Background

Prediction of lymph node invasion (LNI) after radical prostatectomy has been rarely assessed in robotically assisted laparoscopic radical prostatectomy (RALP) series. We aimed to develop and externally validate a pretreatment nomogram for the prediction of LNI following RALP in patients with high- and intermediate-risk prostate cancer.

Methods

1654 RALP patients were prospectively collected between 2009 and 2016 from academic and community hospitals. We included patients with intermediate- and high-risk prostate cancer who underwent pelvic lymph node dissection (e-PLND). Logistic regression analysis was applied to construct a nomogram to predict LNI. Centers were randomly assigned to the training cohort (80%) and validation cohort (20%). The discriminative accuracies were evaluated by the areas under the curve and by the calibration plot. The net benefit of the nomogram to predict LNI was assessed by decision curve analysis and a cut-off was proposed.

Results

In total, 14% of the patients in our cohort had pN1 disease. Applying logistic regression analysis, the following covariates were chosen to develop the nomogram: initial PSA, clinical T stage, biopsy Gleason sum, and proportion of positive biopsy cores. The nomogram showed a median discriminative accuracy of 73% and excellent calibration. The net benefit of the model ranged between 7% and 51% predicted risk of LNI. A cut-off to perform e-PLND was set at 7%. This would permit a 29% of avoidable e-PLND, missing 9.4% of patients with LNI.

Conclusions

We developed and externally validated a nomogram to predict LNI in patients treated with RALP from a prospective, multi-institutional, nationwide series. A risk of LNI > 7% is proposed as cut-off above which e-PLND is recommended.

Androgen deprivation therapy (ADT) is associated with considerable adverse side effects which compromise the health and wellbeing of many men with prostate cancer. Exercise has been identified as a therapy to help manage ADT-related treatment toxicities. This paper systematically reviews the scientific literature investigating the impact of exercise on men receiving ADT and discusses strategies to effectively implement exercise in clinical practice. The findings of this review demonstrate that exercise has therapeutic benefit for the management of ADT-related side effects. Significant positive effects following exercise were observed for aerobic fitness, muscular strength, physical function, body composition, fatigue, sexual wellbeing, mental wellbeing, social function, comorbid disease risk factors, and quality of life. Emerging evidence suggests exercise may also play a role in managing bone loss, cognitive decline, and urinary problems, and may be delivered without exacerbating bone pain. Exercise did not negatively influence ADT treatment efficacy and led to few adverse events of minor severity, rendering it a safe intervention for men receiving ADT. To maximize the therapeutic effect of exercise, men with prostate cancer should participate in moderate-to-high intensity aerobic, resistance and impact exercise which is prescribed and supervised by a qualified exercise physiologist and delivered at a convenient location in a prostate cancer specific group-based environment. The level of evidence now available supports the view that the prescription of exercise medicine should be part of routine prostate cancer care.