (0.75-0.89), respectively, in the training cohort and 0.74 (0.61-0.85), 0.62 (0.48-0.74), and 0.77 (0.64-0.87), respectively, in the testing cohort. The net reclassification improvement demonstrated that the mpMRI radiomics model outperformed the PET/CT one in predicting EPE, with better clinical benefits. The multimodal radiomics model performed better than the single PET/CT radiomics model (P < .05).

CONCLUSION

The mpMRI and 18F-PSMA-PET/CT combination enhanced the predictive power of EPE in patients with PCa. The multimodal radiomics model will become a reliable and robust tool to assist urologists and radiologists in making preoperative decisions.

ADVANCES IN KNOWLEDGE

This study presents the first application of multimodal radiomics based on PET/CT and MRI for predicting EPE.

The bladder neck preservation in robot assisted radical prostatectomy: Surgical and pathological outcome

INTRODUCTION

The post-prostatectomy incontinence is influenced by multiple elements, anatomic components and biological factors. The bladder neck preservation, more accurate during robot assisted radical prostatectomy, works on two anatomic components responsible for post-prostatectomy continence. The bladder neck preservation spares the internal sphincter, which is responsible for passive continence, and results in earlier return to continence and lower rates of post-prostatectomy incontinence. Moreover, this surgical technique spares the zone of urothelium coaptation and provides primary resistance to the urine to maintain postprostatectomy continence. The potential risk of bladder neck positive surgical margins (PSM) may prevent the usage of the bladder neck preservation.

AIM

The purpose of this study is to evaluate the surgical and pathological outcome in prostate cancer patients underwent robot assisted radical prostatectomy with bladder neck preservation.

MATERIALS AND METHODS

Prospectively, we have collected demographic, clinical, surgical and pathological data of prostate cancer patients underwent robot assisted radical prostatectomy with bladder neck preservation, from January 2014 to December 2016, in Urological Clinic of the University of Padua. Moreover, it was valued the presence of alterations or continuous solutions of specimen external capsule, attributable to the surgical technique of bladder neck preservation, by microscopic and macroscopic pathological analysis.

RESULTS

According to D'Amico risk classification, 40 patients (45.4%) had a low risk neoplasia, 35 patients (39.8%) had an intermediate risk neoplasia, 13 patients (14.8%) had an high risk neoplasia. The median prostatic volume, valued on specimen, was 30.84 cc (21.5-44.75 cc). The median prostatic weight, valued on specimen, was 51 gr (36-67 gr). The pathological stage of disease was pT2a in 11 cases (12.5%), pT2b in 37 cases (42.1%), pT3a in 28 cases (31.8%), pT3b in 12 cases (13.6%). The pathological stage of lymph node involvement was pNx in 17 cases (19.3%), pN0 in 66 cases (75%), pN1 in 5 cases (5.7%). The prostate cancers diagnosed had a Gleason score at specimen of 6 in 10 cases (10.4%), 7 (3+4) in 30 cases (34.1%), 7 (4+3) in 20 cases (22.7%), 8 in 19 cases (21.6%) and 9 in 9 cases (10.2%). The prostatic base was involved by neoplasia in 14 patients (15.9%); of these, 5 patients (35.7%) had bladder neck PSM. The patients with bladder neck PSM had: a pathological stage of disease as pT3a in 2 cases (40%) and pT3b in 3 cases (60%); a pathological stage of lymph node involvement as pN0 in 2 cases (40%) and pN1 in 3 cases (60%); a Gleason score at specimen of 8 in 3 cases (60%) and 9 in 2 cases (40%); multiple PSM. Nobody had alterations or continuous solutions of specimen external capsule, attributable to surgical technique of bladder neck preservation.

CONCLUSIONS

The bladder neck preservation, during robot assisted radical prostatectomy, is a safe oncological procedure resulting in a good functional outcome, about post-prostatectomy continence, working on two anatomic components responsible for post-prostatectomy continence. The bladder neck PSM are linked to neoplasia with adverse pathological features, rather than the bladder neck preservation.

Comprehensive analysis of predictive factors for upstaging in intraprostatic cancer after radical prostatectomy: Different patterns of spread exist in lesions at different locations

BACKGROUND

Accurate assessment of the clinical staging is crucial for determining the need for radical prostatectomy (RP) in prostate cancer (PCa). However, the current methods for PCa staging may yield incorrect results. This study aimed to comprehensively analyze independent predictors of postoperative upstaging of intraprostatic cancer.

METHODS

We conducted a retrospective analysis of data from intraprostatic cancer patients who underwent radical surgery between March 2019 and December 2022. Intraprostatic cancer was defined as a lesion confined to the prostate, excluding cases where multiparameter magnetic resonance imaging (mpMRI) showed the lesion in contact with the prostatic capsule. We assessed independent predictors of extraprostatic extension (EPE) and analyzed their association with positive surgical margin (PSM) status. In addition, based on the distance of the lesion from the capsule on mpMRI, we divided the patients into non-transition zone and transition zone groups for further analysis.

RESULTS

A total of 500 patients were included in our study. Logistic regression analysis revealed that biopsy Gleason grade group (GG) (odds ratio, OR: 1.370, 95% confidence interval, CI: 1.093-1.718) and perineural invasion (PNI) (OR: 2.746, 95% CI: 1.420-5.309) were predictive factors for postoperative EPE. Both biopsy GG and PNI were associated with lateral (GG: OR: 1.270, 95% CI: 1.074-1.501; PNI: OR: 2.733, 95% CI: 1.521-4.911) and basal (GG: OR: 1.491, 95% CI: 1.194-1.862; PNI: OR: 3.730, 95% CI: 1.929-7.214) PSM but not with apex PSM (GG: OR: 1.176, 95% CI: 0.989-1.399; PNI: OR: 1.204, 95% CI: 0.609-2.381) after RP. Finally, PNI was an independent predictor of EPE in the transition zone (OR: 11.235, 95% CI: 2.779-45.428) but not in the non-transition zone (OR: 1.942, 95% CI: 0.920-4.098).

CONCLUSION

PNI and higher GG may indicate upstaging of tumors in patients with intraprostatic carcinoma. These two factors are associated with PSM in locations other than the apex of the prostate. Importantly, cancer in the transition zone of the prostate is more likely to spread externally through nerve invasion than cancer in the non-transition zone.

Technical Tips in Managing Large Median Lobes During Robot-assisted Radical Prostatectomy

Prostate cancer surgeons are commonly faced by a technically challenging situation dealing with prostate cancer having large median lobes. Patients with large median lobes often have larger prostates, which makes it difficult to visualize anatomical planes during robot-assisted radical prostatectomy (RARP). Herein, we described our experience in dealing with large median lobes during RARP. We have focused on technical tips to avoid complications and facilitate a smooth procedure in patients with large median lobes during RARP. A total of 2671 patients who underwent RARP were divided into two groups based on the presence or absence of a protruded median lobe (PML): group A (2411 patients without a PML) and group B (260 patients with a PML). All patients underwent preoperative magnetic resonance imaging and final intraoperative confirmation for the presence of a PML. Pre-, intra-, and postoperative parameters were compared in two groups using the Student t test and two-proportion t test as appropriate. Patients in group B have statistically significantly higher median prostate-specific antigen (PSA; 7.7 vs 5.8 ng/dl), PSA density (0.17 vs 0.09), and International Prostate Symptom Score (19.5 vs 7.2); longer median console time (114 vs 134 min) and surgery time (145 vs 170 min); and higher blood loss (150 vs 175 ml) than those in group A. There were no statistically significant differences in pathological stages (T2, T3; 87%, 13% vs 88%, 12%) and rates of positive surgical margins (7% vs 8.5%) between groups A and B. Single-center and retrospective design was the major limitation of our study. We conclude that understanding the key steps to facilitate bladder neck dissection is vital to avoid serious intraoperative events and to maximize outcomes.

Patient summary

In this report, we looked at our robotic radical prostatectomy cohort with large median lobes. We found that surgery in these patients requires more time and blood loss, but similar cancer control. We conclude that following the key steps are important to avoid complications.

