Prostatic Apex Research Articles

Determination of Whether Apex or Non-Apex Prostate Cancer Is the Best Candidate for the Use of Prostate-Specific Antigen Density to Predict Pathological Grade Group Upgrading and Upstaging after Radical Prostatectomy

Objective: Previous studies have demonstrated that prostate-specific antigen density (PSAD) may aid in predicting Gleason grade group (GG) upgrading and pathological upstaging in patients with prostate cancer (PCa). However, the differences and associations between patients with apex prostate cancer (APCa) and non-apex prostate cancer (NAPCa) have not been described. The aim of this study was to explore the different roles of PSAD in predicting GG upgrading and pathological upstaging between APCa and NAPCa. Patients and Methods: Five hundred and thirty-five patients who underwent prostate biopsy followed by radical prostatectomy (RP) were enrolled. All patients were diagnosed with PCa and classified as either APCa or NAPCa. Clinical and pathological variables were collected. Univariate, multivariate, and receiver operating characteristic (ROC) analyses were performed. Results: Of the entire cohort, 245 patients (45.8%) had GG upgrading. Multivariate analysis revealed that only PSAD (odds ratio [OR]: 4.149, p < 0.001) was an independent, significant predictor of upgrading. A total of 262 patients (49.0%) had pathological upstaging. Both PSAD (OR: 4.750, p < 0.001) and percentage of positive cores (OR: 5.108, p = 0.002) were independently significant predictors of upstaging. Of the 374 patients with NAPCa, 168 (44.9%) displayed GG upgrading. Multivariate analysis also showed PSAD (OR: 8.176, p < 0.001) was an independent predictor of upgrading. Upstaging occurred in 159 (42.5%) patients with NAPCa, and PSAD (OR: 4.973, p < 0.001) and percentage of positive cores (OR: 3.994, p = 0.034) were independently predictive of pathological upstaging. Conversely, of the 161 patients with APCa, 77 (47.8%) were identified with GG upgrading, and 103 (64.0%) patients with pathological upstaging. Multivariate analysis demonstrated that there were no significant predictors, including PSAD, for predicting GG upgrading (p = 0.462) and pathological upstaging (p = 0.100). Conclusions: PSAD may aid in the prediction of GG upgrading and pathological upstaging in patients with PCa. However, this may only be practical in patients with NAPCa but not with APCa. Additional biopsy cores taken from the prostatic apex region may help improve the accuracy of PSAD in predicting GG upgrading and pathological upstaging after RP.

The progress of dorsal vascular complex control strategy in radical prostatectomy.

Radical prostatectomy has undergone a development from open to laparoscopic surgery to a surgical robotic approach. With improved surgical equipment and the continuous development of surgical techniques, various surgical strategies for controlling the dorsal vascular complex (DVC) during RP have been investigated, which affect intraoperative blood loss, postoperative tumour control and postoperative urinary and sexual function. The present narrative review summarizes the latest anatomical information about the prostatic apex and DVC and then describes the three types of DVC control. More detailed anatomy of the DVC is required and the optimal DVC control under different situations needs further research.

Role of preoperative magnetic resonance imaging on the surgical outcomes of radical prostatectomy: Does preoperative tumor recognition reduce the positive surgical margin in a specific location? Experience from a Thailand prostate cancer specialized center

ObjectiveMultiparametric magnetic resonance imaging (MRI) has become the standard of care for the diagnosis of prostate cancer patients. This study aimed to evaluate the influence of preoperative MRI on the positive surgical margin (PSM) rates. MethodsWe retrospectively reviewed 1070 prostate cancer patients treated with radical prostatectomy (RP) at Siriraj Hospital between January 2013 and September 2019. PSM rates were compared between those with and without preoperative MRI. PSM locations were analyzed. ResultsIn total, 322 (30.1%) patients underwent MRI before RP. PSM most frequently occurred at the apex (33.2%), followed by posterior (13.5%), bladder neck (12.7%), anterior (10.7%), posterolateral (9.9%), and lateral (2.3%) positions. In preoperative MRI, PSM was significantly lowered at the posterior surface (9.0% vs. 15.4%, p=0.01) and in the subgroup of urologists with less than 100 RP experiences (32% vs. 51%, odds ratio=0.51, p<0.05). Blood loss was also significantly decreased when a preoperative image was obtained (200 mL vs. 250 mL, p=0.02). Multivariate analysis revealed that only preoperative MRI status was associated with overall PSM and PSM at the prostatic apex. Neither the surgical approach, the neurovascular bundle sparing technique, nor the perioperative blood loss was associated with PSM. ConclusionMRI is associated with less overall PSM, PSM at apex, and blood loss during RP. Additionally, preoperative MRI has shown promise in lowering the PSM rate among urologists who are in the early stages of performing RP.

Preoperative predictive model of early urinary continence recovery after laparoscopic radical prostatectomy.

