Postoperative Prostate-specific Antigen Research Articles

Prognosis based on postoperative PSA levels and treatment in prostate cancer with lymph node involvement.

The therapeutic role of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) for prostate cancer is not established. In clinical practice, PLND is primarily performed in cases of high-risk prostate cancer. The detection of lymph node metastasis plays a crucial role in determining the need for subsequent treatments. This study aims to evaluate the prognosis of prostate cancer patients with lymph node involvement (LNI) by stratifying them based on postoperative prostate-specific antigen (PSA) levels to identify biomarkers that can guide postoperative treatment strategies. Analysis was conducted on 383 patients, selected from 572 initially eligible, who underwent RP with LNI across 33 Japanese Urological Oncology Group institutions from 2006 to 2019. Patients were grouped according to postoperative PSA levels and salvage treatments received. Follow-up focused on castration resistance-free survival (CRFS), metastasis-free survival (MFS), and overall survival (OS). In the persistent PSA group (PSA ≥ 0.1ng/mL), CRFS and MFS were significantly shorter compared to the non-persistent PSA group (PSA < 0.1ng/mL), and there was a tendency for shorter OS. In the persistent PSA group, patients with postoperative PSA values above the median (PSA ≥ 0.52ng/mL) showed shorter CRFS and MFS. Furthermore, in the PSA ≥ 0.52 group, androgen deprivation therapy (ADT) plus radiotherapy (RT) combination had prolonged CRFS and MFS compared with ADT alone. This study provides valuable insights into stratifying patients based on postoperative PSA levels to tailor postoperative treatment strategies, potentially improving the prognosis of prostate cancer patients with LNI.

Prognosis based on postoperative PSA levels and treatment in prostate cancer with lymph node involvement.

The therapeutic role of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) for prostate cancer is not established. In clinical practice, PLND is primarily performed in cases of high-risk prostate cancer. The detection of lymph node metastasis plays a crucial role in determining the need for subsequent treatments. This study aims to evaluate the prognosis of prostate cancer patients with lymph node involvement (LNI) by stratifying them based on postoperative prostate-specific antigen (PSA) levels to identify biomarkers that can guide postoperative treatment strategies. Analysis was conducted on 383 patients, selected from 572 initially eligible, who underwent RP with LNI across 33 Japanese Urological Oncology Group institutions from 2006 to 2019. Patients were grouped according to postoperative PSA levels and salvage treatments received. Follow-up focused on castration resistance-free survival (CRFS), metastasis-free survival (MFS), and overall survival (OS). In the persistent PSA group (PSA ≥ 0.1ng/mL), CRFS and MFS were significantly shorter compared to the non-persistent PSA group (PSA < 0.1ng/mL), and there was a tendency for shorter OS. In the persistent PSA group, patients with postoperative PSA values above the median (PSA ≥ 0.52ng/mL) showed shorter CRFS and MFS. Furthermore, in the PSA ≥ 0.52 group, androgen deprivation therapy (ADT) plus radiotherapy (RT) combination had prolonged CRFS and MFS compared with ADT alone. This study provides valuable insights into stratifying patients based on postoperative PSA levels to tailor postoperative treatment strategies, potentially improving the prognosis of prostate cancer patients with LNI.

