Prostate size and adverse pathologic features in men undergoing radical prostatectomy

Quantitative MRI in the Local Staging of Prostate Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Local staging of prostate cancer (PCa) is important for treatment planning. Radiologist interpretation using qualitative criteria is variable with high specificity but low sensitivity. Quantitative methods may be useful in the diagnosis of extracapsular extension (ECE).

PURPOSE

To assess the performance of quantitative MRI markers for detecting ECE.

STUDY TYPE

Systematic review and meta-analysis.

SUBJECTS

4800 patients from 28 studies with histopathologically confirmed PCa on radical prostatectomy were pooled for meta-analysis. Patients from 46 studies were included for systematic review.

FIELD STRENGTH/SEQUENCE

Diffusion-weighted, T2-weighted, and dynamic contrast-enhanced MRI at 1.5 T or 3 T.

ASSESSMENT

PubMed, Embase, Web of Science, Scopus, and Cochrane databases were searched to identify studies on diagnostic test accuracy or association of any quantitative MRI markers with ECE. Results extracted by two independent reviewers for tumor contact length (TCL) and mean apparent diffusion coefficient (ADC-mean) were pooled for meta-analysis, but not for other quantitative markers including radiomics due to low number of studies available.

STATISTICAL TESTS

Hierarchical summary receiver operating characteristic (HSROC) curves were computed for both TCL and ADC-mean, but summary operating points were computed for TCL only. Heterogeneity was investigated by meta-regression. Results were significant if P ≤ 0.05.

RESULTS

At the 10 mm threshold for TCL, summary sensitivity and specificity were 0.76 [95% confidence interval (CI) 0.71-0.81] and 0.68 [95% CI 0.63-0.73], respectively. At the 15 mm threshold, summary sensitivity and specificity were 0.70 [95% CI 0.53-0.83] and 0.74 [95% CI 0.60-0.84] respectively. The area under the HSROC curves for TCL and ADC-mean were 0.79 and 0.78, respectively. Significant sources of heterogeneity for TCL included timing of MRI relative to biopsy.

DATA CONCLUSION

Both 10 mm and 15 mm thresholds for TCL may be reasonable for clinical use. From comparison of the HSROC curves, ADC-mean may be superior to TCL at higher sensitivities.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2.

The influence of prostate volume on pathological outcomes after radical prostatectomy: A single-center retrospective study

Currently, the association between prostate volume (PV) or prostate weight with pathological outcomes in patients with prostate cancer (PCa) is not well understood. This study aimed to explore whether PV can predict the adverse pathological outcomes of PCa patients after radical prostatectomy (RP). A total of 1063 men with confirmed localized PCa who underwent RP at the First Affiliated Hospital of Zhejiang University from January 2014 to April 2019 were retrospectively analyzed. Patients were assigned into small, medium and large groups based on the PV. The analysis of variance, χ2 test or Student t test was performed to compare differences among groups. Univariate and multivariate analyses were performed to identify significant predictors of pathological outcomes upgrading. Among the 1063 cases, approximately 35.0% had an upgrade of postoperative pathology. Compared with the small prostate group, more patients in the large prostate group achieved a Gleason score (GS) 6 and International Society of Urological Pathology (ISUP) grade 1 of postoperative pathological findings, clinical cT1c and cT2a stages and pathological pT2a and pT2b stages; the incidence of positive surgical margins and extraprostatic extension was relatively low (all P < .001). In multiple logistic regression, PV served as a significant predictor of any Gleason score upgrading (GSU) (odds ratio [OR] 0.988, 95% confidence interval [CI] 0.978-0.998), major GSU (OR 0.980, 95% CI 0.965-0.995) and any ISUP grade group upgrading (GGU) (OR 0.989, 95% CI 0.979-0.999). This study shows that PV can predict adverse pathological outcomes in PCa patients after radical prostatectomy. Pca patients with smaller prostate volume tend to have the high-grade disease at postoperative pathology as well as pathological outcome upgrading.