To develop and validate a predictive model include magnetic resonance imaging (MRI) parameters preoperatively which can assess the risk of incontinence after laparoscopic radical prostatectomy (LRP) accurately. We retrospectively reviewed and included 170 patients with prostate cancer who underwent LRP between July 2015 and June 2018 in our institution. All 170 patients were randomly resampled and divided into training set (n = 124) and verification set (n = 46) according to the ratio of 7:3. The Nomogram prediction model of the risk of incontinence after LRP was established through the training set and verified by the verification set. Baseline patient characteristics were obtained, including age, body mass index, and prostate volume. Perioperative characteristics such as pre-biopsy prostate specific antigen, biopsy Gleason score, clinical staging, and NVB sparing status were also collected. MRI parameters preoperatively including membranous urethral length (MUL), prostate apex depth ratio (PADR), and intravesical prostatic protrusion length (IPPL) were obtained. The C index and visual inspection of calibration curve were used to evaluate the discrimination and calibration of the model. According to the urinary incontinence (UI) at 3months postoperatively, the patients were divided into 104 cases (61.2%) in the group with no incontinence and 66 patients (38.8%) in the group with incontinence. Multivariate logistic regression analysis of training set showed that cT3a (OR = 0.427, 95% CI 0.142-1.281, P = 0.1288), MUL (OR = 0.237, 95% CI 0.102-0.551, P < 0.01), PADR (OR = 0.276, 95% CI 0.116-0.655, P < 0.01), and IPPL (OR = 0.073, 95% CI 0.030-0.179, P < 0.01) were independent predictors of urinary incontinence at 3months postoperatively. The model showed good discrimination with an area under the receiver operating characteristic (ROC) curve of 0.880, with the sensitivity and specificity 0.800 and 0.816, respectively, and good calibration (Hosmer-Lemeshow test result of 5.57, P = 0.695). Decision curve analysis demonstrated that the model was clinically useful. This study developed and validated a preoperative model in the form of a nomogram to predict the risk of UI after LRP at 3months. MUL, PADR, and IPPL were significant independent predictive factors of the postoperative early urinary continence.

Landscape and metastases of the lymph nodes in prostatic anterior fat pad at radical prostatectomy

Objectives: To examine the landscape and metastases of the lymph nodes in prostatic anterior fat pad (PAFP) at radical prostatectomy (RP), and to describe the clinical characteristic of the patients with lymph node metastases in PAFP. Methods: The clinical and pathological data of 287 prostate cancer patients underwent RP from December 2019 to August 2021 in Department of Urology, Sun Yat-sen University Cancer Center were collected and analyzed retrospectively. All patients were male, aging (66±7) years (range: 42 to 83 years). The preoperative prostate-specific antigen (PSA) (M(IQR)) were 16.00(29.64) μg/L (range: 0.01 to 99.90 μg/L). There were 244 patients with localized or locally advanced prostate cancer and 43 patients with metastatic prostate cancer. All PAFP were dissected at RP routinely and were sent for pathologic analysis respectively. The PAFP was dissected from the prostate apex caudally toward the bladder neck and dissection extended to the joint of the prostate and the endopelvic fascia bilaterally. All the specimen of PAFP were examined and reported by subspecialty pathologists of genitourinary tumors. Statistical analysis was performed by Student t test, Wilcoxon rank-sum test, χ2 test or Fisher exact test. Results: There were 8.0% (23/287) patients with lymph nodes in PAFP, 3.8% (11/287) patients with PAFP lymph node metastases. Pathologically upstaged occurred in 1 patient due to the PAFP lymph node as the solitary metastatic lesion. Patients with lymph node metastases in PAFP presented higher preoperative PSA (M(IQR): 48.2(73.0) μg/L vs. 15.4(26.5) μg/L, Z=3.158, P=0.002), clinical T stage and N stage (Z=2.977, P=0.003; Z=2.780, P=0.005) and preoperative Gleason score (Z=2.205, P=0.027). Conclusions: Routine dissection of PAFP at RP and separately pathological analysis may allow more lymph nodes and lymph node metastases detection. More accurate pathological N stage may be acquired and consequently may improve the survival of patients by offering more appropriate adjuvant or salvage therapy.

The Use of HA as Rectal Spacer in Prostate Cancer Patients Undergoing Hypofractionated RT: An Australian Experience

<h3>Purpose/Objective(s)</h3> To report the feasibility, post-operative complications and recto-prostatic separation achieved with hyaluronic acid (HA) inserted into the perirectal fat before definitive prostate radiotherapy (RT). <h3>Materials/Methods</h3> Fifty-seven patients with clinical stage T1-3 prostate cancer underwent transrectal ultrasound guided transperineal insertion of fiducial markers and HA into the perirectal space before volumetric arc RT between 7/2020 to 7/2021. Post insertion computerized tomography (CT) and magnetic resonance imaging (MRI) scans were obtained for treatment planning. HA feasibility, safety and recto-prostatic separation were assessed. The prescribed dose to the planning target volume (PTV) ranged from 60-62Gy in 20 fractions. <h3>Results</h3> The mean age was 74.7 years. The median PSA was 8.1 [Interquartile range (IQR)6.2-10.0]. The majority of patients had ISUP 2 adenocarcinoma (60%). The rest had ISUP 1 (11%) and ISUP 3 (30%). The disease risk was staged as early in 11%, favorable intermediate in 30%, unfavorable intermediate in 58% and high in 2%. Androgen deprivation therapy was delivered in 63%. HA insertion was completed with a 100% success rate. This was rated as ‘easy' to ‘very easy' 100% of the time. There were no device related complications, rectal perforation, serious bleeding, infections or allergic reactions. The mean prostate size was 43cc (IQR 30-55cc). Recto-prostatic separation at the base (measured 5mm below the prostate base), mid gland and apex (measured 5mm above the prostate apex) were 12mm (0.2), 11mm (0.2) and 0.9mm (0.1) respectively. The HA was also symmetrically placed in breadth at the mid gland in all patients. The mean rectal volume receiving 53Gy (rV53) was 3.2% (IQR 1.3-5.5) for patients receiving 60-62Gy. The median follow up was 13.5 months (IQR 9.5-17.5). The risk of any acute GU toxicity was 81%. The majority had grade 1 GU toxicity at 67% with urinary frequency, urgency and obstruction being the commonest reported side effects. The risk of any grade 2 GU toxicity was 14% with urinary obstruction (13%) and urgency (7%). The risk of any acute GI toxicity was 2%. Only 1 patient developed grade 1 GI toxicity with diarrhea. The risk of any late GU toxicity was 43%. The majority had grade 1 GU toxicity at 32% with urinary frequency, urgency and obstruction. The risk of any grade 2 GU toxicity was 11% with urinary obstruction (5%), urgency (5%) and incontinence (2%). The risk of any late GI toxicity was 2%. Only 1 patient had grade 1 GI toxicity with diarrhea. <h3>Conclusion</h3> HA was successfully inserted in all patients and was well tolerated. Recto-prostatic separation was symmetrical in length from the base to the apex and in breadth at the midgland. The risk of developing any acute GI toxicity was minimal at 2% with the use of HA. In addition, the risk of late GI toxicity was 2%, albeit with short follow up.

