esting to see the predictive accuracy of percent positivebiopsy in a cohort of patients with standardized biopsyschemes.

Although these data may prove to be promising in select-ing a patient population in which seminal vesicle surgerymay be warranted, the aim of any oncological operation iscomplete removal of cancer. Ultimately a prospective, ran-domized trial of seminal vesicle sparing surgery vs tradi-tional radical retropubic prostatectomy in a large patientpopulation is warranted.

CONCLUSIONS

In contemporary series the proportion of patients with inva-sion of the seminal vesicles with prostate cancer on finalsurgical pathology has significantly decreased. Percent pos-itive biopsy is a powerful predictor of seminal vesicle inva-sion at the time of radical prostatectomy. Percent positivebiopsy, along with other preoperative parameters, would beuseful in defining a patient population in which prospectivetrials can be designed to test the efficacy and safety ofseminal vesicle sparing surgery.

Abbreviations and Acronyms

DRE � digital rectal examinationPSA � prostate specific antigenROC � receiver operating characteristic curves

RP � radical prostatectomySVs � seminal vesicles

REFERENCES

1. Koh, H., Kattan, M. W., Scardino, P. T., Suyama, K., Maru, N.,Slawin, K. et al: A nomogram to predict seminal vesicleinvasion by the extent and location of cancer in systematicbiopsy results. J Urol, 170: 1203, 2003

2. Epstein, J. I., Carmichael, M. and Walsh, P. C.: Adenocarci-noma of the prostate invading the seminal vesicle: definitionand relation of tumor volume, grade and margins of resectionto prognosis. J Urol, 149: 1040, 1993

3. Zlotta, A. R., Roumeguere, T., Ravery, T., Hoffmann, P., Mon-torsi, F., Turkeri, L. et al: Is seminal vesicle ablation man-datory for all patients undergoing radical prostatectomy? Amultivariate analysis on 1283 patients. Eur Urol, 46: 42,2004

4. Han, M., Partin, A. W., Pound, C. R., Epstein, J. I. and Walsh,P. C.: Long-term biochemical disease-free and cancer-specificsurvival following anatomic radical retropubic prostatec-tomy. The 15-year Johns Hopkins experience. Urol ClinNorth Am, 28: 555, 2001

5. Ohori, M., Scardino, P. T., Lapin, S. L., Seale-Hawkins, C., Link,J. and Wheeler, T. M.: The mechanisms and prognostic sig-nificance of seminal vesicle involvement by prostate cancer.Am J Surg Pathol, 17: 1252, 1993

6. Reiner, W. G. and Walsh, P. C.: An anatomical approach to thesurgical management of the dorsal vein and Santorini’splexus during radical retropubic surgery. J Urol, 121: 198,1979

7. Derweesh, I. H., Kupelian, P. A., Zippe, C., Levin, H. S., Brai-nard, J., Magi-Galluzzi, C. et al: Continuing trends in patho-logical stage migration in radical prostatectomy specimens.Urol Oncol, 22: 300, 2004

8. Cooperberg, M. R., Lubeck, D. P, Mehta, S. S. and Carroll, P. R.:Time trends in clinical risk stratification for prostate cancer:implications for outcomes (data from CaPSURE). J Urol, part2, 170: S21, 2003

9. Villers, A. A., McNeal, J. E., Redwine, E. A., Freiha, F. S. andStamey, T. A.: Pathogenesis and biological significance ofseminal vesicle invasion in prostate adenocarcinoma. J Urol,143: 1183, 1990

10. Partin, A. W., Mangold, L. A., Lamm, D. M., Walsh, P. C.,Epstein, J. I. and Pearson, J. D.: Contemporary update ofprostate cancer staging nomograms (Partin Tables) for thenew millennium. Urology, 58: 843, 2001

11. Jepsen, J. V. and Bruskewitz, R. C.: Should the seminal vesiclesbe resected during radical prostatectomy? Urology, 51: 12,1998

12. John, H., Hauri, D. and Maake, C.: The effect of seminal vesicle-sparing radical prostatectomy on serum prostate-specific an-tigen level. BJU Int, 92: 920, 2003

13. John, H. and Hauri, D.: Seminal vesicle-sparing radical prosta-tectomy: a novel concept to restore early urinary continence.Urology, 55: 820, 2000

14. Sanda, M. G., Dunn, R., Wei, J., Resh, J. and Montie, J.: Sem-inal vesicle sparing technique is associated with improvedsexual HRQOL outcome after radical prostatectomy. J Urol,suppl., 167: 151, abstract 606, 2002

15. Aboseif, S., Shinohara, K., Breza, J., Benard, F. and Narayan,P.: Role of penile vascular injury in erectile dysfunction afterradical prostatectomy. Br J Urol, 73: 75, 1994

16. Ohori, M., Shinohara, K., Wheeler, T. M., Aihara, M., Wessels,E. C., Carter, S. S. et al: Ultrasonic detection of non-palpableseminal vesicle invasion: a clinicopathological study. BJUInt, 72: 799, 1993

