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| Role of preoperative magnetic resonance imaging on the surgical outcomes of radical prostatectomy: Does preoperative tumor recognition reduce the positive surgical margin in a specific location? Experience from a Thailand prostate cancer specialized center |
Thitipat Hansomwonga,*( ),Pat Saksirisampantb,Sudhir Isharwalc,Pubordee Aussavavirojekula,Varat Woranisarakula,Siros Jitpraphaia,Sunai Leewansangtonga,Tawatchai Taweemonkongsapa,Sittiporn Srinualnada
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aDivision of Urology, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
bDivision of Urology, Department of Surgery, Somdech Phra Pinklao Hospital, Naval Medical Department, Royal Thai Navy, Bangkok, Thailand
cDepartment of Urology, Oregon Health and Science University, Portland, OR, United States |
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Abstract Objective: Multiparametric magnetic resonance imaging (MRI) has become the standard of care for the diagnosis of prostate cancer patients. This study aimed to evaluate the influence of preoperative MRI on the positive surgical margin (PSM) rates. Methods: We retrospectively reviewed 1070 prostate cancer patients treated with radical prostatectomy (RP) at Siriraj Hospital between January 2013 and September 2019. PSM rates were compared between those with and without preoperative MRI. PSM locations were analyzed. Results: In total, 322 (30.1%) patients underwent MRI before RP. PSM most frequently occurred at the apex (33.2%), followed by posterior (13.5%), bladder neck (12.7%), anterior (10.7%), posterolateral (9.9%), and lateral (2.3%) positions. In preoperative MRI, PSM was significantly lowered at the posterior surface (9.0% vs. 15.4%, p=0.01) and in the subgroup of urologists with less than 100 RP experiences (32% vs. 51%, odds ratio=0.51, p<0.05). Blood loss was also significantly decreased when a preoperative image was obtained (200 mL vs. 250 mL, p=0.02). Multivariate analysis revealed that only preoperative MRI status was associated with overall PSM and PSM at the prostatic apex. Neither the surgical approach, the neurovascular bundle sparing technique, nor the perioperative blood loss was associated with PSM. Conclusion: MRI is associated with less overall PSM, PSM at apex, and blood loss during RP. Additionally, preoperative MRI has shown promise in lowering the PSM rate among urologists who are in the early stages of performing RP.
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Received: 21 January 2022
Available online: 20 October 2023
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Corresponding Authors:
*E-mail address: thitipat.han@gmail.com (T. Hansomwong).
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| Cite this article: |
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Thitipat Hansomwong,Pat Saksirisampant,Sudhir Isharwal, et al. Role of preoperative magnetic resonance imaging on the surgical outcomes of radical prostatectomy: Does preoperative tumor recognition reduce the positive surgical margin in a specific location? Experience from a Thailand prostate cancer specialized center[J]. Asian Journal of Urology,
2023, 10(4): 494-501.
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| URL: |
| http://www.ajurology.com/EN/10.1016/j.ajur.2022.05.012 OR http://www.ajurology.com/EN/Y2023/V10/I4/494 |
| Characteristic | Preoperative MRI (n=322) | Non-MRI (n=748) | p-Value | | Agea, year | 68.29±6.62 | 67.59±6.37 | 0.20 | | Op-timea, min | 182.51±73.11 | 187.64±77.08 | 0.36 | | Blood lossb, mL | 200 (20-400) | 250 (50-450) | 0.02 | | BMIb, kg/m2 | 24.61 (22.49-26.89) | 24.34 (22.41-26.54) | 0.30 | | iPSAb, ng/mL | 10.1 (7.18-18.00) | 10.0 (6.70-16.30) | 0.41 | | Tumor involvementb, % | 12.0 (5.0-22.0) | 15.0 (5.0-25.0) | 0.10 | | Prostate sizea, mL | 44.07±22.97 | 42.77±21.19 | 0.40 | | pTc | 0.50 | | 2 | 182 (56.5) | 365 (48.8) | | | 3a | 102 (31.7) | 243 (32.5) | | | 3b | 35 (10.9) | 130 (17.4) | | | 4 | 3 (0.9) | 10 (1.3) | | | ISUP groupc | 0.07 | | 1 | 28 (8.7) | 91 (12.2) | | | 2 | 109 (33.9) | 261 (34.9) | | | 3 | 74 (23.0) | 136 (18.2) | | | 4 | 34 (10.6) | 61 (8.2) | | | 5 | 58 (18.0) | 106 (14.2) | | | ADT effect | 19 (5.9) | 93 (12.4) | | | Surgical approachc | <0.05 | | ORP | 27 (8.4) | 98 (13.1) | | | LRP | 61 (18.9) | 231 (30.9) | | | RARP | 234 (72.7) | 419 (56.0) | | | Surgeon's experiencec | 0.70 | | 1-100 | 73 (22.7) | 178 (23.8) | | | >100 | 249 (77.3) | 570 (76.2) | | | NVB sparing techniquec | 0.20 | | None | 201 (62.4) | 508 (67.9) | | | Unilateral | 28 (8.7) | 46 (6.1) | | | Bilateral | 93 (28.9) | 194 (25.9) | |
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Clinical and histological characteristics.