Value of the newly developed pelvic dimension index/prostate volume ratio in predicting positive surgical margin in prostate cancer

PURPOSE

To evaluate the diagnostic performance of pelvimetric measurements, in particular the pelvic dimension index (PDI)/prostate volume (PV) ratio (PDI/PV), in predicting positive surgical margin (PSM) in prostate cancer (PC).

MATERIALS AND METHODS

127 patients who had pre-operative pelvic imaging were included in this study. Demographic and clinical data were recorded. Apical depth (AD), interspinous distance (ISD), intertuberous distance (ITD), bony femoral width (BFW), soft-tissue width (SW), symphysis angle (SA), anteroposterior diameter of the pelvic inlet (API), anteroposterior diameter of the pelvic mid-plane (APM), anteroposterior diameter of the pelvic outlet (APO), pelvic depth (PD), bony width index (BWI), soft tissue width index (SWI), pelvic cavity index (PCI), PDI and PV were measured on MRI or CT. Using PDI and PV, we developed a new parameter of "PDI to PV ratio" (PDI/PV). Logistic regression analysis was used to determine the predictive potential of variables in detection of PSM.

RESULTS

The AD, PV, SA and total prostate specific antigen (PSA) were significantly higher in PSM( +), while PDI, BWI, SWI, API, PDI/PV and PD were significantly lower in PSM( +) (p < 0.05). In multivariate analysis, PDI/PV ratio and clinical stage were all significant predictor of PSM, where PDI/PV ratio was the strongest predictor, followed by clinical stage.

CONCLUSION

Pelvimetric measurements indicating deep location of the prostatic apex rather than pelvic width are more effective in predicting PSM. Prediction of PSM with pelvimetric measurements, in particular PDI/PV ratio, may be helpful for surgical planning in preoperative period.

Clinical Significance of Preoperative Assessment of Intravesical Prostatic Protrusion in Radical Prostatectomy

Background: Intravesical prostatic protrusion (IPP) is common in prostate-related diseases, whose clinical significance in radical prostatectomy was unknown. Methods: 791 patients underwent robot-assisted or open radical prostatectomy at our institution were enrolled. The transabdominal ultrasound examination of prostate and IPP was carried out preoperatively, by which IPP was classified as no (0-0.5cm, grade 0), slight (0.6-1.0cm, grade 1) and noticeable (>1.0cm, grade 2). Results: 185 (23.4%), 170 (21.5%) and 436 (55.1%) patients had no, slight and noticeable IPP, respectively. Generally, prostate specific antigen (PSA), Gleason score and pT stage increased with IPP grade. In particular, cases with grade 0 IPP had a decreased proportion of seminal vesicles' involvement than those with grade 1 and grade 2 IPP (p=0.035). Reconstruction of the bladder neck (in robot-assisted group), increased surgical bleeding (>200ml), and prolonged postoperative hospital stays (>14 days) happened more in patients with grade 2 IPP. Blood transfusion only happened in patients with noticeable IPP. PSM of bladder neck was only associated with higher IPP grade in open surgery group (p=0.032), not in robot-assisted surgery group. Conclusion: IPP is associated with cancer aggressiveness, surgery difficulty and PSM of bladder neck in prostate cancer. Assessment of it provides more information for operations.

Predictors of Clinically Significant Prostate Cancer in Patients with PIRADS Categories 3-5 Undergoing Magnetic Resonance Imaging-Ultrasound Fusion Biopsy of the Prostate

