Comparative effectiveness of radical prostatectomy and radiotherapy in prostate cancer: observational study of mortality outcomes

OBJECTIVE

To compare the survival outcomes of patients treated with surgery or radiotherapy for prostate cancer.

DESIGN

Observational study.

SETTING

Sweden, 1996-2010.

PARTICIPANTS

34,515 men primarily treated for prostate cancer with surgery (n=21,533) or radiotherapy (n=12,982). Patients were categorised by risk group (low, intermediate, high, and metastatic), age, and Charlson comorbidity score.

MAIN OUTCOME MEASURES

Cumulative incidence of mortality from prostate cancer and other causes. Competing risks regression hazard ratios for radiotherapy versus surgery were computed without adjustment and after propensity score and traditional (multivariable) adjustments, as well as after propensity score matching. Several sensitivity analyses were performed.

RESULTS

Prostate cancer mortality became a larger proportion of overall mortality as risk group increased for both the surgery and the radiotherapy cohorts. Among patients with non-metastatic prostate cancer the adjusted subdistribution hazard ratio for prostate cancer mortality favoured surgery (1.76, 95% confidence interval 1.49 to 2.08, for radiotherapy v prostatectomy), whereas there was no discernible difference in treatment effect among men with metastatic disease. Subgroup analyses indicated more clear benefits of surgery among younger and fitter men with intermediate and high risk disease. Sensitivity analyses confirmed the main findings.

CONCLUSIONS

This large observational study with follow-up to 15 years suggests that for most men with non-metastatic prostate cancer, surgery leads to better survival than does radiotherapy. Younger men and those with less comorbidity who have intermediate or high risk localised prostate cancer might have a greater benefit from surgery.

Management of prostate cancer. Part 1: chemoprevention

Numerous agents have been investigated in prostate cancer prevention. Many manipulate sex steroid levels or function, some regulate response to oxidative stress and others affect tumor proliferation and/or apoptosis. Some are postulated to even affect downstream targets, such as cyclooxygenase-2, which has been shown to be elevated in prostate cancer by most investigators. The evidence for all these potential chemopreventive agents is critically reviewed. While the current information base is vast, level 1 evidence is lacking, and ongoing trials are not due to provide such evidence for many years to come. In addition, the current lack of ability to accurately differentiate clinically important prostate cancer from latent disease makes chemoprevention in this setting even more challenging. Currently, no reliable biomarkers that can act as surrogate endpoints for the development of clinically relevant prostate cancer exist, which makes performing large chemoprevention trials expensive. At present, there is little to suggest that the urologist or General Practitioner should be recommending any particular chemopreventive agent to either the general population or those deemed to be at higher risk of contracting prostate cancer.

The European Association of Urology Robotic Urology Section (ERUS) survey of robot-assisted radical prostatectomy (RARP)

OBJECTIVE

To evaluate surgeons adherence to current clinical practice, with the available evidence, for robot-assisted radical prostatectomy (RARP) and offer a baseline assessment to measure the impact of the Pasadena recommendations. Recently, the European Association of Urology Robotic Urology Section (ERUS) supported the Pasadena Consensus Conference on best practices in RARP.

SUBJECTS AND METHODS

This survey was performed in January 2012. A specific questionnaire was sent, by e-mail, to 145 robotic surgeons who were included in the mailing-list of ERUS members and working in different urological institutions. Participating surgeons were invited to answer a multiple-choice questionnaire including 24-items evaluating the main RARP surgical steps.

RESULTS

In all, 116 (79.4%) invited surgeons answered the questionnaire and accepted to participate to the ERUS survey. In all, 47 (40.5%) surgeons performed >100 RARPs; 41 (35.3%) between 50 and 100, and 28 (24.1%) <50 yearly. The transperitoneal, antegrade technique was the preferred approach. Minimising bladder neck dissection and the use of athermal dissection of the neurovascular bundles (NVBs) were also popular. There was more heterogeneity in the use of energy for seminal vesicle dissection, the preservation of the tips of the seminal vesicle and the choice between intra- and interfascial planes during the antero-lateral dissection of the NVBs. There was also large variability in the posterior and/or anterior reconstruction steps.

CONCLUSIONS

The present study is the first international survey evaluating surgeon preferences during RARP. Considering that the results were collected before the publication of the Pasadena recommendations, the data might be considered an important baseline evaluation to test the dissemination and effects of the Pasadena recommendations in subsequent years.