New modified technique of hydrogel spacer implantation for prostate cancer: a novel method for separation at the prostate apex level under real-time ultrasound guidance.

New modified technique of hydrogel spacer implantation for prostate cancer: a novel method for separation at the prostate apex level under real-time ultrasound guidance.

Impact of transperineal ultrasound on perineal skin dose in prostate radiation therapy.

IntroductionThis study investigated the relationship between anatomical compression introduced via ultrasound probe pressure and maximum perineum dose in prostate radiotherapy patients using the Clarity transperineal ultrasound (TPUS) system.Methods115 patient ultrasound and computed tomography scans were retrospectively analysed. The probe to prostate apex distance (PPA), probe to inferior corpus spongiosum distance (PICS) and maximum perineum dose were calculated. Compression was represented by the PICS and the calculated corpus to prostate ratio (CPR). Demographics included treatment technique, image quality, body mass index (BMI) and age. Multiple linear regression analysis assessed the relationship between compression measures and perineum dose.ResultsThe maximum dose to perineum ranged from 1.81 to 45.56 Gy, with a median of 5.87 Gy (Interquartile range (IQR) 3.17). The PICS distance and CPR recorded was 1.67 cm (IQR 0.63) and 0.51 (range 0.29–0.85) respectively. Regression analysis demonstrated both PICS and CPR were significant predictors of maximum dose to the perineum (p < 0.001). Patient-specific factors, including age, BMI, treatment technique and ultrasound image quality, were not factors that significantly impacted the maximum perineum dose.ConclusionThere was a statistically significant association between increased anatomical compression and perineal dose measurements. A PICS of 1.2 cm or greater is recommended, with compression reduced as much as possible without losing anatomical US definition. Future investigations would be beneficial to evaluate the optimal balance between ultrasound image quality and transducer compression considering the perineum dose.

Preoperative Multiparametric Prostate Magnetic Resonance Imaging Structured Report Informs Risk for Positive Apical Surgical Margins During Radical Prostatectomy.

The prostatic apex is the most frequent location of positive surgical margin (PSM) after surgery. Data regarding the ability of multiparametric magnetic resonance imaging (mpMRI) to prospectively identify men at risk for apical PSMs (aPSMs) using a structured report are lacking. The aims of the study are to determine and to compare the rate of aPSM in men with versus without prospectively flagged at-risk prostate lesions during clinical mpMRI interpretation using whole-mount histopathology as the reference standard. This single-center, retrospective study of prospectively collected data included treatment-naive men with abnormal 3T mpMRI (PI-RADS v2 score ≥3) between January 2016 and December 2018 followed by surgery. During routine clinical interpretation, radiologists flagged prostate lesions abutting the apical most gland and/or encircling the distal most prostatic urethra using standardized language available as a "pick list" option in the structured report. Logistic regression was used to compare the rate of PSM in 2 groups (flagged vs nonflagged men). Propensity score covariate adjustment corrected for potential selection bias according to age, prostate-specific antigen (PSA), PSA density, grade group, and pT stage. The estimate was further adjusted by including surgeon as a covariate. A total of 428 men were included. A statistically significant higher proportion of aPSMs was noted in flagged (56% [51/91]) compared with nonflagged apical lesions (31% [105/337]; adjusted odds ratio, 2.5; 95% confidence interval, 1.6-4.1; P < 0.01). The difference in aPSM between both groups also varied according to the surgeon performing the RP. Prostate-specific antigen, PSA density, lesion size, apical location, Prostate Imaging Reporting & Data System score, grade group, pT stage, and surgeon's experience were associated with higher PSM rate. Biochemical recurrence, defined as PSA greater than 0.2 ng/mL on 2 measurements after RP, was significantly associated with PSM status (propensity score adjusted odds ratio, 3.1; 95% confidence interval, 1.8-5.3; P < 0.0001); however, patients flagged by radiologists did not have a significant difference in biochemical recurrence rates as compared with nonflagged patients ( P = 0.11). Standard language built into structured reports for mpMRI of the prostate helps identify preoperatively patients at risk for aPSM. Multiparametric MRI is able to identify patients at increased risk for aPSM, and this information can be conveyed in a structured report to urologists, facilitating patient counseling and treatment decisions.