Prostate biopsy is recommended in cases of positive magnetic resonance imaging (MRI), defined as Prostate Imaging Reporting and Data System (PIRADS) category ≥ 3. However, most men with positive MRIs will not be diagnosed with clinically significant prostate cancer (csPC). Our goal was to evaluate pre-biopsy characteristics that influence the probability of a csPC diagnosis in these patients. We retrospectively analyzed 740 consecutive men with a positive MRI and no prior PC diagnosis who underwent MRI-ultrasound fusion biopsies of the prostate in three centers. csPC detection rates (CDRs) for each PIRADS category were calculated. Patient, disease, and lesion characteristics were studied for interdependencies with the csPC diagnosis. The CDR in patients with PIRADS categories 3, 4, and 5 was 10.5%, 30.7%, and 54.6%, respectively. On both uni- and multivariable regression models, older age, being biopsy-naïve, prostate specific antigen ≥ 10 ng/mL, smaller prostate volume, PIRADS > 3, a larger maximum lesion size, a lesion in the peripheral zone, and a positive digital rectal examination were associated with csPC. In this large, multicenter study, we provide new data regarding CDRs in particular PIRADS categories. In addition, we present several strong predictors that further alter the risk of csPC in MRI-positive patients. Our results could help in refining individual risk assessment, especially in PIRADS 3 patients, in whom the risk of csPC is substantially low.

The Impact of the Ongoing COVID-19 Epidemic on the Increasing Risk of Adverse Pathology in Prostate Cancer Patients Undergoing Radical Prostatectomy

We aimed to assess whether the ongoing course of the COVID-19 epidemic has been associated with an increased risk of adverse pathology (AP) findings in prostate cancer (PC) patients treated with radical prostatectomy (RP). We performed a retrospective data analysis which included 408 consecutive, non-metastatic, previously untreated PC patients who underwent RP in our institution between March 2020 and September 2021. Patients were divided into two equally numbered groups in regard to the median surgery date (Early Epidemic [EE] and Late Epidemic [LE]) and compared. Adverse pathology was defined as either grade group (GG) ≥ 4, pT ≥ 3a or pN+ at RP. Patients in the LE group demonstrated significantly higher rates of AP than in the EE group (61 vs. 43% overall and 50 vs. 27% in preoperative non-high-risk subgroup, both p < 0.001), mainly due to higher rates of upgrading. On multivariable analysis, consecutive epidemic week (odds ratio: 1.02, 95% confidence interval: 1.00−1.03, p = 0.009) as well as biopsy GG ≥ 2 and a larger prostate volume (mL) were associated with AP in non-high-risk patients. The study serves as a warning call for increased awareness of risk underassessment in contemporarily treated PC patients.

Any Correlation Between Prostate Volume and Incidence of Prostate Cancer: A Review of Reported Data for the Last Thirty Years

PURPOSE

Prostate cancer (PCa) is the most common non-skin cancer in men worldwide and more than 80% of men with PCa also have histo-anatomical findings of benign prostate hyperplasia (BPH). It is well documented that BPH develops in the transition zone (TZ), whereas 80-85% of PCa originates in the peripheral zone (PZ) of the prostate. Possible causal links between both disease entities are controversially discussed in the current literature. Some studies have reported that larger prostates have a decreased incidence of PCa compared to smaller prostates. The purpose of this systematic review is to comprehensively summarize studies analyzing any association between prostate gland volume and incidence of PCa.

METHODS

A thorough literature review was performed between 01.01.1990 through 02.28.2020 using PubMed and applying the "PRISMA" guidelines. Inclusion and exclusion criteria were defined.

RESULTS

Our systematic review found 41 articles reporting an inverse (negative) relationship between prostate gland volume and incidence of prostate cancer. Sample sizes ranged from 114 to 6692 patients in these single institutional and multi-institutional studies. Thirty-nine (95%) of the 41 articles showed a statistically significant inverse relationship. In our search, no study was found showing a positive correlation between BPH size and the incidence of PCa.

CONCLUSION

To our knowledge, this is the first systematic review on the important clinical question of interaction between prostate size and the incidence of PCa. The results are demonstrating an inverse relationship, and therefore reveal strong evidence that large prostates may be protective of PCa when compared to smaller prostates.

Benign prostate hyperplasia as a potential protective factor against prostate cancer: Insights from a magnetic resonance imaging study of compositional characteristics

PURPOSE

The structural relationship between benign prostate hyperplasia (BPH) and prostate cancer (Pca) is controversial. The purpose of our study was to examine the association between quantitative prostate compositional metrics by magnetic resonance imaging (MRI) and Pca.

