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Magnetic Resonance Imaging for Membranous Urethral Length Assessment Prior to Radical Prostatectomy: Can it Really Improve Prostate Cancer Management?
EURURO-7138; No. of Pages 2 EUROPEAN UROLOGY XXX (2016) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
Magnetic Resonance Imaging for Membranous Urethral Length Assessment Prior to Radical Prostatectomy: Can it Really Improve Prostate Cancer Management? Manuela Tutolo a, Nicola Fossati a, Frank Van der Aa b, Giorgio Gandaglia a, Francesco Montorsi a, Alberto Briganti a,* a
Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; b Department of Urology, University Hospitals Leuven, Leuven, Belgium
Urinary incontinence (UI) still represents a significant side effect for patients treated with radical prostatectomy (RP), leading to clear consequences on their quality of life [1]. Although large efforts aimed at improving functional outcomes have been made over the last years, the overall rate of UI remains approximately 15% in contemporary patients even after robot-assisted RP, ranging from 4% to 30% [2]. This important variability may be related to several factors, such as patient and tumour characteristics [3], surgeon experience [4], surgical technique [5], and, mostly, urinary continence definition [6]. In this month’s issue of European Urology, Mungovan et al. [7] evaluated the predictive value of preoperative membranous urethral length (MUL) for urinary continence recovery. In their study, the authors found that membranous urethral length measured at magnetic resonance imaging (MRI) prior to RP was significantly associated with urinary continence recovery, and that a linear relationship existed between each millimetre of length and faster recovery (hazard ratio: 1.05, p < 0.001). In the light of these findings, a critical interpretation of this systematic review is essential to highlight its relevant clinical implications. Two important parts of the therapeutic pathway of patients affected by prostate cancer may be influenced by the results by Mungovan et al [7]. 1.
Preoperative setting
The first crucial step is represented by preoperative patient counselling. At this stage, the correct risk assessment of
postprostatectomy UI has a dual value. On one hand, patients may be more accurately informed about their individualized risk of UI. This may even be helpful in selecting the most appropriate primary treatment according to each patient profile. For example, in an era when prospective randomized evidence seems to support comparable efficacy of radiotherapy and RP on cancer outcomes [8], higher risk of developing UI after surgery may prompt patients to opt for other forms of therapies. However, it also has to be acknowledged that the ability of MRI for predicting side effects following nonsurgical treatment of prostate cancer is currently unknown, potentially leading to an unbalanced counselling against surgery. On the other hand, the MUL measurement may also be helpful to identify the best candidates for preoperative pelvic floor muscle exercises, which have been shown to improve early postoperative continence after surgery [9]. However, MRI alone is clearly not enough. To achieve all these goals, MUL should be included into a pretreatment predictive model, where other significant predictors of UI, such as patient age, body mass index, comorbidity profile, preoperative urinary, and erectile function, are taken into account. From a methodological point of view, this kind of evaluation has only been partially done [10]. As for cancer diagnosis and staging, MRI needs indeed to complement, rather than substitute the multi-variable clinical risk assessment, which is done in every day clinical practice. To really demonstrate its clinical utility, MUL must prove to be beneficial when added to our clinical risk prediction
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2016.06.023. * Corresponding author. Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Via Olgettina 60, Milan 20132, Italy. Tel. +39 02 2643 7286; Fax: +39 02 2643 7298. E-mail address: [email protected] (A. Briganti). http://dx.doi.org/10.1016/j.eururo.2016.11.011 0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Tutolo M, et al. Magnetic Resonance Imaging for Membranous Urethral Length Assessment Prior to Radical Prostatectomy: Can it Really Improve Prostate Cancer Management? Eur Urol (2016), http://dx.doi.org/10.1016/ j.eururo.2016.11.011
EURURO-7138; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2016) XXX–XXX
models, rather than only showing a significant association with the outcome of interest. Only when such improvement is achieved, will we be able to evaluate its real clinical benefit. For these reasons, leaving to MRI the decision on whether to perform a biopsy, a nerve-sparing procedure, or even RP based on p values, is not only inappropriate but also misleading. Moreover, is MRI cost effective for the prediction of functional outcomes after surgery? This is currently unknown. Certainly, it is true that MRI is anyway becoming a standard preoperative assessment for patients who will receive RP, either in the prebiopsy, or in the preoperative staging setting. Therefore, it is plausible that almost all patients treated with RP will receive a preoperative MRI in the near future.
