Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era

RETRACTED: Recommandations françaises du Comité de Cancérologie de l’AFU – Actualisation 2018–2020 : cancer de la prostate French ccAFU guidelines – Update 2018–2020: Prostate cancer

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). Cet article est retiré de la publication à la demande des auteurs car ils ont apporté des modifications significatives sur des points scientifiques après la publication de la première version des recommandations. Le nouvel article est disponible à cette adresse: DOI:10.1016/j.purol.2019.01.007. C’est cette nouvelle version qui doit être utilisée pour citer l’article. This article has been retracted at the request of the authors, as it is not based on the definitive version of the text because some scientific data has been corrected since the first issue was published. The replacement has been published at the DOI:10.1016/j.purol.2019.01.007. That newer version of the text should be used when citing the article.

Clinical factors affecting perioperative outcomes in robot-assisted radical prostatectomy

The present study investigated clinical factors affecting perioperative outcomes in robot-assisted radical prostatectomy (RARP). The study included 625 Japanese cases treated with RARP between 2009 and 2017. The association between clinical factors (age, overweight status, prostate volume, clinical T-stage, nerve sparing, lympho-node dissection, and the number of experienced cases) and perioperative outcomes (operation time, estimated blood loss, catheterization duration, and perioperative complication) were analyzed. Results revealed that overweight status, prostate volume, lymph-node dissection, and the number of experienced cases were associated with operation time. For estimated blood loss, the identified risk factors were overweight status, prostate volume, nerve sparing, lymph-node dissection, and the number of experienced cases. Lymph-node dissection and the number of experienced cases were also associated with catheterization duration. Additionally, only lymph-node dissection was associated with increased perioperative complication. Taken together, the present study identified several clinical factors affecting perioperative outcomes in RARP. This information may help surgeons to estimate perioperative outcomes as well as to inform patients.

Robotic-assisted vs. open radical prostatectomy: A machine learning framework for intelligent analysis of patient-reported outcomes from online cancer support groups

BACKGROUND

The advantages of Robot-assisted laparoscopic prostatectomy (RARP) over open radical prostatectomy (ORP) in Prostate cancer perioperatively are well-established, but quality of life is more contentious. Increasingly, patients are utilising online cancer support groups (OCSG) to express themselves. Currently there is no method of analysis of these sophisticated data sources. We have used the PRIME-2 (Patient Reported Information Multidimensional Exploration version 2) framework for automated identification and intelligent analysis of decision-making, functional and emotional outcomes in men undergoing ORP vs. RARP from OCSG discussions.

METHODS

The PRIME-2 framework was developed to retrospectively analyse individualised patient-reported information from 5,157 patients undergoing RARP and 579 ORP. The decision factors, side effects, and emotions in 2 groups were analysed and compared using Chi-squared, t tests, and Pearson correlation.

RESULTS

There were no differences in Gleason score, Prostate Specific Antigen (PSA), and age between the groups. Surgeon experience and preservation of erectile function (P < 0.01) were important factors in the decision making process. There were no significant differences in urinary, sexual, or bowel symptoms between ORP and RARP on a monthly basis during the initial 12 months. Emotions expressed by patients undergoing RARP were more consistent and positive while ORP expressed more negative emotions at the time of surgery and 3 months postsurgery (P < 0.05), due to pain and discomfort, and during ninth month due to fear and anxiety of pending PSA tests.

CONCLUSIONS

ORP and RARP demonstrated similar side effect profiles for 12 months, but PRIME-2 enables identification of important quality of life features and emotions over time. It is timely for clinicians to accept OCSG as an adjunct to Prostate cancer care.

Robotic vs. Retropubic radical prostatectomy in prostate cancer: A systematic review and an meta-analysis update

CONTEXT

The safety and feasibility of robotic-assisted radical prostatectomy (RARP) compared with retropubic radical prostatectomy(RRP) is debated. Recently, a number of large-scale and high-quality studies have been conducted.

OBJECTIVE

To obtain a more valid assessment, we update the meta-analysis of RARP compared with RRP to assessed its safety and feasibility in treatment of prostate cancer.

METHODS

A systematic search of Medline, Embase, Pubmed, and the Cochrane Library was performed to identify studies that compared RARP with RRP. Outcomes of interest included perioperative, pathologic variables and complications.