Machine Learning to Delineate Surgeon and Clinical Factors That Anticipate Positive Surgical Margins After Robot-Assisted Radical Prostatectomy

Purpose: Automated performance metrics (APMs), derived from instrument kinematic and systems events data during robotic surgery, are validated objective measures of surgeon performance. Our previous studies showed that APMs are strong outcome predictors of urinary continence after robot-assisted radical prostatectomy (RARP). We now use machine learning to investigate how surgeon performance (i.e., APMs) and clinical factors can predict positive surgical margins (PSMs) after RARP. Methods: We prospectively collected data of patients undergoing RARP at our institution from 2016 to 2019. Random Forest model predicted PSMs based on 15 clinical factors and 38 APMs from 11 standardized RARP steps. Out-of-bag Gini impurity index determined the top 10 variables of importance (VOI). APMs in the top 10 VOI were assessed for confounding effects by extracapsular extension (ECE) and pathologic T (pT) through Poisson regression with Generalized Estimating Equation. Results: 55/236 (23.3%) cases had PSMs. Of the 55 cases with PSMs, 9 (16.4%) were pT2 and 46 (83.6%), pT3. The full model, including clinical factors and APMs, achieved area under the curve (AUC) 0.74. When assessing clinical factors or APMs alone, the model achieved AUC 0.72 and 0.64, respectively. The strongest PSM predictors were ECE and pT stage, followed by APMs in specific steps. After adjusting for ECE and pT stage, most APMs remained as independent predictors of PSM. Conclusion: Using machine learning methods, we found that the strongest predictors of PSMs after RARP are nonmodifiable, disease-driven factors (ECE and pT). While APMs provide minimal additional insight into when PSMs may occur, they are nonetheless capable of independently predicting PSMs based on objective measures of surgeon performance.

Machine learning in predicting extracapsular extension (ECE) of prostate cancer with MRI: a protocol for a systematic literature review

INTRODUCTION

In patients with prostate cancer (PCa), the detection of extracapsular extension (ECE) and seminal vesicle invasion is not only important for selecting the appropriate therapy but also for preoperative planning and patient prognosis. It is of paramount importance to stage PCa correctly before surgery, in order to achieve better surgical and outcome results. Over the last years, MRI has been incorporated in the classical prostate staging nomograms with clinical improvement accuracy in detecting ECE, but with variability between studies and radiologist's experience.

METHODS AND ANALYSIS

The research question, based on patient, index test, comparator, outcome and study design criteria, was the following: what is the diagnostic performance of artificial intelligence algorithms for predicting ECE in PCa patients, when compared with that of histopathological results after radical prostatectomy. To answer this question, we will use databases (EMBASE, PUBMED, Web of Science and CENTRAL) to search for the different studies published in the literature and we use the QUADA tool to evaluate the quality of the research selection.

ETHICS AND DISSEMINATION

This systematic review does not require ethical approval. The results will be disseminated through publication in a peer-review journal, as a chapter of a doctoral thesis and through presentations at national and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42020215671.

Impact of previous transurethral resection of prostate on robot-assisted radical prostatectomy: a matched cohort analysis

We aimed to compare surgical, oncological, and functional outcomes of robot-assisted radical prostatectomy (RARP) in prostate cancer patients with and without prior history of transurethral resection of the prostate (TURP), using a matched cohort analysis. In an IRB-approved protocol, all patients who underwent RARP at our institution between April 2005 and July 2018 with at least 1-year follow-up were included. Among these, patients who had undergone a previous TURP (Group A) were compared with those without TURP (Group B) using the Survival, Continence, and Potency outcomes reporting system. Using propensity score matching for age, PSA and Gleason score, the two cohorts were further subdivided in a 1:2 ratio into Group C (prior TURP from Group A) and Group D (without prior TURP from Group B). Similar comparisons were made between Group C and D. Patients in Group A (n = 40) had lower PSA (p = 0.031) and were more likely to have Gleason grade 1 disease (p = 0.035) than patients in Group B (n = 143). In the propensity-matched group analysis, patients of Group C (n = 38) had higher operative time and blood loss than Group D (n = 76) patients. Group C patients also had lower continence at 3, 6, and 12 months after surgery. However, oncological and potency outcomes were similar in both the groups. We concluded that previous TURP is a predictor for surgical and continence outcomes following RARP. Even though these patients have a potentially lower stage or grade of disease, they are less likely to achieve social continence than men who have not had a previous TURP. This information would be important in counseling them for treatment options.

Prediction of a positive surgical margin and biochemical recurrence after robot-assisted radical prostatectomy

The positive surgical margin (PSM) and biochemical recurrence (BCR) are two main factors associated with poor oncotherapeutic outcomes after prostatectomy. This is an Asian population study based on a single-surgeon experience to deeply investigate the predictors for PSM and BCR. We retrospectively included 419 robot-assisted radical prostatectomy cases. The number of PSM cases was 126 (30.1%), stratified as 22 (12.2%) in stage T2 and 103 (43.6%) in stage T3. Preoperative prostate-specific antigen (PSA) > 10 ng/mL (p = 0.047; odds ratio [OR] 1.712), intraoperative blood loss > 200 mL (p = 0.006; OR 4.01), and postoperative pT3 stage (p < 0.001; OR 6.901) were three independent predictors for PSM while PSA > 10 ng/mL (p < 0.015; hazard ratio [HR] 1.8), pT3 stage (p = 0.012; HR 2.264), International Society of Urological Pathology (ISUP) grade > 3 (p = 0.02; HR 1.964), and PSM (p = 0.027; HR 1.725) were four significant predictors for BCR in multivariable analysis. PSMs occurred mostly in the posterolateral regions (73.8%) which were associated with nerve-sparing procedures (p = 0.012) while apical PSMs were correlated intraoperative bleeding (p < 0.001). A high ratio of pT3 stage after RARP in our Asian population-based might surpass the influence of PSM on BCR. PSM was less significant than PSA and ISUP grade for predicting PSA recurrence in pT3 disease. Among PSM cases, unifocal and multifocal positive margins had a similar ratio of the BCR rate (p = 0.172) but ISUP grade > 3 (p = 0.002; HR 2.689) was a significant BCR predictor. These results indicate that PSA and pathological status are key factors influencing PSM and BCR.

Comparative effectiveness of robotic and open radical prostatectomy

Radical prostatectomy (RP) has undergone a remarkable transformation from open to minimally-invasive surgery over the last two decades. However, it is important to recognize there is still conflicting evidence regarding key outcomes. We aimed to summarize current literature on comparative effectiveness of robotic and open RP for key outcomes including oncologic results, health-related quality of life (HRQOL) measures, safety and postoperative complications, and healthcare costs. The bulk of the paper will discuss and interpret limitations of current data. Finally, we will also highlight future directions of both surgical approaches and its potential impact on health care delivery.

Predictive Factors for Positive Surgical Margins in Patients With Prostate Cancer After Radical Prostatectomy: A Systematic Review and Meta-Analysis

Background and Objectives

Previous studies have demonstrated that positive surgical margins (PSMs) were independent predictive factors for biochemical and oncologic outcomes in patients with prostate cancer (PCa). This study aimed to conduct a meta-analysis to identify the predictive factors for PSMs after radical prostatectomy (RP).

Methods

We selected eligible studies via the electronic databases, such as PubMed, Web of Science, and EMBASE, from inception to December 2020. The risk factors for PSMs following RP were identified. The pooled estimates of standardized mean differences (SMDs)/odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. A fixed effect or random effect was used to pool the estimates. Subgroup analyses were performed to explore the reasons for heterogeneity.