the contrary, this preoperative information is unlikely to modify the therapeutic pathway of a 75-yr-old obese man affected by high-risk disease with apical extent, in which a nerve-sparing procedure is not planned and more extensive surgical resection is needed to maximize oncological outcomes. In other words, a judicious clinical evaluation of the risk/benefit ratio for each case is fundamental to apply and maximize the benefit of the right preoperative tool in the right patient. Conflicts of interest: The authors have nothing to disclose.
References [1] Mottet N, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: screening, diagnosis, and local treatment
2.
Intraoperative setting
with curative intent. Eur Urol. In press. http://dx.doi.org/10.1016/j. eururo.2016.08.003.
The surgical treatment itself represents the second important step where the results by Mungovan et al [7] can find a possible application. Nowadays, there is evidence from prospective studies and randomized-controlled trials [4,5] that surgeon experience plays an important role for oncological and functional outcomes after both open, laparoscopic, and robot-assisted RP. Expert surgeons can achieve a higher rate of urinary continence compared with those with less experience. For this reason, preoperative evaluation of MUL may help to identify patients at higher risk of UI who may benefit the most from the treatment by an expert surgeon. As an example, the apical dissection of the prostate is one of the most challenging steps of RP, where the surgeon has to balance the risk of positive surgical margins with an accurate preservation of the urethral stump aimed at achieving better functional outcomes. As such, an expert surgeon may improve the preservation of urethral stump in patients with shorter membranous urethral length at MRI, without compromising oncological outcomes. But, even in this context, the preoperative risk assessment should be based on predictive models where MUL is integrated with all other clinical predictors, including not only patient but also cancer characteristics. Indeed, it is true that the additional value of MRI-based urethral length measurements in those patients who have decided to undergo RP may significantly vary according to each oncological profile. For example, the urethral length at MRI can probably influence the intraoperative management of a young patient who will be treated with bilateral nerve-sparing RP for a lower risk disease. On
[2] Ficarra V, Novara G, Rosen RC, et al. Systematic review and metaanalysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012;62:405–17. [3] Abdollah F, Sun M, Suardi N, et al. A novel tool to assess the risk of urinary incontinence after nerve-sparing radical prostatectomy. BJU Int 2013;111:905–13. [4] Thompson JE, Egger S, Bo¨hm M, et al. Superior quality of life and improved surgical margins are achievable with robotic radical prostatectomy after a long learning curve: a prospective singlesurgeon study of 1552 consecutive cases. Eur Urol 2014;65:521–31. [5] Yaxley JW, Coughlin GD, Chambers SK, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet 2016;388:1057–66. [6] Liss MA, Osann K, Canvasser N, et al. Continence definition after radical prostatectomy using urinary quality of life: evaluation of patient reported validated questionnaires. J Urol 2010;183:1464–8. [7] Mungovan SF, Sandhu JS, Akin O, Smart NA, Graham PL, Patel MI. Preoperative membranous urethral length measurement and continence recovery following radical prostatectomy: a systematic review and meta-analysis. Eur Urol. In press. http://dx.doi.org/10. 1016/j.eururo.2016.06.023. [8] Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016;375:1415–24. [9] Chang JI, Lam V, Patel MI. Preoperative pelvic floor muscle exercise and postprostatectomy incontinence: a systematic review and meta-analysis. Eur Urol 2016;69:460–7. [10] Paparel P, Akin O, Sandhu JS, et al. Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral fibrosis measured by preoperative and postoperative endorectal magnetic resonance imaging. Eur Urol 2009;55: 629–37.
