Prostate MRI prior to radical prostatectomy: effects on nerve sparing and pathological margin status

Abstract

ObjectivesThe aim of this study was to assess the positive surgical margin (PSM) and nerve sparing (NS) rates in patients who underwent prostate MRI (pMRI) prior to radical prostatectomy (RP) and compare them with matched, nonimaged control RP patients.MethodsWe identified 204 men who underwent preoperative pelvic MRI (pelMRI), of whom 176 (86.3%) underwent pMRIs, within 60 days of RP, and compared them (1:1) with a nonim-aged control group matched by surgeon, age, race, body mass index (BMI), prostate-specific antigen (PSA), pathological Gleason score, prostate specimen weight, and RP year.ResultsThe rates of nonfocal extracapsular extension (nfECE) on RP pathology in the MRI and control groups were similar. PSM rates were lower in the MRI group (13.7% vs 19.3%; P=0.14), but the difference did not meet statistical significance; this was also the case in patients with nfECE on RP pathology (27.7% vs 39.5%; P=0.3). NS rates were similar between groups. In the MRI group, 54 (26.5%) patients had an MRI suspicious for nfECE; their PSM rate (20.4%) was higher than that of patients with an MRI not suspicious for nfECE (11.3%; P=0.11), but the difference lacked statistical significance; the former group had significantly lower rates of NS. Limitations of the study include sample power and nonuniform heeding of MRI results by each surgeon.ConclusionMRI did not significantly decrease the rates of PSM, including in the subset of patients with nfECE on final pathology. Even wider resection may be necessary in patients with MRIs suggesting locally-advanced disease. Studies with greater power are needed.

Clinical utility of MRI in the decision-making process before radical prostatectomy: Systematic review and meta-analysis

“…Our meta-analysis has shown that in those who had preoperative MRI rate of PSMs is no different irrespectively of the direction of surgical technique adaptation (Fig 9). In matched control study, despite the difference in crude numbers, PSM rates in pelvic MRI and non-MRI groups were similar (13.7% vs 19.3%) [21]. This relation was also observed at subgroup analysis in patients with T1c PCa (11.0% vs 18.1%) and more advanced disease as well (21.4% vs 25.0%) [21].…”

“…These diversities may reflect various accommodation of MRI images in different studies. In the trial by Durskin et al, NVB-sparing rates between MRI and non-MRI group were similar despite suggestion of non-focal EPE in pelvic MRI in selected cases [21]. Therefore, despite fairly high diagnostic accuracy these observations indicate, that MRI before RP is being adopted with great caution.…”

“…In matched control study, despite the difference in crude numbers, PSM rates in pelvic MRI and non-MRI groups were similar (13.7% vs 19.3%) [21]. This relation was also observed at subgroup analysis in patients with T1c PCa (11.0% vs 18.1%) and more advanced disease as well (21.4% vs 25.0%) [21]. In other retrospective study MRI before surgery was not associated with improvement in the rate of PSM [32].…”

“Real-time” Assessment of Surgical Margins During Radical Prostatectomy: State-of-the-Art

“…Furthermore, they showed that the appropriateness of the surgical decision modification based on the MRI findings was 77%. 71 Similarly, Druskin et al 70 showed that the use of preoperative MRI in patients undergoing RP resulted in a 5.6% decrease in the PSM rate.…”

“…Several authors studied the clinical value of preoperative MRI on surgical planning and PSM rates showing that it may influence the surgical decision in 26% to 59% of patients. [65][66][67][68][69][70] Recently, Kozikowski et al 71 reported, in their systematic review and meta-analysis, that MRI modified the NVB dissection on 1 or both sides in 35% of patients, of which 63% performed a more aggressive resection of the bundle and 37% had more preservation of the bundle. Furthermore, they showed that the appropriateness of the surgical decision modification based on the MRI findings was 77%.…”