Editorial Comment

Résumé fourni par la source

The authors need to be congratulated for out-of-the-box thinking in the management of prostate cancer about the impact of preoperative multiparametric magnetic resonance imaging (mpMRI) on surgical outcomes of radical prostatectomy.[1] The authors have concluded that mpMRI has an important role in diagnosing and staging prostate cancer but no change in post prostatectomy outcomes and hence no use with respect to surgical planning. It is well known that MRI scores over prostate-specific membrane antigen-Positive emission tomography (PSMA-PET) scan in its soft-tissue resolution and hence offers a better anatomical detailing which might be essential in surgical planning and hence the perceived notion that a preoperative MRI would affect the perioperative outcomes.[2] The authors examined this notion in their retrospective study. They found various factors affecting different aspects of perioperative outcomes, but the preoperative MRI was not found necessary in their multivariate analysis. This seems quite relevant in a resource-constrained society, where mpMRI may not be readily available at all centers. While the authors say that mpMRI was not done since it was not standard of care and that mpMRI is a costly investigation, they remain silent on the imaging study performed in the group who did not undergo MRI. They mention that PSMA-PET scan was done, which is neither the standard of care nor cost-efficient. There are other queries, e.g., how a particular investigation was decided upon. Do the authors intend to propose that in the era of good surgical practices, there is not much role of imaging before surgery? Moreover, propensity matches cannot account for all the biases. I believe the implication of these findings, as per the author’s conclusions is that one need not do a preoperative MRI. The authors also rightly mention that mpMRI is indeed crucial for accurate diagnosis and staging of prostate cancer. These two statements are counterintuitive. If a particular imaging is essential in step one, which is diagnosis then automatically it becomes available before surgery. Is it possible to ignore an investigation which is done for diagnosis during surgical planning? It need not be emphasized that there is a need for good imaging for proper preoperative planning. Correct imaging not only ensures surgeons peace of mind but also helps to counsel the patients with respect to outcomes. Anatomical knowledge of tumor proximity to critical structures can guide decisions about nerve-sparing techniques, which can impact postoperative erectile function. Furthermore, MRI’s ability to offer insights into the length and angulation of the prostate with the membranous urethra can aid in predicting postsurgical continence, an important aspect of patient counseling and expectations.[3] These aspects of surgical management are difficult to prove in a scientific study. Imaging not only helps preoperatively but also helps in intraoperative decisions hence it is an essential component of the WHO checklist.[4] The other most prevalent imaging modalities in the management of localized prostate cancer are PSMA-PET scan and transrectal ultrasound. While PSMA-PET scans are valuable for detecting metastatic disease and local recurrence, they lack the detailed anatomical resolution provided by MRI. MRI remains superior in visualizing local tumor extent and its relationship with surrounding structures. Rectal ultrasound, while useful for initial assessment, does not provide the same level of detail as MRI, particularly for planning purposes. To answer whether mpMRI is beneficial in preoperative planning, a different study was designed with two groups of surgeons, one blinded to mpMRI findings and the other group thoroughly studying the mpMRI preoperatively, for an outcome such as surgeons comfort and trifecta outcomes of radical prostatectomy (sexual function, oncological function, and the continence rate),[5] is desirable. Until then, a preoperative mpMRI serves not only for diagnosis but preoperative surgical planning and counseling. The field of prostate cancer management continues to evolve, and while MRI remains a cornerstone, ongoing research and technological advancements will likely shape its future role and effectiveness. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.