METHODS

We identified 405 patients who underwent prostate MRI and biopsy and/or prostatectomy from January 2019 to January 2021 at our institution. Segmentation volumetric methods were used to assess central gland (CG) and peripheral zone (PZ) volume. PZ mean thickness and mean apparent diffusion coefficient (ADC), marker of underlying histologic components, were measured. Multivariable logistic regression was performed with outcomes of ≥Grade Group (GG) 2 Pca and for multifocal disease.

RESULTS

On multivariable analysis, higher CG volumes were at lower odds of ≥GG2 disease (n = 227) (OR: 0.97, 95% CI 0.96-0.98, p < 0.0001), taking into account PZ volume (p = 0.18) and thickness (p = 0.70). For every one cc increase in CG volume, there was an approximately 3% decrease in odds of ≥GG2 disease. Similar findings were noted for multifocal disease (n = 180) (OR: 0.97, 95% CI 0.96-0.98, p < 0.0001). Notably, ADC of the normal PZ was not significantly associated with CG volume (p = 0.21) nor a predictor of disease (p = 0.49).

CONCLUSIONS

Increasing central gland volume, driven by BPH, is associated with lower odds of significant Pca, including multifocal disease, while PZ anatomic and histologic surrogate changes were noncontributory. Findings support BPH impediment of global tumor growth predicted by theoretical mechanobiological model. This potential stabilizing factor should be further studied for risk stratification and in consideration for BPH therapy.

Association between prostate size and the incidence of prostate cancer: a meta-analysis and review for urologists and clinicians

PURPOSE

To review the literature regarding any clinically significant association between prostate size and the incidence of prostate cancer (PCa). No previous review or meta-analysis has reported this clinical question.

METHODS

A thorough literature review was performed using PubMed and applying the 'PRISMA' guidelines. Inclusion and exclusion criteria were defined.

RESULTS

A total of 30 articles met the search criteria. Of these 30 articles, 27 reported an inverse correlation between prostate volume (PV) and incidence of biopsy-proven PCa. The remaining three articles provided no clear statistically significant results, and there was no study showing a direct or positive correlation between PV and the incidence of PCa.

CONCLUSION

This review and meta-analysis is the first report summarizing the literature on the clinical question of whether prostate size affects the incidence of PCa. Ninety percent of studies (27/30) show significant evidence supporting the hypothesis that prostate size may be protective of PCa. This review and the outlined discussion should encourage other clinical investigators to explore the relationship between PV and the incidence and aggressiveness of PCa. If future studies should confirm the hypothesis of the dynamic interactions between the different prostatic zones in a growing prostate, it will have relevant clinical implications on the management of BPH and PCa.

Locally advanced prostate cancer imaging findings and implications for treatment from the surgical perspective

The anatomy of the prostate is reviewed in the context of discussing the staging of prostate cancer and patterns of tumor spread. The utility of prostate magnetic resonance imaging along with new advancements in tumor staging are discussed specifically in locally advanced disease. What should be included in the radiology report carries a substantial weight to formulate the urologist's decision in regards to the selection of surgical candidates, preoperative planning and avoiding postoperative complications.

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.

Histological changes of the peripheral zone in small and large prostates and possible clinical implications

Introduction

It is well documented in literature that most prostate carcinomas (PCa) arise in the peripheral zone (PZ). Additionally, an inverse relationship between prostate size and the incidence of PCa has been demonstrated in recent studies. However, little is known about gland distribution in the peripheral zone of larger prostates compared to smaller prostates. In this study, we examined the histo-anatomical gland distribution within the peripheral zone in small and large prostates and discuss possible clinical implications.

Methods

A semi-quantitative analysis of gland density and capsule thickness was performed using light microscopy on 10 large (≥80 g) prostate specimens and 10 small (<30 g) prostate specimens from patients who underwent radical prostatectomy at Texas Tech University Health Sciences Center between the years 2010 and 2016. Samples from radical prostatectomies were used to ensure a whole, preserved prostate with an intact surgical capsule. Gland counts were performed on five random fields under 100 × magnification, while capsule thickness was measured on three random fields per case; thus, a total 50 fields and 30 fields were analyzed for each of the two groups for gland counts and capsule thickness measurements, respectively. Microscopy was standardized to the posterior aspect of the prostate, between 4 o'clock and 6 o'clock along the equatorial region between the apex and base.

