Comparison of prostate-specific antigen recurrence-free survival in a contemporary cohort of patients undergoing either radical retropubic or robot-assisted laparoscopic radical prostatectomy

OBJECTIVES

To compare the prostate‐specific antigen (PSA) recurrence (PSAR) rates in patients undergoing robot‐assisted laparoscopic radical prostatectomy (RALP) or radical retropubic prostatectomy (RRP).

PATIENTS AND METHODS

Data from 797 consecutive patients who had RALP or RRP between August 2003 and January 2007 were retrieved from our database. Age, race, body mass index, PSA level, estimated blood loss (EBL), clinical and pathological stage, biopsy and pathological Gleason score, lymph node involvement, positive surgical margin (PSM) status, and prostate weight were compared between the groups. Multivariate analysis (logistic and Cox regression) was used to adjust for differences in clinical and pathological features when comparing the risk for PSM and PSAR.

RESULTS

In all, 362 men had RALP and 435 had RRP; the mean follow‐up was 1.09 and 1.37 years, respectively. RALP patients had a significantly lower clinical stage, Gleason score and EBL (P < 0.001). There was no significant difference in PSM between RALP and RRP in univariate (P = 0.701) and multivariate analyses (P = 0.095). The risk of PSAR for patients undergoing RALP or RRP was not significantly different after adjusting for clinical (hazard ratio 0.82, 95% confidence interval 0.48–1.38; P = 0.448) and pathological differences (0.94, 0.55–1.61; P = 0.824).

CONCLUSIONS

Patients undergoing RALP had a lower EBL and lower‐risk disease. After adjusting for differences in clinical and pathological features, there was no significant difference in early PSAR between patients undergoing RALP or RRP.     

Nongenitourinary complications associated with robot-assisted laparoscopic and radical retropubic prostatectomy: A single institution assessment of 1,100 patients over 11 years

Objectives

Robot-assisted laparoscopic prostatectomy (RALP) and radical retropubic prostatectomy (RRP) provide similar outcomes in terms of biochemical recurrence, postoperative continence, and erectile function. Little is known about other complications of these procedures. To further address this, we examined patient outcomes at our institution over an 11-year period.

Effect of a large prostate gland on open and robotically assisted laparoscopic radical prostatectomy

OBJECTIVE

To evaluate the outcomes based on gland size between robotically assisted radical prostatectomy (RALP) and open RP (RRP), as larger prostates might increase the difficulty of RP.

PATIENTS AND METHODS

We reviewed 660 patients who had RALP and 340 who had RRP from May 2003 to August 2006; the patients were divided into two groups, with a prostate of >75 and ≤75 g. The clinical characteristics, surgical approach, perioperative and postoperative outcomes were evaluated.

RESULTS

Patients with large prostates were significantly older (P < 0.001), but had a lower pathological stage (RALP, P = 0.046, and RRP, P = 0.008) than patients with small glands, regardless of technique. There was no difference in length of stay or transfusion rates between the groups. A large prostate increased the operative duration of RALP (P < 0.001) but not of RRP. For both RALP and RRP, positive margin rates were lower with larger glands (RALP, P = 0.014; RRP, P = 0.033). Overall, the positive margin rates were lower with RALP (9.9% and 19.0%) than RRP (18.5% and 35.5%) among patients with larger or smaller (P < 0.001) glands, respectively.

CONCLUSIONS

Prostates of ≥75 g had fewer positive margins than smaller glands, regardless of surgical technique. There was also a significant decrease in positive margin rate in among prostates of >75 g in favour of RALP. Thus, RALP appears to be comparable with RRP for patients with large glands, and might reduce the positive margin rate.     

Radical prostatectomy after previous transurethral resection of the prostate: robot-assisted laparoscopic versus open radical prostatectomy in a matched-pair analysis

