Presence Of Positive Surgical Margins Research Articles

Accuracy of the LaserSAFE technique for detecting positive surgical margins during robot-assisted radical prostatectomy: blind assessment and inter-rater agreement analysis.

Fluorescence confocal microscopy (FCM) is a new imaging modality capable of generating digital microscopic resolution scans of fresh surgical specimens, and holds potential as an alternative to frozen section (FS) analysis for intra-operative assessment of surgical margins. Previously, we described the LaserSAFE technique as an application of FCM for margin assessment in robot-assisted radical prostatectomy (RARP) using the Histolog® scanner. This study describes the accuracy and inter-rater agreement of FCM imaging compared to corresponding paraffin-embedded analysis (PA) among four blinded pathologists for the presence of positive surgical margins (PSM). RARP specimens from patients enrolled in the control arm of the NeuroSAFE PROOF study (NCT03317990) were analysed from April 2022 to February 2023. Prostate specimens were imaged using the Histolog® scanner before formalin fixation and PA. Four trained assessors, blinded to PA, reviewed and analysed FCM images of the posterolateral prostatic surface. A total of 31 prostate specimens were included in the study. PA per lateral side of the prostate identified 11 instances of positive margins. Among the four histopathologists included in our study, FCM achieved a sensitivity of 73-91 and specificity of 94-100% for the presence of PSM. Fleiss' Kappa for inter-rater agreement on PSM was 0.78 (95% confidence interval = 0.64-0.92), indicating substantial agreement. This blinded analysis of FCM versus PA among histopathologists with different experience levels demonstrated high accuracy and substantial inter-rater agreement for diagnosing PSM. This supports the role of the FCM as an alternative to FS.

Development of preoperative nomograms to predict the risk of overall and multifocal positive surgical margin after radical prostatectomy

ObjectiveTo develop preoperative nomograms using risk factors based on clinicopathological and MRI for predicting the risk of positive surgical margin (PSM) after radical prostatectomy (RP).Patients and methodsThis study retrospectively enrolled patients who underwent prostate MRI before RP at our center between January 2015 and November 2022. Preoperative clinicopathological factors and MRI-based features were recorded for analysis. The presence of PSM (overall PSM [oPSM]) at pathology and the multifocality of PSM (mPSM) were evaluated. LASSO regression was employed for variable selection. For the final model construction, logistic regression was applied combined with the bootstrap method for internal verification. The risk probability of individual patients was visualized using a nomogram.ResultsIn all, 259 patients were included in this study, and 76 (29.3%) patients had PSM, including 40 patients with mPSM. Final multivariate logistic regression revealed that the independent risk factors for oPSM were tumor diameter, frank extraprostatic extension, and annual surgery volume (all p < 0.05), and the nomogram for oPSM reached an area under the curve (AUC) of 0.717 in development and 0.716 in internal verification. The independent risk factors for mPSM included the percentage of positive cores, tumor diameter, apex depth, and annual surgery volume (all p < 0.05), and the AUC of the nomogram for mPSM was 0.790 in both development and internal verification. The calibration curve analysis showed that these nomograms were well-calibrated for both oPSM and mPSM.ConclusionsThe proposed nomograms showed good performance and were feasible in predicting oPSM and mPSM, which might facilitate more individualized management of prostate cancer patients who are candidates for surgery.

Evaluatoion of intraoperative histology during nerve-sparing radical prostatectomy

Background. Currently, for patients with localized PC, intact erectile function, and low risk of extracapsular extension radical prostatectomy (RP) with nerve-sparing (NS) technique is indicated. The proven method of intraoperative control for the presence of positive surgical margin is the study of fresh frozen sections.Aim. To evaluate the method of intraoperative histological examination (cito-histology) in NS RP.Materials and methods. A prospective clinical study was conducted to examine fresh frozen sections in laparoscopic NS RP. Between February of 2021 and May of 2022, 90 patients diagnosed with prostate cancer underwent laparoscopic NS RP performed by the same surgeon. The patients were divided into 2 groups: group A (n = 40) included patients who underwent laparoscopic NS RP and intraoperative histology; group B (control group) (n = 50) included patients who underwent standard laparoscopic NS RP. Rapid histological and final histological examinations of all removed samples were carried out at the City Clinical Hospital No. 1 named after N.I. Pirogov by one pathologist. The presence of tumor tissue in a stained resection margin was considered positive surgical margin.Results. Oncological processes in macrosamples obtained by intraoperative histology were observed in 32 (80 %) patients, of which primary positive surgical margin was found in 9 (22.5 %) patients. Conversion of (cito) positive surgical margin status into final negative surgical margin was observed in 4 (10 %) patients. Conversion of the surgical margin status of (cito) negative to positive was observed in 1 (2.5 %) patient due to the targeted examination of the area of interest, and not the entire surface of the prostate. Overall 2-year survival in groups A and B was 100 % and 96 %, respectively; cancer-specific 2-year survival was 100 % and 100 %, respectively. Depending on the pathological group, recurrence-free 2-year survival was: group A (pT2) – 90 %; group B (pT2) – 92 %, group A (pT3) – 91.3 %; group B (pT3) – 77.3 %.Conclusion. The proposed method of intraoperative histological examination allows to determine the presence and location of positive surgical margin, which indicates to the surgeon the necessity of additional tissue removal in the neurovascular bundle area, reduces the technical and economic burden on pathology department compared to other methods of rapid histological examination, and reduces contraindications to performing the NS technique in RP especially in the intermediate-risk group.