Results

Large prostates possessed a significantly lower mean gland count per field compared to small prostates (10.34±4.15, n=50 vs 18.00±5.41, n=50; t=8.16, df=49, P<0.001). Additionally, large prostates showed a significantly higher average capsule thickness in millimeters compared to small prostates (1.80 mm, ±1.12 mm, n=30 vs 0.90 mm, ±0.56, n=30; t=8.16, df=49, P<0.001).

Conclusion

The results demonstrate that prostate hypertrophy leads to both decreased gland density in the peripheral zone and increased capsule thickness, suggesting that growth-induced expansion of the prostate against its capsule leads to compression-induced atrophy and fibrosis of glandular tissue within the peripheral zone (PZ). A decrease in gland density within the PZ may have clinical implications shedding light, for instance, on the reduction in PCa incidence in patients with large prostates as compared to smaller prostates, a phenomenon well documented in the literature.

How Accurately Can Prostate Gland Imaging Measure the Prostate Gland Volume? Results of a Systematic Review

AIM

The measurement of the volume of the prostate gland can have an influence on many clinical decisions. Various imaging methods have been used to measure it. Our aim was to conduct the first systematic review of their accuracy.

METHODS

The literature describing the accuracy of imaging methods for measuring the prostate gland volume was systematically reviewed. Articles were included if they compared volume measurements obtained by medical imaging with a reference volume measurement obtained after removal of the gland by radical prostatectomy. Correlation and concordance statistics were summarised.

RESULTS

28 articles describing 7768 patients were identified. The imaging methods were ultrasound, computed tomography, and magnetic resonance imaging (US, CT, and MRI). Wide variations were noted but most articles about US and CT provided correlation coefficients that lay between 0.70 and 0.90, while those describing MRI seemed slightly more accurate at 0.80-0.96. When concordance was reported, it was similar; over- and underestimation of the prostate were variably reported. Most studies showed evidence of at least moderate bias and the quality of the studies was highly variable.

DISCUSSION

The reported correlations were moderate to high in strength indicating that imaging is sufficiently accurate when quantitative measurements of prostate gland volume are required. MRI was slightly more accurate than the other methods.

Computer simulations suggest that prostate enlargement due to benign prostatic hyperplasia mechanically impedes prostate cancer growth

Prostate cancer and benign prostatic hyperplasia are common genitourinary diseases in aging men. Both pathologies may coexist and share numerous similarities, which have suggested several connections or some interplay between them. However, solid evidence confirming their existence is lacking. Recent studies on extensive series of prostatectomy specimens have shown that tumors originating in larger prostates present favorable pathological features. Hence, large prostates may exert a protective effect against prostate cancer. In this work, we propose a mechanical explanation for this phenomenon. The mechanical stress fields that originate as tumors enlarge have been shown to slow down their dynamics. Benign prostatic hyperplasia contributes to these mechanical stress fields, hence further restraining prostate cancer growth. We derived a tissue-scale, patient-specific mechanically coupled mathematical model to qualitatively investigate the mechanical interaction of prostate cancer and benign prostatic hyperplasia. This model was calibrated by studying the deformation caused by each disease independently. Our simulations show that a history of benign prostatic hyperplasia creates mechanical stress fields in the prostate that impede prostatic tumor growth and limit its invasiveness. The technology presented herein may assist physicians in the clinical management of benign prostate hyperplasia and prostate cancer by predicting pathological outcomes on a tissue-scale, patient-specific basis.

Effect of prostate gland weight on the surgical and oncological outcomes of extraperitoneal robot-assisted radical prostatectomy

Background

Robot-assisted radical prostatectomy (RARP) is performed by urologists as one of the surgical procedures for treating prostate cancer. Numerous studies have been published with regard to the impact of prostate weight on performing RARP but were limited by the insufficient number of patients and use of the transperitoneal approach. This study aimed to determine the effect of prostate gland weight on the surgical and short-term oncological outcomes of RARP using the extraperitoneal approach.

