Multiparametric magnetic resonance imaging and frozen-section analysis efficiently predict upgrading, upstaging, and extraprostatic extension in patients undergoing nerve-sparing robotic-assisted radical prostatectomy

Abstract

To evaluate the role of multiparametric magnetic resonance imaging (mpMRI) in predicting upgrading, upstaging, and extraprostatic extension in patients with low-risk prostate cancer (PCa). MpMRI may reduce positive surgical margins (PSM) and improve nerve-sparing during robotic-assisted radical prostatectomy (RARP) for localized prostate cancer PCa.This was a retrospective, monocentric, observational study. We retrieved the records of patients undergoing RARP from January 2012 to December 2013 at our Institution. Inclusion criteria were: PSA <10 ng/mL; clinical stage <T3a; biopsy Gleason score <7; prostate mpMRI performed preoperatively at our Institution; intraoperative FSA of the posterolateral aspects of the specimen.All the identified lesions were scored according to the Prostate Imaging Reporting and Data System (PIRADS). We considered the lesion with the highest PIRADS score as index lesion. All the included patients underwent nerve-sparing RARP. During surgery, the specimen was sent for FSA of the posterolateral aspects. The surgeon, according to the localization scheme provided by the mpMRI, inked the region of the posterolateral aspect of the prostate that had to be submitted to FSA.We evaluated association between clinical features and PSM, upgrading, upstaging, and presence of unfavorable disease.Two hundred fifty-four patients who underwent nerve-sparing RARP were included. PSM rate was 29.13% and 15.75% at FSA and final pathology respectively. Interestingly, the use of FSA reduced PSM rate in pT3 disease (25.81%). Higher PIRADS scores demonstrated to be related to high probability of upgrading and upstaging. This significativity remains even when considering PIRADS 2–3 versus 4 versus 5 and PIRADS 2–3 versus 4–5. Also PSM at FSA were associated with higher probability of upgrading and upstaging.PIRADS score and FSA resulted to be strictly related to grading and staging, thus being able to predict upgrading and/or upstaging at final pathology.

Evaluation of MRI for diagnosis of extraprostatic extension in prostate cancer

“…More recently, Lim et al showed that PI‐RADS v2 category 5 lesions were associated with higher Gleason scores and the presence of EPE compared to category 4 lesions. These studies support our observation that higher PI‐RADS v2 scores are associated with EPE . Interobserver agreement for PI‐RADS v2 scoring between radiologists in our study was moderate, which compares favorably with what has been published previously …”

“…These studies support our observation that higher PI-RADS v2 scores are associated with EPE. 40 Interobserver agreement for PI-RADS v2 scoring between radiologists in our study was moderate, which compares favorably with what has been published previously. 41,42 Tumor size and length of capsular contact were both larger in tumors with EPE in our study.…”

The impact of nerve‐sparing robot‐assisted radical prostatectomy on lower urinary tract function: Prospective assessment of patient‐reported outcomes and frequency volume charts

“…The established preoperative clinical variables, for example, digital rectal examination, serum prostatic‐specific antigen, and the Gleason score obtained from biopsy, are used to plan the surgical technique . Recently, several reports have demonstrated that preoperative multiparametric magnetic resonance imaging (MRI) significantly improved decision‐making regarding whether to preserve or resect the neurovascular bundle at radical prostatectomy . In addition, Kitajima et al demonstrated that, after NS radical prostatectomy, the diffusion tensor imaging technique of MRI could visualize changes in the numbers of periprostatic nerve fibers.…”

Positive surgical margin during radical prostatectomy: overview of sampling methods for frozen sections and techniques for the secondary resection of the neurovascular bundles

“…Most of the included studies were retrospective (74%) and only five studies (26%) were prospective in nature. Furthermore, the studies were performed mainly in Germany (seven studies) , the UK (four studies) , USA (three studies) , Turkey (two studies) , Italy , Romania , and Norway (one study each). The sample size (considering only the patients undergoing intraoperative FS) in the included studies ranged from 40 to 5392 patients.…”

“…A total of 19 articles reporting on NS‐zone sampling techniques and NVB secondary resection were published between 2010 and 2019 . Table summarises all the studies reporting FS sampling and secondary resection of a PSM at the NVB.…”