RESULTS

78 studies assessing RARP vs. RRP were included for meta-analysis. Although patients underwent RRP have shorter operative time than RARP (WMD: 39.85 minutes; P < 0.001), patients underwent RARP have less intraoperative blood loss (WMD = -507.67ml; P < 0.001), lower blood transfusion rates (OR = 0.13; P < 0.001), shorter time to remove catheter (WMD = -3.04day; P < 0.001), shorter hospital stay (WMD = -1.62day; P < 0.001), lower PSM rates (OR:0.88; P = 0.04), fewer positive lymph nodes (OR:0.45;P < 0.001), fewer overall complications (OR:0.43; P < 0.001), higher 3- and 12-mo potent recovery rate (OR:3.19;P = 0.02; OR:2.37; P = 0.005, respectively), and lower readmission rate (OR:0.70, P = 0.03). The biochemical recurrence free survival of RARP is better than RRP (OR:1.33, P = 0.04). All the other calculated results are similar between the two groups.

CONCLUSIONS

Our results indicate that RARP appears to be safe and effective to its counterpart RRP in selected patients.

National cohort study comparing severe medium-term urinary complications after robot-assisted vs laparoscopic vs retropubic open radical prostatectomy

OBJECTIVES

To evaluate the occurrence of severe urinary complications within 2 years of surgery in men undergoing either robot-assisted radical prostatectomy (RARP), laparoscopic radical prostatectomy (LRP) or retropubic open radical prostatectomy (ORP).

PATIENTS AND METHODS

We conducted a population-based cohort study in men who underwent RARP (n = 4 947), LRP (n = 5 479) or ORP (n = 6 873) between 2008 and 2012 in the English National Health Service (NHS) using national cancer registry records linked to Hospital Episodes Statistics, an administrative database of admissions to NHS hospitals. We identified the occurrence of any severe urinary or severe stricture-related complication within 2 years of surgery using a validated tool. Multi-level regression modelling was used to determine the association between the type of surgery and occurrence of complications, with adjustment for patient and surgical factors.

RESULTS

Men undergoing RARP were least likely to experience any urinary complication (10.5%) or a stricture-related complication (3.3%) compared with those who had LRP (15.8% any or 5.7% stricture-related) or ORP (19.1% any or 6.9% stricture-related). The impact of the type of surgery on the occurrence of any urinary or stricture-related complications remained statistically significant after adjustment for patient and surgical factors (P < 0.01).

CONCLUSION

Men who underwent RARP had the lowest risk of developing severe urinary complications within 2 years of surgery.

Robot-assisted laparoscopic radical cystectomy is a safe and effective procedure for patients with bladder cancer compared to laparoscopic and open surgery: Perioperative outcomes of a single-center experience

OBJECTIVE

We compared the perioperative outcomes of patients with bladder cancer according to three different procedures: robot-assisted laparoscopic radical cystectomy (RALC), laparoscopic radical cystectomy (LRC), and open radical cystectomy (ORC).

METHODS

From April 2008 to March 2017, 36 consecutive patients underwent radical cystectomy and ileal conduit with RALC (n = 10), LRC (n = 10), or ORC (n = 16). All patients underwent RALC and LRC with extracorporeal urinary diversion. Perioperative data were patient demographics, perioperative laboratory data including hematocrit and creatinine, intraoperative crystalloids and colloids, estimated blood loss (EBL), allogeneic transfusion, respiratory parameters including maximum end-tidal carbon dioxide (EtCO₂) and respiratory rate, arterial blood gas data including highest pH, partial pressure of CO₂ (PaCO₂), partial pressure of oxygen (PaO₂), operative time, opiate consumption including intraoperative and postoperative anesthesia, time of hospital stay, time to oral intake and normal diet, and adverse events.

RESULTS

EBL was less for RALC than for other procedures (p = 0.0004). No blood transfusions were performed for RALC, but ORC required significant blood transfusions (p = 0.003). Respiratory rate was highest and PaCO₂ was lowest for RALC. Preoperative creatinine levels were significantly worse for the RALC group, but no significant differences were noted after surgery. There were no significant differences among the groups in regard to hematocrit levels. Operative time, laparoscopic time, intraoperative anesthesia, and postoperative anesthesia did not differ among the groups. High-grade adverse events were only seen for ORC.

CONCLUSION

Although RALC required a steep Trendelenburg position, which might add elements of risk, RALC was safe even for this small cohort.

Comparative effectiveness of laparoscopic versus open prostatectomy for men with low-risk prostate cancer: a matched case-control study

Little data exist on effect of undergoing laparoscopic prostatectomy(LP) versus open prostatectomy(OP) upon 30-day mortality rates among low-risk prostate cancer patients.

