In the current study, we suggested a new nomogram that demonstrated good accuracy of BCR prediction for patients after LRP. The most crucial post-operative parameter to be evaluated is PSA, which is anticipated to be undetectable in 6 weeks following RP [9]. A high probability of local recurrence or metastasis is indicated by an elevated PSA level following RP [10]. The patient is given the status of BCR [11], which was a signal of cancer progression at a visual undetectable level, if the post-operative PSA level reaches 0.2 ng/mL. Numerous studies have been done on the connection between PSA nadir and BCR following RP. According to a retrospective analysis, men with PSA > = 0.01 ng/mL after RP had a lower chance of developing BCRFS after five years, dropping from 92.4 to 56.8% [12]. PSA persistence after RP was linked to higher BCR and overall mortality in a research by Matsumoto et al. [13], which included 582 patients. These outcomes are consistent with the findings of the current investigation. In comparison to the present analysis, where BCR was detected in 105 patients, several studies have described patients who underwent prostatectomy with a 5-year BCR-free survival rate ranging from 74 to 87% and a median PSA recurrence time of 2.6 years, which also higher compared to our study [14, 15]. Moreover, multivariable analysis identified unfavorable factor to BCRFS which are high initial serum PSA (> 20), ISUP Gleason grade group > = 3, positive margin status and seminal vesicle invasion using for develop a nomogram to predict BCR. Consistent with previous literature, patients with pathologically organ-confined cancer exhibited consistently low hazard rates over the follow-up period, emphasizing the significance of extended surveillance and timely intervention in individuals who undergo radical prostatectomy [16]. Furthermore, positive surgical margins (PSM) have been shown to have a detrimental impact on postoperative functional outcomes (PFP) following radical prostatectomy (RP), emphasizing the need to minimize PSM rates for improved cancer control outcomes, despite the growing prevalence of organ-confined disease resulting from enhanced screening strategies [17]. Similar conclusions have been reported regarding the nomogram in previous studies [18, 19].

Previously, Cooperberg et al. [7] developed the post-operative CAPRA-S score based on pre-operative PSA, Gleason score, seminal vesicle involvement, lymphonodal extension, surgical margin invasion, and Extracapsular extension. We also acknowledge the existence of the nomogram available on the Memorial Sloan Kettering Cancer Center (MSKCC) website, which has been widely used as a valuable tool in predicting BCR [20]. While the MSKCC nomogram has demonstrated its utility and validity in the field, our novel nomogram expands upon the existing models in several key ways. First and foremost, our nomogram incorporates a focus group of the laparoscopic approach, which allows for enhanced generalizability of the predictive model, which was not present in the MSKCC nomogram. By including these updated factors, our nomogram aims to provide an improved and more accurate prediction of BCR after laparoscopic radical prostatectomy. Through these comparative analyses, we have demonstrated that our nomogram exhibits superior predictive performance when applied to our specific patient cohort. This enhanced performance can be attributed to the incorporation of additional relevant variables and a refined model development process.

Our study revealed a significantly higher positive surgical margin (PSM) rate of 31.5% compared to previous findings. According to the previous study by Guillonneau et al. [21] The PSM rates of 6.9%, 18.6%, 30%, and 34% for for pT2a, pT2b, pT3a, and pT3b stages, respectively., our study had a lower proportion of T3 patients at 24.3%. This discrepancy may contribute to the higher overall PSM rate, as T3 tumors typically have increased extracapsular extension and involvement of surgical margins. However, additional analysis is needed to explore other factors such as surgical technique, surgeon expertise, patient characteristics, tumor aggressiveness, and pathological assessment methods. Understanding these factors can inform improvements in procedures, patient selection, and postoperative care to reduce positive surgical margins and enhance outcomes for laparoscopic radical prostatectomy patients.

Due to variations in prostate cancer phenotypes across people in Asian and Western nations, results from Asian countries regarding the prediction of BCR are currently missing [22]. There are many risk factor and its impact on the BCR rate following surgery are still challenging for surgeons to predict. To advance the present understanding of BCR after LRP, we used retrospective cohort data from Songklanagarind hospital in this study.

We created a simple model with comparisons for the PSA cut-off at 20 ng/mL level, Gleason grade group, SM, and pathologic T stage in order to confirm the incremental predictive value of the combination of independent clinical indicators. Our newly developed nomogram has the potential to serve as a valuable tool for predicting biochemical recurrence-free survival (BCRFS) and aiding in the decision-making process for adjuvant treatments. Specifically, when the nomogram indicates a high probability of biochemical recurrence (BCR) or a low score in BCRFS prediction, it suggests the consideration of early adjuvant radiotherapy. Conversely, when the nomogram indicates a low probability of BCR, it may provide the opportunity to omit adjuvant radiotherapy and avoid potential side effects associated with such treatment.

The limitations of this study. First, because this was a retrospective study and the number of patient was much smaller than in other studies, this study has a number of drawbacks. Second, the newly created nomogram, which predicts BCRFS following LRP with good accuracy, incorporated various widely used factors, including PSA, Gleason grade group, and pathologic T stage. Specifically, we acknowledge that all patients underwent transrectal ultrasound-guided prostate biopsy instead of MRI-guided prostate biopsy, which could potentially impact the validity of the nomogram. Moreover, validation cohort was used to confirm accuracy of our nomogram. We emphasize that future studies should aim to externally validate the nomogram in different clinical settings to ensure its broader applicability.

While we agree that MRI-guided biopsy has advantages in terms of accuracy, availability, and target localization, it is important to note that at the time of our study, transrectal ultrasound-guided biopsy was the standard practice in our institution. Nonetheless, we recognize the potential limitations associated with this choice and will include a discussion on the impact of biopsy technique in the revised version of our article. To enhance accuracy, we will incorporate multiple evaluation methods, including PSA levels and other biomarkers or imaging techniques. Implementing these measures will provide a more comprehensive analysis of biochemical recurrence following laparoscopic radical prostatectomy.

The practical implementation of the nomogram in clinical practice to guide adjuvant or salvage treatment is an essential consideration for its real-world applicability. Clinicians interested in utilizing the nomogram as a decision-making tool would benefit from additional clarification on its implementation. Firstly, it is important to provide guidance on how to use the nomogram in a clinical setting. This includes outlining the specific variables and inputs required for accurate predictions. Clear instructions on data collection, such as the recommended imaging modalities or laboratory tests, would facilitate the practical application of the nomogram. Furthermore, discussing the interpretation of the nomogram’s results is crucial. Clinicians need to understand the threshold or cutoff values associated with different treatment recommendations. Guidance on the level of confidence or uncertainty in the predictions would also assist clinicians in evaluating the nomogram’s reliability. In addition to implementation and interpretation, the authors should consider discussing the potential benefits and limitations of integrating the nomogram into clinical practice. Highlighting the advantages, such as its ability to provide individualized risk assessment and guide treatment decisions, would emphasize its utility. However, it is equally important to address any limitations, such as the nomogram’s reliance on specific patient populations or potential biases in the development of the model.