Intraoperative Frozen Section via Neurosafe During Robotic Radical Prostatectomy in the Era of Preoperative Risk Stratifications and Primary Staging With mpMRI and PSMA-PET CT: Is There a Perfect Candidate?

Ersin Köseoğlu; İbrahim Kulaç; Ayşe Armutlu; Bengi Gürses; Hülya Seymen; Metin Vural; İbrahim Can Aykanat; Kayhan Tarım; Ahmet Furkan Sarıkaya; Mert Kılıç; Dilek Ertoy Baydar; Mehmet Onur Demirkol; Mevlana Derya Balbay; Yakup Kordan; Abdullah Erdem Canda; Tarık Esen

doi:10.1016/j.clgc.2023.06.014

Intraoperative Frozen Section via Neurosafe During Robotic Radical Prostatectomy in the Era of Preoperative Risk Stratifications and Primary Staging With mpMRI and PSMA-PET CT: Is There a Perfect Candidate?

Clin Genitourin Cancer. 2023 Oct;21(5):602-611. doi: 10.1016/j.clgc.2023.06.014. Epub 2023 Jun 28.

Authors

Ersin Köseoğlu¹, İbrahim Kulaç², Ayşe Armutlu², Bengi Gürses³, Hülya Seymen⁴, Metin Vural⁵, İbrahim Can Aykanat⁶, Kayhan Tarım⁷, Ahmet Furkan Sarıkaya⁷, Mert Kılıç⁸, Dilek Ertoy Baydar², Mehmet Onur Demirkol⁴, Mevlana Derya Balbay⁹, Yakup Kordan⁷, Abdullah Erdem Canda⁷, Tarık Esen⁹

Affiliations

¹ Department of Urology, Koç University School of Medicine, Istanbul, Turkey. Electronic address: ekoseoglu@kuh.ku.edu.tr.
² Department of Pathology, Koç University School of Medicine, Istanbul, Turkey.
³ Department of Radiology, Koç University School of Medicine, Istanbul, Turkey.
⁴ Department of Nuclear Medicine, Koç University School of Medicine, Istanbul, Turkey.
⁵ Radiology Clinic, VKF American Hospital, Istanbul, Turkey.
⁶ Urology Clinic, Koç University Hospital, Istanbul, Turkey.
⁷ Department of Urology, Koç University School of Medicine, Istanbul, Turkey.
⁸ Urology Clinic, VKF American Hospital, Istanbul, Turkey.
⁹ Department of Urology, Koç University School of Medicine, Istanbul, Turkey; Urology Clinic, VKF American Hospital, Istanbul, Turkey.

PMID: 37451883
DOI: 10.1016/j.clgc.2023.06.014

Abstract

Background: We aimed to analyze the effect of preoperative risk assessment including Ga-68 PSMA PET and multiparametric magnetic resonance imaging (mpMRI) on nerve sparing practices, positive surgical margin (PSM) rates and oncological outcomes based on a comparison between patients underwent RARP with and without Neurosafe (NS).

Methods: Patients underwent RARP with NS (RARP-NS) or without (RARP-only) NS retrospectively evaluated. Suspicion for extracapsular extension on mpMRI and/or Ga-68 PSMA PET was recorded as i(imaging)T3. NS was performed according to the Martini-Klinik technique. PSM at preserved bundle side were called PSM at region of interest (ROI) while the others were elsewhere.

Results: A total of 208 patients (90 in RARP-NS, 118 in RARP-only groups) were included. Preoperatively the RARP-only group showed significantly higher mean PSA (p = .01) and PIRADS 5 (p = .002) findings and had more D'Amico high risk (DAHR) patients (p = .08). The overall PSM rates for pT2 versus pT3 disease were 7.5% versus 21.6 and 15.6% versus 55% in RARP-NS and RARP-only groups, respectively. NS resulted in more bilaterally preserved bundles (81.1% vs. 66.3%) and less PSM at the ROI (3.3% vs. 23.4%) than RARP-only group. NS outperformed RARP-only in all clinical settings had its highest differential benefit in more bilateral nerve sparing and less PSM at ROI in patients with both DAHR and iT3 disease. BCR rates were 2.2% and 2.5% for RARP-NS and RARP only groups, respectively (p = .4). One patient in RARP-NS and 9 in RARP-only groups had PSA persistence (p = .02).

Conclusion: RARP-NS led to more preserved bundles with less PSM. It was especially useful in DAHR patients with preoperative extracapsular extension suspicion in imaging simultaneously.

Keywords: Multiparametric MRI; PSMA; Peroperative frozen; Prostate cancer; Robotics.