Please cite this article in press as: Tutolo M, et al. Magnetic Resonance Imaging for Membranous Urethral Length Assessment Prior to Radical Prostatectomy: Can it Really Improve Prostate Cancer Management? Eur Urol (2016), http://dx.doi.org/10.1016/ j.eururo.2016.11.011
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. x–y of this issue
Magnetic Resonance Imaging for Membranous Urethral Length Assessment Prior to Radical Prostatectomy: Can it Really Improve Prostate Cancer Management? Manuela Tutolo a, Nicola Fossati a, Frank Van der Aa b, Giorgio Gandaglia a, Francesco Montorsi a, Alberto Briganti a,* a
Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; b Department of Urology, University Hospitals Leuven, Leuven, Belgium
Urinary incontinence (UI) still represents a significant side effect for patients treated with radical prostatectomy (RP), leading to clear consequences on their quality of life [1]. Although large efforts aimed at improving functional outcomes have been made over the last years, the overall rate of UI remains approximately 15% in contemporary patients even after robot-assisted RP, ranging from 4% to 30% [2]. This important variability may be related to several factors, such as patient and tumour characteristics [3], surgeon experience [4], surgical technique [5], and, mostly, urinary continence definition [6]. In this month’s issue of European Urology, Mungovan et al. [7] evaluated the predictive value of preoperative membranous urethral length (MUL) for urinary continence recovery. In their study, the authors found that membranous urethral length measured at magnetic resonance imaging (MRI) prior to RP was significantly associated with urinary continence recovery, and that a linear relationship existed between each millimetre of length and faster recovery (hazard ratio: 1.05, p < 0.001). In the light of these findings, a critical interpretation of this systematic review is essential to highlight its relevant clinical implications. Two important parts of the therapeutic pathway of patients affected by prostate cancer may be influenced by the results by Mungovan et al [7]. 1.
Preoperative setting
The first crucial step is represented by preoperative patient counselling. At this stage, the correct risk assessment of
postprostatectomy UI has a dual value. On one hand, patients may be more accurately informed about their individualized risk of UI. This may even be helpful in selecting the most appropriate primary treatment according to each patient profile. For example, in an era when prospective randomized evidence seems to support comparable efficacy of radiotherapy and RP on cancer outcomes [8], higher risk of developing UI after surgery may prompt patients to opt for other forms of therapies. However, it also has to be acknowledged that the ability of MRI for predicting side effects following nonsurgical treatment of prostate cancer is currently unknown, potentially leading to an unbalanced counselling against surgery. On the other hand, the MUL measurement may also be helpful to identify the best candidates for preoperative pelvic floor muscle exercises, which have been shown to improve early postoperative continence after surgery [9]. However, MRI alone is clearly not enough. To achieve all these goals, MUL should be included into a pretreatment predictive model, where other significant predictors of UI, such as patient age, body mass index, comorbidity profile, preoperative urinary, and erectile function, are taken into account. From a methodological point of view, this kind of evaluation has only been partially done [10]. As for cancer diagnosis and staging, MRI needs indeed to complement, rather than substitute the multi-variable clinical risk assessment, which is done in every day clinical practice. To really demonstrate its clinical utility, MUL must prove to be beneficial when added to our clinical risk prediction
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2016.06.023. * Corresponding author. Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Via Olgettina 60, Milan 20132, Italy. Tel. +39 02 2643 7286; Fax: +39 02 2643 7298. E-mail address: [email protected] (A. Briganti). http://dx.doi.org/10.1016/j.eururo.2016.11.011 0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Tutolo M, et al. Magnetic Resonance Imaging for Membranous Urethral Length Assessment Prior to Radical Prostatectomy: Can it Really Improve Prostate Cancer Management? Eur Urol (2016), http://dx.doi.org/10.1016/ j.eururo.2016.11.011
EURURO-7138; No. of Pages 2 2
EUROPEAN UROLOGY XXX (2016) XXX–XXX
models, rather than only showing a significant association with the outcome of interest. Only when such improvement is achieved, will we be able to evaluate its real clinical benefit. For these reasons, leaving to MRI the decision on whether to perform a biopsy, a nerve-sparing procedure, or even RP based on p values, is not only inappropriate but also misleading. Moreover, is MRI cost effective for the prediction of functional outcomes after surgery? This is currently unknown. Certainly, it is true that MRI is anyway becoming a standard preoperative assessment for patients who will receive RP, either in the prebiopsy, or in the preoperative staging setting. Therefore, it is plausible that almost all patients treated with RP will receive a preoperative MRI in the near future.
the contrary, this preoperative information is unlikely to modify the therapeutic pathway of a 75-yr-old obese man affected by high-risk disease with apical extent, in which a nerve-sparing procedure is not planned and more extensive surgical resection is needed to maximize oncological outcomes. In other words, a judicious clinical evaluation of the risk/benefit ratio for each case is fundamental to apply and maximize the benefit of the right preoperative tool in the right patient. Conflicts of interest: The authors have nothing to disclose.