Assessing the Impact of Positive Surgical Margins on Mortality in Patients Who Underwent Robotic Radical Prostatectomy: 20 Years’ Report from the EAU Robotic Urology Section Scientific Working Group

BackgroundPositive surgical margins (PSMs) are frequent in patients undergoing radical prostatectomy (RP). The impact of PSMs on cancer-specific (CSM) and overall (OM) mortality has not yet been proved definitively. ObjectiveTo evaluate whether the presence and the features of PSMs were associated with CSM and OM in patients who underwent robotic-assisted RP. Design, setting, and participantsA cohort of 8141 patients underwent robotic-assisted RP with >10 yr of follow-up. Outcome measurements and statistical analysisCox multivariable analyses assessed the impact of margin status (positive vs negative) and PSM features (negative vs <3 mm vs >3 mm vs multifocal) on the risk of CSM, OM, and biochemical recurrence (BCR) after adjusting for potential confounders. We repeated our analyses after stratifying patients according to clinical (Cancer of the Prostate Risk Assessment [CAPRA] categories) and pathological characteristics (adverse: pT 3–4 and/or grade group [GG] 4–5 and/or pN1 and/or prostate-specific antigen [PSA] persistence). Results and limitationsPSMs were found in 1348 patients (16%). Among these, 48 (3.6%) patients had multifocal PSMs. Overall, 1550 men experienced BCR and 898 men died, including 130 for prostate cancer. At Cox multivariable analyses, PSMs were associated with CSM in patients with adverse clinical (Intermediate risk: hazard ratio [HR]: 1.71, p = 0.048; high risk: HR: 2.20, p = 0.009) and pathological (HR: 1.79, p = 0.005) characteristics. Only multifocal PSMs were associated with CSM and OM in the whole population (HR for CSM: 4.68, p < 0.001; HR for OM: 1.82, p = 0.037) and in patients with adverse clinical (intermediate risk: HR for CSM: 7.26, p = 0.006; high risk: HR for CSM: 9.26, p < 0.001; HR for OM: 2.97, p = 0.006) and pathological (HR for CSM: 9.50, p < 0.001; HR for OM: 2.59, p = 0.001) characteristics. Potential limitations include a selection bias and a lack of information on the Gleason score at PSM location. ConclusionsWe did not find an association between unifocal PSMs and mortality. Conversely, our results underscore the importance of avoiding multifocal PSMs in patients with adverse clinical (intermediate- and high-risk CAPRA score) and pathological (GG ≥4, pT ≥3, pN1, or PSA persistence) characteristics, to enhance overall survival and reduce CSM. Patient summaryIn this study, we evaluated whether the presence and the characteristics of positive surgical margins were associated with mortality in patients who underwent robotic-assisted radical prostatectomy. We found that the presence of positive surgical margins, particularly multifocal margins, was associated with mortality only in patients with adverse clinical and pathological characteristics.

Creation of a Novel, Race-Adjusted, and Risk-Adapted Scoring System to Predict Positive Surgical Margins and Prolonged Operative Time During Robotic Radical Prostatectomy.

