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    Multicenter Multireader Evaluation of an Artificial Intelligence-Based Attention Mapping System for the Detection of Prostate Cancer With Multiparametric MRI
    (AMER ROENTGEN RAY SOC, 2020-01-01) Mehralivand, Sherif; Harmon, Stephanie A.; Shih, Joanna H.; Smith, Clayton P.; Lay, Nathan; Argun, Burak; Bednarova, Sandra; Baroni, Ronaldo Hueb; Canda, Abdullah Erdem; Ercan, Karabekir; Girometti, Rossano; Karaarslan, Ercan; Kural, Ali Riza; Pursyko, Andrei S.; Rais-Bahrami, Soroush; Tonso, Victor Martins; Magi-Galluzzi, Cristina; Gordetsky, Jennifer B.; Silvestre e Silva Macarenco, Ricardo; Merino, Maria J.; Gumuskaya, Berrak; Saglican, Yesim; Sioletic, Stefano; Warren, Anne Y.; Barrett, Tristan; Bittencourt, Leonardo; Coskun, Mehmet; Knauss, Chris; Law, Yan Mee; Malayeri, Ashkan A.; Margolis, Daniel J.; Marko, Jamie; Yakar, Derya; Wood, Bradford J.; Pinto, Peter A.; Choyke, Peter L.; Summers, Ronald M.; Turkbey, Baris
    OBJECTIVE. The purpose of this study was to evaluate in a multicenter dataset the performance of an artificial intelligence (AI) detection system with attention mapping compared with multiparametric MRI (mpMRI) interpretation in the detection of prostate cancer. MATERIALS AND METHODS. MRI examinations from five institutions were included in this study and were evaluated by nine readers. In the first round, readers evaluated mpMRI studies using the Prostate Imaging Reporting and Data System version 2. After 4 weeks, images were again presented to readers along with the AI-based detection system output. Readers accepted or rejected lesions within four AI-generated attention map boxes. Additional lesions outside of boxes were excluded from detection and categorization. The performances of readers using the mpMRI-only and AI-assisted approaches were compared. RESULTS. The study population included 152 case patients and 84 control patients with 274 pathologically proven cancer lesions. The lesion-based AUC was 74.9\% for MRI and 77.5\% for AI with no significant difference (p = 0.095). The sensitivity for overall detection of cancer lesions was higher for AI than for mpMRI but did not reach statistical significance (57.4\% vs 53.6\%, p = 0.073). However, for transition zone lesions, sensitivity was higher for AI than for MRI (61.8\% vs 50.8\%, p = 0.001). Reading time was longer for AI than for MRI (4.66 vs 4.03 minutes, p < 0.001). There was moderate interreader agreement for AI and MRI with no significant difference (58.7\% vs 58.5\%, p = 0.966). CONCLUSION. Overall sensitivity was only minimally improved by use of the AI system. Significant improvement was achieved, however, in the detection of transition zone lesions with use of the AI system at the cost of a mean of 40 seconds of additional reading time.
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    Can We Predict the Surgical Margin Positivity in Patients Treated with Radical Prostatectomy? A Multicenter Cohort of Turkish Association of Uro-Oncology
    (GALENOS YAYINCILIK, 2015-01-01) Bolat, Deniz; Eskicorapci, Saadettin; Karabulut, Erdem; Baltaci, Sumer; Yildirim, Asif; Sozen, Sinan; Ates, Ferhat; Sekerci, Cagri Akin; Kurtulus, Fatih; Dirim, Ayhan; Muezzioglu, Talha; Can, Cavit; Bozlu, Murat; Gemalmaz, Hakan; Ekici, Sinan; Ozen, Haluk; Turkeri, Levent
    Objective To analyze the parameters that predict the surgical margin positivity after radical prostatectomy for localized prostate cancer. Materials and Methods In this multicenter study, the data of 1607 consecutive patients undergoing radical prostatectomy for localized prostate cancer in 12 different clinics in Turkey between 1993-2011 were assessed. Patients who had neoadjuvant treatment were excluded. We assessed the relationship between potential predictive factors and surgical margin status after radical prostatectomy such as age, cancer characteristics, history of transurethral prostate resection, surgical experience and nerve-sparing technique by using univariate and multivariate Cox regression analyses and t test. Results The overall surgical margin positivity rate was 22.6\% (359 patients). In univariate analyses, preoperative prostate specific antigen level, clinical stage, biopsy Gleason score, percentage of tumor involvement per biopsy specimen, transurethral prostate resection history, surgical experience and nerve-sparing technique were significantly associated with positive surgical margin rate. In multivariate analyses, preoperative prostate specific antigen level (OR: 1.03, p=0.06), percentage of tumor involvement per biopsy specimen (OR: 7,14, p<0,001), surgical experience (OR: 2.35, p=0.011) and unilateral nerve-sparing technique (OR: 1.81, p=0.018) were independent predictive factors for surgical margin positivity. Conclusion Preoperative prostate specific antigen level, percentage of tumor involvement per biopsy specimen, surgical experience and nerve-sparing technique are the most important predictive factors of surgical margin positivity in patients undergoing radical prostatectomy for localized prostate cancer.