References [1] Mottet N, Bellmunt J, Bolla M, et al. EAU-ESTRO-SIOG Guidelines on Prostate Cancer. Part 1: screening, diagnosis, and local treatment
2.
Intraoperative setting
with curative intent. Eur Urol. In press. http://dx.doi.org/10.1016/j. eururo.2016.08.003.
The surgical treatment itself represents the second important step where the results by Mungovan et al [7] can find a possible application. Nowadays, there is evidence from prospective studies and randomized-controlled trials [4,5] that surgeon experience plays an important role for oncological and functional outcomes after both open, laparoscopic, and robot-assisted RP. Expert surgeons can achieve a higher rate of urinary continence compared with those with less experience. For this reason, preoperative evaluation of MUL may help to identify patients at higher risk of UI who may benefit the most from the treatment by an expert surgeon. As an example, the apical dissection of the prostate is one of the most challenging steps of RP, where the surgeon has to balance the risk of positive surgical margins with an accurate preservation of the urethral stump aimed at achieving better functional outcomes. As such, an expert surgeon may improve the preservation of urethral stump in patients with shorter membranous urethral length at MRI, without compromising oncological outcomes. But, even in this context, the preoperative risk assessment should be based on predictive models where MUL is integrated with all other clinical predictors, including not only patient but also cancer characteristics. Indeed, it is true that the additional value of MRI-based urethral length measurements in those patients who have decided to undergo RP may significantly vary according to each oncological profile. For example, the urethral length at MRI can probably influence the intraoperative management of a young patient who will be treated with bilateral nerve-sparing RP for a lower risk disease. On
[2] Ficarra V, Novara G, Rosen RC, et al. Systematic review and metaanalysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol 2012;62:405–17. [3] Abdollah F, Sun M, Suardi N, et al. A novel tool to assess the risk of urinary incontinence after nerve-sparing radical prostatectomy. BJU Int 2013;111:905–13. [4] Thompson JE, Egger S, Bo¨hm M, et al. Superior quality of life and improved surgical margins are achievable with robotic radical prostatectomy after a long learning curve: a prospective singlesurgeon study of 1552 consecutive cases. Eur Urol 2014;65:521–31. [5] Yaxley JW, Coughlin GD, Chambers SK, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet 2016;388:1057–66. [6] Liss MA, Osann K, Canvasser N, et al. Continence definition after radical prostatectomy using urinary quality of life: evaluation of patient reported validated questionnaires. J Urol 2010;183:1464–8. [7] Mungovan SF, Sandhu JS, Akin O, Smart NA, Graham PL, Patel MI. Preoperative membranous urethral length measurement and continence recovery following radical prostatectomy: a systematic review and meta-analysis. Eur Urol. In press. http://dx.doi.org/10. 1016/j.eururo.2016.06.023. [8] Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016;375:1415–24. [9] Chang JI, Lam V, Patel MI. Preoperative pelvic floor muscle exercise and postprostatectomy incontinence: a systematic review and meta-analysis. Eur Urol 2016;69:460–7. [10] Paparel P, Akin O, Sandhu JS, et al. Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral fibrosis measured by preoperative and postoperative endorectal magnetic resonance imaging. Eur Urol 2009;55: 629–37.
Please cite this article in press as: Tutolo M, et al. Magnetic Resonance Imaging for Membranous Urethral Length Assessment Prior to Radical Prostatectomy: Can it Really Improve Prostate Cancer Management? Eur Urol (2016), http://dx.doi.org/10.1016/ j.eururo.2016.11.011