Objectives: To compare racial differences and pelvis dimensions between Caucasians and African Americans (AAs) and to develop a risk calculator and scoring system to predict the risk of prolonged operative time and presence of positive surgical margins (PSM) based on these dimensions. Materials and Methods: A retrospective review of 88 consecutive patients undergoing robot-assisted laparoscopic prostatectomy with a preoperative prostate MRI conducted. Data extraction included demographic, perioperative, and postoperative oncologic outcomes. Prostate-specific antigen (PSA) was obtained within 3 months postsurgery. Wilcoxon rank sum and Fisher's exact tests were used to compare continuous and categorical data, respectively. Single and multivariable regression analysis were used to determine contribution of each factor to the composite outcomes. A risk score was created based on this analysis for predicting the composite outcome. Results: We identified 88 consecutive patients with localized prostate cancer that underwent a preoperative prostate MRI. No statistically significant differences were found with respect to age, body mass index, or any postoperative outcome. PSA was lower at diagnosis (6.49 vs 9.72, p = 0.006) and operative times were shorter in Caucasians. Rates of PSM (13 vs 14, p = 0.35), biochemical recurrence (4 vs 2, p = 0.69), and complications did not vary between the groups. Caucasians had wider/shallower pelvis dimensions. Based on these variables, we found that the log (odds of OR time >3 hours or PSM) = -5.333 + 1.158 (if AA) +0.105 × PSA +0.076 × F -0.035 × G with an area under the receiver operating characteristic curve = 0.73. Using the predefined variables, patients can be risk stratified for PSM or prolonged operative times. Conclusions: Several pelvis dimensions were found to be shorter/narrower in AAs and were associated with longer operative times. The presented risk calculator and stratification system may be used to predict prolonged operative time or having PSM.

Robot-assisted radical prostatectomy using the avatera system™: a prospective pilot study.

Robot-assisted radical prostatectomy is a minimally invasive, safe procedure preferred in the management of localized prostate cancer. In this study, we present our initial experience with the avatera™ system (avateramedical GmbH, Jena, Germany) in robot-assisted radical prostatectomy. A total of fourteen patients underwent robot-assisted radical prostatectomy using this newly introduced system in our department from June 2022 to October 2022. The primary endpoints of the study were the time and the successful completion of the operation, the hemoglobin drop and the presence of complications. The pathologic tumor stage and the presence of positive surgical margins were also recorded. Follow-up of the patients for the functional outcomes over a period of 3 months took place. The completion of all the surgeries was successful. The median draping and docking times were 9.5 minutes (7-13) and 10 minutes (5-40), respectively. The median console time was 103.5 minutes (90-121). No conversion to laparoscopic or open prostatectomy was necessary. The median hemoglobin drop was 1.95 g/dL (0.3-2.7), while positive surgical margins were present in two patients postoperatively. No major complications or need for transfusion were noticed. Six months after the procedure, 78.6% of the participants were continent while 77.7% of the nerve-sparing patients reported erections adequate for intercourse. All the operations were completed successfully without major complications or significant blood loss. The functional outcomes were acceptable according to the literature. Based on the early outcomes, robot-assisted radical prostatectomy with the avatera™ system (avateramedical GmbH) could be considered feasible, safe, and efficient.

PD08-08 SHOULD ADJUVANT THERAPY BE CONSIDERED FOR POSITIVE SURGICAL MARGINS IN RENAL CELL CARCINOMA: A STAGE-BASED ANALYSIS OF IMPACT OF POSITIVE SURGICAL MARGINS ON SURVIVAL OUTCOMES USING THE INMARC REGISTRY

PD08-08 SHOULD ADJUVANT THERAPY BE CONSIDERED FOR POSITIVE SURGICAL MARGINS IN RENAL CELL CARCINOMA: A STAGE-BASED ANALYSIS OF IMPACT OF POSITIVE SURGICAL MARGINS ON SURVIVAL OUTCOMES USING THE INMARC REGISTRY

MP58-07 THE IMPACT OF 3D MODELS ON SURGICAL OUTCOMES OF RAPN: IS CT SCAN BECOMING OBSOLETE?

