Outcomes of robot-assisted radical prostatectomy in men with previous transurethral resection of prostate

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE

? To critically analyze and compare surgical, oncological and functional outcomes of robot‐assisted radical prostatectomy (RARP) in patients with and without previous transurethral resection of prostate (TURP).

PATIENTS AND METHODS

? The study comprised 158 cases of RARP for clinically localized prostate cancer, including 26 cases that had undergone previous TURP (Group A). ? Surgical, oncological and functional (short‐ and intermediate‐term) outcomes of Group A were compared with 132 cases without previous TURP (Group B).

RESULTS

? Post TURP patients were found to have significantly greater blood loss (494 vs 324 mL) and a need for bladder neck reconstruction (26.7% vs 9.7%) compared to the non‐TURP group. ? Surgical time (189 vs 166 min), conversion rate, margin positivity rate and biochemical recurrence rate were also higher. ? Incontinence rates were higher both at 6 (14% vs 11.8%) and 12 (25% vs 8%) months follow‐up.

CONCLUSIONS

? RARP is feasible but challenging after TURP. It entails a longer operating time, greater operative difficulty and compromised oncological or continence outcomes. ? These cases should be handled by an experienced robotic surgeon with the appropriate expertise.     

The benefits of radical prostatectomy beyond cancer control in symptomatic men with prostate cancer

OBJECTIVE: To evaluate lower urinary tract symptoms (LUTS) and the symptom-associated quality of life (QoL) after radical prostatectomy. PATIENTS AND METHODS: We carried out a prospective study (January 1999 to March 2001) of 50 consecutive men initially assessed in the nurse-led prostate assessment clinic for their LUTS and subsequently diagnosed to have localized prostate cancer. They had a radical retropubic prostatectomy and were assessed before, 3 and 6 months after surgery with a self-administered International Prostate Symptom Score (IPSS) and QoL questionnaires, and measurements of urinary flow rate and postvoid residual urinary (PVR) volumes. Finally, each patient completed a self-administered continence questionnaire at 6 weeks, 3 and 6 months after surgery. RESULTS: In men with moderate to severe LUTS before surgery there were significant improvements in total IPSS, symptom-associated QoL, mean peak flow rate and PVR (P < 0.05). However, in eight men with mild LUTS, although there was a 33% improvement in the total symptom score, it was not statistically significant. Thirty-eight patients reported complete continence, nine had infrequent stress leaks only on heavy physical activity, and the remaining three used < 2 pads/day for protection before heavy physical activity at 3 months after surgery. CONCLUSIONS: Radical prostatectomy provides major benefits to men with LUTS besides cancer control. These data are important in counselling patients about the treatment options, especially in view of the current enthusiasm for brachytherapy and conformal radiotherapy, which may worsen LUTS.     

Outcomes of extremely low risk prostate cancer following radical prostatectomy

The optimal management of men with very favorable clinicopathological factors who develop biochemical recurrence (BCR) after radical prostatectomy (RP) has not been previously reported. Both local and systemic recurrences are unlikely in this cohort. This study examines their management and outcomes. Between October 2000 to March 2010, 1627 men underwent open RP by a single surgeon. In all, 448 (27.5%) met the following criteria for extremely low risk disease: preoperative PSA level <10?ng?ml(-1), clinical stage T1c/T2a, Gleason score 6, estimated cancer volume in the surgical specimen 5% and no evidence for positive surgical margin. Undetectable PSA was defined as 0.04?ng?ml(-1). BCR was defined as PSA 0.2?ng?ml(-1) or initiation of salvage radiation therapy (SRT) for progressively rising PSA. At 54 months mean follow-up (range 3-114 months), 9 (2%) of the 448 men developed BCR. Mean time to BCR was 63 months (range 12-93) and mean PSA doubling time was 15 months (range 6-27). Six underwent SRT, two elected surveillance and one was lost to follow-up. All men undergoing SRT exhibited more than 75% reduction in pre-SRT PSA, indicating the presence of local disease recurrence. All men undergoing SRT maintained PSA levels <0.1 at last follow-up. The BCR of 2% confirmed that we selected a cohort with extremely low risk for BCR after RP. We demonstrated that men fulfilling our criteria who develop BCR all harbor local disease based on favorable response to SRT. These men should be managed with SRT if recurrence is felt to be biologically significant.     