Virtual cadaver facilitates abdominopelvic anatomy teaching

Purpose CT imaging of the upper abdomen has complex anatomy that can be difficult to parse given similar densities of multiple organs. Understanding of upper abdominal anatomy, limitations of CT imaging, and alternative methods for visualization are important for physicians in multiple surgical and non-surgical fields. We repurposed a novel, open-access resource to facilitate teaching upper abdominal anatomy. Methods This pilot study with medical students had three learning objectives: 1) identify abdominal organs and sub-structures on CT and 3D human cadaver imaging 2) justify why different types of contrast (e.g. oral or IV) are used or can be omitted based on region of interest. 3) Rationalize use of non-CT visualizations such as MRI, endoscopy, or laparotomy for select scenarios. Hybrid in-person and virtual attendance at sessions employing CT images linked with human cadaver image set serially sectioned from Visible Human Project (https://www.nlm.nih.gov/research/visible/visible_human.html). Students identified and outlined structures on CT using three orthogonal planes prior to blending in cadaver images. Facilitated discussion of challenging organ interfaces (e.g. pancreas and duodenum) and techniques to improve contrast or alternative visualization modalities (e.g. MRI or direct visualization). Post-session survey delivered via e-mail same day. Results Seven students attended the pilot session (3 virtually) with five of seven responding to survey (71% response rate). All respondents found the session to be moderately or very helpful and felt that after the session they were moderately or very confident in their ability to identify upper abdominal structures. Regarding the cadaver images, 1 student thought it was very helpful (20%), 3 students thought it was moderately helpful (60%), and 1 student thought it was not at all helpful (20%). Discussion Human cadaver imaging can help facilitate teaching of CT based anatomy in a pilot study of medical students. Additional sessions may better elucidate benefits and limitations. This resource could be adapted for residents identifying hepatobiliary structures, distinguishing prostate apex from genitourinary diaphragm, and differentiating mediastinal nodal levels from vascular spaces. CT imaging of the upper abdomen has complex anatomy that can be difficult to parse given similar densities of multiple organs. Understanding of upper abdominal anatomy, limitations of CT imaging, and alternative methods for visualization are important for physicians in multiple surgical and non-surgical fields. We repurposed a novel, open-access resource to facilitate teaching upper abdominal anatomy. This pilot study with medical students had three learning objectives: 1) identify abdominal organs and sub-structures on CT and 3D human cadaver imaging 2) justify why different types of contrast (e.g. oral or IV) are used or can be omitted based on region of interest. 3) Rationalize use of non-CT visualizations such as MRI, endoscopy, or laparotomy for select scenarios. Hybrid in-person and virtual attendance at sessions employing CT images linked with human cadaver image set serially sectioned from Visible Human Project (https://www.nlm.nih.gov/research/visible/visible_human.html). Students identified and outlined structures on CT using three orthogonal planes prior to blending in cadaver images. Facilitated discussion of challenging organ interfaces (e.g. pancreas and duodenum) and techniques to improve contrast or alternative visualization modalities (e.g. MRI or direct visualization). Post-session survey delivered via e-mail same day. Seven students attended the pilot session (3 virtually) with five of seven responding to survey (71% response rate). All respondents found the session to be moderately or very helpful and felt that after the session they were moderately or very confident in their ability to identify upper abdominal structures. Regarding the cadaver images, 1 student thought it was very helpful (20%), 3 students thought it was moderately helpful (60%), and 1 student thought it was not at all helpful (20%). Human cadaver imaging can help facilitate teaching of CT based anatomy in a pilot study of medical students. Additional sessions may better elucidate benefits and limitations. This resource could be adapted for residents identifying hepatobiliary structures, distinguishing prostate apex from genitourinary diaphragm, and differentiating mediastinal nodal levels from vascular spaces.

Anatomical observation and clinical significance of the prostatic part of neurovascular bundle in total mesorectal excision

Objective: To observe the anatomical architecture of the prostatic part of the neurovascular bundle (NVB) in total mesorectal excision (TME). Methods: A descriptive cohort study and an anatomical observation study were carried out. A total of 38 male patients with rectal cancer who underwent TME in the Department of Colorectal Surgery at the affiliated Union hospital of Fujian Medical University between November 2013 and March 2015 were included. A total of 4 hemipelvis were examined at the Laboratory of Clinical Applied Anatomy, Fujian Medical University. The following outcomes were observed: 1) the clinical significance of bleeding of the prostatic part of NVB: surgical videos were reviewed and the incidence of bleeding was recorded. The urogenital function was assessed using the International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF) score. The correlation between prostatic part bleeding and postoperative urogenital function was evaluated. 2) anatomical observation: the vessels, nerve fibers, as well as their surrounding fatty tissue from the prostatic part were treated as a whole, namely, the fat pad of the prostatic part. The anatomical architecture of the prostatic part in the surgical videos was reviewed and interpreted with the cadaveric findings. Categorical variables were compared between groups using a Fisher exact probability. while continuous variables with skewed distribution were compared between groups using the Mann-Whiteny U test. Results: The median age of the included 38 patients was 57 years (range, 31-75), and the median tumor distance to the anal verge was 6 cm (range, 1-8). Of them, a total number of 21 (55.3%) patients had bleeding of the prostatic part of NVB (bleeding group), while the rest had not (17 cases, 44.7%, non-bleeding group). 1) the clinical significance of bleeding of the prostatic part of NVB. The urinary function significantly decreased in patients in the bleeding group according to IPSS score after the 3rd month and the 6rd month of the surgery [7 (0-16) vs. 2 (0-3), Z=-1.787, P=0.088; 2 (0-15) vs. 0 (0-2), Z=-2.270, P=0.028]. There was no difference regarding the IPSS score between the two groups after 1 year of the surgery (P>0.05). With a total of 23 patients with normal preoperative sexual activity included, 87.5% (7/8) of patients in the non-bleeding group can expect to return to their preoperative baseline, this incidence was significantly higher than that of only 40% (6/15) in the bleeding group (P=0.029). 2) anatomical observation: for cadaveric observation, the prostatic part of NVB was located in the narrow triangular space composed of anterolateral walls of the rectum, the posterolateral surface of the prostate and the medial surface of the levator ani musculature. The tiny vascular branches and nerve fibers from the prostatic part were hard to identify. The cavernosal nerves cannot reliably be distinguished from the neural supply to the prostate, rectum and levator ani. In the cross-section of levels of prostatic base and mid-prostate in cadaveric hemipelvis specimens, the boundary of the prostatic part fat pad was partly overlapped and merged with the boundary of the mesorectum. Intraoperative observation showed that the areas of overlap referred to the rectal branches from the prostatic part piercing the proper fascia to supply the mesorectum, which carried the largest tension and high risk of bleeding during circumferential dissection toward the perirectal plane. The ultrasonic scalpel was required to pre-coagulate the rectal branches at the point close to the proper fascia of the rectum to prevent bleeding. In the cross-section of the prostatic apex level, the prostatic part approached ventrally and its boundary was away from the boundary of the mesorectum. Conclusions: NVB prostatic part injury is one of the causes of urogenital dysfunction after TME. The nerve fibers from the prostatic part were tiny, and its functional zones cannot be distinguished during operation. Therein, the fat pad of the prostatic part should be protected as a whole. Understanding the morphology of the fat pad of the prostatic part provides invaluable surgical guidance to dissect this critical area. When dissecting around the anterolateral rectal wall, appropriate anti-traction tension should be maintained and the rectal branches from the prostatic part should be coagulated with an ultrasonic scalpel to prevent bleeding.