You have accessJournal of UrologyCME1 Apr 2023MP58-07 THE IMPACT OF 3D MODELS ON SURGICAL OUTCOMES OF RAPN: IS CT SCAN BECOMING OBSOLETE? Luigi Nocera, Carlo Bravi, Angelo Mottaran, Adele Piro, Luca Sarchi, Marco Paciotti, Maria Peraire Lores, Eleonora Balestrazzi, Federico Piramide, Rui Farinha, Pieter De Backer, Ruben De Groote, and Alexandre Mottrie Luigi NoceraLuigi Nocera More articles by this author , Carlo BraviCarlo Bravi More articles by this author , Angelo MottaranAngelo Mottaran More articles by this author , Adele PiroAdele Piro More articles by this author , Luca SarchiLuca Sarchi More articles by this author , Marco PaciottiMarco Paciotti More articles by this author , Maria Peraire LoresMaria Peraire Lores More articles by this author , Eleonora BalestrazziEleonora Balestrazzi More articles by this author , Federico PiramideFederico Piramide More articles by this author , Rui FarinhaRui Farinha More articles by this author , Pieter De BackerPieter De Backer More articles by this author , Ruben De GrooteRuben De Groote More articles by this author , and Alexandre MottrieAlexandre Mottrie More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003311.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Since their inception 3D virtual models have helped clinician in surgical indication and preoperative planning, as well as in intraoperative guidance. The added value of 3D models was particularly true in robot-assisted partial nephrectomy (RAPN) given the wide spectrum of possible tumor locations and anatomical variants. We aimed to examine the impact of 3D virtual models on surgical outcomes in a tertiary referral center. METHODS: We relied on 474 patients in our prospectively maintained renal cancer database treated with RAPN between 2009 and 2021. Patients harbouring multiple masses were excluded. The endpoints of the analyses were: 1) presence of positive surgical margins (PSM); 2) warm ischemia time (WIT) and 3) length of stay (LOS). Multivariable regressions examined the impact of the use of 3D virtual model on PSM, WIT and LOS. For all models, the adjustment for casemix included: age, sex, tumor size, tumor side, clinical T stage, PADUA score and estimated blood loss (EBL). RESULTS: Overall, median age was 64 years (interquartile range [IQR]: 55, 73). Median (IQR) tumor size and PADUA score were 3.1 (2.1, 4.5) cm and 8 (7, 10), whereas tumor side was more frequently right (54%). Median WIT was 13 minutes (IQR: 6, 19). OR console time and blood loss were 120 minutes (IQR: 90, 150) and 200 ml (IQR: 100-300), respectively. Median LOS was 3 days (IQR: 3, 5) and 7% of patients had PSM on final pathology. A 3D model was reconstructed for 84 (18%) patients. Patients with reconstructed 3D virtual models had more complex tumors (median PADUA score 9 vs. 8, p<0.05). No other statistically significant differences were recorded, although patients with available 3D models were older (66 vs. 64 years), less frequently male (63% vs. 71%), and exhibited longer WIT (14 vs. 13 minutes), shorter LOS (3 vs. 4 days) and lower PSM rate (3.6% vs 7.4%) (all p>0.05). On multivariable logistic regression models, 3D virtual model usage was an independent predictor of lower PSM rate (odds ratio [OR]: 0.27; p<0.05). Similarly, on multivariable Poisson regressions, 3D virtual model usage was an independent predictor of shorter WIT (OR 0.78; p<0.05) and shorter LOS (OR: 0.82; p<0.01). CONCLUSIONS: Our findings suggest a potentially crucial role of 3D virtual reconstructions for candidates to RAPN for both surgical planning and intraoperative guidance. Indeed, the use of 3D virtual models led to an improvement of potentially both oncological (reduction in PSM) and functional outcomes (reduction in WIT). Further studies are required to confirm these findings at long-term follow-up. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e798 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Luigi Nocera More articles by this author Carlo Bravi More articles by this author Angelo Mottaran More articles by this author Adele Piro More articles by this author Luca Sarchi More articles by this author Marco Paciotti More articles by this author Maria Peraire Lores More articles by this author Eleonora Balestrazzi More articles by this author Federico Piramide More articles by this author Rui Farinha More articles by this author Pieter De Backer More articles by this author Ruben De Groote More articles by this author Alexandre Mottrie More articles by this author Expand All Advertisement PDF downloadLoading ...

Outcomes of High-Grade Cervical Dysplasia with Positive Margins and HPV Persistence after Cervical Conization.

The objective of this work is to assess the 5-year outcomes of patients undergoing conization for high-grade cervical lesions that simultaneously present as risk factors in the persistence of HPV infection and the positivity of surgical resection margins. This is a retrospective study evaluating patients undergoing conization for high-grade cervical lesions. All patients included had both positive surgical margins and experienced HPV persistence at 6 months. Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR). The charts of 2966 patients undergoing conization were reviewed. Among the whole population, 163 (5.5%) patients met the inclusion criteria, being at high risk due to the presence of positive surgical margins and experiencing HPV persistence. Of 163 patients included, 17 (10.4%) patients developed a CIN2+ recurrence during the 5-year follow-up. Via univariate analyses, diagnosis of CIN3 instead of CIN2 (HR: 4.88 (95%CI: 1.10, 12.41); p = 0.035) and positive endocervical instead of ectocervical margins (HR: 6.44 (95%CI: 2.80, 9.65); p < 0.001) were associated with increased risk of persistence/recurrence. Via multivariate analyses, only positive endocervical instead of ectocervical margins (HR: 4.56 (95%CI: 1.23, 7.95); p = 0.021) were associated with worse outcomes. In this high-risk group, positive endocervical margins is the main risk factor predicting 5-year recurrence.

Do bony pelvis parameters affect perioperative outcomes in open radical prostatectomy?