Biochemical Response of

BackgroundIn a subset of patients with oligorecurrent prostate cancer (PCa), salvage surgery with prostate-specific membrane antigen (PSMA) radioguided surgery (PSMA-RGS) seems to be of value. ObjectiveTo evaluate whether a lower level of postoperative prostate-specific antigen (PSA; <0.1 ng/ml) is predictive of therapy-free survival (TFS) following salvage PSMA-RGS. Design, setting, and participantsThis cohort study evaluated patients with biochemical recurrence after radical prostatectomy and oligorecurrent PCa on PSMA positron emission tomography treated with PSMA-RGS in three tertiary care centers (2014–2022). InterventionPSMA-RGS. Outcome measurements and statistical analysisPostsalvage surgery PSA response was categorized as <0.1, 0.1–<0.2, or >0.2 ng/ml. Kaplan-Meier and multivariable Cox regression models evaluated TFS according to PSA response. Results and limitationsAmong 553 patients assessed, 522 (94%) had metastatic soft tissue lesions removed during PSMA-RGS. At 2–16 wk after PSMA-RGS, 192, 62, and 190 patients achieved PSA levels of <0.1, 0.1–<0.2, and >0.2 ng/ml, respectively. At 2 yr of follow-up, TFS rate was 81.1% versus 56.1% versus 43.1% (p < 0.001) for patients with PSA <0.1 versus 0.1–<0.2 versus >0.2 ng/ml. In multivariable analyses, PSA levels of 0.1–0.2 ng/ml (hazard ratio [HR]: 1.9, confidence interval [CI]: 1.1–3.1) and ≥0.2 ng/ml (HR: 3.2, CI: 2.2–4.6, p < 0.001) independently predicted the need for additional therapy after PSMA-RGS. The main limitation is the lack of a control group. ConclusionsFor patients after salvage PSMA-RGS, a lower biochemical response (PSA <0.1 ng/ml) seems to predict longer TFS. This insight may help in counseling patients postoperatively as well as guiding the timely selection of additional therapy. Patient summaryWe studied what happened to prostate cancer patients in three European centers who had salvage surgery using a special method called prostate-specific membrane antigen–targeted radioguidance. We found that patients who had low prostate-specific antigen levels soon after surgery were less likely to need further treatment for a longer time.

Comment on: "Initial Postoperative Prostate Specific Antigen and PSA Velocity Are Important Indicators of Underlying Malignancy After Simple Prostatectomy" by Livingston et al.

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Prognostication in Lymph Node-Positive Prostate Cancer with No PSA Persistence After Radical Prostatectomy.

This study aimed to create a prognostic model to predict disease recurrence among patients with lymph node involvement but no prostate-specific antigen (PSA) persistence and to explore its clinical utility. The study analyzed patients with lymph node involvement after pelvic lymph node dissection with radical prostatectomy in whom no PSA persistence was observed between 2006 and 2019 at 33 institutions. Prognostic factors for recurrence-free survival (RFS) were analyzed by the Cox proportional hazards model. Among 231 patients, 127 experienced disease recurrence. The factors prognostic for RFS were PSA level at diagnosis (≥ 20 vs. < 20ng/mL: hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.09-2.52; P = 0.017), International Society of Urological Pathology grade group at radical prostatectomy (RP) specimen (group ≥ 4 vs. ≤ 3: HR, 1.63; 95% CI 1.12-2.37; P = 0.010), pathologic T-stage (pT3b/4 vs. pT2/3a: HR, 1.70; 95% CI 1.20-2.42; P = 0.0031), and surgical margin status (positive vs. negative: HR, 1.60; 95% CI 1.13-2.28; P = 0.0086). The prognostic model using four parameters were associated with RFS and metastasis-free survival. The prognostic model in combination with postoperative PSA value and number of lymph nodes is clinically useful for discussing treatment choice with patients.

The efficacy of STRATAFIX® spiral PDS for vesicourethral anastomosis during robot-assisted laparoscopic radical prostatectomy: a single-center retrospective study.

To investigate the efficacy of continuous suturing using barbed suture for vesicourethral anastomosis (VUA) during robot-assisted laparoscopic radical prostatectomy (RARP). Seventy-three consecutive patients who underwent RARP by a single surgeon between 2020 and 2022 were retrospectively divided based on the suture type used for VUA: group A, 3-0 poliglecaprone-25 RB-1 needle (Monocryl®), n = 46; group B, 3-0 spiral polydioxanone (PDS) barbed suture with RB-1 needle (STRATAFIX®), n = 27. There was no significant difference in patient background characteristics between groups, including age, body mass index, and clinical stage. However, group B had a significantly shorter operative time, console time, hospital stay, and duration of urethral catheterization. The VUA time was significantly shorter in group B than in group A (17.9min vs. 10.6min; p < 0.001). Only 1 case of minor leakage was observed during the intraoperative leak test (1 patient in group A). There was no significant difference in the number of pads used at 1, 3,6months and 1year postoperatively. There were no urethral strictures, and there was no significant difference in pathologic results or postoperative prostate-specific antigen progression between groups. Our study suggests that the use of barbed suture during VUA for RARP is associated with reduced VUA time.