The role of preoperative prostatic shape in the recovery of urinary continence after robotic radical prostatectomy: a single cohort analysis.

To explore the role of preoperative MRI prostate shape in urinary incontinence after robot-assisted radical prostatectomy (RARP). Patients were stratified into four groups based on the mpMRI prostatic apex shape: Group A (prostatic apex overlapping the membranous urethra anteriorly and posteriorly), Group B and C (overlap of the prostatic apex of the anterior or posterior membranous urethra, respectively) and Group D (no overlap). Preoperative variables and intraoperative data were compared. Continence recovery was defined as no pad/day or 1 safety pad/day by an outpatient evaluation performed at 1, 3, 6, and 12 months after RARP. One hundred patients underwent RARP were classified as belonging to Group A (n = 30), Group B (n = 16), Group C (n = 14), and Group D (n = 40). Group D showed a significantly more favorable urinary continence recovery after RARP respect to all the other shapes presenting any forms of overlapping (HR = 1.9, 95% CI 1.2-3.1, p = 0.007). The estimated HR remained substantially unchanged after adjusting by age, body mass index, CCI, prostate volume, and bladder neck sparing (HR = 1.9, 95% CI 1.1-3.2, p = 0.016). The continence recovery median time was 9 months for Group A + B + C (95% CI 5-11) and 4 months for Group D (95% CI 2-6) (p = 0.023). Shape D showed a better continence recovery when compared to other shapes presenting any kind of overlapping of the prostatic apex over the membranous urethra.

Clinical Study on the Application of Preserved Urethral Mucosa at the Prostatic Apex in Transurethral Plasmakinetic Resection of the Prostate.

ObjectiveTo explore the differences in the clinical efficacy, complications, and safety of transurethral plasmakinetic resection of the prostate (PKRP) by the conventional approach versus the approach preserving the urethral mucosa at the prostatic apex in the treatment of benign prostatic hyperplasia (BPH).MethodsA total of 90 patients with PKRP admitted to the First Hospital of Qinhuangdao from December 2018 to March 2021 were selected and divided into a control group (conventional PKRP, n = 45) and an observation group (PKRP with preserved urethral mucosa at the prostatic apex, n = 45). The clinical efficacy, safety, and sexual function of the groups were evaluated using the patients’ International Prostate Symptom Score (IPSS), quality of life (QoL), prostate volume, maximum flow rate (Qmax), post-void residual (PVR), blood loss, surgical resection efficiency, and surgical complication data.ResultsThe differences in the preoperative indicators, glandectomy quality, and glandectomy rate between the groups were not statistically significant (P > 0.05). However, in the observation group, the surgery time and blood loss were significantly lower compared with the control group, and the resection efficiency was significantly higher, with statistical significance (P < 0.05). In the follow-up, one month after surgery, the IPSS and QoL were lower in the observation group than in the control group, and the differences were statistically significant (P < 0.05); three months after surgery, the PVR, IPSS, QoL, and Qmax scores were similar between the groups, with no statistical significance (P > 0.05). In terms of surgical complications, the incidences of urinary incontinence and other complications after catheter extraction were significantly lower in the observation group than in the control group, and the differences between the groups were statistically significant (P < 0.05).ConclusionCompared with conventional PKRP, PKRP with preserved urethral mucosa at the prostatic apex can lead to immediate urinary continence after catheter extraction, reduce intraoperative blood loss, and shorten the surgery time, thus improving the surgical efficiency.

Prostate MRI in Stereotactic Body Radiation Treatment Planning and Delivery for Localized Prostate Cancer.

Prostate MRI is increasingly being used to make diagnoses and guide management for patients receiving definitive radiation treatment for prostate cancer. Radiologists should be familiar with the potential uses of prostate MRI in radiation therapy planning and delivery. Radiation therapy is an established option for the definitive treatment of localized prostate cancer. Stereotactic body radiation therapy (SBRT) is an external-beam radiation therapy method used to deliver a high dose of radiation to an extracranial target in the body, often in five or fewer fractions. SBRT is increasingly being used for prostate cancer treatment and has been recognized by the National Comprehensive Cancer Network as an acceptable definitive treatment regimen for low-, intermediate-, and high-risk prostate cancer. MRI is commonly used to aid in prostate radiation therapy. The authors review the uses of prostate MRI in SBRT treatment planning and delivery. Specific topics discussed include the use of prostate MRI for identification of and dose reduction to the membranous and prostatic urethra, which can decrease the risk of acute and late toxicities. MRI is also useful for identification and appropriate dose coverage of the prostate apex and areas of extraprostatic extension or seminal vesicle invasion. In prospective studies, prostate MRI is being validated for identification of and dose intensification to dominant intraprostatic lesions, which potentially can improve oncologic outcomes. It also can be used to evaluate the placement of fiducial markers and hydrogel spacers for radiation therapy planning and delivery. ©RSNA, 2022.

