Comparative Effectiveness of Robot-assisted Versus Open Radical Prostatectomy Cancer Control

Background

Robot-assisted radical prostatectomy (RARP) remains controversial, and no improvement in cancer control outcomes has been demonstrated over open radical prostatectomy (ORP).

Objective

To examine population-based, comparative effectiveness of RARP versus ORP pertaining surgical margin status and use of additional cancer therapy.

Design, setting, and participants

This was a retrospective observational study of 5556 RARP and 7878 ORP cases from 2004 to 2009 from Surveillance Epidemiology and End Results–Medicare linked data.

Intervention

RARP versus ORP.

Outcome measurements and statistical analysis

Propensity-based analyses were performed to minimize treatment selection biases. Generalized linear regression models were computed for comparison of RP surgical margin status and use of additional cancer therapy (radiation therapy [RT] or androgen deprivation therapy [ADT]) by surgical approach.

Results and limitations

In the propensity-adjusted analysis, RARP was associated with fewer positive surgical margins (13.6% vs 18.3%; odds ratio [OR]: 0.70; 95% confidence interval [CI], 0.66–0.75), largely because of fewer RARP positive margins for intermediate-risk (15.0% vs 21.0%; OR: 0.66; 95% CI, 0.59–0.75) and high-risk (15.1% vs 20.6%; OR: 0.70; 95% CI, 0.63–0.77) disease. In addition, RARP was associated with less use of additional cancer therapy within 6 mo (4.5% vs 6.2%; OR: 0.75; 95% CI, 0.69–0.81), 12 mo (OR: 0.73; 95% CI, 0.62–0.86), and 24 mo (OR: 0.67; 95% CI, 0.57–0.78) of surgery. Limitations include the retrospective nature of the study and the absence of prostate-specific antigen levels to determine biochemical recurrence.

Conclusions

RARP is associated with improved surgical margin status relative to ORP for intermediate- and high-risk disease and less use of postprostatectomy ADT and RT. This has important implications for quality of life, health care delivery, and costs.

Patient summary

Robot-assisted radical prostatectomy (RP) versus open RP is associated with fewer positive margins and better early cancer control because of less use of additional androgen deprivation and radiation therapy within 2 yr of surgery.     

Brief review: Neuraxial analgesia in refractory malignant pain

Purpose

This narrative review aims to inform health care practitioners of the current literature surrounding the use of intrathecal (IT) and epidural analgesia in cancer patients with refractory pain at end of life. Topics discussed and reviewed include: patient selection, treatment planning, procedure, equipment, medications, complications, policies and procedures, as well as directions for future research.

Principal findings

Cancer pain is inadequately treated in an estimated 10% of patients with malignant pain despite the implementation of the World Health Organization three-step analgesic ladder. This has prompted some to advocate for the addition of a fourth step that would include neuraxial interventions. There is moderate evidence supporting the safety and efficacy of IT drug therapy in cancer patients with refractory pain. A detailed assessment and interdisciplinary team approach is necessary to develop and implement care plans for patients requiring neuraxial analgesia. Neuraxial analgesia can significantly improve pain and reduce side effects, but this must be balanced against the increased complexity of care and the risk of uncommon but serious complications.

Conclusion

Neuraxial drug delivery gives clinicians more options to manage refractory pain at end of life and should be offered to patients with intractable cancer pain. Teams should be interprofessional with clear delineation of roles and responsibilities. They should discuss advanced discharge planning with the patient prior to implantation as well as provide on-call support.     

Use of near infrared spectroscopy to detect impaired tissue oxygen saturation in patients with complex regional pain syndrome type 1

Purpose

Deep tissue hypoxia has been hypothesized in the pathogenesis of complex regional pain syndrome type 1 (CRPS 1) for some patients. The purpose of this study was to determine if near-infrared spectroscopy (NIRS) could detect differences in deep tissue oxygen saturation (StO₂) and microcirculatory function in the hands of patients with CRPS 1.

Methods

Tissue oxygen saturation was evaluated at baseline and during an ischemia reperfusion challenge using vascular occlusion testing (VOT) in affected vs unaffected hands of patients with unilateral upper limb CRPS 1. A non-randomized experimental study design was used with baseline StO₂ as the primary outcome measure. Secondary outcome measures were occlusion and reperfusion slopes from VOT. Values were compared with the unaffected, contralateral hand and with the dominant and non-dominant hands of sex and age-matched volunteers. Correlations between values derived from NIRS and measures of pain and function from the Brief Pain Inventory (BPI) and the Disability of the Arm, Shoulder and Hand (DASH) questionnaires were explored.

Results

Independent of handedness, the baseline StO₂ of the affected hands of ten CRPS 1 patients was significantly lower than that of their unaffected hands (?5.8%; 95% confidence interval [CI] ?10.6 to ?1.0; P = 0.02). The baseline StO₂ of affected CRPS 1 hands was also significantly lower than the non-dominant hands of ten volunteers (?7.3%; 95% CI ?12.4 to ?2.3; P = 0.007). Differences in VOT occlusion and reperfusion slopes did not reveal changes that could be uniquely attributed to CRPS 1. No significant correlations were detected between values derived from VOT and values for pain and function obtained from BPI and DASH questionnaires for patients with CRPS 1.

Conclusions

Hands of patients affected by CRPS 1 of the upper limb showed significantly lower StO₂ compared with their unaffected contralateral hand as well as the hands of control subjects. This trial was registered at: ClinicalTrials.gov: NCT01586377.