Methods

In total, 1168 patients who underwent extraperitoneal RARP (EP-RARP) performed by a single surgeon at Yonsei University Severance Hospital between May 2009 and May 2016 were included in the study. The patients were divided into 4 groups according to the prostate weight measured by transrectal ultrasonography preoperatively. Intraoperative and postoperative outcomes were analyzed retrospectively. One-way analysis of variance and the chi-square test were used in the statistical analyses.

Results

Age, the Gleason score, clinical stage, and pathological stage were significantly different. Patients with a larger prostate size had a longer console time and higher estimated blood loss (P < 0.05). There were no significant differences between the 4 groups in length of hospital stay, duration of catheterization, blood transfusion, body mass index, prostate-specific antigen (PSA) level, history of abdominal surgery, intraoperative complications, positive surgical margin, incidence of lymphocele, and PSA recurrence after 1 year.

Conclusions

The console time and estimated blood loss were significantly increased with a larger prostate size. However, there were no significant differences in the oncologic outcome and intraoperative complications, suggesting that EP-RARP requires meticulous bleeding control in patients with a prostate weighing > 75 g, and if appropriate management is implemented for blood loss intraoperatively, EP-RARP can be performed regardless of the prostate size.

Prostate resected weight and postoperative prostate cancer incidence after transurethral resection of the prostate: A population-based study

To analyze whether different volumes of tissue resected during transurethral resection of the prostate (TURP) would associate with the subsequent development of prostate cancer.This population-based retrospective cohort study recruited 49,206 patients with benign prostate hyperplasia (BPH) undergoing TURP between 2005 and 2012. Patients were recruited from the Taiwan National Health Insurance Research Database. Patients were separated into three groups, based on different volumes of tissue resected during TURP (5-15 g, 15-50 g, >50 g).Of the 49,206 patients, 633 patients were diagnosed with new onset of prostate cancer following TURP. Older age was a risk factor contributing to the onset of prostate cancer (P = .0196) and different volumes of tissue resected were significantly related to the incidence of postoperative prostate cancer (P = .0399). The group of patients with a smaller volume of prostate resected had a higher risk of prostate cancer with a hazard ratio (HR) of 1.221 (95% confidence interval [CI]: 1.035, 1.440; P = .0179). However, the risk in the group of patients with a larger volume of prostrate resected was not significantly different, with an HR of 1.277 (95% CI: 0.981, 1662; P = .0690). The incidence of prostate cancer in Taiwanese males over 30 years of age has previously been reported to be 0.0560%; the mean incidence was 0.2282% in our present study.This study shows that BPH patients who had a smaller volume of tissue resected during TURP show a higher incidence of prostate cancer postoperatively. Currently, no clear mechanism is shown to demonstrate the relationship between resected prostate weight and the incidence of tumors. Patients with a larger prostate volume might have lower urinary tract symptoms earlier and then seek professional help. It is possible that surgical procedures might remove the potentially carcinogenic prostate tissue and thus reduce the risk of an aggressive tumor developing in the future.

Laparoscopic versus open radical prostatectomy in high prostate volume cases: impact on oncological and functional results

Background and objective:

To prospectively compare the laparoscopic versus open approach to RP in cases with high prostate volume and to evaluate a possible different impact of prostate volume.

Materials and Methods:

From March 2007 to March 2013 a total of 120 cases with clinically localized prostate cancer (PC) and a prostate volume>70cc identified for radical prostatectomy (RP), were prospectively analyzed in our institute. Patients were offered as surgical technique either an open retropubic or an intraperitoneal laparoscopic (LP) approach. In our population, 54 cases were submitted to LP and 66 to open RP. We analyzed the association of the surgical technique with perioperative, oncological and postoperative functional parameters.