Treatment outcomes of our patients with prostate cancer who underwent postoperative radiotherapy

Aims: Prostate cancer is one of the most common cancers in men. Surgery, radiotherapy or active surveillance are the treatment options. Treatment is decided according to risk group of the patient. Postoperative radiotherapy is delivered in selected patients to increase the local control rates. The aim of this study is to report the treatment results of patients who received postoperative radiotherapy for localized prostate cancer. Methods: This retrosepctive study included 78 prostate cancer patients who received postoperative radiotherapy between 2011 and 2023. All patients except who had pathologically positive lymph nodes were included into the study. Overall survival, progression free survival, and associated pathological parameters were evaluated by using IBM SPSS programme version 20. Results: The mean follow-up time was 66.7 (IQR 25-75:41,6-89,6) months. Five and 10-year overall survival rates were 93%, and 67.3% respectively; (median (95% CI); NR (not reach): while 5 and 10-year progression-free survival rates were 90.3%, and 50.4, respectively; (median (95% CI); 135.3± (105.9-165.7). Postoperative prostate specific antigen (PSA) and pre-RT PSA values, and the effects of these parameters on progression-free survival was analyzed, median progression-free survival was higher in patients with postoperative PSA values ? 0.185 (135.6±24.4 vs 113.3±6.4, p:0.001). Five and 10 year overall survival and progression-free survival rates of patients with a high gleason score who underwent postoperative radiotherapy was observed lower than the others (86.9% and 46.3%, p=0.006; 86.9% and 33.8%, p=0.009 respectively). Conclusion: Postoperative radiotherapy is generated best results in progression free survival and overall survival in patients with low pre-rt psa and high gleason score prostate cancer cases

Initial experience of laparoendoscopic single-site radical prostatectomy with a novel purpose-built robotic system

ObjectiveThis prospective single-arm clinical trial aimed to evaluated the feasibility and safety of the application of the SHURUI system (Beijing Surgerii Technology Co., Ltd., Beijing, China), a novel purpose-built robotic system, in single-port robotic radical prostatectomy. MethodsSixteen patients diagnosed with prostate cancer were prospectively enrolled in and underwent robotic radical prostatectomy from October 2021 to August 2022 by the SHURUI single-port robotic surgical system. The demographic and baseline data, surgical, oncological, and functional outcomes as well as follow-up data were recorded. ResultsThe mean operative time was 226.3 (standard deviation [SD] 52.0) min, and the mean console time was 183.4 (SD 48.3) min, with the mean estimated blood loss of 116.3 (SD 90.0) mL. The mean length of postoperative hospital stay was 4.50 (SD 0.97) days. Two patients had postoperative complications (Clavien-Dindo Grade II), and both patients improved after conservative treatment. All patients’ postoperative prostate-specific antigen levels decreased to below 0.2 ng/mL 1 month after discharge. The mean prostate-specific antigen level further decreased to a mean of 0.0219 (SD 0.0641) ng/mL 6 months after surgery. Thirty days postoperatively, 12 out of 16 patients reported using no more than one urinary pad per day, and all patients reported satisfactory urinary control without the need for pads 6 months after surgery. ConclusionThe SHURUI system is safe and feasible in performing radical prostatectomy via both transperitoneal and extraperitoneal approaches. Tumor control and urinary continence were satisfying for patients enrolled in. The next phase involves conducting a large-scale, multicenter randomized controlled trial to thoroughly assess the effectiveness and safety of the new technology in a broader population.