Abstract Purpose: To determine whether previous transurethral resection of the prostate (TURP) compromises the surgical outcome and pathologic findings in patient who underwent either radical robot-assisted laparoscopic prostatectomy (RALP) or open retropubic radical prostatectomy (RRP) after TURP, because TURP is reported to complicate radical prostatectomy and there are conflicting data. Patients and Methods: From July 2008 to July 2010, 357 patients underwent RALP. Of these, 19 (5.3%) patients had undergone previous TURP. Operative and perioperative data of patients were compared with those of matched controls selected from a database of 616 post-RRP patients. Matching criteria were age, clinical stage, the level of preoperative prostate-specific-antigen, the biopsy Gleason score, the American Society of Anesthesiologists classification score, and prostate volume assessed during transrectal ultrasonography. All RRP and RALP procedures were performed by experienced surgeons. Results: Mean time to prostatectomy was 67.4 months in the RALP group and 53.1 months in the RRP group. Mean operative time was 217±51.9 minutes for RALP and 174±57.7 minutes for RRP (P<0.05). The overall positive surgical margin rate was 15.8% in both groups (pT(2) tumors: 10.5% for RALP and 5.3% for RRP; P=1.0). Mean estimated blood loss was 333±144?mL in RALP patients and 1103±636?mL in RRP patients (P<0.001). The difference between preoperative and postoperative hemoglobin levels was 3.22±0.98?g/dL for RALP and 5.85±1.95?g/dL for RRP (P=0.0002). The RALP and RRP groups also differed in terms of hospital stay (8.58±1.17 vs 11.74±5.22 days; P=0.0037), duration of catheterization (7.95±5.69 vs 11.78±6.97 days; P=0.0016), postoperative complications according to the Clavien classification system (6 vs 15 patients; P=0.0027), and transfusion rate (0% vs 10.5%; P<0.001). Conclusion: RALP offers advantages over open radical prostatectomy after previous surgery. Although both techniques are associated with adequate surgical outcomes, RALP appeared to be preferable in our population of patients with previous prostate surgery.     

Outcomes assessment in men undergoing open retropubic radical prostatectomy, laparoscopic radical prostatectomy, and robotic-assisted radical prostatectomy

Objectives  

To review the various methods of outcomes assessment used for effectiveness studies comparing retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic prostatectomy (RALP).     

A multi-institutional comparison of radical retropubic prostatectomy, radical perineal prostatectomy, and robot-assisted laparoscopic prostatectomy for treatment of localized prostate cancer

To evaluate the pathological stage and margin status of patients undergoing radical retropubic prostatectomy (RRP), radical perineal prostatectomy (RPP) and robot-assisted laparoscopic prostatectomy (RALP). We performed a retrospective analysis of 196 patients who underwent RRP, RPP, and RALP as part of our multi-institution program. Fifty-seven patients underwent RRP, 41 RPP, and 98 RALP. Patient age, preoperative prostate specific antigen (PSA), preoperative Gleason score, preoperative clinical stage, pathological stage, postoperative Gleason score, and margin status were reviewed. The three groups had similar preoperative characteristics, except for PSA (8.4, 6.5, and 6.2 ng/ml) for the retropubic, robotic, and perineal approaches. Margins were positive in 12, 24, and 36% of the specimens from RALP, RRP, and RPP, respectively (P = 0.004). The positive margin rates in patients with pT2 tumors were 4, 14, and 19% in the RALP, RRP, and the RPP groups, respectively (P = 0.03). Controlling for age and pre-operative PSA and Gleason score, the rate of positive margins was statistically lower in the RALP versus both the RRP (P = 0.046) and the RPP groups (P = 0.02). In the patients with pT3 tumors, positive margins were observed in 36% of patients undergoing the RALP and 53 and 90% of those patients undergoing the RRP and RPP, respectively (P = 0.015). Controlling for the same factors, the rate of positive margins was statistically lower in the RALP versus the RPP (P = 0.01) but not compared with the RRP patients (P = 0.32). The percentage of positive margins was lower in RALP than in RPP for both pT2 and pT3 tumors. RRP had a higher percentage of positive margins than RALP in the pT2 tumors but not in the pT3 tumors.     

A prospective,non‐randomized trial comparing robot‐assisted laparoscopic and retropubic radical prostatectomy in one European institution

OBJECTIVE

To compare the functional results of two contemporary series of patients with clinically localized prostate cancer treated by robot‐assisted laparoscopic prostatectomy (RALP) or retropubic radical prostatectomy (RRP).

PATIENTS AND METHODS

This was a non‐randomized prospective comparative study of all patients undergoing RALP or RRP for clinically localized prostate cancer at our institution from February 2006 to April 2007.