Results:

In those high prostate volume cases, the surgical technique (laparoscopic versus open) does not represent a significant independent factor able to influence positive surgical margins rates and characteristics (p=0.4974). No significant differences (p>0.05) in the overall rates of positive margins was found, and also no differences following stratification according to the pathological stage and nerve sparing (NS) procedure.

The surgical technique was able to significantly and independently influence the hospital stay, time of operation and blood loss (p<0.001). On the contrary, in our population, the surgical technique was not a significant factor influencing all pathological and 1-year oncological or functional outcomes (p>0.05).

Conclusions:

In our prospective non randomized analysis on high prostate volumes, the laparoscopic approach to RP is able to guarantee the same oncological and functional results of an open approach, maintaining the advantages in terms of perioperative outcomes.

Association of prostate volume with incidence and aggressiveness of prostate cancer

Objective

The aim of this study was to investigate the possible correlation between prostate volume and aggressiveness and incidence of prostate cancer (PCa).

Patients and methods

A chart review of a cohort of 448 consecutive prostate biopsy-naive men was performed. These men underwent at least a 12-core biopsy at our institution due to increased prostate-specific antigen serum levels (>4 ng/mL) and/or suspicious findings on digital rectal examination during the period between 2008 and 2013. Transrectal ultrasound was used to determine the prostate volume.

Results

The positive biopsy rate was 66% for patients with a prostate volume of ≤35 cc and 40% for patients with a prostate volume of ≥65 cc (P<0.001). Of the 110 patients testing positive on biopsy with a volume of ≤35 cc, 10 patients (9.1%) had a Gleason score of ≥8. Of the 27 patients testing positive on biopsy with a volume of ≥65 cc, only 1 patient (3.7%) had a Gleason score of ≥8.

Conclusion

These results suggest that there may be an association between prostate volume and the incidence and aggressiveness of PCa. The larger the prostate, the lower the positive biopsy rate for PCa and the lower the Gleason score.

Structural study of endopelvic fascia in prostates of different weights. Anatomic study applied to radical prostatectomy

PURPOSE

To evaluate the structure of the endopelvic fascia in prostates of different weights.

METHODS

We studied 10 patients with BPH (prostates> 90 g); 10 patients with prostate adenocarcinoma (PAC) (prostates< 60 g) and five young male cadavers (control group). During the surgery a small sample of endopelvic fascia was obtained. We analyzed elastic fibers, collagen and smooth muscle. The stereological analysis was done with the Image Pro and Image J programs. Means were statistically compared using the one-way ANOVA with the Bonferroni test and a p<0.05 was considered statistically significant.

RESULTS

The mean of the prostate weight was 122 g in BPH patients, 53.1g in PAC patients and 18.6g in control group. Quantitative analysis documented that there are no differences (p=0.19) in Vv of elastic fibers and in Vv of type III collagen (p=0.88) between the three groups. There was a significant difference (p=0<0.0001) in the quantification of SMC in patients with prostates > 90 g (mean=9.61%) when compared to patients with prostates < 60 g (mean=17.92%) and with the control group (mean=33.35%).

CONCLUSION

There are differences in endopelvic fascia structure in prostates> 90 g, which can be an additional factor for pre-operatory evaluation of radical prostatectomy.

Preoperative Serum Sex Hormone-Binding Globulin Level Is an Independent Predictor of Biochemical Outcome After Radical Prostatectomy