Materials and methods

Using the National Cancer Database, we identified men (2004 to 2013) with biopsy-proven, low-risk prostate cancer who met the eligibility criteria: N0, M0, T-stage≤2A, PSA≤10 ng/mL, and Gleason score=6. We utilized a 1:N matched case-control study, with cases and controls matched by race, insurance status, Charlson-Deyo comorbidity score, surgical margin status, and facility type to investigate the short-term comparative effectiveness of LP versus OP.

Results

Among the 448,773 patients in the National Cancer Database with low-risk prostate cancer, 116,359 patients met the above inclusion criteria. The target group was restricted to patients who received LP or OP, thus, leaving 44,720 patients for the study. The use of LP (compared with OP) was associated with patients with privately insured patients, treatment at an academic/research centers, high-volume hospitals, and white race (all P<0.01). LP was less frequently utilized for black patients, those who received treatment at community centers, and for those with Medicaid insurance(all P<0.01). The odds ratio of death for surgery type (laparoscopy vs. open) was estimated at 0.31 (95% confidence interval, 0.135-0.701; P<0.05). Thus, the risk of death within 30 days was 69% lower with LP compared with OP.

Conclusions

We found that the 30-day mortality rate among low-risk prostate cancer patients is significantly lower among patients who received LP when compared with OP, with various clinicopathologic parameters associated with its preferential use.

Laparoscopic and robot-assisted vs open radical prostatectomy for the treatment of localized prostate cancer: a Cochrane systematic review

OBJECTIVE

To determine the effects of laparoscopic radical prostatectomy (LRP), or robot-assisted radical prostatectomy (RARP) compared with open radical prostatectomy (ORP) in men with localized prostate cancer.

MATERIALS AND METHODS

We performed a comprehensive search using multiple databases (CENTRAL, MEDLINE, EMBASE) and abstract proceedings, with no restrictions on the language of publication or publication status, up until 9 June 2017. We included all randomized or pseudo-randomized controlled trials that directly compared LRP and RARP with ORP. Two review authors independently examined full-text reports, identified relevant studies, assessed the eligibility of studies for inclusion, extracted data and assessed risk of bias. We performed statistical analyses using a random-effects model and assessed the quality of the evidence according to Grading of Recommendations Assessment, Development and Evaluation (GRADE). The primary outcomes were prostate cancer-specific survival, urinary quality of life and sexual quality of life. Secondary outcomes were biochemical recurrence-free survival, overall survival, overall surgical complications, serious postoperative surgical complications, postoperative pain, hospital stay and blood transfusions.

RESULTS

We included two unique studies in a total of 446 randomized participants with clinically localized prostate cancer. All available outcome data were short-term (up to 3 months). We found no study that addressed the outcome of prostate cancer-specific survival. Based on one trial, RARP probably results in little to no difference in urinary quality of life (mean difference [MD] -1.30, 95% confidence interval [CI] -4.65 to 2.05; moderate quality of evidence) and sexual quality of life (MD 3.90, 95% CI: -1.84 to 9.64; moderate quality of evidence). No study addressed the outcomes of biochemical recurrence-free survival or overall survival. Based on one trial, RARP may result in little to no difference in overall surgical complications (risk ratio [RR] 0.41, 95% CI: 0.16-1.04; low quality of evidence) or serious postoperative complications (RR 0.16, 95% CI: 0.02-1.32; low quality of evidence). Based on two studies, LRP or RARP may result in a small, possibly unimportant improvement in postoperative pain at 1 day (MD -1.05, 95% CI: -1.42 to -0.68; low quality of evidence) and up to 1 week (MD -0.78, 95% CI: -1.40 to -0.17; low quality of evidence). Based on one study, RARP probably results in little to no difference in postoperative pain at 12 weeks (MD 0.01, 95% CI: -0.32 to 0.34; moderate quality of evidence). Based on one study, RARP probably reduces the length of hospital stay (MD -1.72, 95% CI: -2.19 to -1.25; moderate quality of evidence). Based on two studies, LRP or RARP may reduce the frequency of blood transfusions (RR 0.24, 95% CI: 0.12-0.46; low quality of evidence). Assuming a baseline risk for a blood transfusion to be 8.9%, LRP or RARP would result in 68 fewer blood transfusions per 1,000 men (95% CI: 78-48 fewer).

CONCLUSIONS

There is no evidence to inform the comparative effectiveness of LRP or RARP compared with ORP for oncological outcomes. Urinary and sexual quality of life appear similar. Overall and serious postoperative complication rates appear similar. The difference in postoperative pain may be minimal. Men undergoing LRP or RARP may have a shorter hospital stay and receive fewer blood transfusions.