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| PSM location | Total | Preoperative MRI | Non-MRI | p-Value | | Apex | 355 (33.2) | 96 (29.8) | 259 (34.6) | 0.30 | | Posterior | 144 (13.5) | 29 (9.0) | 115 (15.4) | 0.01 | | Bladder neck | 136 (12.7) | 34 (10.6) | 102 (13.6) | 0.20 | | Anterior | 115 (10.7) | 36 (11.2) | 79 (10.6) | 0.80 | | Posterolateral | 106 (9.9) | 32 (9.9) | 74 (9.9) | 0.70 | | Lateral | 25 (2.3) | 6 (1.9) | 19 (2.5) | 0.50 | | Overall | 532 (49.7) | 149 (46.3) | 383 (51.2) | 0.14 | | sPSM | 271 (25.3) | 89 (27.6) | 182 (24.3) | 0.25 | | mPSM | 261 (24.2) | 60 (18.6) | 201 (26.9) | <0.05 |
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PSM location.
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| Clinical and pathological characteristics | Empty Cell | PSM, n (%) | Empty Cell | | Preoperative MRI | Non-MRI | p-Value | | Surgical approach | | ORP | 11 (41) | 53 (54) | 0.20 | | LRP | 33 (54) | 118 (51) | 0.70 | | RARP | 105 (45) | 212 (51) | 0.20 | | NVB sparing | | None | 99 (49) | 257 (51) | 0.90 | | Unilateral | 10 (36) | 25 (54) | 0.10 | | Bilateral | 37 (40) | 100 (52) | 0.06 | | pT | | 2 | 62 (34) | 141 (39) | 0.40 | | 3a | 61 (60) | 148 (61) | 0.80 | | 3b | 25 (71) | 94 (72) | 0.40 | | Surgeon experience | | 1-100 | 23 (32) | 91 (51) | <0.05 | | >100 | 126 (51) | 292 (51) | 0.90 |
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Influences of RP approach and pT on PSM.
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| Clinical and pathological characteristics | Univariate analysis | Multivariate analysis | | OR (95% CI) | p-Value | Adjusted OR (95% CI) | p-Value | | Preoperative MRI | | No | 1 (ref) | | 1 (ref) | | | Yes | 0.62 (0.45, 0.86) | <0.05 | 0.59 (0.42, 0.85) | <0.05 | | ISUP group | | 1 | 1 (ref) | | 1 (ref) | | | 2 | 3.1 (1.6, 6.1) | <0.05 | 3.0 (1.5, 6.0) | <0.05 | | 3 | 3.0 (1.5, 6.0) | <0.05 | 2.2 (1.0, 4.7) | <0.05 | | 4 | 4.6 (2.1, 10.0) | <0.05 | 3.5 (1.5, 8.2) | <0.05 | | 5 | 8.3 (3.8, 18.0) | <0.05 | 3.7 (1.6, 8.8) | <0.05 | | ADT effect | 5.3 (2.2, 13.0) | <0.05 | 4.1 (1.6, 10.0) | <0.05 | | Surgeon's experience | | >100 | 1 (ref) | | 1 (ref) | | | 1-100 | 0.57 (0.38, 0.83) | <0.05 | 0.51 (0.32, 0.79) | <0.05 | | NVB sparing | | None | 1 (ref) | | | | | Unilateral | 0.76 (0.42, 1.40) | 0.40 | | | | Bilateral | 1.20 (0.82, 1.70) | 0.30 | | | | pT | | 2 | 1 (ref) | | 1 (ref) | | | 3a | 2.8 (1.9, 4.1) | <0.05 | 2.3 (1.5, 3.5) | <0.05 | | 3b | 4.7 (2.6, 8.5) | <0.05 | 2.7 (1.3, 5.5) | <0.05 | | Tumor involvement percentage | | <50% | 1 (ref) | | 1 (ref) | | | ≥50% | 5.4 (2.2, 13.0) | <0.05 | 2.4 (0.9, 6.3) | <0.05 | | iPSA, ng/mL | | <10 | 1 (ref) | | 1 (ref) | | | 10 to 20 | 2.0 (1.3, 2.9) | <0.05 | 1.8 (1.2, 2.7) | <0.05 | | ≥20 | 2.9 (1.8, 4.4) | <0.05 | 1.7 (1.0, 2.7) | 0.05 | | Op-time, min | | <120 | 1 (ref) | | 1 (ref) | | | 120 to 180 | 0.60 (0.35, 1.0) | 0.07 | 0.79 (0.44, 1.4) | 0.40 | | 180 to 240 | 0.53 (0.30, 0.94) | <0.05 | 0.60 (0.32, 1.1) | 0.10 | | ≥240 | 0.62 (0.34, 1.10) | 0.10 | 0.84 (0.43, 1.7) | 0.60 | | Blood loss, mL | | <600 | 1 (ref) | | | | | 600 to 1200 | 0.89 (0.50, 1.60) | 0.70 | | | | ≥1200 | 1.10 (0.50, 2.40) | 0.80 | | |
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Univariate and multivariate analyses of the risk of overall PSM in the propensity-matched group.