ObjectiveThe present study aimed to evaluate the predictive value of bony pelvic parameters measured by computerized tomography (CT) for use in the estimation of the likely technical difficulties that may be encountered when performing open radical prostatectomy (RP) for localized prostate cancer.Material and methodsOne hundred patients, undergoing open RP for localized prostate cancer, were evaluated between October 2016 to November 2018. All operations were performed by the same experienced surgeon. Pelvic parameters were measured using spiral CT images. Data were retrospectively collected from medical, operative, radiology, and pathology records and analyzed. Positive surgical margin (PSM), presence of vesicourethral anastomosis stricture (VUAS) and urine leakage, operative time, urethral catheterization time, and estimated blood loss were used as indicators of operative difficulty. Univariate and multivariate analyses were performed to determine the significance of these variables.ResultsThere was no significant correlation between the pelvic parameters of the patients and the presence of PSM, VUAS, and urine leakage. Only PSA levels and pathological tumor stage were higher in patients with PSM (p = 0.002 and p = 0.001). On univariate and multivariate analyses, none of the individual pelvic parameters assessed showed a significant relationship with the operation time, estimated blood loss, and urethral catheterization time. In univariate analysis, there was a significant relationship between PSA levels and pathological tumor stage and operation time (p = 0.048 and p = 0.001, respectively).ConclusionBony pelvic parameters may not be a significant factor in influencing the perioperative outcomes of open RP. Higher PSA levels and pathological tumor stage may lead to surgical margin positivity and longer operative time.

PD54-03 ARTIFICIAL INTELLIGENCE IN ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY: DEVELOPING PREDICTIVE MODELS FOR POSITIVE SURGICAL MARGINS

You have accessJournal of UrologyCME1 May 2022PD54-03 ARTIFICIAL INTELLIGENCE IN ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY: DEVELOPING PREDICTIVE MODELS FOR POSITIVE SURGICAL MARGINS Stephen Schmit, Rebecca Ortiz, Philip Caffery, Christopher Tucci, Carsten Eickhoff, Elias Hyams, and Gyan Pareek Stephen SchmitStephen Schmit More articles by this author , Rebecca OrtizRebecca Ortiz More articles by this author , Philip CafferyPhilip Caffery More articles by this author , Christopher TucciChristopher Tucci More articles by this author , Carsten EickhoffCarsten Eickhoff More articles by this author , Elias HyamsElias Hyams More articles by this author , and Gyan PareekGyan Pareek More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002631.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with localized prostate cancer increasingly elect for robotic-assisted laparoscopic prostatectomy (RALP), but this approach may be less preferred when adjuvant therapy is indicated. Adjuvant therapy improves survival but is associated with significant psychological distress and additional treatment complications. The presence of positive surgical margins after RALP is an important indication for adjuvant therapy. The goal of this study was to explore deep learning models for the prediction of positive surgical margins with preoperative data. METHODS: Patient data from a single academic institution was pre-processed to train two artificial intelligence models: a feedforward multilayer perceptron and a random forest model containing 100 trees. A total of 9 preoperative variables were used for model training (prostate specific antigen value, positive biopsy cores, Gleason score on biopsy, perineural invasion on biopsy, body mass index, tobacco use history, family history of cancer, preoperative prostate volume, and age at diagnosis). Model construction was performed using the Python programming language. RESULTS: Data preprocessing yielded a final sample of 461 patients. The optimized neural network demonstrated successful learning with loss minimization over 100 epochs (Figure 1) and a maximum area under the curve (AUC) of 0.60. The random forest model demonstrated an AUC of 0.55 (Figure 2). CONCLUSIONS: Neither model demonstrated significant accuracy in predicting positive surgical margins with preoperative structured data. The integration of structured data may be insufficient for predicting margin status. Future models that utilize raw imaging information should be explored. For example, a convolutional neural network that is trained on preoperative multiparametric resonance imaging data may be a superior approach. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e916 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Stephen Schmit More articles by this author Rebecca Ortiz More articles by this author Philip Caffery More articles by this author Christopher Tucci More articles by this author Carsten Eickhoff More articles by this author Elias Hyams More articles by this author Gyan Pareek More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP27-02 NOT ALL ADVERSE PATHOLOGY FEATURES ARE EQUAL: IDENTIFYING OPTIMAL CANDIDATES FOR ADJUVANT RADIOTHERAPY AMONG PATIENTS WITH ADVERSE PATHOLOGY AT RADICAL PROSTATECTOMY

MP27-02 NOT ALL ADVERSE PATHOLOGY FEATURES ARE EQUAL: IDENTIFYING OPTIMAL CANDIDATES FOR ADJUVANT RADIOTHERAPY AMONG PATIENTS WITH ADVERSE PATHOLOGY AT RADICAL PROSTATECTOMY

