How can mpMRI help surgical planning in high risk prostate cancer?

Multiparametric magnetic resonance imaging (mpMRI)represents nowadays an essential tool to guide radicalprostatectomy (RP). Despite nerve sparing (NS) approachwas traditionally precluded in high risk prostate cancer(HRPC) patients, Kumar et al. [1] suggested that a selectiveNS could be feasible even in HRPC patients with acceptablepositive surgical margins (PSMs) rates. Of note, accuratepreoperative selection of ideal candidates to NS surgery,especially in HRPC [2], is key. For this reason, we readwith interest the article by Baack et al. [3], thought theinnovative way of retrospective survey, the authors eval-uated the impact of mpMRI on surgical plan in HRPC bothconsidering NS approach, pelvic lymph node dissection(PLND) template, bladder neck approach and surgicaltechnique. They found that all patients had at least onechange to their surgical plan by urologists. Interestingly,considering the NS technique, the authors found that NSapproach was changed in 58% of cases with overallappropriateness of 72%, which is consistent with our pre-vious data with overall change in roughly 50% of cases,resulting an overall appropriateness of 75% [4]. This paperconfirms the important role of mpMRI even in HRPC inwhich NS approach is usually not considered for higher riskof extracapsular extension, suggesting that in selective casesof HRPC an incremental NS approach could be oncologi-cally safe only with a preoperative mpMRI.However, one important limitation is the lack of com-parison between the intended approach from the survey andthe real surgical plan performed during surgery. As weknow, the preoperative intended surgical plan (even afterrevision of mpMRI) could go through some modifications during surgery. Moreover, the definition of appropriatenessof the surgical plan change (defined as presence of extra-prostatic extension at pathologic specimen) is not ideal,since it considers only thefirst surgical outcomes of roboticRP (moreover it does not consider the presence of PSMs)rather than a real oncologic outcome (i.e. biochemicalrecurrence) or the postoperative erectile function.One more important aspect the authors underline is thepotential role of mpMRI to impact the PNLD template,suggesting that the use of mpMRI can modify the surgicalextension of PLND. We believe that an accurate mpMRI isuseful to investigate both the local stage of PC and the nodaland skeletal status within the pelvis, which is the mostcommon andfirst site of dissemination. Moreover, the PCcharacteristics detected at mpMRI, combined with clinicaldata, have the potential to influence surgeon during PLND.In fact, Gandaglia et al. [5] found that the information frommpMRI (i.e clinical stage at mpMRI, grade group at MRI-targeted biopsy and maximum size of index lesion) canimprove the accuracy of Briganti’s nomogram to predict thepresence of nodal metastases in patients with PC detected atMRI-targeted biopsy. Of course, further studies are neededto evaluate the role of mpMRI for both preoperative plan-ning of NS approach and the decision when to perform orhow to modify the template of PLND.