17. Ikonen, S., Karkkainen, P., Kivisaari, L., Salo, J. O., Taari, K.,Vehmas, T. et al: Endorectal magnetic resonance imaging ofprostatic cancer: comparison between fat-supressed T2weighted fast spin echo and three-dimensional dual-echo,steady state sequences. Eur Radiol, 11: 236, 2001

18. Pandey, P., Fowler, J. E., Jr., Seaver, L. E., Feliz, T. P. andBrooks, J. P.: Ultrasound guided seminal vesicle biopsies inmen with suspected prostate cancer. J. Urol, 154: 1798, 1995

19. Korman, H. J., Watson, R. B., Civantos, F., Block, N. L. andSoloway, M. S.: Radical prostatectomy: is complete resectionof the seminal vesicles really necessary? J Urol, 156: 1081,1996

20. Theodorescu, D., Lippert, M. C., Broder, S. R. and Boyd, J. C.:Early prostate-specific antigen failure following radical peri-neal versus retropubic prostatectomy: the importance of sem-inal vesicle excision. Urology, 51: 277, 1998

EDITORIAL COMMENT

This study by Guzzo et al further demonstrates that withthe dramatic shift in the clinical presentation of prostatecancer, and especially in the number of patients with T1Cdisease and PSA less than 10 ng/ml, the percentage of pa-tients with seminal vesicle invasion on final pathology hasdramatically decreased compared to more historical series.

Overall 79 of 1,056 patients had seminal vesicle involve-ment. More than 50 of those 79 patients had a PSA greaterthan 10 ng/ml. Therefore, in patients with T1C disease andPSA less than 10 ng/ml, seminal vesicle invasion is an un-likely event seen in low percentages of patients these days.The question derived from this observation is why should wecontinue to surgically remove structures with limited onco-logical reasons to do so?

This series is an interesting confirmation of our Europeanreport on a similar series of more than 1,200 patients (ref-

PREDICTING SEMINAL VESICLE INVOLVEMENT IN PATIENTS WITH PROSTATE CANCER 521

erence 3 in article). In that article we showed, as in thepresent study, that the percentage of positive biopsies, Glea-son score and preoperative serum PSA were all highly pre-dictive of seminal vesicle invasion. These parameters maydefine a subset of patients in which prospective studies coulddetermine the value and safety of seminal vesicle sparingsurgery in terms of oncological control and functional out-come.

The data presented by Guzzo et al are interesting, but thevalue of the study does not lie only in the confirmation thatAmerican patients are no different from contemporary Eu-ropean patients in terms of prostate cancer pathology. Thisarticle is interesting because the conventional way of think-ing about radical prostate surgery could be revisited asrefinements in the understanding of the nerve bundle loca-tion and anatomical relations, as well as their dissection,have been brought about by the advent of the magnificationpower of laparoscopy. Laparoscopy has also pushed the opensurgeons to improve their technique and results. It has alsoprobably contributed to a better understanding of prostateanatomy. From a practical point of view, the reader mightnot be able to easily translate the findings of the presentstudy into daily practice.

The authors mention that in the group of patients withless than 20% of positive biopsies, less than 1% had seminalvesicle involvement. This finding still leaves a large numberof patients who could probably be safely spared this time ofthe operation while still achieving a sensitivity greater than95%. What percentage of risk is one ready to accept? Is it1%? 5%? Of course it depends on the potential functionalbenefits of vesicle sparing prostatectomy.

It could have been interesting to further combine differ-ent percentages of positive biopsies with Gleason score bycombining the predictive value of those 2 parameters, to

ultimately define a population of patients who could be in-cluded in randomized prospective trials, thereby evaluatingthe benefits of seminal vesicle sparing surgery. A nomogramcould have been helpful in translating the observed data intodaily clinical practice.

Several centers, such as Zurich (reference 13 in article),Ann Harbor (reference 14 in article) and Miami (reference19 in article), among many others, have been the advocatesof vesicle sparing radical prostatectomy. Given the amountof data now available regarding the possibility of improve-ments in quality of life and functionality of seminal vesiclesparing surgery, and the increased definition of those pa-tients who might be safely selected for that type of surgery,prospective studies comparing seminal vesicle sparing sur-gery to classical radical prostatectomy, whether in Europe orin the United States, should be encouraged to provide defin-itive answers regarding the real benefits of such an ap-proach. This concept has been in the air for some time, butwhether it is functionally helpful or not should be addressedscientifically.

However, the limitation of these studies remains the factthat the number of biopsies performed is constantly in-creased, therefore raising doubts as to whether it is possibleto directly translate data obtained from 8, 10 or 12 biopsiesin patients who have undergone 15 to 36 biopsies whenselecting patients for seminal sparing surgery. However,these limitations should not prevent us from going further inthis potentially interesting direction.

Alexandre R. ZlottaDepartment of Urology

Erasme HospitalBrussels, Belgium

PREDICTING SEMINAL VESICLE INVOLVEMENT IN PATIENTS WITH PROSTATE CANCER522