Improving the prediction of biochemical recurrence after radical prostatectomy with the addition of detailed pathology of the positive surgical margin and cribriform growth

The risk on biochemical recurrence (BCR) after radical prostatectomy (RP) is usually estimated using PSA and pathological stage and grading including the presence of positive surgical margins (PSM). Objective was to investigate whether the presence of cribriform growth in the primary tumor, Grade Group (GG) at the PSM, and length of the PSM have added value in the prognostication. We analyzed data of 835 patients initially treated with RP between 2000 and 2017. Cox regression models were developed to compare the baseline model (PSA, pT-stage, pN-stage, GG at RP, and presence of PSM) with an extended model (adding the presence of cribriform growth, length and GG at the PSM) using the likelihood ratio test. Discrimination was assessed at internal validation by the time-dependent area under the receiver operating characteristic curve (AUC) at 3- and 5-year. A total of 224 men experienced BCR. Median follow-up for men without BCR was 50.4 months (interquartile range, IQR 11.9–95.5). The extended model had a significant better fit, χ2(4) = 31.0, p < 0.001 than the baseline model. The AUC of the 3- and 5-year extended model was 0.85 (95% CI 0.81–0.88) compared to 0.83 (95% CI 0.79–0.87) for the baseline model. Importantly, the presence of cribriform growth in the primary tumor, and GG ≥ 2 at PSM were associated with a higher risk on BCR. In conclusion, the addition of pathological variables improved the prediction of the risk on BCR after RP slightly. However, the clinical implications of this model are important.

Comparison between minimally-invasive partial and radical nephrectomy for the treatment of clinical T2 renal masses: results of a 10-year study in a tertiary care center.

Even if partial nephrectomy (PN) is nowadays considered the standard for managing cT1 renal masses, its role in the management of cT2 kidney tumors is controversial. We aimed to compare oncologic and functional outcomes of minimally invasive radical nephrectomy (RN) and PN in cT2 renal masses. Patients with cT2 renal masses underwent minimally-invasive PN or RN performed by a highly experienced single surgeon from 2009 to 2019 were considered. Demographic, perioperative and functional variables were compared. Cumulative incidence plot and competing risks regression (CRR) models were used to test differences in 5-year cancer-specific mortality (CSM) and 5-year other-cause mortality (OCM) rates. Kaplan-Meier and Cox regression model was used to test differences in 5-year progression free survival (PFS) rates. Overall, 52 PN vs. 64 RN patients were identified. Relative to RN, PN patients recorded higher rates of complications (25% vs. 7.8%, P=0.02) but lower upstaging rate (≥pT3a 64.1% vs. 19.2%, P<0.0001). Functional outcomes were in favor of PN (all P<0.001). No differences were recorded between 5-year CSM and OCM according to nephrectomy type. At CRR models, older age and upstaging were independent predictors of 5-year OCM and CSM, respectively (all P<0.01). Finally, only upstaging, high grade tumors and presence of positive surgical margins were identified as independent predictors of 5-year PFS (all P<0.01). In experienced hands the treatment of cT2 renal neoplasms with minimally-invasive PN is feasible, providing perioperative and oncological safety profiles comparable to RN, with advantages in terms of functional outcomes.

MRI utility in predicting extraprostatic extension of prostate cancer and biochemical recurrence after radical prostatectomy

Introduction. The study aimed to evaluate the performance of multiparametric magnetic resonance imaging (mpMRI) and the Martini model to predict extraprostatic extension (EPE) and biochemical recurrence (BCR) of prostate cancer (PCa). Materials and methods. 61 patients underwent a radical laparoscopic prostatectomy. The preoperative risk of EPE was determined using mpMRI and the Martini model. Results. MpMRI predicts the presence of EPE of PCa with a sensitivity and specificity of 47.4% and 85.7%, respectively (AUC 0.66, 95% CI: 0.51–0.82, p = 0.046). The Martini model’s sensitivity was higher, but the specificity was lower than that of mpMRI and was 84.2% and 66.7%, respectively (AUC 0.78, 95% CI: 0.66–0.89, p &lt; 0.001). Univariate and multivariate Cox analysis indicated that EPE in mpMRI (HR 6.6, 95% CI: 1.8–24.1), and the presence of positive surgical margins (PSM) (HR 7.1, 95% CI: 1.9–26.7) are independent factors increasing the probability of BCR. Conclusions. MpMRI and Martini model are valuable tools in local staging of PCa, managing and predicting the oncological treatment outcomes of patients with PCa.

