Utilization of pelvic lymph node dissection in patients undergoing robot-assisted radical prostatectomy in India versus the United States - A Vattikuti Collective Quality Initiative database analysis

BACKGROUND

The utilization and extent of pelvic lymph node dissection (PLND) varies depending on the disease and practice patterns.

AIMS

This study compares practice patterns in utilization of PLND between Indian and United States (US) practices.

SETTINGS AND DESIGN

We focused on 415 patients (204 India; 211 US) prostate cancer patients treated with robot-assisted radical prostatectomy, between 2015 and 2016, within the Vattikuti Collective Quality Initiative database.

SUBJECTS AND METHODS

Utilization of PLND and number of nodes removed were evaluated for the entire cohort, and after stratifying for Country of treatment and D'Amico risk groups. Logistic regression tested the relationship between PLND and country of treatment, after adjusting for disease risk.

RESULTS

Indian patients had a higher risk distribution (D'Amico high-risk 53.4% in India vs. 27% in the US; P< 0.001) compared to their US counterparts. Overall, 193/204 (94.6%) Indian patients underwent PLND versus 181/211 (85.8%) US patients (P = 0.003). When stratified based on disease risk, PLND was performed more frequently in Indian patients with low-risk disease (81.0% vs. 41.4%,P= 0.008), but not in those with intermediate and high-risk disease. On multivariable analysis, Indian patients had a 2.57-fold higher probability of undergoing PLND than their US counterparts (P = 0.02). The analysis of the number of lymph nodes removed showed similar trends.

CONCLUSIONS

Indian patients are more likely to undergo PLND than US patients. This is, especially true for patients with low-risk disease, who are unlikely to benefit from this procedure. Efforts should focus on optimizing the utilization of PLND, and deliver it only when there is clinical indication.

Minimally invasive surgery and its impact on 30-day postoperative complications, unplanned readmissions and mortality

BACKGROUND

A critical appraisal of the benefits of minimally invasive surgery (MIS) is needed, but is lacking. This study examined the associations between MIS and 30-day postoperative outcomes including complications graded according to the Clavien-Dindo classification, unplanned readmissions, hospital stay and mortality for five common surgical procedures.

METHODS

Patients undergoing appendicectomy, colectomy, inguinal hernia repair, hysterectomy and prostatectomy were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Non-parsimonious propensity score methods were used to construct procedure-specific matched-pair cohorts that reduced baseline differences between patients who underwent MIS and those who did not. Bonferroni correction for multiple comparisons was applied and P < 0·006 was considered significant.

RESULTS

Of the 532 287 patients identified, 53·8 per cent underwent MIS. Propensity score matching yielded an overall sample of 327 736 patients (appendicectomy 46 688, colectomy 152 114, inguinal hernia repair 59 066, hysterectomy 59 066, prostatectomy 10 802). Within the procedure-specific matched pairs, MIS was associated with significantly lower odds of Clavien-Dindo grade I-II, III and IV complications (P ≤ 0·004), unplanned readmissions (P < 0·001) and reduced hospital stay (P < 0·001) in four of the five procedures studied, with the exception of inguinal hernia repair. The odds of death were lower in patients undergoing MIS colectomy (P < 0·001), hysterectomy (P = 0·002) and appendicectomy (P = 0·002).

CONCLUSION

MIS was associated with significantly fewer 30-day postoperative complications, unplanned readmissions and deaths, as well as shorter hospital stay, in patients undergoing colectomy, prostatectomy, hysterectomy or appendicectomy. No benefits were noted for inguinal hernia repair.

Medical androgen deprivation therapy and increased non-cancer mortality in non-metastatic prostate cancer patients aged ≥66 years

PURPOSE

To examine the potential relationship between androgen deprivation therapy and other-cause mortality (OCM) in patients with prostate cancer treated with medical primary-androgen deprivation therapy, prostatectomy, or radiation.

METHODS

A total of 137,524 patients with non-metastatic PCa treated between 1995 and 2009 within the Surveillance Epidemiology and End Results Medicare-linked database were included. Cox-regression analysis tested the association of ADT with OCM. A 40-item comorbidity score was used for adjustment.

RESULTS

Overall, 9.3% of patients harbored stage III-IV disease, and 57.7% of patients received ADT. The mean duration of ADT exposure was 22.9 months (median: 9.1; IQR: 2.8-31.5). Mean and median follow-up were 66.9, and 60.4 months, respectively. At 10 years, overall-OCM rate was 36.5%; it was 30.6% in patients treated without ADT vs. 40.1% in patients treated with ADT (p < 0.001). In multivariable-analysis, ADT was associated with an increased risk of OCM (Hazard-ratio [HR]: 1.11, 95% Confidence-interval [95% CI]: 1.08-1.13). Patients with no comorbidity (10-year OCM excess risk: 9%) were more subject to harm from ADT than patients with high comorbidity (10-year OCM excess risk: 4.7%).

CONCLUSIONS

In patients with PCa, treatment with medical ADT may increase the risk of mortality due to causes other than PCa. Whether this is a simple association or a cause-effect relationship is unknown and warrants further study in prospective studies.

The effect of age at diagnosis on prostate cancer mortality: a grade-for-grade and stage-for-stage analysis

OBJECTIVE

To evaluate the effect of advancing age on cancer-specific mortality (CSM) after radical prostatectomy (RP).

MATERIALS AND METHODS

Overall, 205,551 patients with PCa diagnosed between 1988 and 2009 within the Surveillance Epidemiology and End Results (SEER) database were included in the study. Patients were stratified according to age at diagnosis: ≤ 50, 51-60, 61-70, and ≥ 71 years. The 15-year cumulative incidence CSM rates were computed. Competing-risks regression models were performed to test the effect of age on CSM in the entire cohort, and for each grade (Gleason score 2-4, 5-7, and 8-10) and stage (pT2, pT3a, and pT3b) sub-cohorts.

RESULTS

Advancing age was associated with higher 15-year CSM rates (2.3 vs. 3.4 vs. 4.6 vs. 6.3% for patients aged ≤ 50 vs. 51-60 vs. 61-70 vs. ≥ 71 years, respectively; P < 0.001). In multivariable analyses, age at diagnosis was a significant predictor of CSM. This relationship was also observed in sub-analyses focusing on patients with Gleason score 5-7, and/or pT2 disease (all P ≤ 0.05). Conversely, age failed to reach the independent predictor status in men with Gleason score 2-4, 8-10, pT3a, and/or pT3b disease.

CONCLUSIONS

Advancing age increases the risk of CSM. However, when considering patients affected by more aggressive disease, age was not significantly associated with higher risk of dying from PCa. In high-risk patients, tumor characteristics rather than age should be considered when making treatment decisions.