RESULTS

We enrolled 105 patients in the RRP and 103 in the RALP group; the two groups were comparable for all clinical and pathological variables, except median age. For RRP and RALP the respective median operative duration was 135 and 185 min (P < 0.001), the intraoperative blood loss 500 and 300 mL (P < 0.001) and postoperative transfusion rates 14% and 1.9% (P < 0.01). There were complications in 9.7% and 10.4% of the patients (P = 0.854) after RRP and RALP, respectively; the positive surgical margin rates in pT2 cancers were 12.2% and 11.7% (P = 0.70). For urinary continence, 41% of patients having RRP and 68.9% of those having RALP were continent at catheter removal (P < 0.001). The 12‐month continence rates were 88% after RRP and 97% after RALP (P = 0.01), with the mean time to continence being 75 and 25 days (P < 0.001), respectively. At the 12‐month follow‐up, 20 of 41 patients having bilateral nerve‐sparing RRP (49%) and 52 of 64 having bilateral nerve‐sparing RALP (81%) (P < 0.001) had recovery of erectile function.

CONCLUSIONS

RALP offers better results than RRP in terms of urinary continence and erectile function recovery, with similar positive surgical margin rates.     

Good outcome for patients with few lymph node metastases after radical retropubic prostatectomy

BACKGROUND: Conflicting results exist regarding the value of an extended pelvic lymph node dissection (PLND) in node-positive patients undergoing radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. OBJECTIVE: To assess the long-term outcome in node-positive patients who underwent extended PLND followed by RRP. DESIGN, SETTING, AND PARTICIPANTS: A consecutive series of 122 node positive patients with negative preoperative staging examinations, no neoadjuvant hormonal or radiotherapy, and who underwent extended PLND (>/=10 lymph nodes in the surgical specimen) followed by RRP were analyzed. None of the patients received immediate androgen deprivation therapy (ADT). INTERVENTION: All patients underwent extended PLND followed by RRP. MEASUREMENTS: Biochemical recurrence-free survival, cancer-specific, and overall survival were assessed using the Kaplan-Meier technique. RESULTS AND LIMITATIONS: Median prostate-specific antigen (PSA) was 16ng/ml. At pathological examination 76% of the 122 patients had pT3-pT4 tumours, 50% seminal vesicle infiltration. A median of 22 nodes were removed per patient. Median cancer-specific survival at 5 and 10 yr was 84.5% and 60.1%, respectively. In patients with /=3 positive nodes removed, median cancer-specific survival at 10 yr was 78.6% and 33.4%, respectively (p<0.001). After a median period of 33 mo, 61 of the 122 patients (50%) received ADT, particularly those (69%) with >/=3 positive nodes removed. This retrospective study includes a significant percentage of patients with high tumour burden, and therefore may not reflect current patient series. CONCLUSIONS: Patients with /=3 positive nodes, despite extended PLND and despite ADT in 69% of patients.     

Cost Comparison of Robotic,Laparoscopic, and Open Radical Prostatectomy for Prostate Cancer

Background

Demand and utilization of minimally invasive approaches to radical prostatectomy have increased in recent years, but comparative studies on cost are lacking.

Objective

To compare costs associated with robotic-assisted laparoscopic radical prostatectomy (RALP), laparoscopic radical prostatectomy (LRP), and open retropubic radical prostatectomy (RRP).

Design, setting, and participants

The study included 643 consecutive patients who underwent radical prostatectomy (262 RALP, 220 LRP, and 161 RRP) between September 2003 and April 2008.

Measurements

Direct and component costs were compared. Costs were adjusted for changes over the time of the study.

Results and limitations

Disease characteristics (body mass index, preoperative prostate-specific antigen, prostate size, and Gleason sum score 8–10) were similar in the three groups. Nerve sparing was performed in 85% of RALP procedures, 96% of LRP procedures, and 90% of RRP procedures (p < 0.001). Lymphadenectomy was more commonly performed in RRP (100%) compared to LRP (22%) and RALP (11%) (p < 0.001). Mean length of hospital stay was higher for RRP than for LRP and RALP. The median direct cost was higher for RALP compared to LRP or RRP (RALP: $6752 [interquartile range (IQR): $6283–7369]; LRP: $5687 [IQR: $4941–5905]; RRP: $4437 [IQR: $3989–5141]; p < 0.001). The main difference was in surgical supply cost (RALP: $2015; LRP: $725; RRP: $185) and operating room (OR) cost (RALP: $2798; LRP: $2453; RRP: $1611; p < 0.001). When considering purchase and maintenance costs for the robot, the financial burden would increase by $2698 per patient, given an average of 126 cases per year.