Hem-o-lok-free and Retzius-sparing robot-assisted laparoscopic radical prostatectomy with retrograde release of the neurovascular bundle

Abstract Background: Robot-assisted laparoscopic radical prostatectomy (RARP) has gradually become the standard surgical procedure for prostate cancer. This video, http://links.lww.com/CURRUROL/A10 aimed to demonstrate a new and improved surgical approach for prostate cancer that passes through the pouch of Douglas and allows retrograde release of the neurovascular bundle (NVB). The technique is Hem-o-lok-free and Retzius-sparing and is performed without opening the pelvic floor fascia during RARP. Methods: A 69-year-old man was diagnosed with prostate cancer (clinical stage T2bN0M0). We followed the process of Retzius-sparing RARP [published by Galfano et al. in 2013] and did some modification. The critical technical points associated with this technique included locating the fascial layer at the prostatic apex and performing complete retrograde release of the NVB along the anatomical structure. We used diathermy to perform precision hemostasis on large vessels, especially those around the basal part of prostate, with relatively less damage. In addition, Hem-o-lok was not used in this procedure. Results: Negative surgical margin and stage T2bN0M0 were confirmed. Continence was achieved immediately after cathter removal. One month after surgery, prostate specific antigen was undetectable. Erectile function was preserved 3 months postoperatively. Conclusions: Hem-o-lok-free and Retzius-sparing RARP is a feasible surgical approach that combines the benefits of complete retrograde release of the NVB, preserving the nerves and vascular structures around the prostate, protecting the pelvic floor structure, and ensuring rapid recovery of micturition control.

Pan-segmental intraprostatic lesions involving mid-gland and apex of prostate (mid-apical lesions): assessing the true value of extreme apical biopsy cores

ObjectiveWhen considering increased morbidity of apical biopsies, the added diagnostic value of separate targeting of mid-gland and apical segment of the pan-segmental mid-apical mpMRI prostate cancer (PCa) suspicious lesions was assessed.Materials and methodsA total of 420 patients with a single mpMRI PCa-suspicious PI-RADS ≥ 3 intraprostatic lesion extending from the mid-gland to the apical segment of the gland underwent transrectal MRI-targeted (TBx) and systematic prostate biopsy. Clinically significant PCa (CsPCa) was defined as Gleason Score (GS) ≥ 3 + 4. PCa detection rates of TBx cores were assessed according to targeted anatomical segments. Finally, the diagnostic values of two theoretical TBx protocols utilizing 1-core (A) vs. 2-cores (B) per anatomical segment were compared.ResultsTBx within the pan-segmental mid-apical lesions yielded 44% of csPCa. After stratification into mid- vs. apical segment of the lesion, csPCa was detected in 36% (mid-gland) and 32% (apex), respectively. Within the patients who had no csPCa detection by mid-gland sampling (64%, n = 270), extreme apical TBx yielded additional 8.1% of csPCa. Comparison of extreme apical TBx strategy B vs. overall PCa detection in our cohort revealed corresponding similar rates of 49 vs.50% and 31 vs.32%, respectively.ConclusionSeparate analyses of both segments, mid-gland and apex, clearly revealed the diagnostic contribution of apical TBx. Our findings strongly suggest to perform extreme apical TBx even within pan-segmental lesions. Moreover, our results indicate that a higher number of cores sampled from the mid-gland segment might be avoided if complemented with a two-core extreme apical TBx.