Preoperative characteristics of men with unfavorable high-Gleason prostate cancer at radical prostatectomy

IntroductionSome men with Gleason sum 8–10 prostate cancer (PC) at RP have favorable outcomes: Biochemical recurrence free (BFS) and prostate cancer-specific survival (CSS) are improved for such men with pT2 or pT3a disease compared with pT3b or N1 disease at radical prostatectomy (RP). We examine biopsy characteristics of men with high-grade PC at RP to better select those who may benefit from surgery.Materials and MethodsA total of 1,174 men from our Institutional Database (1982–2010) had Gleason 8–10 cancer at RP. Their demographic and prostate biopsy characteristics were compared among those with disease defined as favorable (pT2 or pT3a) vs. unfavorable (pT3b or N1). Logistic regression was used to determine predictors of unfavorable disease. Kaplan-Meier analysis was used to determine survival outcomes.ResultsBiopsy data were available for 1,157 men (median cores 12 [2–20]); 779 (66.4%) favorable, 394 (33.6%) unfavorable; 102 (8.7%), 515 (44.1%), and 552 (47.2%) were low, intermediate, and high-risk. For favorable and unfavorable cases, 10-year BFS was 40.0% and 5.7% (P < 0.001) and CSS was 84.9% and 60.3% (P < 0.001). Multivariate logistic regression revealed that PSA ≥ 20 and perineural invasion (PNI) at biopsy increased the likelihood of unfavorable, high-grade disease. Considering PSA ≥ 20 and PNI as adverse features, 23.7%, 40.1%, and 71.4% of patients with none, 1, or 2 adverse features had unfavorable, high-Gleason PC (P < 0.001).ConclusionsHigh-Gleason PC was not uniformly associated with poor outcomes after RP, though men with unfavorable (pT3b/N1) disease fared poorly. Preoperative predictors of high-Gleason, unfavorable disease in a cohort of predominantly intermediate and high-risk patients were PSA ≥ 20 and PNI.     

Health-related quality of life after radical prostatectomy in Japanese men with localized prostate cancer

PURPOSE: We evaluated retrospectively health-related quality of life (HRQOL) after radical prostatectomy (RP) in Japanese men with localized prostate cancer. METHODS: The study was based on self-reported HRQOL of 280 patients. Patients were divided into seven groups: time 0 (T0), baseline before operation; T1, 1-3 months after RP; T2, 4-6 months after RP; T3, 7-12 months after RP; T4, 13-24 months after RP; T5, 25-36 months after RP; and T6, more than 36 months after RP. We measured the general and disease-specific HRQOL using the RAND 36-item Health Survey 1.0 (SF-36) and the University of California, Los Angeles Prostate Cancer Index (UCLA PCI). RESULTS: The general HRQOL of the postoperative groups was assessed by SF-36. The postoperative groups showed almost the same or higher scores than those of the baseline group. Urinary function scores decreased substantially after surgery. In contrast, there was no difference in urinary bother between the baseline and postoperative groups. Sexual function deteriorated substantially in all postoperative groups. Similarly, the sexual bother score significantly deteriorated after RP. The sexual bother score of men aged 65-years or younger was significantly worse than that of their counterparts in the T1-2 groups. CONCLUSION: Despite reports of problems with sexual activity and urinary continence, general HRQOL was mostly unaffected by RP. Although there was a substantial decrease in urinary function, recovery from urinary bother was rapid. Since the deterioration of sexual function was marked through the postoperative period, careful attention should be paid to this issue during preoperative counseling, especially for younger patients.     

