Background: Robot-assisted radical prostatectomy (RARP) is a common treatment option for prostate cancer. A 3D model for surgical guidance can improve surgical outcomes. Manual expert radiologist segmentation of the prostate and tumor in prostate MRI to create 3D models is labor-intensive and prone to inter-observer variability, highlighting the need for automated segmentation methods. Methods: This study evaluates the performance of the prostate and tumor segmentation using a commercially available AI tool without (fully automated) and with manual adjustment (AI-assisted) compared to manual segmentations on 120 patients, using several metrics, including Dice Coefficient and Hausdorff distance. Tumor detection rates were assessed with recall and precision. Results: For the prostate, both the fully automated AI model and AI-assisted model achieved a mean Dice score of 0.88, while AI-assisted had a lower Hausdorff distance (7.22 mm) compared to the fully automated (7.40 mm). For tumor segmentations, the Dice scores were 0.53 and 0.62, with Hausdorff distances of 9.53 mm and 6.62 mm obtained for fully automated AI and AI-assisted methods, respectively. The fully automated AI method had a recall of 0.74 and a precision of 0.76 in tumor detection, while the AI-assisted method achieved 0.95 recall and 0.94 precision. Fully automated segmentation required less than 1 min, while adjustments for the AI-assisted segmentation took an additional 81 s, and manual segmentation took approximately 15–30 min. Conclusions: The fully automated AI model shows promising results, offering high tumor detection rates and acceptable segmentation metrics. The AI-assisted strategy improved the relevant metrics with minimal additional time investment. Therefore, the AI-assisted segmentation method is promising for allowing 3D-model-guided surgery for all patients undergoing RARP.

Background: The currently advised follow-up scheme of PSA testing after robot-assisted radical prostatectomy (RARP) is strict and might pose a burden to our healthcare system. We aimed to optimize the 1-year follow-up scheme for patients who undergo RARP. Methods: All patients with histologically-proven prostate cancer (PCa) who underwent RARP between 2018 and August 2022 in the Prostate Cancer Network in the Netherlands were retrospectively evaluated. We excluded patients who underwent salvage RARP and patients who had 0.10 ng/mL at 0–4 months after RARP, whereas biochemical recurrence (BCR) was defined as PSA level >0.2 ng/mL at any time point after RARP. We aimed to identify a group of patients who had a very low risk of BCR at different time points after surgery. Results: Of all 1155 patients, BCP was observed in 151 (13%), of whom 79 (6.8%) had PSA ≥ 0.2 ng/mL. BCR further developed in 51 (4.7%) and 37 (3.4%) patients at 5–8 and 9–12 months after RARP, respectively. In 12 patients, BCR was found at 5–8 months after RARP in the absence of BCP. These patients represented 1.2% (12/1004) of the entire group. In other words, 98.8% (992/1004) of patients who had an unmeasurable PSA level at 0–4 months after RARP also had an unmeasurable PSA level 5–8 months after surgery. Limitations are the retrospective design and incomplete follow-up. Conclusions: Patients with an unmeasurable PSA level at 3–4 months after RARP may not need to be retested until 12 months of follow-up, as almost 100% of patients will not have the biochemically recurrent disease at 5–8 months of follow-up. This will reduce PSA testing substantially at the cost of hardly any missed patients with recurrent disease.