Initial Postoperative Prostate Specific Antigen and Prostate Specific Antigen Velocity Are Important Indicators of Underlying Malignancy After Simple Prostatectomy.

Background: There is a paucity of guidelines for prostate-specific antigen (PSA) monitoring after simple prostatectomy (SP) despite these patients remaining at risk for prostate cancer (PCa). Our objective was to determine if PSA kinetics can be a potential indicator of PCa after SP. Methods: A retrospective review was performed of all simple prostatectomies at our institution from 2014 to 2022. All patients who met criteria were included in the study. Relevant clinical variables were collected preoperatively, including PSA value, prostate size, and voiding symptoms. Surgical and urinary function outcomes were analyzed. Results: A total of 92 patients were divided into two groups based on malignancy status. Sixty-eight patients did not have PCa, while 24 patients had known PCa before surgery (14) or were diagnosed as having incidental PCa from the pathological specimen (10). Patients with benign prostates had an initial postoperative PSA value of 0.76 ng/mL compared with 1.68 ng/mL for those with cancer (p < 0.01). PSA velocity for the first 24 months after surgery was 0.042 ± 1.61 ng/(mL·year) for the benign cohort compared with 1.29 ± 1.02 ng/(mL·year) for the malignant cohort (p = 0.01). Voiding improvements were noted by objective (postvoid residual and flow rate) and subjective (American Urological Association symptom score and quality of life score) measures in both groups. Conclusions: PSA interpretation and monitoring after SP have not been well established. Our study indicates that initial postoperative PSA value and PSA velocity are important indicators of underlying malignancy in patients after SP. Further efforts are needed to establish threshold values and formal guidelines.

Holmium Laser Enucleation of the Prostate vs Robot-Assisted Simple Prostatectomy for Lower Urinary Tract Symptoms in Patients with Extremely Large Prostates ≥200 cc: A Comparative Analysis.

Introduction and Objectives: Robot-assisted simple prostatectomy (RASP) and holmium laser enucleation of the prostate (HoLEP) are both well-established, minimally invasive surgical treatment options for lower urinary tract symptoms caused by benign prostatic enlargement. We have reported the first comparative analysis of both techniques in patients with prostates of ≥200 cc. Materials and Methods: Between 2009 and 2020 a total of 53 patients with a prostate volume of ≥200 cc were surgically treated at OLV Hospital Aalst (Belgium): 31 underwent RASP and 22 underwent HoLEP. Preoperative and postoperative assessments included uroflowmetry with maximum urinary flow rate (Qmax) and postvoid residual volume (PVR), as well as the International Prostate Symptom Score (IPSS) and quality of life (IPSS-QoL). The complication rates were evaluated according to the Clavien-Dindo Classification. Results: Patients treated with RASP had significantly larger prostate volumes compared with HoLEP (median 226 cc vs 204.5 cc, p = 0.004). After a median follow-up of 14 months, both groups showed a significant improvement in the maximum flow rate (+10.60 mL/s vs +10.70 mL/s, p = 0.724) and a reduction of the IPSS score (-12.50 vs -9, p = 0.246) as well as improvement of the QoL (-3 vs -3, p = 0.880). Median operative time was similar in both groups (150 minutes vs 132.5 minutes, p = 0.665). The amount of resected tissue was lower in the RASP group (134.5 g vs 180 g, p = 0.029) and there was no significant difference in postoperative prostate-specific antigen (1.2 ng/mL vs 0.8 ng/mL, p = 0.112). Despite a similar median catheterization time (3 days vs 2 days, p = 0.748), the median hospitalization time was shorter in the HoLEP group (4 days vs 3 days, p = 0.052). Complication rates were similar in both groups (32% vs 36%, p = 0.987). Conclusion: Our results suggest similar outcomes for RASP and HoLEP in patients with very large prostates ≥200 cc. These findings will require external validation at other high-volume centers.

