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Background: Salvage radical prostatectomy (sRP) historically yields poor functional outcomes and high complication rates. However, recent reports on robotic sRP show improved results. Our objectives were to evaluate sRP oncological outcomes and predictors of positive margins and biochemical recurrence (BCR)., Methods: We retrospectively collected data of sRP for recurrent prostate cancer after local nonsurgical treatment at 18 tertiary referral centers in United States, Australia and Europe, from 2000 to 2016. SM and BCR were evaluated in a univariate and multivariable analysis. Overall and cancer-specific survival were also assessed., Results: We included 414 cases, 63.5% of them performed after radiotherapy. Before sRP the majority of patients had biopsy Gleason score (GS) ≤7 (55.5%) and imaging negative or with prostatic bed involvement only (93.3%). Final pathology showed aggressive histology in 39.7% (GS ≥9 27.6%), with 52.9% having ≥pT3 disease and 16% pN+. SM was positive in 29.7%. Five years BCR-Free, cancer-specific survival and OS were 56.7%, 97.7% and 92.1%, respectively. On multivariable analysis pathological T (pT3a odds ratio [OR] 2.939, 95% confidence interval [CI] 1.469-5.879; ≥pT3b OR 2.428-95% CI 1.333-4.423) and N stage (pN1 OR 2.871, 95% CI 1.503-5.897) were independent predictors of positive margins. Pathological T stage ≥T3b (OR 2.348 95% CI 1.338-4.117) and GS (up to OR 7.183, 95% CI 1.906-27.068 for GS >8) were independent predictors for BCR. Limitations include the retrospective nature of the study and limited follow-up., Conclusions: In a contemporary series, sRP showed promising oncological control in the medium term despite aggressive pathological features. BCR risk increased in case of locally advanced disease and higher GS. Future studies are needed to confirm our findings., (Copyright © 2020. Published by Elsevier Inc.)

Objective: To evaluate the accuracy in histologic grading of MRI/US image fusion biopsy by comparing histopathology between systematic biopsies (SB), targeted biopsies (TB) and the combination of both (SB + TB) with the final histopathologic outcomes of radical prostatectomy specimens., Materials and Methods: Retrospective, multicentric study of 443 patients who underwent SB and TB using MRI/US fusion technique (Urostation ® and Trinity ® ) prior to radical prostatectomy between 2010 and 2017. Cochran's Q test and McNemar test were conducted as a post hoc test. Uni-multivariable analyses were performed on several clinic-pathological variables to analyze factors predicting histopathological concordance for targeted biopsies., Results: Concordance in ISUP (International Society of Urological Pathology) grade between SB, TB and SB + TB with final histopathology was 49.4%, 51.2%, and 63.2% for overall prostate cancer and 41.2%, 48.3%, and 56.7% for significant prostate cancer (ISUP grade ≥ 2), respectively. Significant difference in terms of concordance, downgrading and upgrading was found between SB and TB (ISUP grade ≥ 2 only), SB and SB + TB, TB and SB + TB (overall ISUP grade and ISUP grade ≥ 2) (p < 0.001). Total number of cores and previous biopsies were significant independent predictive factors for concordance with TB technique., Conclusion: In this retrospective study, combination of SB and TB significantly increased concordance with final histopathology despite a limited additional number of cores needed.

Purpose: Salvage radical prostatectomy has historically yielded a poor functional outcome and a high complication rate. However, recent reports of robotic salvage radical prostatectomy have demonstrated improved results. In this study we assessed salvage radical prostatectomy functional outcomes and complications when comparing robotic and open approaches., Materials and Methods: We retrospectively collected data on salvage radical prostatectomy for recurrent prostate cancer after local nonsurgical treatment at 18 tertiary referral centers from 2000 to 2016. The Clavien-Dindo classification was applied to classify complications. Complications and functional outcomes were evaluated by univariable and multivariable analysis., Results: We included 395 salvage radical prostatectomies, of which 186 were open and 209 were robotic. Robotic salvage radical prostatectomy yielded lower blood loss and a shorter hospital stay (each p <0.0001). No significant difference emerged in the incidence of major and overall complications (10.1%, p=0.16, and 34.9%, p=0.67), including an overall low risk of rectal injury and fistula (1.58% and 2.02%, respectively). However, anastomotic stricture was more frequent for open salvage radical prostatectomy (16.57% vs 7.66%, p <0.01). Overall 24.6% of patients had had severe incontinence, defined as 3 or more pads per day, for 12 or 6 months. On multivariable analysis robotic salvage radical prostatectomy was an independent predictor of continence preservation (OR 0.411, 95% CI 0.232-0.727, p=0.022). Limitations include the retrospective nature of the study and the absence of a standardized surgical technique., Conclusions: In this contemporary series to our knowledge salvage radical prostatectomy showed a low risk of major complications and better functional outcomes than previously reported. Robotic salvage radical prostatectomy may reduce anastomotic stricture, blood loss and hospital stay, and improve continence outcomes.

