Use of Multiparametric MR with Neurovascular Bundle Evaluation to Optimize the Oncological and Functional Management of Patients Considered for Nerve-Sparing Radical Prostatectomy

Abstract

Introduction To obtain the best results with radical prostatectomy, either from an oncological or a functional point of view, a correct selection of cases and planning of surgery are crucial. Multiparametric magnetic resonance imaging (MRI) promises to make it a successful imaging tool for improving many aspects of prostate cancer management. Aim The aim of this study is to evaluate whether a modern multiparametric MRI can help either to better select prostate cancer cases for a nerve-sparing radical prostatectomy or to improve the functional evaluation related to neurovascular bundles preservation. Main Outcome Measures The effect of preoperative MRI on neurovascular bundle management was examined for the frequency and the appropriateness of changes of the surgical plane on the basis of MRI indications. Methods In a prospective study, 125 consecutive patients with biopsy proven prostate cancer who were scheduled to undergo bilateral nerve-sparing surgery. All patients included into the study were submitted to a preoperative multiparametric MRI. On the basis of MRI evaluation, patients were divided into two groups. Patients in group A were then submitted to a bilateral nerve-sparing (NS) radical prostatectomy (RP), whereas patients in group B were submitted to unilateral NS or non-NS RP. Results In group A, the confirmation from the MRI study to perform a bilateral NS procedure was appropriate in 70 of 73 cases (95.9%), whereas in group B, the surgical plan was appropriate in 28 of 32 cases (87.5%). On the contrary, MRI findings suggested a change in the initial surgical plan (group B) for 32 of 105 cases (30.5%). Of these 32 cases in group B, MRI suggested to perform a unilateral NS procedure in 21 of 32 cases (65.6%) and a non-NS procedure in 11 of 32 cases (34.4%). Conclusions Multiparametric MRI analysis can significantly improve the standard selection and management of prostate carcinoma cases considered for an NS RP.

Multiparametric magnetic resonance imaging for pre-treatment local staging of prostate cancer: A Cancer Care Ontario clinical practice guideline

“…[30][31][32][33][34][35] All six studies were consistent in showing increased intensity of therapy as a result of MRI staging, with <1-43% of patients experiencing increased therapy due to MRI staging. [30][31][32][33][34][35] Three studies reported that MRI-informed treatment plans were correct, as shown in 63-97% of patients. 31,32,35 There were 21/61 (34.4%) studies that reported on the outcome of change in stage classification.…”

“…The impact of pre-treatment local staging by MRI ± DWI, DCE, MRS on clinical and patient outcomes is still not clear. Although studies consistently demonstrated upstaging by imaging compared to clinical staging, this was only correct by pathology in a few studies and the magnitude was highly variable (11% to 85%), 16,17,32,34,38,41,44 thus making any conclusions to be drawn imprecise. There was limited information on the outcome of risk stratification category; 30,34 however, the results were consistent with the trend of upstaging.…”

“…There was limited information on the outcome of risk stratification category; 30,34 however, the results were consistent with the trend of upstaging. Changes to treatment plan with imaging were mixed, as they included both an increase [30][31][32][33][34][35] and decrease 31,35 to therapy intensity, with a tendency towards more intense therapy across included studies. [30][31][32][33][34][35] The correctness of treatment changes was under-studied.…”

“…There were 20/21 (95.2%) studies that consistently demonstrated upstaging by MRI, 33,36 and upstaging by MRI compared to routine clinical staging. 12,13,16,17,20,21,23,30,32,34,[37][38][39][40][41][42][43][44][45] Upstaging by MRI was correct by pathology in seven studies, with a range from 11-85%. 16 …”

“…[30][31][32][33][34][35] Three studies reported that MRI-informed treatment plans were correct, as shown in 63-97% of patients. 31,32,35 There were 21/61 (34.4%) studies that reported on the outcome of change in stage classification. There were 20/21 (95.2%) studies that consistently demonstrated upstaging by MRI, 33,36 and upstaging by MRI compared to routine clinical staging.…”