Could HoLEP change the further management of incidental prostate cancer?

IntroductionHolmium Laser Enucleation of the Prostate (HoLEP) represents an effective and well-established technique in the treatment of lower urinary tract symptoms (LUTS) related to benign prostatic hypertrophy (BPH). We evaluated patients with BPH and concomitant or incidentally detected prostate cancer (PCa) treated with HoLEP and the subsequent clinical management.Materials and MethodsWe performed a retrospective review of patients treated with HoLEP at a single institution. We analyzed total pre- and postoperative prostate-specific antigen (tPSA), multi-parametric magnetic resonance (mpMRI) imaging, and pathology results in patients with a PCa diagnosis performed before HoLEP (group 1) and incidentally at HoLEP (group 2).ResultsWe analyzed a total of 147 consecutive patients: 16 (10.9%) patients already had a PCa diagnosis before HoLEP, and in 18 (12.2%) patients PCa was incidentally detected at HoLEP. The tPSA level at 3 months after HoLEP dropped by 85.8% (from 14.34 ng/ml to 2.04 ng/ml) in patients of group 1 and by 86.5% (from 3.94 ng/ml to 0.53 ng/ml) in patients of group 2; the values remained stable up to 12 months after HoLEP. By including even those patients who underwent cancer treatment post-HoLEP, all patients in both groups survived without cancer progression (based on their initial PCa status).ConclusionsPatients undergoing HoLEP might receive a PCa diagnosis in more than 10% of cases. The HoLEP technique can be performed even in patients with PCa, at any stage of the disease, to treat LUTS. The procedure does not negatively impact oncological outcomes even when PCa is diagnosed before or at HoLEP. Surely, the durability of the success of this approach to management needs further investigation.

Salvage Versus Adjuvant Radiation Therapy Following Radical Prostatectomy in Localised Prostate Cancer: A War Without a Winner

ObjectiveTo review current literature regarding the efficacy of adjuvant radiation therapy (ART) and salvage radiation therapy (SRT) following radical prostatectomy (RP) in patients with undetectable postoperative prostate-specific antigen (PSA) levels and high-risk features of prostate cancer (PCa) recurrence.MethodsSeven randomized controlled trials focused on the use of ART compared with either observation or SRT after RP that had been published in PubMed up to May 2022 were reviewed.ResultsThe use of ART following RP has been the treatment of choice over the past decade. Three RCTs comparing ART with early SRT show that SRT given as soon as biochemical recurrence (BCR) is detected is not inferior to ART while it offers the opportunity to avoid overtreatment and potential RT-related side effects. A meta-analysis summarizing the results from these trials supports these findings.ConclusionsEarly SRT may be suggested as the standard of care for patients with PCa and high-risk features for disease recurrence following RP. Nevertheless, further investigations are needed to identify those patients who will benefit from ART, particularly, in case of lymph node involvement. Moreover, some patients might avoid SRT despite reaching detectable postoperative serum PSA levels.

Anterior fibromuscular stroma-preserved endoscopic enucleation of the prostate: a precision anatomical approach.

Benign prostate obstruction (BOO) is becoming increasingly important in this aging society. Some urge/stress urinary incontinence (UUI/SUI) still occurs after endoscopic enucleation of the prostate (EEP). It remains unclear how post-EEP incontinence can be avoided. Currently, early apical release to ameliorate the traction of the external sphincter is the best technique for incontinence prevention. To describe our surgical technique of anterior fibromuscular stroma (AFS)-preserved EEP for BOO. The medical records of 60 consecutive patients who underwent AFS-preserved EEP for BOO in our center from September 2019 to December 2019 were retrospectively reviewed. AFS-preserved EEP starts at the 12 o'clock position of the urethra, and the junction between the AFS and transitional zone (T-zone) was identified. The AFS and T-zone were separated first to protect the AFS in the initial operative procedure. Then, following the usual enucleation procedure, AFS-preserved EEP could be achieved. Postoperative prostate-specific antigen (PSA), testosterone, urethral stricture, and voiding status, such as incontinence, uroflow, and postvoiding residual urine were assessed. The data show that AFS-preserved EEP could achieve similar surgical outcomes as other early apical release approaches. The preserved AFS provides a nice landmark at the 12 o'clock position during EEP.

