Nathan L. Lawrentschuk

With the availability of PSMA-PET scans, it is controversial whether pelvic lymph node dissection (PLND) at the time of radical prostatectomy (RP) is still the most reliable and accurate staging modality for lymph node assessment. Furthermore, the oncological benefit of PLND remains unclear. The aim of this study was to assess whether omitting PLND in patients undergoing RP for prostate cancer (PCa) is associated with the risk of tumor recurrence and progression to metastasis. In this longitudinal multicenter cohort study, we reviewed data of 2346 consecutive patients with PCa who underwent RP with (n = 1650) and without (n = 696) extended PLND between January 1996 and December 2021. Recurrence-free survival and metastasis-free survival (MFS) were analyzed as a time-to-event outcome using Kaplan-Meier analyses with log-rank tests. To assess the effect of PLND, we created multivariable Cox proportional hazards models adjusting for relevant clinical and demographic characteristics. Median follow-up was 44 months. There was no difference in recurrence-free survival between men who had a PLND and those who did not (HR, 1.07, 95% CI, 0.87-1.32, P = .52). Patients with D'Amico high-risk disease (PSA >20 µg/L and/or International Society of Urological Pathology grade group ≥4) demonstrated a significantly prolonged MFS if they underwent PLND (HR, 0.57, 95% CI, 0.36-0.91, P = .02). PLND also improved MFS in patients with intermediate-risk disease (HR, 0.48, 95% CI, 0.25-0.90, P = .023). Further significant prognostic variables for MFS on multivariable Cox proportional hazards regression were PSA, International Society of Urological Pathology grade group, and pathological T-stage. PLND improves MFS in patients with D'Amico intermediate-risk and high-risk PCa and may therefore be considered in men undergoing RP.

Active surveillance remains the preferred treatment for men with low-risk prostate cancer and select men with favourable intermediate-risk prostate cancer. It involves the close observation of clinicopathological parameters to assess for disease progression, aiming to delay or avoid definitive treatment and related toxicities for as long as possible, without compromising oncological outcomes. A recent advancement in prostate cancer staging is the PSMA PET scan, which uses a tracer that strongly binds a highly expressed cellular biomarker for prostate cancer. Recent articles have also demonstrated that PSMA PET may be a useful tool for risk-stratifying prostate cancer, with the SUVMax of the scan correlated with higher-grade prostate cancer. This has ignited interest in the potential use of PSMA PET to identify men with higher-risk prostate cancer who may be unsuitable for active surveillance, particularly those who were incorrectly classified as lower risk upon initial diagnosis. This review article aims to assess the current state of the literature and clinical guidelines regarding the use of PSMA PET as a tool to risk-stratify prostate cancer, and whether it can be incorporated into active surveillance protocols to identify men who were incorrectly risk-stratified at time of initial diagnosis.

Risk assessment plays a critical role in surgical decision-making and influences patient care, resource allocation, surgical planning, and postoperative outcomes. Accurate stratification facilitates better treatment selection and planning, and identification of teaching cases. Existing tools such as POSSUM and the Surgical Apgar Score are widely used but focus primarily on general surgery and often lack urology-specific considerations or integration of intraoperative factors. Urological surgery requires a dedicated tool that accounts for preoperative factors (eg, prostate size, tumour extent), intraoperative findings (eg, fibrosis, adhesions), and patient-specific complexities. We propose a comprehensive scoring system for risk and surgical difficulty that ranges from 0 (no risk) to 100 (procedure abandonment or death) covering five parameter categories: preoperative patient characteristics; intraoperative patient factors; preoperative organ-specific parameters; intraoperative organ-specific factors; and unexpected postoperative conditions. The aims of the proposed system are to improve surgical planning, enhance risk prediction, and identify suitable teaching cases. By incorporating surgeon-specific factors such as case volume and learning curves, the system stratifies procedures by difficulty and can facilitate comparisons between surgeons and hospitals. The system can also promote transparency in patient counselling and may improve the quality of patient consent. Once validated, the scoring system could be integrated into standard practice to improve surgical care, resource allocation, and research efforts. Despite challenges such as comprehensive data collection, this tool offers significant potential to enhance surgical outcomes and multidisciplinary decision-making. Risk assessment is essential in helping surgeons and anaesthetists to make better decisions before, during, and after surgery. The aim of our work is to create a tool that predicts potential risks and challenges during surgery and makes it easier to prepare for these challenges. This tool can improve management of resources and surgical planning, and may ensure smooth recovery after an operation. Finally, it could also help patients and their families to understand the potential risks involved, giving them clearer information about what to expect and making the process more transparent and reassuring.

Objective: More than half of men who undergo a prostate biopsy based on positive multiparametric magnetic resonance imaging (mpMRI) findings do not have clinically significant prostate cancer (csPCa). Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) may complement mpMRI to better triage men with suspected prostate cancer (PCa) and reduce the number of unnecessary biopsies performed. A diagnostic test accuracy systematic review and meta-analysis was performed to determine the diagnostic accuracy of combined imaging for csPCa detection with pairwise comparisons with mpMRI and PSMA-PET alone. A decision curve analysis (DCA) compared the strategies of performing an upfront biopsy versus combined imaging for suspected PCa patients, across varying thresholds for accepting the risk of missing a csPCa diagnosis. Methods: A search of the PubMed, Embase, Central, and Scopus databases, from inception to January 2024, was conducted. Twenty studies (2153 patients) that referenced combined imaging against histopathology were included. Bivariate meta-analyses and metaregression were performed to determine the diagnostic parameters and assess the differences between imaging modalities. Combined imaging had sensitivity, specificity, positive predictive value (PPV), and negative predictive value of, respectively, 92% (95% confidence interval [CI] 87, 95), 64% (95% CI 48, 77), 80% (95% CI 68, 92), and 82% (95% CI 68, 97) at patient-level, and 82% (95% CI 77, 94), 85% (95% CI 77, 94), 79% (95% CI 52, 97), and 81% (95% CI 74, 98) at lesion-level analyses. Head-to-head comparisons showed significantly higher specificity and PPV than mpMRI at patient- and lesion-level analyses. On the DCA, combined imaging outperforms upfront biopsy at risk thresholds of 8% onwards. Synchronous reading of PSMA-PET/computed tomography (CT) with mpMRI was significantly more sensitive but less specific than PSMA-PET/MRI. Conclusions: Combined imaging improves the diagnostic accuracy of csPCa and may help better select patients for a prostate biopsy.