Results

Twenty-seven studies including 50,014 patients with PCa were eligible for further analysis. The results showed that PSMs were significantly associated with preoperative prostate-specific antigen (PSA) (pooled SMD = 0.37; 95% CI: 0.31–0.43; P < 0.001), biopsy Gleason Score (<6/≥7) (pooled OR = 1.53; 95% CI:1.31–1.79; P < 0.001), pathological Gleason Score (<6/≥7) (pooled OR = 2.49; 95% CI: 2.19–2.83; P < 0.001), pathological stage (<T2/≥T3) (pooled OR = 3.90; 95% CI: 3.18–4.79; P < 0.001), positive lymph node (PLN) (pooled OR = 3.12; 95% CI: 2.28–4.27; P < 0.001), extraprostatic extension (EPE) (pooled OR = 4.44; 95% CI: 3.25–6.09; P < 0.001), and seminal vesicle invasion (SVI) (pooled OR = 4.19; 95% CI: 2,87–6.13; P < 0.001). However, we found that age (pooled SMD = 0.01; 95% CI: −0.07–0.10; P = 0.735), body mass index (BMI) (pooled SMD = 0.12; 95% CI: −0.05–0.30; P = 0.162), prostate volume (pooled SMD = −0.28; 95% CI: −0.62–0.05; P = 0.097), and nerve sparing (pooled OR = 0.90; 95% CI: 0.71–1.14; P = 0.388) had no effect on PSMs after RP. Besides, the findings in this study were found to be reliable by our sensitivity and subgroup analyses.

Conclusions

Preoperative PSA, biopsy Gleason Score, pathological Gleason Score, pathological stage, positive lymph node, extraprostatic extension, and seminal vesicle invasion are independent predictors of PSMs after RP. These results may helpful for risk stratification and individualized therapy in PCa patients.

Robotic radical prostatectomy: analysis of midterm pathologic and oncologic outcomes: A historical series from a high-volume center

Background

Identifying predictors of positive surgical margins (PSM) and biochemical recurrence (BCR) after radical prostatectomy (RP) may assist clinicians in formulating prognosis. Aim of the study was to report the midterm oncologic outcomes, to identify the risk factors for PSM and BCR and assess the impact of the PSM on BCR-free survival following robot-assisted laparoscopic radical prostatectomy (RALP).

Methods

From 2005 to 2010, 1679 consecutive patients underwent transperitoneal RALP. Data was retrospectively collected by an independent statistical company and analyzed in 2014. Median postoperative follow-up was 33.5 mo. BCR was defined as any detectable serum prostate-specific antigen (PSA) ≥ 0.2 ng/mL in two consecutive measurements. BCR-free survival was estimated using the Kaplan–Meier method. Univariate and multivariate analysis were applied to identify risk factors for PSM and BCR.

Results

In pN0/pNx cancers, pathologic stage was pT2 in 1186 patients (71.8%), pT3 in 455 patients (27.6%), and pT4 in 11 patients (0.6%). PSM rate was 17.4% and 36.9% of pT2 and pT3 cancers, respectively. Pathologic Gleason score was < 7, = 7 and > 7 in 42.1%, 53% and 4.9% of the patients, respectively. Overall BCR-free survival was 73.1% at 5 years; the 5-year BCR-free survival was 87.9% for pT2 with negative surgical margins. PSA, Gleason score (both bioptic and pathologic), pathologic stage (pT) and surgeon's volume were significant independent predictors of PSM. PSA, pathologic Gleason score, pT and PSM were significant independent predictors of BCR-free survival. Seminal vesicle-sparing, nerve-sparing approach and the extent of nerve-sparing (intra vs interfascial dissection) did not negatively affect margin status or BCR rates.

Conclusions

PSMs are a predictor of BCR. Being the only modifiable factor influencing the PSM rate, surgical experience is confirmed as a key factor for high-quality oncologic outcomes.

Is "extreme" bladder neck preservation in robot-assisted radical prostatectomy a safe procedure?

INTRODUCTION

The aim was to investigate the surgical and pathological outcomes of an "extreme" bladder neck preservation in prostate cancer patients treated with robotic radical prostatectomy. The greatest concern about the "extreme" bladder neck preservation is the potential risk of creating a positive surgical margin at the level of bladder neck.

MATERIALS AND METHODS

We prospectively collected data from 88 patients with diagnosed prostate cancer who underwent robotic radical prostatectomy with "'extreme' bladder neck preservation." All surgical procedures were performed by the same expert surgeon (F.D.M.). In this study, "'extreme' bladder neck preservation" was considered when the length of the spared intraprostatic segment of bladder neck was ⩾1 cm. We compared the histopathologic data with those of a homogeneous similar cohort of 88 consecutive patients who underwent robotic radical prostatectomy without bladder neck preservation.

RESULTS

The two groups analyzed were comparable according to clinical and pathological characteristics. A positive surgical margin at the level of bladder neck was found in five (5.7%) cases in the "extreme" bladder neck preservation group and in six cases (6.8%) in the no-bladder neck preservation group. The prostatic base was involved by neoplasia in 14 and 19 patients (15.9% and 21.6%, respectively); of these, five (35.7%) and six (31.6%) had positive surgical margin at the level of bladder neck, respectively. The pathological staging in positive surgical margin at the level of bladder neck patients was pT3 in five (100%) cases in the "extreme" bladder neck preservation group and in four (66.7%) cases when we decided not to preserve the bladder neck.

CONCLUSION

We demonstrated that "extreme" bladder neck preservation is a safe oncological procedure with similar pathologic findings of a comparable no-bladder neck preservation series. Positive surgical margins at the level of bladder neck are linked to neoplasia with adverse pathological features, rather than the "extreme" bladder neck preservation procedure.

Linear extent of positive surgical margin impacts biochemical recurrence after robot-assisted radical prostatectomy in a high-volume center

The objective of this study is to evaluate if surgeon volume and stratifying positive surgical margins (PSM) into focal and non-focal may differentially impact the risk of biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP). Between January 2013 and December 2017, 732 consecutive patients were evaluated. The population included negative cases (control group) and PSM subjects (study group). PSMs were stratified as focal (≤ 1 mm) or non-focal (> 1 mm). A logistic regression model assessed the independent association of factors with the risk of PSM. The risk of BCR of PSM and other factors was assessed by Cox's multivariate proportional hazards. Overall, 192 (26.3%) patients had PSM focal in 133 patients; non-focal in 59 cases. Focal PSM was associated with the percentage of biopsy positive cores (BPC; OR 1.011; p = 0.015), extra-capsular extension (pT3a stage; OR 2.064; p = 0.016), seminal vesicle invasion (pT3b; OR 2.150; p = 0.010), body mass index (odds ratio, OR 0.914; p = 0.006), and high surgeon volume (OR 0.574; p = 0.006). BPC (OR 1.013; p = 0.044), pT3a (OR 4.832; p < 0.0001) and pT3b stage (OR 5.153; p = 0.001) were independent predictors of the risk of non-focal PSM. Surgeon volume was not a predictor of non-focal PSM (p = 0.224). Independent factors associated with the risk of BCR were baseline PSA (hazard ratio, HR 1.064; p = 0.004), BPC (HR 1.015; p = 0.027), ISUP biopsy grade group (BGG) 2/3 (HR 2.966; p 0.003) and BGG 4/5 (HR 3.122; p = 0.022) pathologic grade group 4/5 (HR 3.257; p = 0.001), pT3b (HR 2.900; p = 0.003), and non-focal PSM (HR 2.287; p = 0.012). Surgeon volume was not a predictor of BCR (p = 0.253). High surgeon volume is an independent factor that lowers the risk of focal PSM. Surgeon volume does not affect non-focal PSM and BCR. Negative as well as focal PSM are not associated with BCR.

Comparison of outcomes of salvage robot-assisted laparoscopic prostatectomy for post-primary radiation vs focal therapy

OBJECTIVES

To compare salvage robot-assisted laparoscopic prostatectomy (RALP) outcomes in patients who underwent radiation and those who underwent focal ablation as primary therapies.

PATIENTS AND METHODS

We evaluated 126 patients who underwent salvage RALPbetween 2008 and 2018. Of these, 94 (74.6%) received radiation and 32 focal ablation (25.4%) as primary therapy. These groups were compared with regard to clinical, oncological and functional outcomes. Kaplan-Meier curves and regression models were used to identify survival estimations and their predictors.