Cystolithotomy during robotic radical prostatectomy: Single-stage procedure for concomitant bladder stones

Asymptomatic concomitant vesical calculi are an occasional finding on routine radiologic staging and evaluation of patients with early prostate cancer. We report the first case of single-stage robotic cystolithotomy for multiple bladder stones in a 64-year-old man undergoing robotic-assisted radical prostatectomy, and discuss the approaches available for ensuring complete stone clearance in this unique setting. We show that concomitant bladder stone extraction during robotic-assisted radical prostatectomy is feasible and does not add significantly to operative time. This technique avoids the need to undergo additional general anesthetic procedures with potential complications such as bleeding, urethral stricture formation, and bladder perforation, prior to the prostatectomy.

Robotic-assisted laparoscopic vesiculectomy for lower urinary tract obstruction by a large seminal vesicle cyst

INTRODUCTION

Seminal vesicle (SV) cysts are rare, benign lesions. Most of them are congenital in origin and are usually diagnosed incidentally due to extensive imaging. When symptomatic, surgical excision is recommended.

PRESENTATION OF CASE

We describe the case of a 17.2cm seminal vesicle cyst removed using a transperitoneal, robotic-assisted laparoscopic approach in a 45-year old male with lower urinary tract symptoms and no other genitourinary abnormality.

DISCUSSION

Laparoscopic excision of seminal vesicle cysts is a minimal invasive alternative to the open technique with single-center studies reporting high success rates. With the advent of the robotic platform, urologists have shifted to this approach especially for confined anatomical spaces such as the pelvis. To our knowledge this is the largest seminal vesicle cyst described in the literature that has been managed by minimally invasive surgery.

CONCLUSION

With the advantage of combined 3D vision and wristed instrumentation, excision of large seminal vesicle cysts by robotic assisted laparoscopic approach is feasible, safe and regarded as a natural continuity of conventional laparoscopy. Previous experience in Robotic assisted laparoscopic prostatectomy (RALP) especially in the posterior dissection technique is recommended.

Pathological outcomes and strategies to achieve optimal cancer control during robotic radical prostatectomy in Asian-Indian men

INTRODUCTION AND OBJECTIVES

There is a paucity of information in the literature about the characteristics of prostate cancer in the Asian-Indian population. We wanted to evaluate the oncological outcomes of Asian-Indians and Caucasians. We also derived a nomogram for prediction of extraprostatic extension (EPE) and presented biochemical recurrence (BCR) rates in the Asian-Indian population.

MATERIALS AND METHODS

A total of 2367 D'Amico low-risk patients underwent robotic-assisted radical prostatectomy (RARP) for clinically localized prostate cancer between January 2005 and July 2010 by a single surgeon. Of these 56 (2.4%) patients were Asian-Indians and 2025 were Caucasians (85.6%). Univariate and multivariate models were created for predicting EPE. A multivariate logistic regression model was used to develop a predictive nomogram. BCR was defined as a prostate-specific antigen ≥0.2 at any postoperative time point. Kaplan-Meier survival analysis was used to investigate BCR rates.

RESULTS

A significantly greater percentage of Asian-Indians compared to Caucasians had EPE (32.3 vs. 16.5; P = 0.01). In multivariate analysis adjusted for significant variables from univariate analyses, Asian-Indian race (P = 0.028), age (P = 0.050), maximum percentage cancer on biopsy (P < 0.001), and pathology prostate weight (P = 0.047) were independent predictors of EPE. Kaplan-Meier analysis demonstrated BCR free rates of 94.6% and 95.4%, for Asian-Indians and Caucasians, respectively, at a median follow-up of 16 months (range 2-70 months). There was no statistically significant difference in BCR rates across the two cohorts (log-rank P-value = 0.405).

CONCLUSIONS

This study highlights that while Asian-Indians have more advanced cancer variables, their risk of BCR after surgery is similar to Caucasian patients. Further work is required to better understand the social, genetic and environmental factors that affect the biology of prostate cancer in men of Asian-Indian descent.

Anatomical grades of nerve sparing: a risk-stratified approach to neural-hammock sparing during robot-assisted radical prostatectomy (RARP)

OBJECTIVES

• To report the potency and oncological outcomes of patients undergoing robot-assisted radical prostatectomy (RARP) using a risk-stratified approach based on layers of periprostatic fascial dissection. • We also describe the surgical technique of complete hammock preservation or nerve sparing grade 1.

PATIENTS AND METHODS

• This is a retrospective study of 2317 patients who had robotic prostatectomy by a single surgeon at a single institution between January 2005 and June 2010. • Included patients were those with ≥ 1 year of follow-up and who were potent preoperatively, defined as having a sexual health inventory for men (SHIM) questionnaire score of >21; thus, the final number of patients in the study cohort was 1263. • Patients were categorized pre-operatively by a risk-stratified approach into risk grades 1-4, where risk grade 1 patients received nerve-sparing grade 1 or complete hammock preservation and so on for risk grades 2-4, as long as intraoperative findings permitted the planned nerve sparing. • We considered return to sexual function post-operatively by two criteria: i) ability to have successful intercourse (score of ≥ 4 on question 2 of the SHIM) and ii) SHIM >21 or return to baseline sexual function.