“Robotic fatigue?” – The impact of case order on positive surgical margins in robotic-assisted laparoscopic prostatectomy

PurposeMultiple robotic-assisted surgeries are often performed within a single operating day; however, the impact of this practice on patient outcomes has not been examined. We aim to determine whether outcomes for robotic-assisted laparoscopic prostatectomy (RALP) differed when performed sequentially. Materials and methodsA multi-institutional, retrospective cohort study was conducted involving a total of 8 academic centers between years 2015 and 2018. Participants were adult males undergoing RALP for localized prostate cancer on operative days in which 2 RALP cases were performed sequentially by the same resident-attending team. The primary outcome of the study was presence of positive surgical margin (PSM). Secondary outcomes were lymph node yield, operative time, and estimated blood loss. The primary analysis was a random effects meta-analysis model for PSM. ResultsOverall, 898 RALP cases (449 sequential pairs) were included in the study. There was no significant difference in PSM rate (27.2% vs. 30.3%, P= 0.338) between first and second case groups, respectively. Utilizing random effects meta-analysis, the second case cohort had no increased risk of PSM (OR 0.761.231.97, P= 0.40). Higher blood loss was noted in the second case cohort (186.7 ml vs. 221.7 ml, P = 0.002). Additionally, factors associated with PSM were increasing prostate specific antigen, higher percent tumor involvement, extraprostatic extension, and seminal vesicle invasion. ConclusionCase sequence was not associated with PSM, lymph node yield, or operative time for RALP. Disease specific factors and institutional experience are associated with increased risk for positive surgical margin which can aid providers in scheduling of patients.

Preoperative prostate health index predicts adverse pathology and Gleason score upgrading after radical prostatectomy for prostate cancer

BackgroundWe aimed to explore the utility of prostate specific antigen (PSA) isoform [− 2] proPSA and its derivatives for prediction of pathological outcome after radical prostatectomy (RP).MethodsPreoperative blood samples were prospectively and consecutivelyanalyzed from 472 patients treated with RP for clinically localized prostate cancerat four medical centers. Measured parameters were PSA, free PSA (fPSA), fPSA/PSA ratio, [− 2] proPSA (p2PSA), p2PSA/fPSA ratio and Prostate Health Index (PHI)(p2PSA/fPSA)*√PSA]. Logistic regression models were fitted to determine the accuracy of markers for prediction of pathological Gleason score (GS) ≥7, Gleason score upgrading, extracapsular extension of the tumor (pT3) and the presence of positive surgical margin (PSM). The accuracy of predictive models was compared using area under the receiver operating curve (AUC).ResultsOf 472 patients undergoing RP, 339 (72%) were found to have pathologic GS ≥ 7, out of them 178 (53%) experienced an upgrade from their preoperative GS = 6. The findings of pT3 and PSM were present in 132 (28%) and 133 (28%) cases, respectively. At univariable analysis of all the preoperative parameters, PHI was the most accurate predictor of pathological GS ≥7 (OR 1.02, 95% CI 1.01–1.03, p<0.001), GS upgrading (OR 1.02, 95% CI 1.01–1.03, p<0.003), pT3 disease (OR 1.01, 95% CI 1.00–1.02, p<0.007) and the presence of PSM (OR 1.01, 95% CI 1.00–1.02, p<0.002). Adding of PHI into the base multivariable model increased significantly the accuracy for prediction of pathological GS by 4.4% to AUC = 66.6 (p = 0.015) and GS upgrading by 5.0% to AUC = 65.9 (p = 0.025), respectively.ConclusionsPreoperative PHI levels may contribute significantly to prediction of prostate cancer aggressiveness and expansion of the tumor detected at final pathology.

An Abnormal Precone Endocervical Curettage Result Is an Independent Risk Factor for Positive Margins in Conization Specimens

Objective: This study aimed to identify risk factors associated with the presence of positive surgical margins in cervical conization specimens. Methods: This study is a retrospective analysis of data from women who had undergone conization for cervical intraepithelial neoplasia (CIN) from 2012 to 2018 at Fujian Maternity and Child Health Hospital. Factors extracted from the database included age, gravidity, parity, menopausal status, precone Thinprep cytology test, human papillomavirus (HPV) test, precone biopsy, precone endocervical curettage (ECC) result, conization method, operating surgeon, cone dimension, and pathology of the conization specimen, including grade of CIN, margin status and glandular involvement. Univariate and multivariate analyses were performed to identify risk factors associated with positive margins. Results: Data from 495 women were analysed. The proportion of positive margins was 24.85% overall, which varied according to the conization method (27.22% for loop electrosurgical excision procedure vs. 18.52% for cold-knife conization, p = 0.047) and was increased as the severity of the treated lesion increased (10.07% for CIN2 vs. 30.62% for CIN3, p < 0.001). HPV-16 genotype infection, abnormal precone ECC result, higher grade of biopsy, larger cone length and volume, and glandular involvement were significantly associated with positive margins on univariable analysis. After logistic regression analysis, only an abnormal precone ECC result (odds ratio 1.952; 95% confidence interval 1.037–3.676; p = 0.038) remained significant. Conclusions: In the present study, an abnormal precone ECC result was identified as an independent risk factor for positive margins in cervical conization specimens. More aggressive treatment may be considered in patients with abnormal precone ECC results in clinical practice.