RESULTS

Before surgery, more patients were potent in the focal ablation group compared to the radiation group (46.9% vs 22.6%; P = 0.013). Peri-operative characteristics and complication rates were not significantly different between the two groups. Postoperative catheterization duration was shorter in the focal ablation group (mean 10 vs 16 days; P = 0.018). At final pathology, the focal ablation group had higher non-organ-confined disease (71% vs 50%; P = 0.042) and positive surgical margin (PSM) rates (43.8% vs 17%; P = 0.004) as compared to the radiation group; however, 5-year biochemical recurrence (BCR)-free survival rates were similar (59% vs 56%; P = 0.761). Postoperative 1-year full (no pads/day) and social (0-1 pad/day) continence rates were significantly higher in the focal ablation as compared to the radiation group (77.3% vs 39.2%, P = 0.002, and 87.5% vs 51.3%, P = 0.002, respectively). Multivariate analyses showed primary focal ablation and nerve-sparing to be predictors of postoperative continence. Erectile function was preserved in 13% and 27% of preoperatively potent patients in the radiation and focal ablation groups, respectively (P = 0.435). No predictors were identified for postoperative potency.

CONCLUSIONS

Radiation was associated with inferior functional outcomes after salvage RALP. Focal therapies were associated with higher non-organ-confined disease and PSMrates, with no significant difference in short-term BCR-free survival.

High surgeon volume and positive surgical margins can predict the risk of biochemical recurrence after robot-assisted radical prostatectomy

Background:

The aim of this study was to determine whether any clinical factors are independent predictors of positive surgical margins (PSM), and to assess the association of PSM and biochemical recurrence (BR) after robot-assisted radical prostatectomy (RARP).

Methods:

The population included cases with negative surgical margins (control group) and patients with PSM (study group). Tumor grade was evaluated according to the International Society of Urologic Pathology (ISUP) system. A logistic regression model assessed the independent association of factors with the risk of PSM. The risk of BR was assessed by Cox’s multivariate proportional hazards.

Results:

A total of 732 consecutive patients were evaluated. Extend pelvic lymph node dissection (ePLND) was performed in 342 cases (46.7%). Overall, 192 cases (26.3%) had PSM. The risk of PSM was positively associated with the percentage of biopsy positive cores (BPC; odds ratio, OR = 1.012; p = 0.004), extracapsular extension (pT3a; OR=2.702; p < 0.0001), invasion of seminal vesicle (pT3b; OR = 2.889; p < 0.0001), but inversely with body mass index (OR = 0.936; p = 0.021), and high surgeon volume (OR = 0.607; p = 0.006). Independent clinical factors associated with the risk of BR were baseline prostate-specific antigen (PSA; hazard ratio, HR = 1.064; p = 0.004), BPC (HR = 1.015; p = 0.027), ISUP biopsy grade group (BGG) 2/3 (HR = 2.966; p = 0.003), and BGG 4/5 (HR = 3.122; p = 0.022). Pathologic factors associated with the risk of BR were ISUP group 4/5 (HR = 3.257; p = 0.001), pT3b (HR = 2.900; p = 0.003), and PSM (HR = 2.096; p = 0.045).

Conclusions:

In our cohort, features related to host, tumor, and surgeon volume are associated with the risk of PSM, which is also an independent parameter predicting BR after RARP. The surgical volume of the operating surgeon is an independent factor that decreases the risk of PSM, and, as such, the risk of BR.

The impact of single positive surgical margin features on biochemical recurrence after robotic radical prostatectomy

OBJECTIVE

Parameters predictive of biochemical or clinical recurrence after Radical Prostatectomy (RP) were determined as pre-treatment PSA value, pathologic tumor stage, tumor grade and presence of Positive Surgical Margin (PSM), extracapsular extension and seminal vesicle invasion and the status of pelvic lymph nodes. The aim of our study is to evaluate the effect of additional features in patients undergoing RP in our clinic.

MATERIALS AND METHODS

We studied 556 RP operations performed between 2009 and 2016 for prostate cancer at this clinic. Preoperative and postoperative data of the patients were retrospectively reviewed. RP specimens were examined by two pathologists specialized in this subject. Of these patients, 78 (14.02%) patients with PSM were included in the study. The pathology slides of these patients were reassessed. The length of PSM (mm), localization (apex, basis and posterolateral) and Gleason pattern at this margin was determined and statistical correlations with BCR were calculated.

RESULTS

The mean follow-up after the RP of 41 patients included in the study was 37.4 ± 13.2 months. During the follow-up period of the patients, BCR was observed in 16 patients (39.02%). No statistically significant difference was observed in age and prostate volume between the groups with and without BCR development (p > 0.05). Preoperative PSA level was found to be statistically significantly higher in the group with BCR development compared to the group without recurrence (p = 0.004). In-group comparisons in each aforementioned Gleason score groups were performed in terms of BCR development and the preoperative Gleason score in the group with development of recurrence was found to be statistically significantly higher compared to the group without recurrence (p = 0.007). The length of the surgical margin was measured as 7.4 ± 4.4 mm in the BCR-developing group and 4.7 ± 3.8 mm in the no-BCR- developing group; it was statistically significantly higher in the group with development of recurrence (p = 0.03).

CONCLUSION

Length and location of the PSM and the Gleason score detected in the PSM region could not predict biochemical recurrence according to the results of this present study. However high preoperative PSA value is an independent prognostic factor for biochemical recurrence.

Surgeon volume and body mass index influence positive surgical margin risk after robot-assisted radical prostatectomy: Results in 732 cases

Objectives: To evaluate clinicopathological and perioperative factors associated with the risk of focal and non-focal positive surgical margins (PSMs) after robot-assisted radical prostatectomy (RARP).

Patients and methods: The study was retrospective and excluded patients who were under androgen-deprivation therapy or had prior treatments. The population included: negative SM cases (control group), focal and non-focal PSM cases (study groups). PSMs were classified as focal when the linear extent of cancer invasion was ≤1 mm and non-focal when >1 mm. The independent association of factors with the risk of focal and non-focal PSMs was assessed by multinomial logistic regression.

Results: In all, 732 patients underwent RARP, from January 2013 to December 2017. An extended pelvic lymph node dissection was performed in 342 cases (46.7%). In all, 192 cases (26.3%) had PSMs, which were focal in 133 (18.2%) and non-focal in 59 (8.1%). Independent factors associated with the risk of focal PSMs were body mass index (odds ratio [OR] 0.914; P = 0.006), percentage of biopsy positive cores (BPC; OR 1.011; P = 0.015), pathological extracapsular extension (pathological tumour stage [pT]3a; OR 2.064; P = 0.016), and seminal vesicle invasion (pT3b; OR 2.150; P = 0.010). High surgeon volume was a protective factor in having focal PSM (OR 0.574; P = 0.006). Independent predictors of non-focal PSMs were BPC (OR 1,013; P = 0,044), pT3a (OR 4,832; P < 0.001), and pT3b (OR 5,153; P = 0.001).

Conclusions: In high-volume centres features related to host, tumour and surgeon volume are factors that predict the risk of focal and non-focal PSMs after RARP.

Abbreviations: AJCC: American joint committee on cancer; AS: active surveillance; ASA: American society of anesthesiologists; BCR: biochemical recurrence; BMI: body mass index; BPC: percentage of biopsy positive cores; ePLND: extended lymph node dissection; H&E: haematoxylin and eosin; IQR, interquartile range; ISUP: international society of urologic pathology; LNI: lymph node invasion; LOS: length of hospital stay; mpMRI: multiparametric MRI; (c)(p)N: (clinical) (pathological) nodal stage; OR: odds ratio; OT: operating time; PSA-DT: PSA-doubling time; (P)SM: (positive) surgical margin; (NS)(RA)RP: (nerve-sparing) (robot-assisted) radical prostatectomy; RT: radiation therapy; (c)(p)T: (clinical) (pathological) tumour stage

Safety and Clinical Outcomes of Robot-Assisted Radical Prostatectomy in Kidney Transplant Patients: A Systematic Review

OBJECTIVE

To evaluate the safety and outcomes of robot-assisted radical prostatectomy (RARP) in renal transplant recipients (RTRs) based on available literature.