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    Are the Recommended Criteria for Clinically Insignificant Prostate Cancer Applicable to 12-core Prostate Biopsy Scheme? A Multicentre Study of Urooncology Association, Turkey
    (GALENOS PUBL HOUSE, 2021-01-01) Celik, Serdar; Kizilay, Fuat; Yorukoglu, Kutsal; Ozen, Haluk; Akdogan, Bulent; Izol, Volkan; Bayazit, Yildirim; Aslan, Guven; Sozen, Sinan; Baltaci, Sumer; Muezzinoglu, Talha; Narter, Fehmi; Turkeri, Levent; Assoc, Urooncology
    Objective: The aim of this study is to investigate the relevance of the Epstein criteria for the 12-core transrectal prostate biopsy (TRUS-Bx) scheme with the evaluation of clinicopathologic data recorded in the Urologic Cancer Database - Prostate (UroCaD-P), Urooncology Association, Turkey (UOAT). Materials and Methods: Patients with detailed pathological 12-core TRUS-Bx data for each biopsy core and who underwent RP due to PCa were included in this study. A total of 1167 patients from seven different centres were analysed. TRUS-Bx pathological findings were separately evaluated in the areas matching the sextant biopsy (6-core paramedian-lateral) scheme and in all 12-core biopsy areas (12-core biopsy scheme). Overall detection rates of PCa and ratios of clinically significant (sPCa) and insignificant PCa (insPCa) after RP were defined and compared between the biopsy schemes. Biopsy findings, according to the Epstein criteria, were also compared between the two schemes. A model for each biopsy scheme was created, including the Epstein criteria and additional biopsy findings using logistic regression analysis to predict clinically sPCa after RP. Results: There was a high correlation for the prediction of clinically insPCa between the two biopsy schemes in the same population. However, 7.3\% of PCa could not be diagnosed in the 6-core TRUS-Bx scheme. Also, 69.4\% of these had clinically sPCa according to the Epstein criteria in 12-core TRUS-Bx scheme and 51.8\% of these were clinically sPCa after RP. The presence of perineural invasion (PNI) in 12-core biopsy was also significant regarding predicting sPCa (p<0.001). Conclusion: The Epstein criteria in 12-core prostate biopsy provide a better prediction of clinically sPCa than the 6-core biopsy scheme. Biopsy PNI findings appeared to improve the effectiveness of 12-core prostate biopsy, in addition to the Epstein criteria.
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    Risk Factors of Patients with Prostate Cancer Upgrading for International Society of Urological Pathology Grade Group 1 After Radical Prostatectomy
    (GALENOS YAYINCILIK, 2022-01-01) Ozgur, Abdurrahman; Ozgur, Gunal; Sahin, Bahadir; Filinte, Deniz; Tinay, Ilker; cam, Haydar Kamil; Turkeri, Levent
    Objective: This study aimed to determine the predictive factors for patients whose International Society of Urological Pathology (ISUP) score was upgraded in radical prostatectomy (RP) pathologies with a prostate biopsy pathology of ISUP grade group 1. Materials and Methods: Among patients who underwent RP in our clinic within 10 years, 158 patients with prostate biopsy pathology of ISUP grade group 1 were examined retrospectively. Age, serum prostate-specific antigen (PSA) level, prostate biopsy ISUP grade group, number of cores taken in the prostate biopsy, number of tumor-positive cores, RP pathology ISUP grade group, and pathological stage were evaluated. Results: The mean age (+/- standard) of the 158 patients whose prostate biopsy pathology was ISUP grade group 1 were 64.07 (+/- 6.6). ISUP group upgrading was detected in 47 patients (29.7\%). The mean PSA value of these patients was 10.6 ng/mL (+/- 6.9). The mean PSA value of the other 111 patients without ISUP group upgrading was 7.98 ng/mL (+/- 4.9). The serum PSA level was significantly higher in patients with upgraded ISUP in the RP pathology (p=0.02). The percentage of tumor-positive cores in the group with ISUP group upgrading (37\%) was significantly higher than that in the group without ISUP group upgrading (27\%) (p=0.01). The detection rates of surgical margin positivity (42.6\% vs. 18\%), capsule invasion (55.3\% vs. 19.8\%), and seminal vesicle invasion (23.6\% vs. 3.6\%) were also significantly higher in the upgraded ISUP group after RP (p<0.05). Conclusion: The results of this trial suggest that active surveillance may not be an appropriate option for patients with biopsy ISUP grade group 1 with PSA level >10 ng/mL. Moreover, the presence of a higher number and percentage of tumor-positive cores constituted risks of ISUP group upgrading with concomitant poor pathological outcomes such as surgical margin positivity, capsule invasion, and seminal vesicle invasion.