Oncological results of radical prostatectomy depending on the data of multiparametric magnetic resonance imaging and patient selection for nerve-sparing technique

Background. Selecting patients for radical prostatectomy (RP) using nerve-sparing technique (NST) is crucial to optimize oncological and functional results. Correlation of multiparametric magnetic resonance imaging (mpMRI) data with RP results remains insufficiently studied, at the same time existing prognostic tools and nomograms show moderate effectiveness during third-party validation and have some drawbacks. Objective: to study pathomorphological results and evaluate the recurrence-free survival of patients after RP, depending on mpMRI data; develop a patient selection algorithm for NST. Materials and methods. The study included 95 patients with clinically localized prostate cancer (PCa), who underwent RP within 2012—2017. All mpMRI series were retrospectively reviewed and evaluated using the Prostate Imaging Reporting and Data System (PI-RADS) version 2 (v2) by one radiologist diagnostician who neither had access to database and clinical information about patients nor participated in data collection and statistical analysis. Patients were divided into 2 groups: low probability of PCa and suspected PCa (PI-RADS 2—3; n = 43); high and very high probability of PCa (PI-RADS 4—5; n = 52). We assessed the presence of positive surgical margins, as well as extracapsular extension and relapse-free survival. We also developed an algorithm to select patients for nerve-sparing PCa based on the PI-RADS category according to mpMRI data. Results. PI-RADS 2—3 group showed less positive surgical margins as compared to PI-RADS 4—5group (2.3 % versus 21.2 %; p = 0.025), as well as no cases of tumor extracapsular extension versus 36.5 % in PI-RADS 4—5group (p &lt;0.001). Patients with Gleason score 6 after demonstrated the same trends: extracapsular extension on the tumor side was observed in 0 and 33.3 % of cases (p &lt;0.001), positive surgical margins — in 2.4 and 15.2 % of cases (p = 0.046), respectively. An increase of the Gleason score after RP was observed in 12.2 % of patients of PI-RADS 2—3 group and in 30.3 % of PI-RADS 4—5 group (p = 0.04). Recurrence-free survival after 60 months was 93.0 and 71.1 %, respectively (p = 0.015). Conclusion. Risk categories for PCa according to mpMRI data are associated with pathomorphological results and recurrence-free survival after RP. Using PI-RADS v2 categories in the patient selection algorithm for NST optimizes the assessment of oncological safety and allows selecting a group of patients for a thorough individual analysis of the benefit/risk profile.

Retroperitoneal soft-tissue sarcomas: Radiotherapy experience from a tertiary cancer center and review of current evidence.

Surgery remains to be the main therapeutic approach for retroperitoneal sarcomas (RPS) although evidence supports that complementary radiotherapy increases local-control and survival. We present a multidisciplinary management and experience of a tertiary cancer center in the treatment of RPS and analyze current evidence of radiotherapy efficacy. We retrospectively reviewed 19 patients with primary or relapsed RPS treated between November 2009 and October 2018. Multidisciplinary approach comprised complete resection in 15 patients (79%) achieving resection R0 in 11 patients (58%), R1 in 4 patients (21%) and R2 in 2 patients (10%). Seven patients (37%) underwent a preoperative radiation (PRORT), 10 patients (53%), post-operative radiation (PORT) and 2 patients (10%), received radiotherapy exclusively. Ten patients (53%) received adjuvant chemotherapy. With a median follow-up of 24 months (2-114 months), actuarial rates of loco-regional relapse free survival (LRFS) at 1, 2 and 3 years were 77%, 77% and 67%, respectively. Actuarial rates of distant-metastases-free survival (DMFS), disease-free survival (DFS) and overall survival (OS) at 1, 2 and 3 years were 100%, 100% and 80% for DMFS; 94%, 77% and 67% for DFS and 100%, 91% and 91% for OS, respectively. Only surgical margins (negative vs. positive) showed significance for 3y-LRFS: 100% vs. 34.3%, p=0.018. Treatment tolerance was acceptable with no acute or late toxicity higher than grade 2. Complementary radiotherapy appears to be useful and well tolerated for the multidisciplinary management of RPS. Presence of positive surgical margins seems to be the most relevant prognostic factor through the follow-up.