Novel nomogram to predict biochemical recurrence-free survival after radical prostatectomy.

Conditional survival represents the probability of subsequent survival given that patients have already survived a certain length of time. Several models predict biochemical recurrence (BCR) after radical prostatectomy. However, none of them include postoperative prostate-specific antigen (PSA). We aimed to analyze BCR-free survival evolution over time and develop a nomogram incorporating the postoperative PSA value to predict BCR-free survival. We included patients treated with robot-assisted radical prostatectomy (RARP) for prostate cancer between 2009 and 2021 and calculated conditional survival. Cox proportional hazard regression analysis was used to assess the predictive variables of BCR. We developed a nomogram predicting BCR-free survival three and five years after RARP. We used c-index and decision curve analyses to compare the nomogram with the Cancer of the Prostate Risk Assessment post-Surgical (CAPRA-S) score. We included 718 patients. The overall 3- and 5-year BCR-free survival rates were 85.1% and 75.7%, respectively. The 5-year BCR-free survival rates increased to 78.9%, 82.9%, 85.2%, and 84.7% for patients surviving 1, 2, 3, and 4years without BCR, respectively. We developed a nomogram including the pathological Gleason score and T stage, positive surgical margin, PSA ≥ 0.05ng/mL at one year, and lymph node involvement to predict BCR at 3 and 5years postoperatively. Our nomogram presented a higher c-index (0.89) than the CAPRA-S score (0.78; p = 0.001) and a positive net benefit at 3 and 5years postoperatively in the decision curve analyses. The 5-year conditional BCR-free survival increased with survival without BCR. The developed nomogram significantly improved the accuracy in predicting BCR-free survival after RARP.

Comparison of outcomes of holmium laser versus bipolar enucleation of prostates weighing >80 g with bladder outlet obstruction

Transurethral enucleation of the prostate has been increasingly recognized as an effective minimally invasive technique for management of enlarged prostates. We aimed to compare holmium laser enucleation (HoLEP) and bipolar transurethral enucleation (B-TUEP) of large-volume prostates. A prospectively maintained database in two tertiary referral centers was reviewed for patients with HoLEP and B-TUEP for prostates >80 g. Operative data, perioperative complications, and early postoperative outcomes were compared. The study included 101 patients, 70 who underwent HoLEP and 31 who underwent B-TUEP. The operative enucleation rate (weight of adenoma enucleated in g/min) was higher in HoLEP compared to B-TUEP (P < 0.0001). The operative complication rate, hemoglobin drop, and readmission rate were comparable in both groups (P = 0.13, 0.35, 0.29, 0.59, respectively). The HoLEP arm had a shorter hospital stay and shorter catheterization time (P = 0.001, 0.012). Follow-up data showed a lower International Prostate Symptom Score and serum prostate-specific antigen level in the HoLEP group. The incontinence rate was comparable in both groups. In conclusion, both techniques were effective in managing a high-volume prostate, although HoLEP had a shorter enucleation time, better symptom score, lower postoperative prostate-specific antigen level, shorter catheterization time, and shorter hospital stay compared to B-TUEP.

Holmium laser enucleation of the prostate in men on active surveillance for prostate cancer with refractory lower urinary tract symptoms secondary to enlarged prostates.