Conclusions

RALP is associated with higher cost, predominantly due to increased surgical supply and OR costs. These costs may have a significant impact on overall cost of prostate cancer care.     

Robotic-assisted laparoscopic radical prostatectomy after aborted retropubic radical prostatectomy

Robotic-assisted laparoscopic prostatectomy (RALP) has surged in popularity since US Food and Drug Administration approval in 2000. Advantages include improved visualization and increased instrument dexterity within the pelvis. Obesity and narrow pelves have been associated with increased difficulty during open retropubic radical prostatectomy (RRP), but the robotic platform theoretically allows one to perform a radical prostatectomy despite these challenges. We present an example of a RALP performed following an aborted RRP. A 49-year-old male with intermediate risk prostate cancer and body mass index of 38 kg/m² presented for RALP after RRP was aborted by an experienced open surgeon following incision of the endopelvic fascia due to poor visualization, a prominent pubic tubercle, and a narrow pelvis. The enhanced visualization and precision of the robotic platform allowed adequate exposure of the prostate and allowed us to proceed with an uncomplicated prostatectomy, which was not possible to perform easily via an open approach. The bladder was densely adherent to the pubis and the anterior prostatic contour and apex were difficult to develop due to a dense fibrotic reaction from the previous endopelvic fascia incision. However, we were able to successfully complete RALP with subtle technical modifications. Estimated blood loss was 160 mL and operating time was 145 min. The patient’s pathology was significant for a positive peri-prostatic lymph node and he has been referred to radiation oncology for adjuvant radiotherapy and androgen deprivation therapy. At 3 months follow-up he had a prostate-specific antigen level of 0.06 ng/mL, partial erections, and mild urinary incontinence requiring one pad per day. Superior intracorporeal laparoscopic visualization and improved instrument dexterity afforded by the robotic surgical platform may make RALP the preferred approach in obese men or men with difficult pelvic anatomy who are deemed poor RRP candidates.     

Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Thus far, no institution has investigated the impact of the most commonly used surgical techniques – open, laparoscopic and robotic radical prostatectomy – on biochemical outcome. However, recent data from large meta‐analysis suggest that the impact of the chosen surgical technique on biochemical outcome is minimal and statistically not relevant. We are the first to apply the method of propensity score matching in the urology literature to compare three different surgical techniques. This method is intended to simulate a randomized trial which is unlikely to be undertaken for radical prostatectomies. We confirmed previous data that the surgical technique does not seem to have an impact on biochemical outcome following radical prostatectomy.

OBJECTIVE

? To investigate a single institution experience with radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot‐assisted radical prostatectomy (RARP) with respect to pathological and biochemical outcomes.

PATIENTS AND METHODS

? A group of 522 consecutive patients who underwent RARP between 2003 and 2008 were matched by propensity scoring on the basis of patient age, race, preoperative prostate‐specific antigen (PSA), biopsy Gleason score and clinical stage with an equal number of patients who underwent LRP and RRP at our institution. ? Pathological and biochemical outcomes of the three cohorts were examined.

RESULTS

? Overall positive surgical margin rates were lower among patients who underwent RRP (14.4%) and LRP (13.0%) compared to patients who underwent RARP (19.5%) (P= 0.010). There were no statistically significant differences in positive margin rates between the three surgical techniques for pT2 disease (P= 0.264). ? In multivariate logistic regression analysis, surgical technique (P= 0.016), biopsy Gleason score (P < 0.001) and preoperative PSA (P < 0.001) were predictors of positive surgical margins. ? Kaplan–Meier analysis did not show any statistically significant differences with respect to biochemical recurrence for the three surgical groups.

CONCLUSIONS

? RRP, LRP and RARP represent effective surgical approaches for the treatment for clinically localized prostate cancer. A higher overall positive SM rate was observed for the RARP group compared to RRP and LRP; however, there was no difference with respect to biochemical recurrence‐free survival between groups. ? Further prospective studies are warranted to determine whether any particular technique is superior with regard to long‐term clinical outcomes.     