Long-term outcome following radical prostatectomy in men with clinical stage T3 prostate cancer

PURPOSE: We evaluated patients at our institution who underwent radical prostatectomy for clinical stage T3 prostate cancer to determine their long-term clinical outcomes. MATERIALS AND METHODS: We reviewed our prospective surgical database and identified 176 men who underwent radical retropubic prostatectomy for clinical stage T3 prostate cancer from 1983 to 2003. Clinical and pathological data were reviewed and evaluated in a Cox proportional hazards model to determine preoperative predictors of biochemical recurrence. Clinical progression following biochemical recurrence was evaluated and clinical failure was defined as the development of clinical metastases or progression to hormone refractory prostate cancer. RESULTS: Of the 176 patients with cT3 prostate cancer 64 (36%) received neoadjuvant hormonal therapy. At a mean followup of 6.4 years 84 (48%) patients had disease recurrence with a median time to biochemical recurrence of 4.6 years. The actuarial 10-year probability of freedom from recurrence was 44%. On multivariate analysis biopsy Gleason score, pretreatment serum prostate specific antigen and year of surgery were independent predictors of biochemical recurrence. Neoadjuvant hormonal therapy was not a significant predictor of biochemical recurrence. Following biochemical recurrence clinical failure developed in 30 of 84 (36%) men with a median time of 11 years. Overall the 5, 10 and 15-year probabilities of death from prostate cancer were 6%, 15% and 24%, respectively. CONCLUSIONS: More than half (52%) of our patients remained free of disease recurrence following radical prostatectomy. In our series neoadjuvant hormonal therapy offered no advantage with respect to disease recurrence. Radical prostatectomy remains an integral component in the treatment of select patients with clinical stage T3 prostate cancer.     

Predicting erectile function outcome in men after radical prostatectomy for prostate cancer

What's known on the subject? and What does the study add? Over the last decade, the surgical treatment of prostate cancer has evolved towards minimal access surgery, particularly via a robot‐assisted technique. However, there is still debate regarding the true benefit for patients with respect to a functional outcome such as erectile function. The present prediction model provides a reliable estimation of the likelihood of regaining erectile function after prostatectomy.

OBJECTIVE

• ? To identify the reported rates of potency after prostatectomy in the recent literature for men without preoperative erectile dysfunction (ED) and to develop a statistical model for predicting the expected potency after prostatectomy.

MATERIALS AND METHODS

• ? A Medline search was conducted with the keywords ‘potency’ and ‘prostatectomy’ from 2003 to 2009.
• ? In total, 33 studies in the English language reporting pre‐ and postoperative erectile function were identified.
• ? Data from studies reporting outcome after open, laparoscopic and robot‐assisted prostatectomy were analyzed separately.
• ? Only data obtained from potent men before surgery were included in the analysis.

RESULTS

• ? In potent men before surgery, the main predictors of post‐treatment erectile function are age and time after treatment.
• ? The cumulative range of potency rates at 48 months for all ages (45–75 years) was 49–74% for open, 58–74% for laparoscopic and 60–100% for robotic prostatectomy.
• ? The predicted outcome differs by type of operation and patient age.

CONCLUSIONS

• ? Men aged <60 years have a significant likelihood of regaining erectile function after radical prostatectomy.
• ? The reported statistical model provides a reliable estimation of erectile function outcome after prostatectomy for men with localized prostate cancer and intact erectile function.

     

Androgen replacement after curative radical prostatectomy for prostate cancer in hypogonadal men

PURPOSE: We documented the experience of 2 urology practices with the use of testosterone supplementation to treat hypogonadal men who had undergone curative radical prostatectomy for localized prostate cancer. We also reviewed the literature for reports of the use of testosterone in men surgically cured of prostate cancer. MATERIALS AND METHODS: A retrospective review of clinical records of 2 busy private urology practices was used to compile brief case histories of hypogonadal men treated with testosterone who had undergone curative radical prostatectomy for localized prostate cancer. Using MEDLINE and BIOSIS Previews (Biological Abstracts, Inc., Philadelphia, Pennsylvania), the literature was searched for articles describing the use of testosterone in men surgically cured of organ confined prostate cancer. RESULTS: The case records of 7 hypogonadal men who had undergone curative radical prostatectomy were identified. All men had clinical symptoms of hypogonadism and low serum testosterone levels. Each man was treated with an androgen preparation. After variable followup periods no biochemical or clinical evidence of cancer recurrence was found in any of the group. No reports in the literature were found of a similar therapeutic approach for such patients. CONCLUSIONS: Based on the clinical experience with this small group of men, and indirect evidence of the safety of this approach from epidemiological and clinical data, further cautious use of testosterone in a carefully selected population seems warranted.     

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).     