The surgical treatment of men with lower urinary tract symptoms (LUTS) and significantly enlarged symptomatic prostates on active surveillance (AS) for low-risk prostate cancer (PCa) is not well defined. We report our single-institution initial experience with holmium laser enucleation of the prostate (HoLEP) for LUTS in men with low-risk PCa being managed with AS. Men on AS who underwent HoLEP between 2013 and 2019 were identified. Data regarding preoperative cancer workup, prostate-specific antigen (PSA), perioperative outcomes, and voiding parameters were analyzed. Postoperative surveillance for PCa including PSA nadir, prostate magnetic resonance imaging, prostate biopsy (PBx), and PSA at last follow-up were evaluated. Twenty men met the inclusion criteria. Preoperative mean max flow 7.9 ml/s, median postvoid residual 101 cc, and mean transrectal ultrasound prostate size 99 cc. Patients had a median adjusted preoperative PSA of 8.5 (interquartile range[IQR]: 4.8-13.2) ng/ml. Mean resected tissue weight was 65.5 gwith improved postoperative flow rate and significantly decreased residual. A total of 5/20 men had PCa in the specimen (all GleasonGrade Group 1).The median postoperative PSA nadir was 1.2 (IQR: 0.5-1.8) ng/ml at median of 5 months. At the last follow-up (median 18.5 months, IQR: 10.5-37.8), the median postoperative PSA was 1.4 (IQR: 0.63-2.48) ng/ml. Nine men underwent postoperative multiparametric magnetic resonance imaging(mpMRI) with the identification of a new prostate imaging reporting and data system 5 lesion in onepatient who underwent negative fusion biopsy. Five men underwent post-HoLEP PBx with progression in two patients, who both successfully underwent radical prostatectomy. Men on AS for low-risk PCa can safely undergo HoLEP with significantly improved voiding parameters. Postoperative monitoring with PSA, mpMRI, and PBx can detect disease progression requiring definitive treatment. Further research is needed to optimize surveillance strategies and long-term cancer-specific outcomes.

Quality-of-Life Outcomes and Toxicity Profile Among Patients With Localized Prostate Cancer After Radical Prostatectomy Treated With Stereotactic Body Radiation: The SCIMITAR Multicenter Phase 2 Trial

Postoperative radiation therapy (RT) is an underused standard-of-care intervention for patients with prostate cancer and recurrence/adverse pathologic features after radical prostatectomy. Although stereotactic body RT (SBRT) is a well-studied and convenient option for definitive treatment, data on the postprostatectomy setting are extremely limited. The purpose of this study was to evaluate short-term physician-scored genitourinary (GU) and gastrointestinal (GI) toxicities and patient-reported outcomes after postprostatectomy SBRT. The SCIMITAR trial was a phase 2, dual-center, open-label, single-arm trial that enrolled patients with postoperative prostate-specific antigen >0.03 ng/mL or adverse pathologic features. Coprimary endpoints were 4-year biochemical recurrence-free survival, physician-scored acute and late GU and GI toxicities by the Common Terminology Criteria for Adverse Events (version 4.03) scale, and patient-reported quality-of-life (QOL) outcomes, as represented by the Expanded Prostate Cancer Index-26 and the International Prostate Symptom Score. Patients received SBRT 30 to 34 Gy/5 fractions to the prostate bed ± bed boost ± pelvic nodes with computed tomography (CTgRT) or magnetic resonance imaging guidance (MRgRT) in a nonrandomized fashion. Physician-scored toxicities and patient-reported QOL outcomes were collected at baseline and at 1, 3, and 6 months of follow-up. Univariable and multivariable analyses were performed to evaluate predictors of toxicities and QOL outcomes. One hundred participants were enrolled (CTgRT, n=69; MRgRT, n=31). The median follow-up was 29.5 months (CTgRT: 33.3 months, MRgRT: 22.6 months). The median (range) prostate bed dose was 32 (30-34) Gy. Acute and late grade 2 GU toxicities were both 9% while acute and late grade 2 GI toxicities were 5% and 0%, respectively. Three patients had grade 3 toxicity (n=1 GU, n=2 GI). No patient receiving MRgRT had grade 3 GU or grade ≥2 GI toxicity. Compared with CTgRT, MRgRT was associated with a 30.5% (95% confidence interval, 11.6%-49.5%) reduction in any-grade acute GI toxicity (P=.006). MRgRT was independently associated with improved any-grade GI toxicity and improved bowel QOL. Postprostatectomy SBRT was well tolerated at short-term follow-up. MRgRT may decrease GI toxicity. Longer toxicity and/or efficacy follow-up and randomized studies are needed.