The effect of the approach to radical prostatectomy on the profitability of hospitals and surgeons

Study Type – Therapy (economics analysis)
Level of Evidence 2b

OBJECTIVE

To evaluate the profit margins for radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot‐assisted laparoscopic prostatectomy (RALP), and the effect on the reimbursement to the urologist, as there has been a dramatic increase in use of RALP, with the cost of the robot borne by hospitals.

METHODS

Data on costs and payments to hospital and surgeon from 2003 to 2008 for RRP, LRP and RALP were obtained from the hospital and urology department. We determined the profit based on the difference between payments received and total cost.

RESULTS

Between 2000 and 2008, 1279 RPs were performed at our private hospital. The introduction of RALP increased total number of RPs and replaced most RRPs. RRP represents the only procedure where payments exceed total costs. For RRP there was a significantly higher profit for patients with comorbidities. The type of payer had a large effect on profit. Medicare provides a small profit for RRP but a significant loss of >US$4000 for RALP. While all insurance companies resulted in losses for LRP and RALP, there was variability of almost $600/case for LRP and >$1400/case for RALP. RALP provided the highest reimbursement for the surgeon due to additional reimbursement for the S2900 code (use of robot).

CONCLUSIONS

The introduction of RALP has increased the case volume at our hospital and improved profits for the surgeon. The hospital loses money on each LRP and RALP case compared with RRP, which provides a small profit.     

Multicenter evaluation of guideline adherence for pelvic lymph node dissection in patients undergoing open retropubic vs. laparoscopic or robot assisted radical prostatectomy according to the recent German S3 guideline on prostate cancer

Purpose

Pelvic lymph node dissection (PLND) is recommended for patients with prostate cancer (PCa) and significant risk for nodal metastases. This study aimed to assess guideline adherence regarding PLND according to the German S3 guideline as example for a national but highly used guideline on prostate cancer and to compare the rate of complications different approaches for radical prostatectomy (RP).

Methods

Patients undergoing open (RRP), laparoscopic (LARP) or robot-assisted (RARP) RP in six centers in Germany and Austria were included. The primary endpoint was the total number of removed lymph nodes (LN) between the different surgical approaches according to recent guideline recommendations. Secondary endpoints were the number of patients undergoing a sufficient PLND, defined as a removal of at least 10 LN and associated complication rates.

Results

2634 patients undergoing RP were included (RRP: 66%, RARP/LARP: 34%). PLND was performed in 88% (RRP: 88.5%, RARP/LARP: 86.8%, p = 0.208). In intermediateor high risk PCa, PLND was performed in 97.2% (RRP: 97.7%, RARP/LARP: 96.2, p = 0.048). Of those, the mean number of LN was 19 (RRP: 19 vs. RARP/LARP: 17, p < 0.005) and sufficient PLND was observed in 84.6% of RRP compared to 77.2% of RARP/LARP (p < 0.005). Symptomatic lymphoceles requiring surgical treatment occurred more often in RRP than in RARP/LARP (4.0% vs. 1.6%, p = 0.001).

Conclusions

The general guideline adherence regarding performing PNLD and the LN yield is high, regardless of the surgical approach. As expected, lymph node yield was higher when very experienced surgeons conducted the procedure. This should be considered in patients’ counseling.

     

Outcomes and complications of pelvic lymph node dissection during robotic-assisted radical prostatectomy

Purpose

Describe the outcomes and complications of patients who underwent standard pelvic lymphadenectomy (SPLND) and extended PLND (EPLND), or who did not undergo PLND (non-PLND) at the time of robotic-assisted laparoscopic radical prostatectomy (RALP).

Methods

Retrospective analysis of prospectively collected longitudinal data of 492 RALPs performed by a single surgeon (Kane) over a 5-year period. Patients are subdivided into three treatment groups: 54 EPLND; 231 SPLND; and 207 non-PLND. Indications for EPLND include Gleason score ≥8, PSA ≥10 ng/mL, and higher D’Amico risk group. Patient demographics, perioperative complications, and short-term oncologic outcomes are compared.

