Association of Prostate Size and Tumor Grade in Korean Men with Clinically Localized Prostate Cancer

The association between prostate weight and positive surgical margins in prostate cancer: A meta-analysis

There have been some conflicting claims whether larger prostate weight (PW) reduces the risk of positive surgical margins (PSMs). This study aims to examine the associations between PW and PSMs. PubMed, Web of Science and Cochrane library were systematically retrieved. Relative risks (RRs) and the corresponding 95% confidence intervals (CIs) were synthesised utilising random-effect models. Ultimately, 22 cohort studies met criteria were enrolled in this meta-analysis, of which 18 studies reporting the RR of the highest VS lowest category of PW yielded the combined RR of PSMs of 0.61 (95% CI 0.50-0.74). Subgroup analysis showed that geographic region and surgical modalities were considered as potential confounders of influence of PW on PSMs. The nonlinear dose-response relationship demonstrated that PSM risk decreased by 1% (RR = 0.99, 95% CI, 0.98-0.99) for every one gram increment in PW. This study suggests PW has a negative association with risk of PSMs, and having a appropriate PW is very important.

Impact of prostate volume on oncologic, perioperative, and functional outcomes after radical prostatectomy

BACKGROUND

The impact of prostate volume (PV) on oncologic, perioperative and functional outcomes after radical prostatectomy (RP) remains controversial, as recent studies present inconsistent results. We studied the influence of PV on outcomes in a large single center dataset and summarized the existing literature.

METHODS

5,477 patients who underwent RP between January 2008 and December 2011 were analyzed. The impact of PV on biochemical recurrence (BCR) and metastasis-free survival (MFS) was assessed using Kaplan-Meier curves and multivariate Cox proportional hazard model. Uni- and multivariate logistic regressions were used to estimate the impact of PV on surgical margin (SM), 1-week, 3-months and 12-months continence and 3-months and 12-months potency. Finally, the impact of PV on intraoperative blood loss was analyzed using uni- and multivariate linear regressions.

RESULTS

Median follow-up was 36.1 months. Overall, 16.5% of patients recurred during the follow-up period. The mean preoperative PV was 43.3 ml. One-week, 3-months and 12-months continence rates were 55.6%, 69.3%, and 87.4% for patients with PV ≥ 70 compared to 64.4%, 78.3%, and 92.1% for patients with PV < 30, respectively. Three-months and 12-months potency rates were 37.1% and 54.8% for men with large glands (≥70) and 56.3% and 65.0% for men with PV < 30. In multivariate analysis, continence at 1 week, 3 months and 12 months was significantly worse in patients with glands ≥70 ml, while potency was not influenced by PV in multivariate analysis. There was a higher mean blood loss (P < 0.001) in patients with larger glands. In univariate analysis, higher PV was significantly associated with lower BCR (P = 0.019), but not with metastasis free survival (P = 0.112).

CONCLUSIONS

PV significantly influences BCR-free survival only in univariate analysis. Especially early (1-week and 3-months) postoperative continence is negatively affected by higher PV in multivariate analysis, while PV did not influence potency after adjusting for further covariates in a specialized high-volume institution.

Number of positive preoperative biopsy cores is a predictor of positive surgical margins (PSM) in small prostates after robot-assisted radical prostatectomy (RARP)

OBJECTIVE

To determine the impact of prostate size on positive surgical margin (PSM) rates after robot-assisted radical prostatectomy (RARP) and the preoperative factors associated with PSM.

PATIENTS AND METHODS

In all, 1229 men underwent RARP by a single surgeon, from 2005 to August of 2013. Excluded were patients who had transurethral resection of the prostate, neoadjuvant therapy, clinically advanced cancer, and the first 200 performed cases (to reduce the effect of learning curve). Included were 815 patients who were then divided into three prostate size groups: <31 g (group 1), 31-45 g (group 2), >45 g (group 3). Multivariate analysis determined predictors of PSM and biochemical recurrence (BCR).

RESULTS

Console time and blood loss increased with increasing prostate size. There were more high-grade tumours in group 1 (group 1 vs group 2 and group 3, 33.9% vs 25.1% and 25.6%, P = 0.003 and P = 0.005). PSM rates were higher in prostates of <45 g with preoperative PSA levels of >20 ng/dL, Gleason score ≥7, T3 tumour, and ≥3 positive biopsy cores. In group 1, preoperative stage T3 [odds ratio (OR) 3.94, P = 0.020] and ≥3 positive biopsy cores (OR 2.52, P = 0.043) were predictive of PSM, while a PSA level of >20 ng/dL predicted the occurrence of BCR (OR 5.34, P = 0.021). No preoperative factors predicted PSM or BCR for groups 2 and 3.

