Study Type – Therapy (case series)
Level of Evidence 4 OBJECTIVE To critically analyse the learning curve for one experienced open surgeon converting to robotic surgery for radical prostatectomy (RP). PATIENTS AND METHODS From February 2006 to December 2008, 502 patients had retropubic RP (RRP) while concurrently 212 had robot‐assisted laparoscopic RP (RALP) by one urologist. We prospectively compared the baseline patient and tumour characteristics, variables during and after RP, histopathological features and early urinary functional outcomes in the two groups. RESULTS The patients in both groups were similar in age, preoperative prostate‐specific antigen level, and prostatic volume. However, there were more high‐stage (T2b and T3, P= 0.02) and ‐grade (Gleason 9, P= 0.01) tumours in the RRP group. The mean (range) operative duration was 147 (75–330) min for RRP and 192 (119–525) min for RALP (P < 0.001); 110 cases were required to achieve ‘3‐h proficiency’. Major complication rates were 1.8% and 0.8% for RALP and RRP, respectively. The overall positive surgical margin (PSM) rate was 21.2% in the RALP and 16.7% in the RRP group (P= 0.18). PSM rates for pT2 were comparable (11.6% vs 10.1%, P= 0.74). pT3 PSM rates were higher for RALP than RRP (40.5% vs 28.8%, P= 0.004). The learning curve started to plateau in the overall PSM rate after 150 cases. For the pT2 and pT3 PSM rates, the learning curve tended to flatten after 140 and 170 cases, respectively. The early continence rates were comparable (P= 0.07) but showed a statistically significant improvement after 200 cases. CONCLUSIONS Our analysis of the learning curve has shown that certain components of the curve for an experienced open surgeon transferring skills to the robotic platform take different times. We suggest that patient selection is guided by these milestones, to maximize oncological outcomes.

ObjectiveTo evaluate the ability of prostate-specific membrane antigen (PSMA)-positron-emission tomography (PET)/computed tomography (CT) to detect intermediate-grade intra-prostatic prostate cancer (PCa), and to determine if PSMA-PET improves the diagnostic accuracy of multiparametric magnetic resonance imaging (mpMRI). Patients and MethodsA total of 56 consecutive patients with International Society of Urological Pathology (ISUP) grade 2-3 PCa after radical prostatectomy, who underwent both mpMRI and PSMA-PET CT (hereafter PSMA-PET) preoperatively, were enrolled in this study. The accuracy of PSMA-PET, mpMRI alone, and the two procedures in combination was analysed for identifying ISUP grades 1-3 within a 12-segment model. The accuracy of a combined predictive model (PSMA-PET and mpMRI) was determined. Receiver-operating characteristic curve analysis to determine the optimal standardized uptake value (SUV max ) for PSMA-PET in discriminating between ISUP grades 1 and ≥2 was performed. ResultsOn a per-patient basis, the sensitivities for PSMA-PET and mpMRI in identifying ISUP grades 2-3 PCa were 100% and 97%, respectively. Assessing ISUP grade ≥2 PCa using a 12segment analysis, PSMA-PET demonstrated greater diagnostic accuracy (area under the curve), sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV), with values of 0.91, 88%, 93%, 95% and 85%, respectively, than did mpMRI (Prostate Imaging Reporting and Data System [PI-RADS] 3-5), at 0.79, 68%, 91%, 87%, and 75%, respectively. When used in combination (PSMA-PET and mpMRI PIRADS 4-5), sensitivity, specificity, NPV and PPV were 92%, 90%, 96% and 81%, respectively. The sensitivity for both techniques reduced markedly when assessing ISUP grade 1 PCa (18% for PSMA-PET, 10% for mpMRI). An SUV max value of 3.95 resulted in 94% sensitivity and 100% specificity. ConclusionPSMA-PET is accurate in detecting segments containing intermediate-grade intra-prostatic PCa (ISUP grade ≥ 2), compared with and complementary to mpMRI. By contrast the detection rate for ISUP grade 1 disease for both PSMA-PET and mpMRI was low.

Overall transrectal and transperineal biopsy identify cancers that are similar in size, stage and significance. However, transperineal biopsy detected proportionally more anterior tumors (16.2% vs 12%), and identified them at a smaller size (1.4 vs 2.1 cm(3)) and stage (extracapsular extension 13% vs 28%) compared to transrectal biopsy. Identifying anterior tumors early is important because the positive surgical margin rate for anterior pT3 lesions is significantly higher.

What's known on the subject? and What does the study add?• With an aging population and routine use of PSA testing, there is an increase in men undergoing biopsy to assess for prostate cancer. The most common route for accessing the prostate is through the rectum, which potentially exposes the patient to otherwise innocuous Enterobacteriaceae. The rising incidence of extended-spectrum beta-lactamase has been linked to a rise in post-TRUS biopsy infection rates internationally.• The study describes an alternative route for biopsy of the prostate that is associated with a very low infection rate, whilst still maintaining a good tumour detection rate. Objective• To present the template-guided transperineal prostate biopsy (TPB) outcomes for patients of two urologists from a single institution. Patients and Methods• We conducted a prospective study of 409 consecutive men who underwent TPB between December 2006 and June 2008 in a tertiary referral centre using a standardized 14-region technique.• The procedure was performed as day surgery under general anaesthesia with fluoroquinolone antibiotic cover.• Follow-up took place within 2 weeks, during which time men were interviewed using a standardized template.• Results were compared with those of the Australian national prostate biopsy audits performed by the Urological Society of Australia and New Zealand (USANZ). Results• Indications for biopsy included elevated prostate-specific antigen (PSA) level (75%), with a median PSA level of 6.5 ng/mL, abnormal digital rectal examination (8%) and active surveillance (AS) re-staging (18%).• The mean patient age was 63 years and two-thirds of patients were undergoing their first biopsy. • A positive biopsy was found in 232 men, 74% of whom had a Gleason score of Ն7. The overall cancer detection rate was 56.7% (USANZ 2005 national audit = 56.5%).Stratified between those having their first TPB or a repeat procedure (after a previous negative biopsy), the detection rates were 64.4 and 35.6%, respectively. Significantly higher detection rates were found in prostates <50 mL in volume than in larger prostates (65.2 vs 38.3%, respectively, P < 0.001).• Haematuria was the most common side effect (51.7%).Others included dysuria (16.4%), acute urinary retention (4.2%) and fever (3.2%). One patient (0.2%) had septicaemia requiring i.v. antibiotics. • Repeat biopsy was not associated with increased complication rates. Conclusions• TPB is a safe and efficacious technique, with a cancer detection rate of 56.7% in the present series, and a low incidence of major side effects. Stratified by prostate volume, the detection rate of TPB was higher in smaller glands.• Given the relatively low rate of serious complications, clinicians could consider increasing the number of TPB biopsy cores in larger prostates as a strategy to improve cancer detection within this group. Conversely, in patients on AS programmes, a staging TPB may be a superior approach for patients undergoing repeat biopsy so as to minimize their risk of serious infection.