MATERIALS AND METHODS

A literature search was performed using PubMed, Embase, and Web of Science through "robot" AND "prostatectomy" AND "transplant." Three authors separately reviewed the records to select the relevant articles with any discrepancies solved by open discussion. Patient age, prostate-specific antigen, Gleason score, and tumor stage were recorded as well as intraoperative and postoperative complications, length of stay, surgical margin status, and disease recurrence, if provided. The operative techniques and modification/adjustments to standard port placements were also reviewed. We also include our case report in this review.

RESULTS

We retrieved 10 articles reporting clinical data on RARP for kidney transplant patients, including 5 case series (level 4) and 5 case reports (level 4). A total of 35 kidney transplant recipients undergoing RARP were analyzed in this systematic review, one case in our institution included. None of the cases had major technical difficulties precluding the operation. Technical modifications to the standard technique were described in 10 of the 11 articles specifically including modifications to port placement (54% of patients), development of the space of Retzius (60% of patients), and performance of lymphadenectomy. Mean operative time was 220 minutes. Perioperative complication rate was 17.1% (6 of 35 patients), with only one Clavien III or greater complication. The rate of positive surgical margins was found to be 31.4%. Data on biochemical recurrence revealed a combined rate of 18.1%.

CONCLUSIONS

RARP is technically feasible for treating localized prostate cancer in RTRs. Graft function did not deteriorate in any patient. Modifications to the standard technique should be considered specifically for port placement, development of the space of Retzius, and performance of lymphadenectomy. Oncologic outcomes remain difficult to interpret given the small number of reported cases.

Positive surgical margins and biochemical recurrence following minimally-invasive radical prostatectomy - An analysis of outcomes from a UK tertiary referral centre

Background

Positive surgical margins are a strong prognostic marker of disease outcome following radical prostatectomy, though prior evidence is largely from a PSA-screened population. We therefore aim to evaluate the biochemical recurrence in men with positive surgical margins (PSM) after minimally-invasive radical prostatectomy (MIRP) in a UK tertiary centre.

Methods

Retrospective study of men undergoing laparoscopic or robotic-assisted radical prostatectomy between 2002 and 2014. Men with positive surgical margins (PSM) were identified and their biochemical recurrence (BCR) rate compared with men without PSM. The primary outcome measures were BCR rates and time to BCR. Cox regression was used to estimate adjusted hazard ratios for biochemical recurrence rate (BCR), accounting for potential confounders.

Results

Five hundred ninety-two men were included for analysis. Pre-operative D’Amico risk stratification showed 37.5%, 53.3% and 9.3% of patients in the low, intermediate and high-risk groups, respectively. On final pathological analysis, the proportion of patients with local staging pT2, pT3a and pT3b was 68.8%, 25.2% and 6.1% respectively. Overall positive margin rate was 30.6%. On multivariate analysis, the only pre-operative factor associated with PSM was age >65years. Patients with PSM were more likely to have higher tumour volume and more advanced pathological local stage. The BCR rate was 10.7% in margin-positive patients and 5.1% in margin-negative patients, at median 4.4-year follow-up. Upon multivariate analysis, high pre-operative PSA and high Gleason group were the only significant predictors of BCR (P<0.05).

Conclusions

In comparison to patients with negative surgical margins, those with PSM do not translate into worse medium-term oncological outcomes in the majority of cases amongst our cohort. We found that high pre-operative PSA and high Gleason group were the only significant predictors of BCR.

Electronic supplementary material

The online version of this article (10.1186/s12894-017-0262-y) contains supplementary material, which is available to authorized users.

Preoperative characteristics of the P.R.O.S.T.A.T.E. scores: a novel predictive tool for the risk of positive surgical margin after radical prostatectomy

OBJECTIVES

To propose a novel scoring system to predict the risk of positive surgical margin (PSM) after radical prostatectomy (RP) in prostate cancer (PCa) patients.

MATERIALS AND METHODS

Eight reproducible variables available from preoperative characteristics of PCa patients were measured: PSA level (P), ratio of positive biopsy needles (R), obesity (O), scores of Gleason (S), T stage by preoperative MRI scan (T), age (A), tumor volume (T) and experience of the surgeon (E). Of the eight components, seven were scored on a 0-, 1- or 2-point scale, with only the "A" component on a 0- or 1-point scale. The P.R.O.S.T.A.T.E. scores can range from 0 to 15.

RESULTS

A total of 441 patients were included from the Peking University First Hospital between November 2007 and March 2016, among whom 195 patients (44.2%) had a PSM identified by a postoperative pathological examination. The preoperative P.R.O.S.T.A.T.E. scores statistically correlated with the postoperative SM status (p < 0.001) when the 441 consecutive patients were divided into three groups (low-risk group: score of 0-4, moderate-risk group: score of 5-9 and high-risk group: score of 10-15). The risk of PSM after RP in the low-risk, moderate-risk and high-risk groups was 21.1, 40.1 and 87.0%, respectively.

CONCLUSIONS

The novel scoring system of P.R.O.S.T.A.T.E. that we presented was found to predict the risk of PSM after RP. A combination of reproducible, standardized parameters obtained from preoperative characteristics of PCa patients can be used as a tool for predicting PSM, thus assisting in the strategy of performing surgical procedures. More careful manipulation or wider resection may be of utmost importance in the high-risk group.

Oncological results at 2 years after robotic radical prostatectomy - the Romanian experience

Introduction

To assess the oncological outcomes of robotic radical prostatectomy in a country where there are no on-going national screening programs for prostate cancer.

Material and methods

Between November 2009 and November 2014, 220 robotic radical prostatectomies were performed at our Robotic Surgery Center. We already have the complete data for the 2-year follow-up of the first 105 patients, who were therefore included in the study group. Pre-operative (age, prostate-specific antigen, body-mass index, prostate volume, clinical staging, biopsy characteristics), post-operative (surgical technique, surgical margin status, lymph node status, pathological stage, Gleason score) and follow-up parameters (biochemical recurrence) were assessed.

Results

The global rate of positive surgical margins was 34.3%, with rates of 17.2% in stage pT2 and 55.3% in stage pT3. The most frequent localization for positive surgical margins was at the base and apex of the prostate. The positive surgical margins rate was correlated with the pre-operative prostate-specific antigen, clinical and pathological Gleason score, lymph node status and the number of positive biopsy cores. The rate of biochemical recurrence at the 2-year follow-up was 11.8%. The most important predictors for the biochemical recurrence were the positive surgical margins, pathological staging and Gleason score on the prostatectomy specimen.

Conclusions

Robotic surgery is validated by the oncological results at medium follow-up (2 years) for localized and locally advanced prostate cancer, even in countries where there is no on-going national screening program.

[RETROSPECTIVE ANALYSIS OF POSITIVE SURGICAL MARGIN AT RADICAL PROSTATECTOMY]

We retrospectively reviewed 182 patients who underwent radical prostatectomy in our hospital between April, 2009 to December, 2012, and who had not received any prior hormonal therapy. We also excluded the patients who couldn't followed up more than 6 months after surgery and pN1 patients. Positive surgical margins were observed in 65 cases. We determined what were the significant factors associated with the margin status. The another aim of present study is to evaluate the risk factor which might have significance for biochemical recurrence. BMI ≥ 25.0, prostate volume < 40 cm3, and biopsy positive core ≥ 25% were significant predictors of positive surgical margin. PSA nadir ≥ 0.02 ng/ml and pT3 were the significant factors which associated with biochemical recurrence of those patients with positive margin status.

Predictive preoperative factors for positive surgical margins in robotic radical prostatectomy in low-risk prostate cancer

OBJECTIVE

Positive surgical margins after radical prostatectomy for localized prostate cancer is a powerful predictor of PSA recurrence. Clinical stage, Gleason score and preoperative PSA are predictive factors for positive surgical margin after radical prostatectomy. In this study, we aimed to identify preoperative factors affecting surgical margin positivity in low-risk prostate cancer after robotic radical prostatectomy (RARP).