RESULTS

• There was a significant difference across different NS grades in terms of the percentages of patients who had intercourse and returned to baseline sexual function (P < 0.001), with those that underwent NS grade 1 having the highest rates (90.9% and 81.7%) as compared to NS grades 2 (81.4% and 74.3%), 3 (73.5% and 66.1%), and 4 (62% and 54.5%). • The overall positive surgical margin (PSM) rates for patients with NS grades 1, 2, 3, and 4 were 9.9%, 8.1%, 7.2%, and 8.7%, respectively (P = 0.636). • The extraprostatic extension rates were 11.6%, 14.3%, 29.3%, and 36.2%, respectively (P < 0.001). • Similarly, in patients younger than 60, intercourse and return to baseline sexual function rates were 94.9% and 84.3% for NS grade 1 as compared to 85.5% and 77.2% for NS grades 2, 76.9% and 69% for NS grades 3, and 64.8% and 57.7% for NS Grade 4 (P < 0.001).

CONCLUSIONS

• The risk-stratified approach and anatomical technique of neural-hammock sparing described in the present manuscript was effective in improving potency outcomes of patients without compromising cancer control. • Patients with greater degrees of NS had higher rates of intercourse and return to baseline sexual function without an increase in PSM rates.

Is robotic technology facilitating the minimally invasive approach to partial nephrectomy?

OBJECTIVE

• To establish its current status, this study reviews the literature, and reports developments in robotic-assisted partial nephrectomy (RPN), highlighting results from various studies that investigate the oncological and functional efficacy of RPN. Partial nephrectomy has become the standard therapy for the management of small renal masses. In an effort to overcome the perioperative morbidity associated with an open approach, and the extended warm ischaemia times associated with a laparoscopic approach, robotic platforms have been introduced.

PATIENTS AND METHODS

• A search of Medline, EMBASE and Cochrane library databases was completed in July 2010 and used to identify pertinent original articles, editorials, comments and reviews, using the search term 'partial nephrectomy'. Links to related references were surveyed, and all articles finally included were based on relevance and importance of content, as determined by the authors.

RESULTS

• The robotic platform may offer the solution to bridge the gap between open and laparoscopic approaches, achieving warm ischaemia times that consistently average 20 minutes, and providing similar oncological and functional results via a shorter learning curve. It offers cosmesis and convalescence equivalent to that from laparoscopic partial nephrectomy, but with potentially fewer postoperative complications.

CONCLUSION

• In terms of oncological and functional outcomes, the early experiences of RPN in selected series of patients appear at least equivalent to open and laparoscopic partial nephrectomy series. Randomized comparisons between the approaches are lacking, as are longer-term follow-up data for the robotic technique and formal cost analysis; these will be necessary before RPN can replace open partial nephrectomy as the new standard for the management of small renal masses. Trends continue to emerge that highlight the advantage of using the robotic platform to achieve a minimally invasive approach for partial nephrectomy, and with time and increasing expertise, this may become further apparent.

Learning curve for robotic assisted laparoscopic prostatectomy: a multi-institutional study of 3794 patients

AIM

The aim of this study was to define the learning curve for positive surgical margin (PSM) rate and operative time (OT) for robotic assisted laparoscopic radical prostatectomy (RALP); while the learning curve appears shorter for surgical safety for RALP compared to other surgical modalities, this has not been well established for the above parameters.

METHODS

We performed a retrospective cohort study of 3794 patients who underwent RALP between Jan 2003 and Sep 2009 by three surgeons (DL, PW, AKT) from three centers (UPenn, Karolinska, Cornell). Mean overall PSM rates and mean overall OT were calculated for all three surgeons at intervals of 50 RALPs per surgeon, and learning curves for these means were fit using a loess method. R version 2.71 was used for all statistical analysis.

RESULTS

The learning curve for PSM rates for all patients demonstrated improvements continued with increasing surgeon experience, with over 1600 cases required to get a PSM rate <10%. When pT3 patients were evaluated, the learning curve started to plateau after 1000-1500 cases. Mean OT plateaued after 750 cases though with further surgical experience the OTs started to climb again.

CONCLUSION

The learning curve for RALP is not as short as previously thought, and a large number of cases are needed to get PSM rates and OTs to a minimum. This suggests that RALP should be performed by high volume surgeons in order to optimize patient outcomes.

Biobanking after robotic-assisted radical prostatectomy: a quality assessment of providing prostate tissue for RNA studies

BACKGROUND

RNA quality is believed to decrease with ischaemia time, and therefore open radical prostatectomy has been advantageous in allowing the retrieval of the prostate immediately after its devascularization. In contrast, robotic-assisted laparoscopic radical prostatectomies (RALP) require the completion of several operative steps before the devascularized prostate can be extirpated, casting doubt on the validity of this technique as a source for obtaining prostatic tissue. We seek to establish the integrity of our biobanking process by measuring the RNA quality of specimens derived from robotic-assisted laparoscopic radical prostatectomy.