Results

Patients who underwent EPLND had higher-risk prostate cancer as evidenced by higher mean PSA (8.5 ng/mL), biopsy Gleason sum (≥8) (57.7 %), and D’Amico risk group (75.9 %), compared to SPLND and/or non-PLND groups (p ≤ 0.001). The EPLND total lymph node yield was similar compared to SPLND (20 vs. 18; p = 0.070). When the EPLND (n = 41) and SPLND (n = 57) were examined among only high-risk patients, the lymph node (IQR) yields [20 (14–29) vs. 17 (12–23)] and the proportion of positive nodes [29.3 % (12/41) vs. 12.3 % (7/57)] differed significantly (p = 0.048 and p = 0.042, respectively). Complication rates for all groups were similar and lymphocele formation was 5 %; 2.5 % were clinically significant.

Conclusions

Robotic PLND can be performed with nodal yield comparable to open or laparoscopic PLND. Robotic EPLND improves nodal yield and the proportion of high-risk patients with nodal metastases recognized. Robotic PLND is associated with an approximately 5 % lymphocele rate. There is no difference in complications between EPLND and SPLND.     

A prospective trial comparing consecutive series of open retropubic and robot-assisted laparoscopic radical prostatectomy in a centre with a limited caseload

Background

Robot-assisted radical prostatectomy (RALP) is performed worldwide, even in institutions with limited caseloads. However, although the results of large RALP series are available, oncologic and functional outcomes as well as complications from low-caseload centres are lacking.

Objective

To compare perioperative, oncologic, and functional outcomes from two consecutive series of patients with localised prostate cancer treated by retropubic radical prostatectomy (RRP) or recently established RALP in our hospital, which has a limited caseload.

Design, setting, and participants

One hundred fifty consecutive patients were enrolled. Their data and outcomes were collected and extensively evaluated.

Intervention

Seventy-five consecutive patients underwent RRP, and 75 consecutive patients underwent RALP, including all patients of the learning curve.

Measurements

Patient baseline characteristics, perioperative and postoperative outcomes, and complications were evaluated. End points were oncologic data (positive margins, prostate-specific antigen [PSA]), perioperative complications, urinary continence, and erectile function at 3- and 12-mo follow-up.

Results and limitations

The preoperative parameters from the two groups were comparable. The positive surgical margin (PSM) rates were 32% for RRP and 16% for RALP (p = 0.002). For RRP and RALP, the PSA value was <0.2 ng/ml in 91% and 88% of patients 3 mo postoperatively (p = 0.708) and in 87% and 89% of patients 12 mo postoperatively (p = 0.36), respectively. Continence rates for RRP and RALP were 83% and 95% at 3-mo follow-up (p = 0.003) and 80% and 89% after 12-mo follow-up (p = 0.092), respectively. Among patients who were potent without phosphodiesterase type 5 inhibitors (PDE5-I) before RRP and RALP, recovery of erectile function with and without PDE5-Is was achieved in 25% (12 of 49 patients) and 68% (25 of 37 patients) 3 mo postoperatively (p = 0.009) and in 26% (12 of 47 patients) and 55% (12 of 22 patients) 12 mo postoperatively (p = 0.009), respectively. Minimal follow-up for RRP was 12 mo; median follow-up for the RALP group was 12 mo (range: 3–12). According to the modified Clavien system, major complication rates for RRP and RALP were 28% and 7% (p = 0.025), respectively; minor complication rates were 24% and 35% (p = 0.744), respectively.

Conclusions

Despite a limited caseload and including the learning curve, RALP offers slightly better results than RRP in terms of PSM, major complications, urinary continence, and erectile function.     

Critical assessment of the European Association of Urology guideline indications for pelvic lymph node dissection at radical prostatectomy

Study Type – Prognosis (retrospective cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Lymphadenectomy is the most accurate lymph node staging procedure in patients with prostate cancer. We presented the first formal validation of the 2010 European Association of Urology guidelines for lymphadenectomy in prostate cancer patients.

OBJECTIVE

? To assess the 2010 European Association of Urology (EAU) guidelines for prostate cancer, which recommend a pelvic lymph node dissection (PLND) at radical prostatectomy in all individuals with a nomogram‐predicted lymph node invasion (LNI) risk of >7%.

PATIENTS and methods

? We focused on 1520 patients treated with radical prostatectomy and PLND, between 2006 and 2010, at a single European institution. We examined the ability of the EAU proposed threshold to correctly predict histologically confirmed LNI. Moreover, we tested the ability of a range of nomogram thresholds between 1 and 14% to correctly predict histologically confirmed LNI. Finally, we externally validated the EAU PLND guideline nomogram.