V07-09 ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY AND URETHRAL PULL THROUGH OF MEMBRANOUS URETHRA TO BLADDER

You have accessJournal of UrologyCME1 May 2022V07-09 ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY AND URETHRAL PULL THROUGH OF MEMBRANOUS URETHRA TO BLADDER Safiya-Hana Belbina, Scott Spivey-Provencio, Pegah Taheri, E. Charles Osterberg, and Aaron A. Laviana Safiya-Hana BelbinaSafiya-Hana Belbina More articles by this author , Scott Spivey-ProvencioScott Spivey-Provencio More articles by this author , Pegah TaheriPegah Taheri More articles by this author , E. Charles OsterbergE. Charles Osterberg More articles by this author , and Aaron A. LavianaAaron A. Laviana More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While robotic assisted laparoscopic prostatectomy has been a durable treatment option for men with localized prostate cancer over the past two decades, salvage prostatectomies are performed less frequently. In this video, we report a unique case of a salvage prostatectomy and membraneous urethra pull-through in an individual who was treated with both high-intensity focused ultrasound and external beam radiation therapy complicated by prostate cancer recurrence and a severe bulbar urethral stricture that failed direct visual internal urethrotomy. METHODS: The case presents a 71-year-old male with a urological history of prostate cancer in 2010 treated with HIFU. Following biochemical recurrence in 2013 he subsequently underwent salvage EBRT. This was complicated by a severe bulbar urethral stricture necessitating two DVIUs In addition, the patient underwent transurethral resection of the prostate for obstructed voiding symptoms and placement of an inflatable penile prosthesis. From a cancer standpoint, his PSA slowly rose after EBRT from 1.3 in 2019 to 2.7 in 2021. Repeat prostate biopsy showed 1/14 cores positive for Gleason Score 4+4=8 prostate cancer. The patient proceed with a robotic-assisted laparoscopic prostatectomy with a urethral pull through and bilateral pelvic lymph node dissection. The video begins with dissection of the prostatic apex to entirely free up and remove the prostate. Once the prostate is separated from the urethra, the dissection continues until the old bulbar urethral scar is completely removed. After we ensure the remnant urethra is free of scar and patent, the urethra is seen being passed through from below into the pelvic cavity and the anastomosis is performed. We then proceeded with a bilateral pelvic lymphadenectomy using the synchroseal device which obviates the need for any clips. The patient’s inflatable prosthesis reservoir makes the right side more challenging, however, it is feasible with careful dissection. RESULTS: The patient was discharged on post-operative day 1 with all drains removed and his post-operative course remained uncomplicated. On post-operative day 19, he had a normal voiding cystourethrogram. CONCLUSIONS: This case discusses the surgical technique used in a salvage robotic-assisted prostatectomy with membranous urethral pull-through in a patient with previous history of HIFU, salvage EBRT, bulbar urethral stricture, and inflatable penile prosthesis. In this video, we show this is a feasible option in select men and may spare them the burden from undergoing a radical cystoprostatectomy. Source of Funding: n/a © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e661 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Safiya-Hana Belbina More articles by this author Scott Spivey-Provencio More articles by this author Pegah Taheri More articles by this author E. Charles Osterberg More articles by this author Aaron A. Laviana More articles by this author Expand All Advertisement PDF downloadLoading ...

V07-06 RETZIUS-SPARING ROBOT-ASSISTED RADICAL PROSTATECTOMY IN HIGH-RISK PROSTATE CANCER PATIENTS

You have accessJournal of UrologyCME1 May 2022V07-06 RETZIUS-SPARING ROBOT-ASSISTED RADICAL PROSTATECTOMY IN HIGH-RISK PROSTATE CANCER PATIENTS Paolo Dell'Oglio, Stefano Tappero, Mattia Longoni, Carlo Buratto, Pietro Scilipoti, Silvia Secco, Alberto Olivero, Michele Barbieri, Erika Palagonia, Giancarlo Napoli, Elena Strada, Giovanni Petralia, Dario Di Trapani, Angelo Vanzulli, Aldo Massimo Bocciardi, and Antonio Galfano Paolo Dell'OglioPaolo Dell'Oglio More articles by this author , Stefano TapperoStefano Tappero More articles by this author , Mattia LongoniMattia Longoni More articles by this author , Carlo BurattoCarlo Buratto More articles by this author , Pietro ScilipotiPietro Scilipoti More articles by this author , Silvia SeccoSilvia Secco More articles by this author , Alberto OliveroAlberto Olivero More articles by this author , Michele BarbieriMichele Barbieri More articles by this author , Erika PalagoniaErika Palagonia More articles by this author , Giancarlo NapoliGiancarlo Napoli More articles by this author , Elena StradaElena Strada More articles by this author , Giovanni PetraliaGiovanni Petralia More articles by this author , Dario Di TrapaniDario Di Trapani More articles by this author , Angelo VanzulliAngelo Vanzulli More articles by this author , Aldo Massimo BocciardiAldo Massimo Bocciardi More articles by this author , and Antonio GalfanoAntonio Galfano More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retzius-sparing (RS) robot assisted radical prostatectomy is a valid surgical treatment option for prostate cancer (PCa) patients. However, there is a lack of evidence on the feasibility of this approach in high-risk (HR) PCa patients. In this video we describe our RS-RARP technique for HRPCa patients. METHODS: We present the case of a 66 year-old patient with PSA of 13.8 ng/ml, cT3 on the left side at DRE, an MRI showing 16 mm PIRADS 5 on the left lobe and an ISUP 4 grade PCa at biopsy (17/21 cores). No distant metastases were found at total body CT and bone scan. Left extrafascial and interfascial right nerve sparing RS with extended lymph node dissection was performed with a four-arm da Vinci Si Surgical System at a high volume centre. After incision of the parietal peritoneum at the anterior surface of the Douglas pouch, dissection of the vasa deferentia, isolation of the seminal vesicles, the Denonvillier’s fascia is medially incised starting from an extrafascial layer and pushed upwards with the posterior surface of the prostate. The dissection is carried out forward to the prostatic apex. On the left side part of the perirectal fat is also pushed upwards with the specimen. Once isolated the posterior aspect of the prostate, a wide left extrafascial plane is carried out laterally to the levator ani fascia. A right unilateral inter-fascial nerve sparing is performed in a standard fashion. The bladder neck is dissected, the anterior surface of the gland is isolated, the Santorini plexus is partially resected. Finally, the apex is isolated from the urethra and the latter is incised. RESULTS: Operative time and estimated blood loss were 185 min and 150 ml. No intraoperative complications occurred. Final pathology revealed a ISUP 4 grade, pT3aN0R0. The patient was discharged on POD 2 and the suprapubic catheter was removed on POD 7. Follow-up period was uneventful and at 8 months from surgery PSA was undetectable and the urinary continence (UC) fully recovered. 340 HRPCa patients were treated with this technique at our centre. Final pathology reported 9.4% focal and 19.4% extended positive surgical margins. Median follow-up was 47 months. At 4 years of follow-up, BCR-free and additional treatment-free survival were 64 and 57%. The 2-year UC and erectile function recovery were respectively 85% and 50%. CONCLUSIONS: RS in HR-PCa patients is safe and allows optimal intra- peri- and postoperative, oncologic and functional outcomes. RS should be considered a valid surgical treatment option for HRPCa patients in expert hands. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e660 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Paolo Dell'Oglio More articles by this author Stefano Tappero More articles by this author Mattia Longoni More articles by this author Carlo Buratto More articles by this author Pietro Scilipoti More articles by this author Silvia Secco More articles by this author Alberto Olivero More articles by this author Michele Barbieri More articles by this author Erika Palagonia More articles by this author Giancarlo Napoli More articles by this author Elena Strada More articles by this author Giovanni Petralia More articles by this author Dario Di Trapani More articles by this author Angelo Vanzulli More articles by this author Aldo Massimo Bocciardi More articles by this author Antonio Galfano More articles by this author Expand All Advertisement PDF downloadLoading ...