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| Clinical and pathological characteristics | Univariate analysis | Multivariate analysis | | OR (95% CI) | p-Value | Adjusted OR (95% CI) | p-Value | | Preoperative MRI | | No | 1 (ref) | | 1 (ref) | | | Yes | 0.69 (0.49, 0.96) | <0.05 | 0.69 (0.48, 0.98) | <0.05 | | ISUP group | | 1 | 1 (ref) | | 1 (ref) | | | 2 | 2.5 (1.1, 5.7) | <0.05 | 2.5 (1.1, 5.8) | <0.05 | | 3 | 2.2 (1.0, 5.2) | 0.06 | 2.1 (0.9, 5.1) | 0.09 | | 4 | 2.4 (1.0, 6.1) | 0.06 | 2.1 (0.8, 5.4) | 0.10 | | 5 | 4.4 (1.9, 10) | <0.05 | 3.2 (1.3, 8.2) | <0.05 | | ADT effect | 3.5 (1.3, 9.0) | <0.05 | 3.1 (1.2, 8.4) | <0.05 | | Surgeon experience | | >100 | 1 (ref) | | | | | 1-100 | 0.69 (0.45, 1.10) | 0.08 | | | | NVB sparing | | None | 1 (ref) | | 1 (ref) | | | Unilateral | 0.42 (0.20, 0.87) | <0.05 | 0.58 (0.27, 1.2) | 0.20 | | Bilateral | 0.79 (0.54, 1.2) | 0.20 | 0.96 (0.63, 1.5) | 0.80 | | pT | | 2 | 1 (ref) | | 1 (ref) | | | 3a | 1.2 (0.9, 1.8) | 0.30 | 0.90 (0.59, 1.40) | 0.60 | | 3b | 1.8 (1.1, 3.0) | <0.05 | 0.81 (0.42, 1.60) | 0.50 | | Tumor involvement percentage | | <50% | 1 (ref) | | 1 (ref) | | | ≥50% | 2.9 (1.6, 5.3) | <0.05 | 2.0 (1.0, 4.1) | 0.05 | | iPSA, ng/mL | | <10 | 1 (ref) | | 1 (ref) | | | 10 to 20 | 1.6 (1.1, 2.4) | <0.05 | 1.6 (1.0, 2.4) | <0.05 | | ≥20 | 2.6 (1.7, 3.9) | <0.05 | 2.1 (1.3, 3.5) | <0.05 | | Op-time, min | | <120 | 1 (ref) | | 1 (ref) | | | 120 to 180 | 0.65 (0.39, 1.10) | 0.10 | 0.78 (0.45, 1.30) | 0.40 | | 180 to 240 | 0.51 (0.29, 0.90) | <0.05 | 0.54 (0.29, 0.98) | <0.05 | | ≥240 | 0.89 (0.50, 1.60) | 0.70 | 0.97 (0.53, 1.80) | 0.90 | | Blood loss, mL | | <600 | 1 (ref) | | | | | 600 to 1200 | 1.10 (0.59, 1.90) | 0.80 | | | | ≥1200 | 0.93 (0.41, 2.10) | 0.90 | | |
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Univariate and multivariate analyses of the risk of apical PSM in the propensity-matched group.
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