RESULTS

? Overall, 10.6% of patients had LNI. The use of the 7% limit would have allowed the avoidance of 49% of PLNDs, at the cost of missing 11% of patients with LNI. The use of thresholds of 6% and 8% would have allowed the avoidance of respectively 46% and 52% of PLNDs, at the cost of missing respectively 9% and 11% of patients with LNI. Overall, the accuracy of the EAU guideline nomogram according to the receiver operating characteristics derived area under curve was 81%

CONCLUSION

? Our observations indicate that the EAU guideline nomogram is highly accurate. The recommended threshold of 7%, above which a PLND should be performed, is associated with a favourable compromise between avoidable PLNDs and potentially missed LNI cases.     

Recovery of urinary function after robotic-assisted laparoscopic prostatectomy versus radical perineal prostatectomy for early-stage prostate cancer

Introduction

Robotic-assisted laparoscopic prostatectomy (RALP) has largely replaced open radical prostatectomy in many centers. Radical perineal prostatectomy (RPP) is another less invasive approach that has not been widely adopted. RPP offers excellent exposure of the urinary sphincter and bladder neck that may provide good urinary function outcomes. We evaluate urinary function after RALP and RPP.

Methods

Retrospective review of a prospective radical prostatectomy database was performed. Urinary modules from the Expanded Prostate Cancer Index Composite—Urinary Function (EPIC-UF) questionnaire were used to determine urinary symptoms at baseline and at 6, 12, 18, and 24 months after surgery.

Results

753 men underwent RALP (n?=?623) or RPP (n?=?130). Of these, 558 had complete data and were included in our study (RALP: n?=?458, RPP: n?=?100). A higher number of patients undergoing RALP than RPP had pelvic lymph node dissection (20.2% vs. 0%, p?<?0.0001) and cavernosal neurovascular bundle sparing (79.2% vs. 68.4%, p?<?0.0001). 558 patients had complete EPIC-UF data. Overall urinary recovery was greater for RALP than RPP at 6 months (p?=?0.028). Urinary incontinence and function were also more improved after RALP compared to RPP at 6 months (p?=?0.021, p?=?0.006). However, no differences in overall, urinary incontinence, or urinary function scores were seen at 12, 18, or 24 months. There was no difference between groups in urinary bother or irritative/obstructive symptoms at any time point.

Conclusions

RALP had more rapid recovery of urinary function at 6 months vs. RPP; at 12–24 months, however, RALP and RPP had similar urinary function recovery in all urinary subdomains.

     

Reconsidering the role of pelvic lymph node dissection with radical prostatectomy for prostate cancer in an era of improving radiological staging techniques

Background

Performing an extended pelvic lymph node dissection (PLND) on all men with intermediate- and high-risk prostate cancer at the time of a radical prostatectomy (RP) remains controversial. The majority of patients PLND histology is benign, and the long-term cancer-free progression in men with positive lymph node metastasis is low. The objective is to investigate the probability of long-term biochemical freedom from recurrent disease (bNED) in men with lymph node metastasis identified at the time of radical prostatectomy (RP).

Subjects and methods

A retrospective review of the pathology of 1184 pelvic lymph node dissections performed at the time of a radical prostatectomy by multiple surgeons referred to a single uro-pathology laboratory between 2008 and 2014 identified 61 men with node-positive prostate cancer. Of the men with positive nodes, 24 had a standard PLND and 37 an extended PLND (ePLND). bNED was defined as a post-operative serum PSA < 0.2 ng/ml.

Results

The median follow-up is 4 years (2–8). The median lymph node count was 7 (range 2–16) for PLND and 22 (range 6–46) for the ePLND. A single lymph node metastasis was identified in 56% of the 61 men. Only 10% of men with a positive lymph node metastasis remained free of biochemical recurrence of disease, and only 5% had undetectable serum PSA. There was no difference in bNED outcome between a PLND and ePLND. The number of men needed to be treated with a PLND at the time of RP (NNT) to result in an undetectable post-operative PSA at a median follow-up of 4 years is 395.