V07-11 VARYING APPROACHES TO THE PROSTATE APEX TO OPTIMIZE URETHRAL STABILITY AND EARLY CONTINENCE RECOVERY AFTER ROBOTIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyCME1 May 2022V07-11 VARYING APPROACHES TO THE PROSTATE APEX TO OPTIMIZE URETHRAL STABILITY AND EARLY CONTINENCE RECOVERY AFTER ROBOTIC RADICAL PROSTATECTOMY Claudia Mercader, J. Francisco Lopez, Nitesh Ranasinha, Mutie Raslan, Ruth McPherson, Richard Bell, Tom Leslie, Richard Bryant, Freddie Hamdy, Alastair, and Lamb Claudia MercaderClaudia Mercader More articles by this author , J. Francisco LopezJ. Francisco Lopez More articles by this author , Nitesh RanasinhaNitesh Ranasinha More articles by this author , Mutie RaslanMutie Raslan More articles by this author , Ruth McPhersonRuth McPherson More articles by this author , Richard BellRichard Bell More articles by this author , Tom LeslieTom Leslie More articles by this author , Richard BryantRichard Bryant More articles by this author , Freddie HamdyFreddie Hamdy More articles by this author , AlastairAlastair More articles by this author , and Lamb Lamb More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002598.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pre-operative membranous urethral length (MUL) is a well-known non-modifiable factor predicting continence recovery after surgery, but there are also refinements in surgical techniques to optimize early continence after robotic-assisted radical prostatectomy (RARP). These include modifications in apical dissection to maximize urethral length and maximizing preservation of periurethral structures responsible for urethral stability. METHODS: We reviewed data of patients who underwent RARP between January 2018 and October 2021. MUL, anterior Retzius sparing approach and continence (pads) 6-weeks after surgery were recorded. We present five surgical scenarios often encountered while planning the apical dissection in RARP: non urethral preservation, half-supported full or non-full-length urethral preservation, full length unstable urethra, full length stable urethra and full-length stable preservation in the context of unusual apical anatomy. All patients consented to data storage and video-recording. RESULTS: Following on from the video footage of this surgical scenarios, we present 342 patients for quantitative analysis. Those patients with a MUL >10 mm had 9.7 increased chance of being completely dry at 6-weeks (OR 9.7 CI 95% 2.2–42.1). Those patients with a MUL >10 mm who also had anterior Retzius sparing their chances increased by a further 4.3 (OR 4.3 IC 95% 2.1–8.8). CONCLUSIONS: The apical approach in a RARP can be planned and tailored for each case depending on both patients and tumour anatomy to optimize urethral stability post-RARP and early continence recovery. We advocate both preservation of urethral length and those structures responsible for urethral stability. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e662 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Claudia Mercader More articles by this author J. Francisco Lopez More articles by this author Nitesh Ranasinha More articles by this author Mutie Raslan More articles by this author Ruth McPherson More articles by this author Richard Bell More articles by this author Tom Leslie More articles by this author Richard Bryant More articles by this author Freddie Hamdy More articles by this author Alastair More articles by this author Lamb More articles by this author Expand All Advertisement PDF downloadLoading ...

Long-term outcomes of whole gland high-intensity focused ultrasound for localized prostate cancer.

To report the 10-year oncologic and functional outcomes of whole-gland HIFU as first-line treatment for localized prostate cancer (PCa). Patients were retrospectively included between January 2005 and July 2018 from a prospectively maintained database at a single academic institution. No patient underwent androgen deprivation therapy prior to HIFU. Primary endpoint was biochemical recurrence-free survival (BRFS). Secondary oncological endpoints included salvage treatment-free survival (STFS), cancer-specific survival (CSS) and overall survival (OS). A total of 97 patients met our inclusion criteria and were included in the final analysis. According to D'Amico classification, the numbers of patients with low-, intermediate-, and high-risk disease were 38 (39.2%), 52 (53.6%), and 7 (7.2%). A total of 21 (21.6%) patients received salvage treatment at a mean of 4.1years (± 2.8) after HIFU. The 10-year OS, CSS and BRFS rates were 91.8%, 100% and 40.3% in the overall cohort, respectively. In multivariate analysis, predictive factors for biochemical recurrence were intermediate-risk group (RR = 2.065; 95% CI 1.008-4.230; p = 0.047) and PSA nadir > 0.5ng/mL (RR = 4.963; 95% CI 2.251-10.947; p < 0.001). Symptoms related to bladder outlet obstruction were the most frequently recorded adverse events. In multivariate analysis, positive biopsy on the prostatic apex was predictor of obstructive complications (RR = 3.2, 95% CI 1.092-9.476, p = 0.034). Only four patients developed severe urinary incontinence (> 1 pad/day). HIFU showed low PCa-specific mortality, but biochemical recurrence rates were highly variable among patients. Future studies are needed to improve patient selection.