To investigate the significance of preoperative serum sex hormone-binding globulin (SHBG) level regarding the postoperative biochemical outcome in patients who were followed up for relative longer periods after undergoing radical prostatectomy (RP). Preoperative serum levels of testosterone (T), free T, and SHBG level were prospectively analyzed in 307 consecutive patients who underwent RP at our institution between January 2006 and July 2007. We analyzed potential associations of sex hormones with postoperative biochemical recurrence (BCR)-free survival via multivariate Cox proportional regression analysis. Mean postoperative follow-up duration for 307 total patients was 72.1 ± 19.6 months. Kaplan-Meier curve demonstrated that BCR-free survival was significantly worse in patients with higher (≥ 40  ng/mL) SHBG level than others (P < 0.001). Serum T (P = 0.280) and free T (P = 0.606) levels showed no significant association with biochemical outcome. In multivariate analysis encompassing postoperative variables along with PSA, T, and free T, SHBG level (HR 1.825, 1.061-3.138; P = 0.030) was observed to be independently associated with BCR-free survival. Addition of SHBG level to the multivariate model for prediction of BCR-free survival resulted in increased accuracy (83.5% vs. 82.2%; P = 0.164). Our study of patients who were followed up for relative longer periods after RP shows that preoperative serum SHBG level, but not T, is an independent predictor of postoperative BCR-free survival. According to our findings, SHBG measurement may be useful in the selection of candidates for adjuvant treatment following RP.

Importance of prostate volume in the stratification of patients with intermediate-risk prostate cancer

OBJECTIVES

To evaluate the role of prostate volume assessed at final pathology in the risk of biochemical recurrence in patients with clinically localized prostate cancer treated with radical prostatectomy.

METHODS

Overall, 5637 patients treated with radical prostatectomy between January 1993 and August 2013 were identified. Multivariable Cox regression analyses tested the association between prostate volume and biochemical recurrence in the overall population and after stratifying patients according to the D'Amico risk groups.

RESULTS

Mean (median) prostate volume was 50.61 mL (46 mL). When patients were stratified according to D'Amico risk groups, mean (median) prostate volume was 51.7 mL (48 mL), 49.8 mL (45 mL) and 50.6 mL (46 mL) in low-, intermediate-, and high-risk prostate cancer, respectively (P = 0.04). Overall, the 5-year biochemical recurrence-free survival rate was 87.9%. In multivariable Cox regression analyses, prostate volume was associated with a lower risk of biochemical recurrence (hazard ratio 0.99, 95% confidence interval 0.99-1.00), after accounting for disease characteristics. However, when patients were stratified according to D'Amico risk groups, prostate volume represented an independent predictor of biochemical recurrence only in individuals with intermediate-risk disease (hazard ratio 0.99, 95% confidence interval 0.99-1.00). Conversely, prostate volume was not associated with the risk of experiencing biochemical recurrence in patients with low- and high-risk disease.

CONCLUSIONS

Smaller prostates are associated with increased risk of biochemical recurrence after surgery only in men with intermediate-risk disease. In this category, the preoperative assessment of prostate volume might be helpful in order to identify patients at higher risk of biochemical recurrence after surgery. Additionally, prostate volume might be used to individualize follow-up schedules after radical prostatectomy.

Insignificant disease among men with intermediate-risk prostate cancer

PURPOSE

A paucity of data exists on the insignificant disease potentially suitable for active surveillance (AS) among men with intermediate-risk prostate cancer (PCa). We tried to identify pathologically insignificant disease and its preoperative predictors in men who underwent radical prostatectomy (RP) for intermediate-risk PCa.

METHODS

We analyzed data of 1,630 men who underwent RP for intermediate-risk disease. Total tumor volume (TTV) data were available in 332 men. We examined factors associated with classically defined pathologically insignificant cancer (organ-confined disease with TTV ≤0.5 ml with no Gleason pattern 4 or 5) and pathologically favorable cancer (organ-confined disease with no Gleason pattern 4 or 5) potentially suitable for AS. Decision curve analysis was used to assess clinical utility of a multivariable model including preoperative variables for predicting pathologically unfavorable cancer.

RESULTS

In the entire cohort, 221 of 1,630 (13.6 %) total patients had pathologically favorable cancer. Among 332 patients with TTV data available, 26 (7.8 %) had classically defined pathologically insignificant cancer. Between threshold probabilities of 20 and 40 %, decision curve analysis demonstrated that using multivariable model to identify AS candidates would not provide any benefit over simply treating all men who have intermediate-risk disease with RP.

CONCLUSION

Although a minority of patients with intermediate-risk disease may harbor pathologically favorable or insignificant cancer, currently available conventional tools are not sufficiently able to identify those patients.