Blood Prostate-specific Antigen by Volume of Benign, Gleason Pattern 3 and 4 Prostate Tissue

ObjectiveTo evaluate how blood levels of prostate-specific antigen (PSA) relate to prostate volume of benign tissue, Gleason pattern 3 (GP3) and Gleason pattern 4 (GP4) cancer. MethodsThe cohort included 2209 consecutive men undergoing radical prostatectomy at 2 academic institutions with pT2N0, Grade Group 1-4 prostate cancer and an undetectable postoperative PSA. Volume of benign, GP3, and GP4 were estimated. The primary analysis evaluated the association between PSA and volume of each type of tissue using multivariable linear regression. R2, a measure of explained variation, was calculated using a multivariable model. ResultsEstimated contribution to PSA was 0.04/0.06 ng/mL/cc for benign, 0.08/0.14 ng/mL/cc for GP3, and 0.62/0.80 ng/ml/cc for GP4 for the 2 independent cohorts, respectively. GP4 was associated with 6 to 8-fold more PSA per cc compared to GP3 and 15-fold higher compared to benign tissue. We did not observe a difference between PSA per cc for GP3 vs. benign tissue (P = 0.2). R2 decreased only slightly when removing age (0.006/0.018), volume of benign tissue (0.051/0.054) or GP3 (0.014/0.023) from the model. When GP4 was removed, R2 decreased 0.051/0.310. PSA density (PSA divided by prostate volume) was associated with volume of GP4 but not GP3, after adjustment for benign volume. ConclusionGleason pattern 4 cancer contributes considerably more to PSA and PSA density per unit volume compared to GP3 and benign tissue. Contributions from GP3 and benign are similar. Further research should examine the utility of determining clinical management recommendations by absolute volume of GP4 rather than the ratio of GP3 to GP4.

Effect of 3-Dimensional, Virtual Reality Models for Surgical Planning of Robotic Prostatectomy on Trifecta Outcomes: A Randomized Clinical Trial.

Planning complex operations such as robotic-assisted radical prostatectomy requires surgeons to review 2-dimensional magnetic resonance imaging (MRI) cross-sectional images to understand 3-dimensional (3D), patient-specific anatomy. We sought to determine surgical outcomes for robotic-assisted radical prostatectomy when surgeons reviewed 3D, virtual reality (VR) models for operative planning. A multicenter, randomized, single-blind clinical trial was conducted from January 2019 to December 2020. Patients undergoing robotic-assisted laparoscopic radical prostatectomy were prospectively enrolled and randomized to either a control group undergoing usual preoperative planning with prostate biopsy results and MRI only or to an intervention group where MRI and biopsy results were supplemented with a 3D VR model. The primary outcome measure was margin status, and secondary outcomes were oncologic control, sexual function and urinary function. Ninety-two patients were analyzed, with trends toward lower positive margin rates (33% vs 25%) in the intervention group, no significant difference in functional outcomes and no difference in traditional operative metrics (p >0.05). Detectable postoperative prostate specific antigen was significantly lower in the intervention group (31% vs 9%, p=0.036). In 32% of intervention cases, the surgeons modified their operative plan based on the model. When this subset was compared to the control group, there was a strong trend toward increased bilateral nerve sparing (78% vs 92%), and a significantly lower rate of postoperative detectable prostate specific antigen in the intervention subset (31% vs 0%, p=0.038). This randomized clinical trial demonstrated patients whose surgical planning involved 3D VR models have better oncologic outcomes while maintaining functional outcomes.

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

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