Background: Robot-assisted radical prostatectomy (RARP) has become the standard surgical procedure for localized prostate cancer (PCa). Nerve sparing with neurovascular structure-adjacent frozen-section examination (NeuroSAFE) has been associated with improved functional outcomes while maintaining oncological outcomes. This study investigates the impact of NeuroSAFE on nerve sparing during RARP, using the fascia preservation (FP) score. This score (range 0–6 per side) reflects the extent of preserved fascia at twelve circumferential positions; higher scores indicate greater nerve preservation. Methods: A single-center retrospective cohort study was conducted between January 2022 and December 2024, including 100 PCa patients selected for RARP. A preoperative surgical plan was created, including an estimated FP score using NeuroSAFE. Patients subsequently underwent prostatectomy with NeuroSAFE. The actual FP score was determined perioperatively. Postoperatively, four urologists retrospectively estimated FP scores assuming prostatectomy had been performed without NeuroSAFE. Actual and estimated scores were compared. Interobserver agreement among urologists was assessed using the intraclass correlation coefficient. Results: RARP with NeuroSAFE resulted in statistically significantly higher FP scores on both sides compared to the estimated FP scores without NeuroSAFE (P<0.001). The median FP score was 5 per side (full nerve sparing) with NeuroSAFE versus 4 (partial nerve sparing) without. Interobserver agreement among urologists was moderate for single measurements and high for average measurements. Conclusions: NeuroSAFE enables greater nerve sparing during RARP, as estimated by four expert urologists. Although functional outcomes were not assessed in this cohort, previous randomized evidence has demonstrated an association between greater nerve sparing and improved erectile function.

Background: Positive surgical margins (PSMs) serve as outcome metrics after robot-assisted radical prostatectomy (RARP) and are frequently used in quality assurance programs (QAPs). Despite their central role as a quality indicator, the prognostic significance of PSMs remains debated, and limited research examines how clinicians actually interpret and use this metric within QAPs. This qualitative study explores how urologists collectively interpret and use PSM metrics within a regional prostate cancer QAP and considers the implications for quality improvement and clinical collaboration. Methods: We conducted a qualitative study examining how urologists interpret and use PSMs within the Prostate Cancer Network Netherlands. We audio-recorded 12 monthly QAP meetings and completed structured fieldnotes. Semi-structured interviews were conducted with all six participating RARP urologists. Transcripts and fieldnotes were analyzed using the Gioia-method. Results: Positive surgical margins operated in three interconnected ways within QAPs. First, as quality improvement instruments: they shaped clinical interpretation by helping urologists balance oncological control and functional outcomes, while supporting peer learning, knowledge sharing, and alignment across hospitals. Second, as vehicles of professional legitimation: they helped justify QAP to administrators, patients, and peer institutions. Third, as instruments of power and positioning: they enabled professional differentiation and ranking but were contested in their definition, sometimes reinforcing hierarchy or competition. Across all three themes, PSMs were not neutral outcome metrics but active forces shaping quality assurance practices and professional relations. Conclusion: Understanding how PSMs operate in practice reveals their multifaceted role beyond quality measurement, where they could simultaneously serve as tools for clinical interpretation, legitimation vehicles, and instruments of professional power.

Background: The currently advised follow-up scheme of PSA-testing after robot-assisted radical prostatectomy (RARP) is strict and might pose a burden to our healthcare system. We aimed to optimize the 1-year follow-up scheme for patients who undergo RARP. Methods: All patients with histologically-proven prostate cancer (PCa) who underwent RARP between 2018 and August 2022 in the Prostate Cancer Network the Netherlands were retrospectively evaluated. We excluded patients who underwent salvage RARP and patients who had 0.10 ng/mL at 0-4 months after RARP, whereas biochemical recurrence (BCR) was defined as PSA-level >0.2 ng/mL at any time point after RARP. We aimed to identify a group of patients who had a very low risk of BCR at different time-points after surgery. Results: Of all 1155 patients, BCP was observed in 151 (13%), of whom 79 (6.8%) had PSA ≥0.2 ng/mL. BCR further developed in 51 (4.7%), and 37 (3.4%) patients at 5-8 and 9-12 months after RARP, respectively. In 12 patients, BCR was found at 5-8 months after RARP in absence of BCP. These patients represented 1.2% (12/1004) of the entire group. In other words, 98.8% (992/1004) of patients who had an unmeasurable PSA-level at 0-4 months after RARP also had unmeasurable PSA-level 5-8 months after surgery. Limitations are the retrospective design and incomplete follow-up. Conclusions: Patients with an unmeasurable PSA-level at 3-4 months after RARP may not need to be retested until 12 months of follow-up as almost 100% of patients will not have biochemically recurrent disease at 5-8 months of follow-up. This will reduce PSA-testing substantially at the costs of hardly any missed patients with recurrent disease.