CONCLUSION

A preoperative biopsy with ≥3 positive cores in men with small prostates predicts PSM after RARP. In small prostates with PSM, a PSA level of >20 ng/dL is a predictor of BCR. These factors should guide the choice of therapy and indicate the need for closer postoperative follow-up.

The prognostic value of pathologic prostate-specific antigen mass ratio in patients with localized prostate cancer with negative surgical resection margins

OBJECTIVE

To investigate potential predictors of biochemical recurrence (BCR) in patients with localized prostate cancer with negative surgical resection margin (SRM).

MATERIALS AND METHODS

Data from 582 consecutive patients diagnosed with localized prostate cancer with negative SRM who underwent only radical prostatectomy between November 2003 and April 2010 were reviewed. Pathologic prostate-specific antigen (PSA) mass ratio was defined as total circulating PSA protein per surgical prostate volume. Cox regression models tested the association between clinicopathologic variables and BCR-free survival.

RESULTS

Mean age at surgery was 64.9 ± 6.9 years and mean PSA was 8.3 ± 4.4 ng/mL. The mean follow-up period was 40.7 ± 7.9 months. Pathologic stage was T2a in 113 of 582 patients (19.3%), T2b in 4 of 582 (0.7%), and T2c in 465 of 582 (79.9%). Surgical Gleason score was ≤6 in 215 of 582 patients (37.0%), 7 in 342 of 582 (58.8%), and ≥8 in 25 of 582 (4.3%). Mean pathologic prostate volume and pathologic PSA mass ratio were 42.4 ± 15.8 mL (14.6-176.0 mL) and 0.48 ± 0.37 μg/mL (0.03-2.62 μg/mL), respectively. Five-year BCR-free survival rate was 90.9%. PSA, surgical Gleason score, and pathologic PSA mass ratio were significantly associated with BCR-free survival in univariate analysis. In multivariate analysis, surgical Gleason score (P <.001, hazards ratio = 9.804) and pathologic PSA mass ratio (P = .037, hazards ratio = 3.753) were independent predictors of BCR-free survival.

CONCLUSION

In patients with localized prostate cancer and negative SRM after radical prostatectomy, surgical Gleason score and pathologic PSA mass ratio were significant prognostic indicators of BCR-free survival.

Impact of prostate size on pathologic outcomes and prognosis after radical prostatectomy

Purpose

We investigated prostate size and its correlation with final pathologic outcomes and prognosis.

Materials and Methods

From 1993 to 2009, 830 consecutive patients who underwent radical prostatectomy with follow-up duration of 12 months or more were included in this study. Patients were categorized according to prostate size as follows: group 1, prostate size ≤40 g (n=458), and group 2, prostate size >40 g (n=472). Preoperative parameters and postoperative pathologic outcomes were compared between groups. Multivariate analysis with Cox proportional hazards regression model was used to identify the pathologic and clinical factors affecting biochemical recurrence.

Results

Patients in group 1 had higher pathologic T stage (pT2a=17.7% vs. 23.9%, pT2b=1.1% vs. 0%, pT2c=40.4% vs. 39.8%, pT3a=29.5% vs. 21.0%, pT3b=10.7% vs. 13.2%, p=0.003) and higher positive surgical margin (40.3% vs. 33.1%, p=0.033) than did patients in group 2. Pathologic Gleason score was not significantly different between the two groups. The 5-year biochemical-recurrence-free survival was 62.3% for patients in group 1 and 73.2% for patients in group 2 (p=0.005). Multivariate Cox regression analysis showed that prostate size of 40 g or less (hazard ratio [HR], 1.378; 95% confidence interval [CI], 1.027 to 1.848; p=0.032), extracapsular extension (HR, 1.592; 95% CI, 1.147 to 2.209; p=0.005), positive surgical margin (HR, 2.348; 95% CI, 1.701 to 3.242; p<0.001), and pathologic Gleason sum (HR, 1.507; 95% CI, 1.292 to 1.758; p<0.001) were independent predictors of biochemical recurrence.

Conclusions

Smaller prostate size was associated with increased risk of higher pT stage and positive surgical margin after radical prostatectomy. Also, prostate size less than 40 g was an independent prognostic factor for biochemical recurrence.

The impact of bladder neck mucosal eversion during open radical prostatectomy on bladder neck stricture and urinary extravasation

PURPOSE

To determine whether the bladder neck mucosal eversion (BNM-eversion) during radical retropubic prostatectomy (RRP) reduces the risk of bladder neck stricture (BNS) and of peri-anastomotic extravasation (PAE) in postoperative cystography.

METHODS

Two hundred and eleven patients with clinically localized prostate cancer underwent RRP and were prospectively randomized into patients with BNM-eversion (group I) and without BNM-eversion (group II). All patients underwent an evaluation of PAE by retrograde cystography on postoperative day 8. We assessed BNS after 6 months.

