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Background: This study aimed to evaluate the histopathological concordance rates between prostate biopsies and radical prostatectomy specimens according to the applied biopsy approach (transrectal or transperineal)., Methods: We studied patients who had been newly diagnosed with clinically significant prostate cancer and who underwent a radical prostatectomy between 2018 and 2022. Patients were included if they underwent a prebiopsy magnetic resonance imaging and if they had not been previously treated for prostate cancer. Histopathological grading on prostate biopsies was compared with that on radical prostatectomy specimens. Univariable and multivariable logistic regression analyses were performed to assess the effect of the applied biopsy approach on histopathological concordance. Additional analyses were performed to assess the effect of the applied biopsy approach on American Urological Association risk group migration, defined as any change in risk group after radical prostatectomy., Results: In total, 1058 men were studied, of whom 49.3% (522/1058) and 50.7% (536/1058) underwent transrectal and transperineal prostate biopsies, respectively. Histopathological disconcordance was observed in 37.8% (400/1058) of men while American Urological Association risk group migration was observed in 30.2% (320/1058) of men. A transperineal biopsy approach was found to be independently associated with higher histopathological concordance rates (OR 1.33 [95% CI 1.01-1.75], p = 0.04) and less American Urological Association risk group migration (OR 0.70 [95% CI 0.52-0.93], p = 0.01)., Conclusions: The use of a transperineal biopsy approach improved histopathological concordance rates compared to the use of a transrectal biopsy approach. A transperineal biopsy approach may provide more accurate risk stratification for clinical decision-making. Despite recent improvements, histopathologic concordance remains suboptimal and should be considered before initiating management., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Objective: To develop an assessment instrument for the evaluation of surgical videos to elucidate the association between surgical skills and postoperative outcomes after a robot-assisted radical prostatectomy (RARP)., Design: A Delphi study consisting of two consecutive online surveys and a consensus group meeting., Setting: Urology departments of general, teaching and university hospitals in the Netherlands., Participants: All Dutch urologists with a specialization in RARP., Results: Of 18 invited experts, 12 (67%) participated in the first online survey. In the second round, 9 of the 18 invited experts participated (50%). The Delphi meeting was attended by 5 of the 18 (27%) invited experts. The panel identified seven surgical steps with a possible association to postoperative outcomes. The experts also expected an association between adverse postoperative outcomes and the frequency of camera removals, the number of stitches placed, the amount of bleeding, and the extent of coagulation. These factors were incorporated into an assessment instrument., Conclusions: Experts in the field of RARP achieved consensus on 7 surgical steps and 4 aspects of the RARP procedure that may be related to adverse postoperative outcomes. The resulting assessment instrument will be tested in future research to determine its validity.

Robot-assisted radical prostatectomy (RARP) is performed in patients with prostate cancer. Unfortunately, 10-46% of patients may still suffer from limited erectile function (EF) after RARP. This study aimed to develop a prediction model based on the extent of fascia preservation (FP) and postoperative EF after RARP. A previously developed FP score quantizing the extent and regions of nerve-preservation was determined in a cohort of 1241 patients who underwent RARP. The predictive value of the FP score for post-prostatectomy EF (following the international index erectile function (IIEF) score, EF domain) was analyzed. To increase the predictive value of the scoring system, the FP regions were related to postoperative EF, nerve distribution and co-morbidity factors. Finally, a prediction model for EF was developed based on the studied cohort. When corrected for the preoperative IIEF-EF, the FP score was shown to be a significant denominator for IIEF (p = 2.5 × 10 - 15 ) with an R 2 of 35%. Variable selection performed using the Akaike information criterion led to a final prediction model for postoperative IIEF after nerve-preservation based on the FP score. Furthermore, patient's age, preoperative IIEF score, CCIS and use of clips for nerve sparing were significantly associated with postoperative IIEF-EF. More anterior fascia preservation was correlated with better EF outcome and age was a strong independent predictor of EF outcome. In older men, the relative benefit of more extensive fascia preservation was at least similar to younger men, despite a lower baseline IIEF-EF score. Quantitative nerve-sparing FP scoring could be related to the postoperative IIEF-EF and integrated into a multivariate prediction model, which includes with age, use of surgical clips, the Charlson Comorbidity Index Score (CCIS), and preoperative IIEF-EF. When further validated the prediction model could provide patients and care-givers a qualitative estimation of EF outcome after RARP.