MATERIAL AND METHODS

Between 2008 and 2011 (<cT2b, PSA <10, Gleason <7), data from 112 patients with low-risk (<cT2b, PSA <10, Gleason <7), prostate cancer who had undergone RARP were examined prospectively. The effects of PSA, body mass index, surgery time after biopsy, percentage of positive cores, tumor length and prostate weight on positive surgical margin were evaluated. For statistical analyses, Mann-Whitney U, Pearson chi-square and logistic regression tests were used.

RESULTS

It was observed that mean age and body mass index had no effect on positive surgical margins (p=0.2 and 0.6). According to univariate analysis, it was found that an elapsed time of less than six weeks from biopsy to surgery (p=0.07), tumor percentage of more than 5% in a biopsy specimen (p=0.003), a positive core percentage of more than 20% (p=0.045) and a prostate volume below 50 cc (p=0.037) increased the rate of positive surgical margins. Based on multivariate analysis, PSA levels above 5 ng/mL (OR: 8.006, p=0.012) and an elapsed time of less than 6 weeks between biopsy and surgery (OR: 10.814, p=0.029) increased the risk of positive surgical margins.

CONCLUSION

In low-risk prostate cancer, a waiting time of less than six weeks between biopsy and surgery and PSA levels above 5 ng/mL are predictive of high surgical margin positivity after robotic radical prostatectomy.

Number of positive preoperative biopsy cores is a predictor of positive surgical margins (PSM) in small prostates after robot-assisted radical prostatectomy (RARP)

OBJECTIVE

To determine the impact of prostate size on positive surgical margin (PSM) rates after robot-assisted radical prostatectomy (RARP) and the preoperative factors associated with PSM.

PATIENTS AND METHODS

In all, 1229 men underwent RARP by a single surgeon, from 2005 to August of 2013. Excluded were patients who had transurethral resection of the prostate, neoadjuvant therapy, clinically advanced cancer, and the first 200 performed cases (to reduce the effect of learning curve). Included were 815 patients who were then divided into three prostate size groups: <31 g (group 1), 31-45 g (group 2), >45 g (group 3). Multivariate analysis determined predictors of PSM and biochemical recurrence (BCR).

RESULTS

Console time and blood loss increased with increasing prostate size. There were more high-grade tumours in group 1 (group 1 vs group 2 and group 3, 33.9% vs 25.1% and 25.6%, P = 0.003 and P = 0.005). PSM rates were higher in prostates of <45 g with preoperative PSA levels of >20 ng/dL, Gleason score ≥7, T3 tumour, and ≥3 positive biopsy cores. In group 1, preoperative stage T3 [odds ratio (OR) 3.94, P = 0.020] and ≥3 positive biopsy cores (OR 2.52, P = 0.043) were predictive of PSM, while a PSA level of >20 ng/dL predicted the occurrence of BCR (OR 5.34, P = 0.021). No preoperative factors predicted PSM or BCR for groups 2 and 3.

CONCLUSION

A preoperative biopsy with ≥3 positive cores in men with small prostates predicts PSM after RARP. In small prostates with PSM, a PSA level of >20 ng/dL is a predictor of BCR. These factors should guide the choice of therapy and indicate the need for closer postoperative follow-up.

Risk factors for biochemical recurrence after robotic assisted radical prostatectomy: a single surgeon experience

Background

Radical prostatectomy is a standard surgical treatment of clinically localized prostate cancer. Margin status has been found to be an independent predictor of biochemical recurrence (BCR) after open radical prostatectomy in several large series but this is still controversy in Robotic Assisted Radical Prostatectomy (RARP) series. We therefore wanted to investigate the prognostic significance of positive surgical margin (PSM) and other pathological factors on BCR in patients treated with RARP by a single surgeon.

Methods

Prospectively collected data of 439 patients treated with RARP between October 2005 and June 2013 by a single surgeon at a single institution were analyzed. BCR was defined as follow-up PSA level > 0.2 ng/ml on two separate occasions or patients who had to undergo salvage therapy. Kaplan Meier curves and Log Rank test were used to compare the risk of BCR. Univariate and Multivariate Cox Regression analyses were performed to determine the prognostic impact of age, BMI, prostate weight, PSA prior to surgery, pathological T-stage, pathological Gleason sum, PSM and operative period.

Results

In this study period, 34 out of 439 had BCR, giving an overall BCR rate of 7.7% for this cohort. Overall 2- and 3-year BCR-free survival rates were 93% and 88%, respectively. Patients with a PSM had a 2-year BCR free survival of 88% compared to 94% in those with negative margins (p < .0001). On the multivariate analysis, PSM as well as pathological Gleason sum > = 8, PSA, pathological stage and operative period were significantly associated with BCR.

Conclusions

In our case series of RARP performed by a single surgeon, PSM as well as pathological Gleason sum, PSA, pathological stage and early operative period for this surgeon were the independent predictors of BCR.

Electronic supplementary material

The online version of this article (doi:10.1186/s12894-015-0024-7) contains supplementary material, which is available to authorized users.

Incidence of positive surgical margins after robotic assisted radical prostatectomy: Does the surgeon's experience have an influence on all pathological stages?

OBJECTIVE

The aim of this study is to analyze the clinical and surgical features of patients who underwent robotic-assisted radical prostatectomy (RARP) at our institution, and the impact of the surgeon's experience in the oncological results related to pathological stage.

MATERIAL AND METHODS

An analysis of 300 RARP consecutively performed by the same urologist was conducted. Patients were divided into 3 groups of 100 patients in chronological order, according to surgery date. All patients had organ-confined clinical stage. Variables which could impact in positive margins rates were analyzed. Finally, positive surgical margins (PSM) in regard to pathological stage and surgeon's experience were compared and analyzed.

RESULTS

No significant differences were found in variables which could impact in PSM rates. The overall PSM rate was 21%, with 28% in the first group, 20% in the second, and 16% in the third (P = .108). Significant lineal decreasing tendency was observed (P = .024). In pT2 patients, the overall PSM rate was 16.6%, with 27%, 13.8%, and 7.3% in each group respectively (P = .009). A significant difference was found between group 1 and group 3 (P = .004). In pT3 patients, the surgeon's experience was not significantly associated with margin reductions with an overall PSM rate of 27.7% (28.2%, 28.6%, and 26.7% in each group respectively).

CONCLUSIONS

Clinical and surgical features in our patients did not vary over time. We found a significant reduction of PSM related to surgeon's experience in pT2 patients. Contrariwise, the margin status remained stable despite increasing experience in pT3 patients.

[Prostate cancer surgical margin: review by the CCAFU (Oncology Committee of the French Association of Urology)]

OBJECTIVE

Literature showed the impact of surgical margin status on prognosis after radical prostatectomy (mostly on biochemical survival). Margin status is an easy self-evaluation of surgical practice to assess. The aim of this paper was to define what a positive surgical margin (PSM) is and how to prevent the occurrence, to precise the impact on survival and how to treat.

METHOD

A literature analysis with Pubmed has been performed to 2012, furthermore conclusions of the main congresses with selection committee and review publication have also been studied.

RESULTS

PSM is defined as "tumor cells touching the ink on the specimen edge". The most frequent reported incidence is between 15 to 20%. Margin status remains one of the major criteria to determine the need of adjuvant radiotherapy after surgery. Quality of life is not or only lightly modified by radiotherapy with the current techniques. Adjuvant radiotherapy improves biological survival but is synonymous with overtreatment in many times. Salvage radiotherapy has to be quickly performed after Prostate Specific Antigen (PSA) relapse (PSA<1 ng/mL even<0.5 ng/mL).

CONCLUSION

This literature review did not allow to suggest superiority of one surgical technique over another. In the same way, the kind of dissection i.e. bladder neck or neurovascular bundle preservation does no clearly modify PSM rate. However, it seems logical to "customize" dissection according to prostate cancer characteristics (D'Amico criteria for instance) guided with multiparametric MRI. Intrafascial dissection has to be applied only to low risk. Lastly, the debate between adjuvant or salvage radiotherapy is always ongoing.

Do robotic prostatectomy positive surgical margins occur in the same location as extraprostatic extension?