RESULTS

Ninety-two patients with and 113 patients without BNM-eversion were included. There was no significant difference in baseline characteristics, including age, TNM-classification, Gleason score, PSA, prostate volume, and blood loss in both groups. A complete follow-up of 6 months for BNS was available for 188 patients (89.1 %). Sixteen BNS out of 188 patients were recorded, 4.7 % (n = 4) in group I and 11.7 % (n = 12) in group II (p = 0.09). Data from 205 out of 211 patients were available for the evaluation of the extravasation by cystography. Peri-anastomotic extravasation was detectable in 11.96 %, (11/205) in group I and in 21.24 % (24/205) in group II (p = 0.08).

CONCLUSION

BNM-eversion does not have a positive influence on the prevention of bladder neck strictures. Peri-anastomotic extravasation detected by cystography does not correlate with a formation of bladder neck stricture.

Smaller prostate gland size and older age predict Gleason score upgrading

OBJECTIVES

Gleason score is important for prostate cancer (CaP) risk stratification and prognostication but has a significant rate of upgrading. We examined the effect of prostate size and age on upgrading of Gleason 6 CaP.

MATERIALS AND METHODS

A retrospective review was performed of patients with Gleason 6 CaP who underwent radical prostatectomy from 2001 through 2010. Preoperative clinical and pathologic variables were assessed to determine association with risk of upgrading at prostatectomy.

RESULTS

A total of 1,836 patients were identified with Gleason 6 on prostate biopsy. Upgrading was observed in 543 (29.6%) patients with a final Gleason score of 3+4 in 463 (25.2%), 4+3 in 49 (2.7%), and 8-10 in 31 (1.7%). On univariate logistic regression, age, prostate weight, and PSA were significant predictors of Gleason score upgrading and remained significant on multiple logistic regression. Prostate weight was inversely related to risk of upgrading. To further explore this effect, we performed multiple logistic regression to examine risk of Gleason 6, 7, or 8-10 disease in 2,493 patients with Gleason 6-10 at prostatectomy. After controlling for age and PSA, there was a progressively increased risk of Gleason 6, 7, and 8-10 disease with decreasing prostate weight.

CONCLUSIONS

Older age, higher PSA, and smaller prostate gland size are associated with increased risk of Gleason score upgrading. The inverse relationship of prostate weight to risk of Gleason upgrading may be related to increased high-grade disease in smaller glands.

Prostate volume has prognostic value only in pathologic T2 radical prostatectomy specimens

The objective of this study was to evaluate the prognostic roles of the prostate volume, tumor volume, and tumor percentage as a function of the pathologic T stage in radical prostatectomy specimens. This study included 259 patients who underwent radical prostatectomy between 2005 and 2010. The mean follow-up period was 41.2 months. In all of the specimens, prostate volume (P = 0.021), the Gleason score (P = 0.035), and seminal vesicle invasion (P = 0.012) were independent predictors of biochemical recurrence (BCR). In the T2 group, multivariate analysis showed that the BCR was significantly associated with prostate specific antigen (PSA) (P = 0.028), a lower prostate volume (P = 0.004), and the Gleason score (P = 0.040). The Kaplan-Meier survival curve showed that a smaller prostate volume was significantly associated with a greater risk of BCR (< 30 vs ≥ 30 mL; P = 0.010). In the T3 group, patients with seminal vesicle invasion had a significantly shorter mean BCR-free survival (P = 0.030). In this study, tumor volume and tumor percentage did not predict BCR. Notably, a lower prostate volume is an independent predictor for BCR only in the organ-confined radical prostatectomy specimens. But, prostate volume could not predict BCR in most locally advanced tumors.

Intermediate versus low or high prostate-specific antigen density level: comparison of cancer detection rate between 12- and 18-core prostate biopsy

OBJECTIVE

To compare the diagnostic values of 12- and 18-core biopsies with respect to prostate-specific antigen (PSA) levels, prostate volumes (PV) and prostate-specific antigen density (PSAD).

MATERIAL AND METHODS

Transrectal ultrasound-guided prostate biopsies were performed on 233 patients at a single tertiary academic center. Patients were prospectively randomized to the two protocols (12 or 18 core). The cancer detection rates achieved using these two methods were analyzed at different PSA levels, PVs and PSADs.

RESULTS

Considering PSA level and PV simultaneously, patients were stratified into four groups (group A: PSA < 7 ng/ml and PV ≥ 45 cm(3); group B: PSA < 7 ng/ml and PV < 45 cm(3); group C: PSA ≥ 7 ng/ml and PV ≥ 45 cm(3); group D: PSA ≥ 7 ng/ml and PV < 45 cm(3)). 18-core biopsy had a higher cancer detection rate than 12-core biopsy only in group C (55.2% vs 24.1%, p = 0.015). The 233 patients were also stratified into three groups according to PSAD level: the low PSAD group (PSAD < 0.15 ng/ml/cm(3)), the intermediate PSAD group (0.15 ng/ml/cm(3) ≤ PSAD < 0.25 ng/ml/cm(3)) and the high PSAD group (PSAD ≥ 0.25 ng/ml/cm(3)). In the intermediate PSAD group, 18-core biopsy had a higher cancer detection rate than 12-core biopsy (54.2% vs 28.9%, p = 0.048).