The role of a cystogram to assess the vesico-urethral anastomosis (VUA) after robot-assisted laparoscopic radical prostatectomy (RARP) has been debated. Early catheter removal without cystogram was reported to be associated with a trend towards an increased risk of acute urinary retention (AUR). In two cohorts we studied the effects of VUA leakage on cystogram and functional outcome after RARP. Cohort A contained 1390 consecutive men that routinely underwent a cystogram after RARP. Transurethral catheter (TUC) was removed in the absence of VUA leakage or minimal leakage on subsequent repeat cystogram. Outcome was compared to a group of 120 men that underwent cystography 7-10 days after RARP but had the TUC removed independent of cystography findings (cohort B). Outcome was assessed by early clinical follow-up and quality of life (QOL) questionnaires at 6 months. Men in cohort B had an increased risk of AUR and 6 months voiding complaints when compared to cohort A. The incidence of AUR and voiding complaints was associated with grade 2-3 leakage on cystography in cohort B but not in cohort A. Grade 2-3 leakage on cystogram was more likely in men with larger prostates larger and preoperative voiding complaints. Selective cystogram in men with larger prostates and preoperative lower urinary tract symptoms (LUTS) may prevent early AUR and voiding complaints after RARP when prolonged TUC use is applied.

Robot assisted laparoscopic prostatectomy (RALP) has become a widely accepted and applied surgical method of localized prostate cancer treatment. Initial studies suggest a shorter learning curve for RALP when compared to conventional laparoscopic prostatectomy. Although dexterity for the RALP procedure is increased by the da Vinci surgical robotic system compared to laparoscopic approaches, the anatomical and technical approaches to prostatectomy still require considerable experience in anatomical variations to become proficient and improve oncological and surgical approaches. Several aspects with respect to that can be recognized in the early phases of training. The following aspects helped the author in his initial 150 cases to improve surgical skills: use intraoperative transrectal ultrasound for bladder neck recognition, record and review surgical procedures, experiment with port positioning, training of table assistance. The more recent da Vinci surgical robot systems allow for new dimensions in surgical approaches with particular intraoperative imaging modalities not earlier so easy accessible during surgery. These properties render robot procedures appealing for the now-a-days more and more image-guided approach to surgery.

Objectives: To test a simple intraoperative scoring system for the circumferential extent of fascia preservation (FP) for the prediction of postoperative erectile function. With the advent of robotic and endoscopic surgery for prostate cancer, more extensive FP has emerged as a method to improve postoperative erectile function., Methods: A total of 107 consecutive cases with normal preoperative erectile function were treated using robot-assisted laparoscopic prostatectomy for localized prostate cancer. The erectile, sexual, and global quality of life outcomes using the European Organization for Research and Treatment and Cancer Quality of Life questionnaire-C30 and prostate cancer-specific 25-item questionnaire were assessed at 6 months postoperatively., Results: At 6 months postoperatively, 57 men (53%) reported no or minimal effects on erectile function with or without the use of a phosphodiesterase type 5 inhibitor. The patient age at surgery, prostate size, and FP score were associated with erectile function at 6 months postoperatively. The mean FP score was 9.2 +/- 2.8 and 4.7 +/- 2.4 for patients without and with erectile dysfunction postoperatively, respectively. On multivariate analysis, the FP score and patient age at surgery were the best predictors of postoperative erectile function. No correlation between the FP score and positive surgical resection margin rate was observed. A greater FP score predicted for greater questionnaire-based libido, sexual activity, and sexual function scores., Conclusions: A scoring system for the extent of circumferential FP during prostatectomy is a stronger predictor of postoperative erectile function recovery than is laterality (bilateral or unilateral) or fascial depth (interfascial or intrafascial). More ventral FP significantly contributed to postoperative erectile function recovery.

To compare toxicity and efficacy of both salvage prostatectomy and salvage radiotherapy for prostate cancer a retrospective analysis was conducted. Thirty-two and 41 patients were treated with external beam radiotherapy or prostatectomy for cT1c-T2 prostate cancer later requiring salvage surgery or radiotherapy. Salvage surgery was performed when a local recurrence was biopsy confirmed and life-expectancy was more than 10 years. Salvage external beam radiotherapy was performed when PSA rose over 0.1 ng/ml in the absence of systemic disease. Ten-year PSA-recurrence free survival after primary treatment in the salvage surgery group and salvage radiotherapy groups was 55% and 44% (P > 0.05) respectively whereas prostate cancer specific survival was 93% and 89%, respectively (P > 0.05). Both, biopsy Gleason score prior to primary treatment and PSADT prior to salvage treatment were predictive of PSA-recurrence free survival. Patients after salvage radiotherapy (13%) were less likely to wear pads for urinary incontinence compared to patients after salvage surgery (56%). Erectile dysfunction was more frequent after salvage surgery (81%) compared to salvage radiotherapy (61%). Salvage surgery and salvage prostatectomy after primary cT1-2 prostate cancer provide comparable PSA-recurrence free survival after primary treatment. Genitourinary functions were better preserved in the salvage radiotherapy group compared to the salvage prostatectomy group., ((Copyright) 2008 Wiley-Liss, Inc.)