METHODS

We describe our biobanking process and report the RNA quality of prostate specimens using advanced electrophoretic techniques (RNA Integrity Numbers, RIN). Using multivariate regression analysis we consider the impact of various clinicopathological correlates on RNA integrity.

RESULTS

Our biobanking process has been used to acquire 1709 prostates, and allows us to retain approximately 40% of the prostate specimen, without compromising the histopathological evaluation of patients. We collected 186 samples from 142 biobanked prostates, and demonstrated a mean RIN of 7.25 (standard deviation 1.64) in 139 non-stromal samples, 73% of which had a RIN ≥ 7. Multivariate regression analysis revealed cell type--stromal/epithelial and benign/malignant--and prostate volume to be significant predictors of RIN, with unstandardized coefficients of 0.867(p = 0.001), 1.738(p < 0.001) and -0.690(p = 0.009) respectively. A mean warm ischaemia time of 120 min (standard deviation 30 min) was recorded, but multivariate regression analysis did not demonstrate a relationship with RIN within the timeframe of the RALP procedure.

CONCLUSIONS

We demonstrate the robustness of our protocol--representing the concerted efforts of dedicated urology and pathology departments--in generating RNA of sufficient concentration and quality, without compromising the histopathological evaluation and diagnosis of patients. The ischaemia time associated with our prostatectomy technique using a robotic platform does not negatively impact on biobanking for RNA studies.

Predictive models for worsening prognosis in potential candidates for active surveillance of presumed low-risk prostate cancer

PURPOSE

Low-risk prostate cancer patients clinically eligible for active surveillance can also be managed surgically. We evaluated the pathologic outcomes for this cohort that was treated by radical prostatectomy and devised nomograms to predict patients at risk of upgrading and/or upstaging.

MATERIALS AND METHODS

Seven hundred and fifty patients treated by radical prostatectomy from Jan 2005 to the present fulfilled conventional active surveillance criteria and formed the study cohort. Preoperative data on standard clinicopathologic parameters were available. The radical prostatectomy specimens were graded and staged, and any upgrading to Gleason sum >6 or upstaging to ≥pT3 ('worsening prognosis') were noted. Multivariable logistic regression models were used to develop predictive nomograms.

RESULTS

Of the 750 patients, 303 (40.4%) patients were either upgraded or upstaged. Multivariable analysis found that preoperative PSA, number of positive cores, and prostate volume were significantly predictive of worsening prognosis and formed the nomogram criteria.

CONCLUSIONS

Of patients deemed eligible for active surveillance based on conventional criteria, 40.4% have worse prognostic factors after radical prostatectomy. Current active surveillance criteria may be too relaxed, and the use of nomograms which we have devised, may aid in counseling primary prostate cancer patients considering active surveillance as their therapy of choice.

Nomograms based on the Tyrol screening data of 2,271 patients to predict prostate cancer biopsy positivity

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Background: There are no published nomograms that predict prostate cancer in a screened population. We describe three nomograms that predict for prostate cancer on biopsy derived from a large screening population.

Methods: Patients from the Tyrol screening study of known age, total prostate-specific antigen (tPSA), digital rectal examination (DRE), prostate volume, and percent free PSA (%fPSA), and who underwent an initial prostate biopsy from January 1992 to June 2004, were included (n=2271). Multivariable logistic regression models were used to develop the biopsy positivity predictive nomograms: nomogram 1- age, DRE, tPSA; nomogram 2- age, DRE, tPSA, prostate volume; nomogram 3- age, DRE, tPSA, prostate volume, %fPSA. The predictive accuracy of the models was assessed in terms of discrimination and calibration. External validation of the nomograms was performed by comparison with a urologically referred population of patients who underwent prostate biopsy (n=599).

Results: All three nomograms discriminated well between biopsy positive and biopsy negative patients for both the screening and urologically referred cohorts (nomogram 3 better than nomogram 2 better than nomogram 1). All three nomograms were well calibrated internally, but the nomograms under-predicted the probability of a positive biopsy in the urologically referred cohort.

Conclusions: Our nomogram based on age, total PSA, and DRE has a good predictive ability to differentiate between screened patients that will show cancer on initial prostate biopsy and those that will not. Adding prostate volume and percent free PSA improves this predictive power further. All three nomograms under-predict prostate cancer in a urologically referred cohort. These simple nomograms may be of value in counseling screened men with raised PSA and/or abnormal DRE regarding the need for biopsy.

No significant financial relationships to disclose.