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    A survey of patient expectations regarding sexual function following radical prostatectomy
    (WILEY-BLACKWELL, 2016-01-01) Deveci, Serkan; Gotto, Geoffrey T.; Alex, Byron; O'Brien, Keith; Mulhall, John P.
    Objective To assess the understanding of patients, who had previously undergone radical prostatectomy (RP), about their postoperative sexual function, as clinical experience suggests that some RP patients have unrealistic expectations about their long-term sexual function. Patients and Methods Patients presenting within 3 months of their open RP or robot-assisted laparoscopic prostatectomy (RALP) were questioned about the sexual function information that they had received preoperatively. Patients were questioned about erectile function (EF), postoperative ejaculatory status, orgasm, and postoperative penile morphology changes. Statistical analyses were performed to assess for differences between patients who underwent open RP vs RALP. Results In all, 336 consecutive patients (from nine surgeons) with a mean (SD) age of 64 (11) years had the survey instrument administered (216 underwent open RP and 120 underwent RALP). There were no significant differences in patient age or comorbidity profiles between the two groups. Only 38\% of men had an accurate recollection of their nerve-sparing status. The mean (SD) elapsed time after RP at the time of postoperative assessment was 3 (2) months. RALP patients expected a shorter EF recovery time (6 vs 12 months, P = 0.02), a higher likelihood of recovery back to baseline EF (75\% vs 50\%, P = 0.01), and a lower potential need for intracavernosal injection therapy (4\% vs 20\%, P = 0.01). Almost half of all patients were unaware that they were rendered anejaculatory by their surgery. None of the RALP patients and only 10\% of open RP patients recalled being informed of the potential for penile length loss (P < 0.01) and none were aware of the association between RP and Peyronie's disease. Conclusions Patients who have undergone RP have largely unrealistic expectations about their postoperative sexual function.
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    Laparoscopic Extraperitoneal Radical Prostatectomy
    (GALENOS YAYINCILIK, 2020-01-01) Tekin, Ali; Yuksel, Alpaslan; Taskiran, Arda Taskin; Senoglu, Yusuf; Kayikci, Muhammet Ali
    Radical prostatectomy (RP) involves removing the entire prostate with its capsule intact and the seminal vesicles (SV). In this video article, we summarized the extraperitoneal laparoscopic RP with pelvic lymph node dissection procedure along with a video presentation of a case. The patient is placed in a Trendelenburg position. Through a small transverse infraumblical incision, the anterior rectus aponeurosis is identified and incised. The extraperitoneal surgical field is developed bluntly by a balloon dilator, and a 10 mm trocar is placed for the camera. CO2 insufflation at a 12-15 mmHg pressure is established, and the remaining trocars are placed. The fatty tissue is swept laterally to create a wide operative field. The endopelvic fascia is incised on both sides. The levator ani muscle fibers are separated from the lateral surface of the prostate. Dorsal vascular complex (DVC) is ligated with 2 consecutive sutures. Identification of the bladder neck (BN) is critical for proper dissection between the prostate and the BN. BN is incised until the catheter is seen. The urethral catheter is removed and a Bougie dilator is inserted through the urethra to elevate the prostate. With posterior oblique dissection, the vasa deferentia are exposed and clip-ligated, and SVs are identified and freed. Then, lateral pedicles are ligated with hemoclips and divided. Lateral dissection proceeds with an anterolateral incision from the base to the prostatic apex. The neurovascular bundles lie posterolateral to the prostate. Apical dissection and division of the DVC and urethra is a critical step to ensure a safe surgical margin and good postoperative erectile function and continence. The urethra is divided with a small rim on the prostate. The gland is totally freed, put into an endobag, and extracted. The vesicourethral anastomosis is done using two 3-0 monocryl sutures in a running fashion, starting from the posterior in both direction and tied together at the 12 o'clock position, anteriorly.