CONCLUSION

An 18-core biopsy is more useful than a 12-core biopsy for detecting prostate cancer in patients with high PSA and large PV, that is, with intermediate PSAD level.

Does the size matter?: Prostate weight does not predict PSA recurrence after radical prostatectomy

Previous studies suggest that low prostate weight is a significant negative prognostic factor for prostate cancer. In the current study, the data for 431 men who underwent radical retropubic prostatectomy between 1990 and 1998 were analyzed for association between prostate weight and various clinical and pathologic parameters. These included age, preoperative prostate-specific antigen (PSA) level, PSA recurrence, pathologic stage, Gleason grade, extraprostatic extension, positive surgical margins, tumor volume, associated high-grade prostatic intraepithelial neoplasia, perineural invasion, and lymph node metastasis. Potential associations were probed by using Cox regression model analysis. A significant positive correlation was found between prostate weight and increasing patient age or increasing preoperative PSA level. There was no significant independent association between prostate weight and any of the other variables examined. No association was found between prostate weight and PSA recurrence. Although increasing prostate weight correlates with increased patient age and higher preoperative PSA level, it does not independently predict postoperative cancer recurrence.

Prostate size is associated with surgical difficulty but not functional outcome at 1 year after radical prostatectomy

PURPOSE

We assessed the impact of prostate size on operative difficulty as measured by estimated blood loss, operating room time and positive surgical margins. In addition, we assessed the impact on biochemical recurrence and the functional outcomes of potency and continence at 1 year after radical prostatectomy as well as postoperative bladder neck contracture.

MATERIALS AND METHODS

From 1998 to 2007, 3,067 men underwent radical prostatectomy by 1 of 5 dedicated prostate surgeons with no neoadjuvant or adjuvant therapy. Pathological specimen weight was used as a measure of prostate size. Cox proportional hazards and logistic regression analysis was used to study the association between specimen weight, and biochemical recurrence and surgical margin status, respectively, controlling for adverse pathological features. Continence and potency were analyzed controlling for age, nerve sparing status and surgical approach.

RESULTS

With increasing prostate size there was increased estimated blood loss (p = 0.013) and operative time (p = 0.004), and a decrease in positive surgical margins (84 of 632 [14%] for 40 gm or less, 99 of 862 [12%] for 41 to 50 gm, 78 of 842 [10%] for 51 to 65 gm, 68 of 731 [10%] for more than 65 gm, p <0.001). Biochemical recurrence was observed in 186 of 2,882 patients followed postoperatively and was not significantly associated with specimen weight (p = 0.3). Complete continence was observed in 1,165 of 1,422 patients (82%) and potency in 425 of 827 (51%) at 1 year. Specimen weight was not significantly associated with potency (p = 0.8), continence (p = 0.08) or bladder neck contracture (p = 0.22).

CONCLUSIONS

Prostate size does not appear to affect biochemical recurrence or 1-year functional results. However, estimated blood loss and operative time increased with larger prostate size, and positive surgical margins are more often observed in smaller glands.

A comparison of prostate cancer detection rates by 12 or 6 core biopsy at different prostate-specific antigen densities in Korean men

OBJECTIVES

To evaluate the diagnostic value of 12 core biopsy versus sextant biopsy at different prostatic-specific antigen densities (PSAD).

METHODS

We retrospectively analyzed the records of 1,463 patients who underwent transrectal ultrasound-guided prostate biopsies at our institution. 995 patients underwent 12 core biopsy and 468 sextant biopsy of the prostate. The cancer detection rates achieved by these two methods were analyzed at different PSAD levels.

RESULTS

All patients were stratified into 5 groups according to PSAD level; group A: PSAD < 0.1 (n = 290), group B: 0.1 < or = PSAD < 0.2 (n = 572), group C: 0.2 < or = PSAD < 0.3 (n = 248), group D: 0.3 < or = PSAD < 0.4 (n = 122), and group E: PSAD > or = 0.4 (n = 231). In group B, 12 core biopsy had a higher detection rate than 6 core biopsy (P = 0.017).

CONCLUSIONS

These results demonstrate 12 core biopsy is better able to detect cancer than 6 core biopsy in patients with a PSAD in the range 0.1-0.2, which suggests that PSAD be considered when deciding on the number of prostate biopsy cores required.