PURPOSE

Positive surgical margins (PSMs) may reflect incomplete surgical resection, while extraprostatic extension (EPE) could suggest that complete tumor resection is more difficult. This study evaluated cases with both EPE and PSMs in robotic-assisted radical prostatectomy (RARP) specimens to determine the respective locations of each.

METHODS

A single institutional retrospective review of RARP performed between 2007 and 2009 was conducted to identify cases with both EPE and PSM. Prostates were entirely submitted and processed in whole mount format. All locations of EPE and PSM were recorded as was the size of the largest focus of EPE and PSM.

RESULTS

About 8.5 % (112/1,315) of RARP had both EPE and PSM. Analysis of cases with concurrent EPE and PSM revealed that EPE occurred most commonly in the mid-gland, particularly in the posterolateral mid-prostate. In contrast, PSM was most frequent at the base (bladder neck), specifically the anterior base. 51.8 % of the cases had EPE and PSM in discordant locations, 19.6 % had EPE and PSM in the same location, and 28.6 % had areas of EPE and PSM both in the same location as well as in different locations. Cases with both concordant and discordant locations of EPE and PSM had significantly more high-risk features including higher tumor volume, more frequent positive nodes, and more frequent Gleason score ≥ 8 compared to concordant or discordant subgroups.

CONCLUSION

PSMs frequently did not occur in the same location as EPE. A better understanding of where EPE and PSMs occur may help guide surgical technique to decrease residual tumor.

Comparison of oncological outcomes between retropubic radical prostatectomy and robot-assisted radical prostatectomy: an analysis stratified by surgical experience

OBJECTIVES

To compare oncological outcomes of a consecutive retropubic radical prostatectomy (RRP) and robot-assisted radical prostatectomy (RARP) series performed by a single surgeon who had performed >750 prior RRPs and was starting to perform RARPs.

MATERIALS AND METHODS

Prospectively collected longitudinal data of 277 RRP and 730 RARP cases over a 5-year period were retrospectively analyzed. The RARP series were divided into 3 subgroups (1st, <250 cases; 2nd, 250-500; and 3rd, >500) according to the surgical period. The positive surgical margin (PSM) and biochemical recurrence-free survival (BCRFS) rates were compared at each pathological stage.

RESULTS

The pT2 PSM rates showed no significant difference between the RRP (7.8%) and RARP series (1st, 9.5%; 2nd, 14.1%; and 3rd, 9.8%) throughout the study period (P = 0.689, 0.079, and 0.688, respectively). Although the pT3 PSM rates of the 1st (50.6%) and 2nd RARP series (50.0%) were higher than that of the RRP series (36.0%; P = 0.044 and P = 0.069, respectively), the 3rd RARP series had a comparable pT3 PSM rate (32.4%, P = 0.641). The 3-year BCRFS rates of the RRP and RARP series were similar at each pathological stage (pT2, 92.1 vs. 96.8%, P = 0.517; pT3, 60.0 vs. 67.3%, P = 0.265, respectively).

CONCLUSIONS

The pT2 PSM and short-term BCRFS rates were similar between RRP and RARP, and RARP showed comparable pT3 PSM rate with RRP after >500 cases of surgical experience. Our data suggest that an experienced robotic surgeon at a high-volume center may achieve comparable oncological outcomes with open prostatectomy even in locally advanced disease.

Perineural invasion as a predictor of extraprostatic extension of prostate cancer: a systematic review and meta-analysis

A systematic review of the literature was performed to assess the relationship between the presence of perineural invasion (PNI) at prostate biopsy and extraprostatic extension (EPE) of prostate cancer. In August 2012, Medline, Embase, Scopus and Web of Science databases were searched. A "free-text" protocol using the terms "perineural invasion prostate cancer" was applied. Studies published only as abstracts and reports from meetings were not included in this review. In total, 341 records were retrieved from Medline, 507 from Embase, 374 from Scopus and 65 from the Web of Science database. The records were reviewed to identify studies correlating the presence of PNI with that of EPE. A cumulative analysis was conducted using Review Manager software v. 5.1 (Cochrane Collaboration, Oxford, UK). In univariate analysis, PNI showed a statistically significant association with pT3 tumours (p < 0.00001), which could be observed for both pT3a (p < 0.0001) and pT3b (p < 0.0001). In conclusion, the cumulative analysis shows a statistically significant higher incidence of EPE in patients who had PNI at needle biopsy. The main limitation of the analysis was that it was not possible to perform a multivariate analysis. Further attempts to build a nomogram for the prediction of EPE could include the presence of PNI at needle biopsy.

Pioneering robotic-assisted laparoscopic prostatectomy in a regional UK centre: first 100 cases with a minimum 12 months’ follow-up

Objective:

Robotic-assisted laparoscopic prostatectomy (RALP) has become an increasingly popular choice of treatment for prostate cancer, but there is a paucity of published outcome data in the UK. We aim to assess the safety and feasibility of RALP at a regional UK hospital.

Methods:

The first 100 cases of RALP performed by four surgeons at our institution were analysed. Demographic, clinical, surgical, pathological and outcome data were collected with a minimum of 12 months’ follow up.

Results:

The mean age of the patients was 60.7 years. The D’Amico risk stratifications were 41% low risk, 55% intermediate risk and 4% high risk. The median operating time was 245 min (150–522 min) and the median blood loss was 200ml (50–1800ml). Eighty-four per cent were pathological T1/T2; 16% were T3/T4. The positive margin rate was 22% with T3/T4 disease the dominant risk factor ( p<0.05). The stage specific positive margin rate was 16.7% for T1/T2 and 50.0% for T3/T4 disease. At 12-month follow-up the pad free continence rate was 82.0%. The 0–1 pad rate was 96%. The 12-month potency rates were 62.8% for bilateral nerve spare and 31.8% for unilateral nerve spare procedures. Two patients experienced biochemical recurrence at six and 18 months, respectively.

Conclusion:

RALP is a safe and feasible procedure at a regional non-teaching hospital.

Systematic review and meta-analysis of studies reporting oncologic outcome after robot-assisted radical prostatectomy

CONTEXT

Despite the large diffusion of robot-assisted radical prostatectomy (RARP), literature and data on the oncologic outcome of RARP are limited.

OBJECTIVE

Evaluate lymph node yield, positive surgical margins (PSMs), use of adjuvant therapy, and biochemical recurrence (BCR)-free survival following RARP and perform a cumulative analysis of all studies comparing the oncologic outcomes of RARP and retropubic radical prostatectomy (RRP) or laparoscopic radical prostatectomy (LRP).

EVIDENCE ACQUISITION

A systematic review of the literature was performed in August 2011, searching Medline, Embase, and Web of Science databases. A free-text protocol using the term radical prostatectomy was applied. The following limits were used: humans; gender (male); and publications dating from January 1, 2008. A cumulative analysis was conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK) and Stata 11.0 SE software (StataCorp, College Station, TX, USA).

EVIDENCE SYNTHESIS

We retrieved 79 papers evaluating oncologic outcomes following RARP. The mean PSM rate was 15% in all comers and 9% in pathologically localized cancers, with some tumor characteristics being the most relevant predictors of PSMs. Several surgeon-related characteristics or procedure-related issues may play a major role in PSM rates. With regard to BCR, the very few papers with a follow-up duration >5 yr demonstrated 7-yr BCR-free survival estimates of approximately 80%. Finally, all the cumulative analyses comparing RARP with RRP and comparing RARP with LRP demonstrated similar overall PSM rates (RARP vs RRP: odds ratio [OR]: 1.21; p=0.19; RARP vs LRP: OR: 1.12; p=0.47), pT2 PSM rates (RARP vs RRP: OR: 1.25; p=0.31; RARP vs LRP: OR: 0.99; p=0.97), and BCR-free survival estimates (RARP vs RRP: hazard ratio [HR]: 0.9; p=0.526; RARP vs LRP: HR: 0.5; p=0.141), regardless of the surgical approach.

CONCLUSIONS

PSM rates are similar following RARP, RRP, and LRP. The few data available on BCR from high-volume centers are promising, but definitive comparisons with RRP or LRP are not currently possible. Finally, significant data on cancer-specific mortality are not currently available.