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    The Comparison of Conventional and Retzius-Sparing Robot-Assisted Radical Prostatectomy for Clinical, Pathological, and Oncological Outcomes
    (GALENOS YAYINCILIK, 2022-01-01) Karsiyakali, Nejdet; Ozgen, Mahir Bulent; Ozveren, Bora; Durak, Haydar; Saglican, Yesim; Turkeri, Levent
    Objective: This study aimed to assess and compare the conventional and Retzius-sparing robot-assisted radical prostatectomy (cRARP and RsRARP) in term of perioperative clinical, pathological, and oncological outcomes. Materials and Methods: This study included 238 consecutive male patients who underwent RARP between May 2008 and November 2020. RARP operations were performed by a single-surgeon. Patients were divided into groups according to the surgical approach and were statistically compared in terms of perioperative clinical, final pathological, and oncological outcomes. Results: The mean age of patients was 64 +/- 7 years. cRARP was performed in 134 (56.3\%) patients, whereas RsRARP in 104 (43.7\%). The frequency of patients with the American Society of Anesthesiologists Class-2 score was higher in the RsRARP group (p<0.001). The median surgery duration was 300 (270-360) min. The median surgery duration was shorter in RsRARP group (290 vs. 330 minute) (p<0.001). No difference was found between the groups in terms of estimated blood loss and postoperative complication rates (p=0.112 and p=0.182, respectively). No difference was found between the groups when they were compared for surgical margin positivity (p=0.453). Although not statistically significant, the frequency of surgical margin positivity with pT3a/pT3b disease was higher in patients who underwent cRARP (p=0.412 and p=0.261, respectively). At a median follow-up of 13 (6-36) months, no difference was found between the groups in terms of biochemical recurrence at months-3,-6,-9,-12,-18,-24, and-30, respectively (p>0.05, for each). Conclusion: RsRARP allows a safe operation with a shorter surgical time and similar surgical margin positivity, oncological outcomes, and complication rates compared to cRARP.
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    Increased Prostate Imaging-Reporting and Data System Scores in Multiparametric Magnetic Resonance Imaging May Predict More Extensive Disease in Radical Prostatectomy Specimens
    (GALENOS YAYINCILIK, 2021-01-01) Karsiyakali, Nejdet; Ozgen, Mahir Bulent; Ozveren, Bora; Akbal, Cem; Dincer, Alp; Durak, Haydar; Turkeri, Levent
    Objective: This study aimed to investigate the correlation between index lesion prostate imaging-reporting and data system (PI-RADS) version-2 score and histopathological outcomes of prostatectomy specimens. Materials and Methods: A total of 78 male patients with prostate cancer (PCa) treated with robot-assisted radical prostatectomy between August 2015 and June 2020 were included in this study. In this cohort, suspicious lesions on multiparametric magnetic resonance imaging (mpMRI) were scored according to PI-RADS version-2 criteria. MpMRI-targeted prostate biopsy was performed for all suspicious lesions with a PI-RADS score of >= 3 followed by systematic prostate biopsy. The relationship between index lesion PI-RADS score and histopathological outcomes of prostatectomy specimens were evaluated statistically. Results: The mean age of the patients was 65.0 +/- 7.0 years. The distribution of PI-RADS scores of 3, 4, and 5 of the index lesions were 6 (7.7\%), 29 (37.2\%), and 43 (55.1\%), respectively. Lower tumor volume and tumor volume ratio were observed in patients with a PI-RADS score of 3 when they were compared with patients with PI-RADS scores of 4 and PI-RADS-5 (p<0.001, for each). No significant correlation was found between index lesion PI-RADS score in mpMRI and clinically significant PCa in prostatectomy specimens (r<0.200, p>0.05). However, a significant correlation was observed between index lesion PI-RADS score and extracapsular extension (ECE), as well as seminal vesicle invasion (SVI) and pT stage (r=0.327, p=0.004