Prostate MRI: Value in surgical planning?

Dr. Gomella is chairman of the department of urology and senior director for clinical affairs, Jefferson Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia.

The focus of recent prostate MRI investigations has been on the identification and biopsy of intraprostatic lesions. Conversely, the role of preoperative MRI in staging and surgical planning has not received much recent attention.

With the expanding use of MRI in the diagnosis of prostate cancer through targeted biopsy, a reasonable question to ask is, what is the role of MRI the surgical management of men with localized disease treated by radical prostatectomy? Gross extension of the cancer beyond the prostate is often suspected based on rectal exam or other clinical data. However, the identification of microscopic extension that may alter the surgical approach and possibly the long-term outcomes of the procedure may not be readily apparent in men with low-risk disease.

Related: Pre-RP MRI does not affect surgical outcomes

A study reported at the 2017 AUA annual meeting by Kim et al from Washington University in St. Louis showed no significant differences in selected surgical outcomes (operative time, blood loss, complications, or positive surgical margins) among men who did or did not have preoperative prostate MRI before radical prostatectomy (see article). When considering using preoperative imaging to direct changes in surgical approach, the suggestion of extraprostatic disease may alter plans for nerve sparing or lead to more aggressive local resection. There is limited published data how MRI might influence surgical technique such as neurovascular bundle preservation, with very few supporting the utility of MRI in this regard.

MRI of the prostate has evolved since its first use in the 1980s. A trial reported in 1990 noted that prostate MRI available at that time could not identify microscopic spread of disease. While prostate MRI technology continues to develop, the detection of microscopic disease outside of the prostate in early-stage disease remains a challenge. Based on the limited ability to detect microscopic extraprostatic extension and this contemporary study by Kim and associates, it appears that for radical prostatectomy surgical planning in early-stage disease, MRI does not add value.

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