Background: Puboprostatic ligament preservation has been proposed as a method to accelerate continence recovery after radical prostatectomy (RP). However, these ligaments present anatomic continuity with the bladder, and there must be interruption at some point to expose the prostatourethral junction., Objectives: To describe the surgical steps of pubovesical complex (PVC)-sparing robot-assisted laparoscopic RP (RALP) and present the preliminary results of our technique., Design, Setting, and Participants: Thirty PVC-sparing RALP procedures were performed in patients <60 yr with clinically localised prostate cancer between 2007 and 2009 by the same surgeon., Surgical Procedure: The principles of bladder neck preservation, tension and energy-free dissection of the bundles as well as seminal vesicle sparing are applied. Ventrally, a plane of dissection is developed between the detrusor apron and the prostate. The soft connective tissue between Santorini's plexus and the prostate is blandly dissected, leaving the plexus intact and in place., Measurements: The rates and location of positive surgical margins (PSM) as well as functional outcomes are presented., Results and Limitations: Three of 30 patients (10%) had a PSM (two apical margins and one on the left posterolateral side). At catheter removal, 24 of 30 patients (80%) were dry (0 pads), and 6 of 30 patients (20%) needed one security pad. After 3 mo, 22 of 30 patients (73%) presented an International Index of Erectile Function score >17 (with or without phosphodiesterase type 5 inhibitors). Thirteen of 22 potent patients had an Erection Hardness Score of 3, and 9 of 22 patients had a score of 4. Small sample size, low mean age of enrolled patients (52 yr), and the absence of diseases that could impair the continence and potency recovery are some of the limitations of the study. Moreover, it is difficult to quantify the effect of each applied continence-sparing technique., Conclusions: The holistic preservation of the PVC during RALP is technically feasible. It leads towards an absolute preservation of the periprostatic anatomy that may enhance early functional outcomes. Further studies are needed to confirm our results., ((c) 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: To describe our technique of nerve sparing laparoscopic radical prostatectomy (LRP). We present the oncological and functional results (potency and urinary continence)., Material and Methods: LRP has become standard at our institution based on experience with more than 2800 consecutive cases operated on between 1997 and 2005. From May 2003 to March 2005 a total of 677 LRP were performed, 425 consecutive patients candidates for a nerve sparing technique have been operated using the intrafascial approach. The challenge of our technique is to remove the prostate without any thermic and mechanic traumatism, avoiding dissection of outer layer. Oncological data were assessed by pathological examination and post-operative PSA level. Functional results were assessed with a self questionnaire., Results: By pathological stage, 2 pT2a specimens (7.4%), 7 pT2b specimens (21%), 44 pT2c specimens (24%), 63 pT3a specimens (43%), 11 pT3b specimens (46%) were found to have positive surgical margins (SMs). In 86 specimen (59%) positive SMs were focal inframillimetric. Median follow-up was 11 months (range 1-22). The continence rate (no leakage/no pad) was 95% at 6 months, confirmed at 12 months among 202 patients. For 137 patients, potency rate was 58.5% at 12 months., Conclusion: Intrafascial LRP provides satisfactory results in regard to recovery of continence and sexual function. Long-term progression and survival outcome are necessary before this procedure should be offered as a replacement for interfascial nerve sparing technique.

Objective: The aim of the present work is to describe the surgical technique and to assess the feasibility of laparoscopic extraperitoneal adenomectomy in a pilot study., Methods: Eighteen consecutive patients in whom an open adenomectomy was planned were operated on in a laparoscopic extraperitoneal fashion. In all patients indication was based on objective signs of obstruction. The laparoscopic approach was standard in all cases as follows: creation of a preperitoneal workspace, haemostatic control of lateral venous vesicoprostatic pedicles, transversal anterior incision of the prostate capsule, progressive enucleation of the adenoma with the help of an harmonic scalpel, suture of the posterior bladder neck to the prostate fossa, closure of the prostate capsule, and retrieval of the specimen. Feasibility was assessed by objective operative parameters (reconversion, operating time, and blood loss and transfusion requirements) and per operative complications. Data on short term follow-up are also available., Results: Mean age of the patients was 67.8 years (S.D. 6.2) and mean prostatic weight calculated by TRUS 95.1cm(3) (S.D. 28.1). Mean maximal flow (Q(max)) was 4.3ml/s (S.D. 3.4) with four patients (22.2%) presenting in retention. Mean duration of intervention was 145min (S.D. 32.5) and mean blood loss 192ml (S.D. 178). Mean excised tissue was 47.6g (S.D. 30). Neither conversions to open prostatectomy nor transfusions were required. The urethral catheter remained in place an average of 3.0 days (S.D. 2.4) in 14 patients, while 4 needed a re-catheterization. Mean postoperative hospital stay was 5.9 days (S.D. 5.5). Five patients (27.7%) presented complications during follow-up, mild in most of the cases but one who required a secondary intervention for persistent obstruction., Conclusions: Laparoscopic extraperitoneal adenomectomy (Millin's procedure) is feasible with a reasonable complication rate. Although comparison with open adenomectomy is not yet available, this technique might have potential advantages in terms of blood loss and postoperative catheter time.