Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
BJU Int. 2019 Jul;124(1):103-108. doi: 10.1111/bju.14655. Epub 2019 Jan 22.
To update the algorithm for performing incremental nerve sparing (NS) using our multiparametric magnetic resonance imaging (mpMRI)-based nomogram.
We applied the coefficients of the nomogram to the observations extracted from our population of patients who underwent robot-assisted radical prostatectomy between February 2014 and October 2015 and who received preoperative mpMRI. The information considered were PSA level, highest side-specific biopsy Gleason grade group, highest ipsilateral percentage core involvement with the highest Gleason grade group, and extracapsular extension (ECE) on mpMRI. The nomogram-derived probability [P (%)], after internal validation, was used as the independent variable on a classification tree to identify the most significant thresholds for ECE prediction. Incremental NS was performed as follows: Grade 1 NS: intrafascial dissection between the peri-prostatic veins and the pseudocapsule of the prostate; Grade 2 NS: inter-fascial dissection along the peri-venous plane; Grade 3 NS: inter-fascial dissection through the outer compartment of the lateral prostatic fascia; Grade 4 NS: extrafascial dissection.
Data from 561 patients were considered, and 829 prostatic lobes with biopsy-documented tumour were analysed. Overall, 142 lobes presented ECE that was focal in 27 (19%) cases. The classification tree identified four risk categories. In the low- [P (%) ≤10], intermediate- [P (%) 10-21], high [P (%) 21-73] and very-high-risk [P(%) >73] groups, the ECE rates were 3.3%, 16%, 61.6% and 90%, respectively. Amongst those, ECE was focal in 41.7%, 31.7%, 7.9% and 0%, respectively.
We suggest that Grade 1 NS (intrafascial) should be performed in the low-risk group. The inter-fascial approach, namely grades 2 and 3 NS, should be performed in the intermediate- and high-risk categories, respectively. Grade 4 NS (extrafascial) should be performed in the very-high-risk group. The current algorithm yields a better accuracy than the previous one; however, prospective validation is warranted.
更新我们基于多参数磁共振成像（mpMRI）的列线图进行增量神经保留（NS）的算法。
我们将列线图的系数应用于 2014 年 2 月至 2015 年 10 月期间接受机器人辅助根治性前列腺切除术并接受术前 mpMRI 的患者人群中提取的观察结果。考虑的信息包括 PSA 水平、最高侧特定活检 Gleason 分组、同侧最高 Gleason 分组核心受累的最高百分比以及 mpMRI 上的包膜外扩展（ECE）。内部验证后，列线图得出的概率[P（%）]用作分类树的自变量，以确定预测 ECE 的最重要阈值。增量 NS 如下进行：1 级 NS：前列腺周围静脉和前列腺假包膜之间的筋膜内解剖；2 级 NS：沿静脉平面的筋膜间解剖；3 级 NS：通过外侧前列腺筋膜的外部隔室的筋膜间解剖；4 级 NS：筋膜外解剖。
共考虑了 561 名患者的数据，并分析了 829 个经活检证实有肿瘤的前列腺叶。总体而言，142 个叶有 ECE，其中 27 个（19%）为局灶性。分类树确定了四个风险类别。在低[P（%）≤10]、中[P（%）10-21]、高[P（%）21-73]和极高[P（%）>73]组中，ECE 发生率分别为 3.3%、16%、61.6%和 90%。其中，ECE 局灶性分别为 41.7%、31.7%、7.9%和 0%。
我们建议在低危组中进行 1 级 NS（筋膜内）。在中危和高危组中，应采用筋膜间方法，即 2 级和 3 级 NS。在极高危组中，应进行 4 级 NS（筋膜外）。目前的算法比以前的算法具有更高的准确性；然而，需要进行前瞻性验证。