Quality of life in men with localized prostate cancer treated by radical prostatectomy or radiotherapy

Radical prostatectomy and radiotherapy are the most commonly utilized modalities for managing patients with localized prostate cancer. Each has effects on quality of life that are important in decision making. Long term side effects of these treatment modalities include urinary, bowel and sexual dysfunction, and have been documented. Comparison of the side effects of these different modalities continues to be explored, emphasizing their effects on quality of life (QOL) from the patient's viewpoint. Questionnaires were mailed to 224 eligible patients and a response was elicited in 161 men (72%). The final number of patients who completed all the questionnaires was 151. Of these, 73 (48%) had radical prostatectomy and 78 (52%) had radiotherapy. General well being measures demonstrated a definite advantage favoring men treated with radical prostatectomy. Prostate cancer specific QOL measures were similar among men treated with surgery or radiotherapy. Radiotherapy treated men were slightly more likely to report bowel-related problems than surgically treated men. Urinary QOL measures were no different between treated groups. Surgically treated men reported lower level of sexual function than radiotherapy treated men.     

A prospective study measuring penile length in men treated with radical prostatectomy for prostate cancer

PURPOSE: Some patients report that the penis is smaller after radical retropubic prostatectomy for prostate cancer. We performed a prospective study which measured penile length before and after radical retropubic prostatectomy. MATERIALS AND METHODS: A total of 124 men consented to penile measurements before radical prostatectomy performed by the same surgeon. Repeat measurements were performed at 3-month intervals following surgery. Penile measurements (cm.) consisted of flaccid length, stretched length, depth of prepubic fat pad and circumference. Statistical analysis of penile measurements was performed using the paired samples and independent Student's t test, Pearson's correlation and analysis of variance. RESULTS: Mean patient age was 59.1 (range 42 to 76). No patient had a penile abnormality, for example Peyronie's disease, or history of penile or urethral surgery. The size of the penis was significantly smaller after prostatectomy, and there was a significant difference for flaccid (p <0.001), stretched (p <0.001), prepubic fat pad (p = 0.02) and circumference measurements (p <0.01). Twelve patients (19%) had a 15% or greater decrease in stretched penile length. When dichotomizing groups at the cut point of 15% decrease, the independent t test of prostate size was not significant (t[df 36.7] = -1.83, p = 0.076). Nerve sparing was not significant in relation to change in penile stretched length, (F[df 2, 62] = 0.501, p = 0.609). CONCLUSIONS: Our findings support observations of decreased penile length after radical prostatectomy. Men should be counseled before radical prostatectomy that penile shortening may occur.     

Delay of radical prostatectomy and risk of biochemical progression in men with low risk prostate cancer

PURPOSE: Men newly diagnosed with prostate cancer are faced with multiple treatment options. Understanding these options and their associated side effects, and making a decision often requires time, resulting in a delay before receiving treatment. This is particularly pertinent in men with low risk disease who may be considered candidates for watchful waiting and, thus, may not experience strong pressure to undergo treatment promptly. Whether delays and especially prolonged delays, eg greater than 180 days, before RP negatively impact the disease outcome is unclear. MATERIALS AND METHODS: We examined the association between time from diagnosis to surgery, and pathological features of the RP specimen and risk of biochemical progression in 895 men with low risk prostate cancer (prostate specific antigen less than 10 ng/ml and biopsy Gleason sum 6 or less) treated with RP between 1988 and 2004 in the Shared-Equal Access Regional Cancer Hospital Database using logistic regression and Cox proportional hazards, respectively. RESULTS: Time from biopsy to surgery was not significantly related to high grade disease in the RP specimen, positive surgical margins or extraprostatic extension (all p-trend >0.05). After adjustment for multiple clinical covariates a longer time from biopsy to surgery was significantly associated with an increased risk of biochemical progression (p-trend = 0.002). However, this increased risk of progression was only apparent in men with delays greater than 180 days (median 263, vs 90 or fewer days RR 2.73, 95% CI 1.51 to 4.94). CONCLUSIONS: Our data suggest that patients with low risk prostate cancer can be reassured that immediate treatment is not necessary. Whether long delays (greater than 180 days) decrease the likelihood of curability in some patients requires further study.