Conclusions

In men with lymph node metastasis, the probability of long-term bNED is low and the NNT for cure is high. With emerging improved radiological imaging techniques increasing the detection of lymph node metastasis outside the extended lymph node dissection templates, more scientific investigation is required to evaluate which men will benefit from a PLND and which men can avoid an unnecessary PLND procedure.

     

Robot‐assisted laparoscopic prostatectomy is not associated with early postoperative radiation therapy

OBJECTIVE

To compare open radical prostatectomy (RP) and robot‐assisted laparoscopic prostatectomy (RALP), and to determine whether RALP is associated with a higher risk of features that determine recommendations for postoperative radiation therapy (RT).

PATIENTS AND METHODS

Patients undergoing RP from 2003 to 2007 were stratified into two groups: open RP and RALP. Preoperative (PSA level, T stage and Gleason score), pathological factors (T stage, Gleason score, extracapsular extension [ECE] and the status of surgical margins and seminal vesicle invasion [SVI]) and early treatment with RT or referral for RT within 6 months were compared between the groups. Multivariate analysis was used to control for selection bias in the RALP group.

RESULTS

In all, 904 patients were identified; 368 underwent RALP and 536 underwent open RP (retropubic or perineal). Patients undergoing open RP had a higher pathological stage with ECE present in 24.8% vs 19.3% in RALP (P = 0.05) and SVI in 10.3% vs 3.8% (P < 0.001). In the RALP vs open RP group, there were positive surgical margins in 31.5% vs 31.9% (P = 0.9) and there were postoperative PSA levels of ³ 0.2 ng/mL in 5.7% vs 6.3% (P = 0.7), respectively. On multivariate analysis to control for selection bias, RALP was not associated with indication for RT (odds ratio (OR) 1.10, P = 0.55), or referral for RT (OR 1.04, P = 0.86).

CONCLUSION

RALP was not associated with an increase in either indication or referral for early postoperative RT.     

Surgical management of lymph-node-positive prostate cancer: improves symptomatic control

Study Type – Therapy (case series)
Level of Evidence 4 What’s known on the subject? and What does the study add? There is a paucity of data regarding symptomatic local progression of patients treated with radical prostatectomy in the setting of lymph‐node‐positive prostate cancer. Our retrospective study shows that radical prostatectomy with adjuvant hormonal therapy improves local control of patients in this cohort.

OBJECTIVE

? To assess the impact of primary surgical therapy on local control for patients with lymph‐node‐positive prostate cancer.

METHODS

? A retrospective analysis from January 1982 to January 2001 identified 192 patients treated by radical retropubic prostatectomy (RRP, N= 87), hormonal ablative therapy (ADT, N= 74), or RRP plus adjuvant hormones (RRP + ADT, N= 31). ? Statistical analyses were conducted using the Kruskal–Wallis test, chi‐squared or Fisher’s exact test, log‐rank test and logistic regression with the statistical significance level set at P < 0.05.

RESULTS

? The incidence of local relapse in the three treatment groups (RRP, ADT and RRP + ADT) was 40.2%, 59.5% and 12.9%, respectively. ? Among those with local relapse, the incidence of symptomatic local relapse (defined as local symptoms secondary to locally recurrent prostate cancer) was 25.7%, 75.0% and 50.0%, respectively. ? Logistic regression analysis used to identify predictors of local relapse indicated that patients treated with ADT (OR = 1.96; P= 0.270) had higher odds of having a local relapse whereas patients treated with RRP + ADT (OR = 0.20; P= 0.032) had significantly lower odds of having a local relapse compared with patients treated with RRP (reference group) after adjusting for other significant predictors such as increases in serum PSA at diagnosis (OR = 1.09; P= 0.018) and biochemical failure after primary therapy (OR = 48.3; P < 0.001). ? Logistic regression analysis used to identify predictors of symptomatic local relapse, among patients having had a relapse, indicated that patients treated with RRP + ADT (OR = 2.90; P= 0.322) had higher odds of having a symptomatic local relapse whereas patients treated with ADT alone (OR = 8.67; P < 0.001) had significantly higher odds of having a symptomatic local relapse compared with patients treated with RRP (reference group).

CONCLUSIONS

? Radical prostatectomy (with adjuvant hormonal therapy) provides improved local control in patients with lymph‐node‐positive prostate cancer. ? This important endpoint must be considered when determining the optimal treatment of patients with node‐positive disease.