Effects of robotic-assisted laparoscopic prostatectomy on surgical pathology specimens

BACKGROUND

Robotic-assisted laparoscopic prostatectomy (RALP) has greatly changed clinical management of prostate cancer. It is important for pathologists and urologists to compare RALP with conventional open radical retropubic prostatectomy (RRP), and evaluate their effects on surgical pathology specimens.

METHODS

We retrospectively reviewed and statistically analyzed 262 consecutive RALP (n = 182) and RRP (n = 80) procedures performed in our institution from 2007 to 2010. From these, 49 RALP and 33 RRP cases were randomly selected for additional microscopic examination to analyze the degree of capsular incision and the amount of residual prostate surface adipose tissue.

RESULTS

Positive surgical margins were present in 28.6% RALP and 57.5% RRP cases, a statistically significant difference. In patients with stage T2c tumors, which represent 61.2% RALP and 63.8% RRP patients, the positive surgical margin rate was 24.1% in the RALP group and 58.8% in the RRP group (statistically significant difference). For other pathologic stages, the differences in positive margins between RALP and RRP groups were not statistically significant. The incidence of positive surgical margins after RALP was related to higher tumor stage, higher Gleason score, higher tumor volume and lower prostate weight, but was not related to the surgeons performing the procedure. When compared with RRP, RALP also caused less severe prostatic capsular incision and maintained larger amounts of residual surface adipose tissue in prostatectomy specimens.

CONCLUSIONS

In this study RALP showed a statistically significant lower positive surgical margin rate than RRP. Analysis of capsular incision and amount of prostatic surface residual adipose tissue suggested that RALP caused less prostatic capsular damage than RRP.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1278078279667611.

Critical review of 'pentafecta' outcomes after robot-assisted laparoscopic prostatectomy in high-volume centres

• Historically, the ideal outcome of radical prostatectomy (RP) has been measured by achievement of the so-called 'trifecta', or the concurrent attainment of continence and potency with no evidence of biochemical recurrence. However, in the PSA era, younger and healthier men are more frequently diagnosed with prostate cancer. Such patients have higher expectations from the advanced minimally invasive surgical technologies. Mere trifecta is no longer an ideal outcome measure to meet the demands of such patients. • Keeping the limitations of trifecta in mind, we have earlier proposed a new method of outcomes analysis, called the 'pentafecta', which adds early complications and positive surgical margins (PSMs) to trifecta. • We performed a Medline search for articles reporting the complications, PSM rates, continence, potency and biochemical recurrence after robot-assisted RP. Related articles were selected and individual outcomes were reviewed.

Impact of median lobe anatomy: does its presence affect surgical margin rates during robot-assisted laparoscopic prostatectomy?

PURPOSE

To measure and describe the impact of median lobe anatomy on surgical margin status after robot-assisted laparoscopic prostatectomy (RALP).

PATIENTS AND METHODS

We prospectively collected median lobe status, surgical margin status, and other perioperative data on 791 patients who underwent RALP at our institution by 12 surgeons between August 2008 and December 2010. We performed univariable and multivariable analysis to measure the association between median lobe status and positive surgical margin rates, including site.

RESULTS

Compared with patients without a median lobe (n=672), patients with a median lobe (n=119) were less likely to have a positive surgical margin (16% vs 24.4%). They had a higher prostate-specific antigen (PSA) level (6.1 ng/dL vs 5.4 ng/dL), lower Gleason scores (<7, 58.1% vs 42.1%), lower pathologic stages (T(2), 87.4% vs 75.4%), and larger prostates (64 g vs 48 g) (all P<0.05). In our multivariable model, the effect of median lobe anatomy on surgical margin status, after adjusting for these factors, was not statistically significant (relative risk 0.97, 95% confidence interval, 0.64-1.47, P=0.88). Lower PSA level, Gleason score, and pathologic stage and larger prostates, however, predicted decreased positive surgical margin rates (P<0.01).

CONCLUSION

Although presence of median lobe anatomy is not an independent predictor of positive surgical margins in RALP, it is associated with favorable pathologic characteristics that are known to predict decreased positive surgical margins.

Positive surgical margins after robotic assisted radical prostatectomy: a multi-institutional study

PURPOSE

Positive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies.

MATERIALS AND METHODS

We analyzed the records of 8,418 patients who underwent robotic assisted radical prostatectomy at 7 institutions. Of the patients 323 had missing data on margin status. Positive surgical margins were categorized into 4 groups, including apex, bladder neck, posterolateral and multifocal. The records of 6,169 patients were available for multivariate analysis. The variables entered into the logistic regression models were age, body mass index, preoperative prostate specific antigen, biopsy Gleason score, prostate weight and pathological stage. A second model was built to identify predictive factors for positive surgical margins in the subset of patients with organ confined disease (pT2).

RESULTS

The overall positive surgical margin rate was 15.7% (1,272 of 8,095 patients). The positive surgical margin rate for pT2 and pT3 disease was 9.45% and 37.2%, respectively. On multivariate analysis pathological stage (pT2 vs pT3 OR 4.588, p<0.001) and preoperative prostate specific antigen (4 or less vs greater than 10 ng/ml OR 2.918, p<0.001) were the most important independent predictive factors for positive surgical margins after robotic assisted radical prostatectomy. Increasing prostate weight was associated with a lower risk of positive surgical margins after robotic assisted radical prostatectomy (OR 0.984, p<0.001) and a higher body mass index was associated with a higher risk of positive surgical margins (OR 1.032, p<0.001). For organ confined disease preoperative prostate specific antigen was the most important factor that independently correlated with positive surgical margins (4 or less vs greater than 10 ng/ml OR 3.8, p<0.001).

CONCLUSIONS

The prostatic apex followed by a posterolateral site was the most common location of positive surgical margins after robotic assisted radical prostatectomy. Factors that correlated with cancer aggressiveness, such as pathological stage and preoperative prostate specific antigen, were the most important factors independently associated with an increased risk of positive surgical margins after robotic assisted radical prostatectomy.

Frequency of positive surgical margin at prostatectomy and its effect on patient outcome

A positive surgical margin at prostatectomy is defined as tumor cells touching the inked edge of the specimen. This finding is reported in 8.8% to 42% of cases (median about 20%) in various studies. It is one of the main determinants of eventual biochemical (PSA) failure, generally associated with a doubled or tripled risk of failure. The effect of a positive margin on outcome can be modified by stage or grade and the length, number and location of positive margins, as well as by technical operative approach and duration of operator experience. This paper tabulates data from the past decade of studies on margin status.

[Prognostic role of perineural invasion in prostate biopsy]

INTRODUCTION

Despite tumour cell dissemination through the intraprostatic nervous system being considered as a prostate cancer progression mechanism, the significance of perineural invasion in prostate biopsies to predict extraprostatic extension and its use as a potential prognosis factor is controversial.

MATERIALS AND METHODS

Retrospective study carried out at an institution on 208 patients treated with radical prostatectomy (January 2007 - July 2010) in which the presence of perineural invasion and the Gleason score in the preoperative biopsy were determined, as well as the clinical stage and the pre-surgery PSA. We classified the patients in risk groups in accordance with the D'Amico classification. We performed bivariate and multivariate statistical analyses to establish the correlations between the different variables.

RESULTS

We objectified PNI in 18.3% of the prostate biopsies. 71% of the prostatectomy specimens with perineural invasion presented extraprostatic extension in the previous biopsy against 23.1% when this was not found (p<0.0001) and 47% of the cases showed positive margins with PNI, against 18.3% without perineural invasion (p<0.0001). In fact, in the multivariate analysis, perineural invasion proved to be an independent risk factor in the presentation of extraprostatic extension and positive margins in the prostatectomy specimen.

CONCLUSIONS

The presence of perineural invasion is a useful prognostic factor for predicting extraprostatic extension and the involvement of surgical margin in the radical prostatectomy specimen. We believe that determining it may be a useful tool for improving preoperative diagnosis and planning treatment.