Can Anterior Prostatic Fat Harbor Prostate Cancer Metastasis? A Prospective Cohort Study

OBJECTIVES

Traditionally anterior prostatic fat (APF) hasn't been included in pelvic lymph node (LN) dissection templates following radical prostatectomy. In this study we evaluate the incidence of lymphoid tissue in the APF and the incidence of LN metastasis in APF in patients who have undergone robotic-assisted laparoscopic radical prostatectomy (RALP).

METHODS

A prospective database of RALP has been maintained between January 2010 and September 2015. APF is routinely excised and sent separately for histopathological evaluation to identify lymphoid tissue and metastatic prostate cancer.

RESULTS

A total of 629 underwent RALP. Forty-six (7.3%) of the patients had lymphoid tissue on histopathological evaluation. Two patients had meta-static disease. Both patients with positive LNs were intermediate risk on pre-operative evolution (A-PSA 16.6 ng/ml, Gleason 3 + 4; B PSA 7.3 ng/ml, Gleason 4 + 3) and upgraded on final prostate pathological evaluation to high risk disease (A-Gleason 4 + 5, pT3b, B-Gleason 4 + 3, pT4).

CONCLUSION

There appears to be lymphatic drainage to the APF from the prostate. Hence APF should be included in pelvic LN dissection templates when lymphadenectomy is contemplated in patients undergoing radical prostatectomy.

Cost of New Technologies in Prostate Cancer Treatment: Systematic Review of Costs and Cost Effectiveness of Robotic-assisted Laparoscopic Prostatectomy, Intensity-modulated Radiotherapy, and Proton Beam Therapy

CONTEXT

Some of the high costs of robot-assisted radical prostatectomy (RARP), intensity-modulated radiotherapy (IMRT), and proton beam therapy may be offset by better outcomes or less resource use during the treatment episode.

OBJECTIVE

To systematically review the literature to identify the key economic trade-offs implicit in a particular treatment choice for prostate cancer.

EVIDENCE ACQUISITION

We systematically reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement and protocol. We searched Medline, Embase, and Web of Science for articles published between January 2001 and July 2016, which compared the treatment costs of RARP, IMRT, or proton beam therapy to the standard treatment. We identified 37, nine, and three studies, respectively.

EVIDENCE SYNTHESIS

RARP is costlier than radical retropubic prostatectomy for hospitals and payers. However, RARP has the potential for a moderate cost advantage for payers and society over a longer time horizon when optimal cancer and quality-of-life outcomes are achieved. IMRT is more expensive from a payer's perspective compared with three-dimensional conformal radiotherapy, but also more cost effective when defined by an incremental cost effectiveness ratio <$50 000 per quality-adjusted life year. Proton beam therapy is costlier than IMRT and its cost effectiveness remains unclear given the limited comparative data on outcomes. Using the Grades of Recommendation, Assessment, Development and Evaluation approach, the quality of evidence was low for RARP and IMRT, and very low for proton beam therapy.

CONCLUSIONS

Treatment with new versus traditional technologies is costlier. However, given the low quality of evidence and the inconsistencies across studies, the precise difference in costs remains unclear. Attempts to estimate whether this increased cost is worth the expense are hampered by the uncertainty surrounding improvements in outcomes, such as cancer control and side effects of treatment. If the new technologies can consistently achieve better outcomes, then they may be cost effective.

PATIENT SUMMARY

We review the cost and cost effectiveness of robot-assisted radical prostatectomy, intensity-modulated radiotherapy, and proton beam therapy in prostate cancer treatment. These technologies are costlier than their traditional counterparts. It remains unclear whether their use is associated with improved cure and reduced morbidity, and whether the increased cost is worth the expense.

A systematic review of instrumental variable analyses using geographic region as an instrument

BACKGROUND

Instrumental variables analysis is a methodology to mitigate the effects of measured and unmeasured confounding in observational studies of treatment effects. Geographic area is increasingly used as an instrument.

METHODS

We conducted a literature review to determine the properties of geographic area in studies of cancer treatments. We identified cancer studies performed in the United States which incorporated instrumental variable analysis with area-wide treatment rate within a geographic region as the instrument. We assessed the degree of treatment variability between geographic regions, assessed balance of measured confounders afforded by geographic area and compared the results of instrumental variable analysis to those of multivariable methods.

RESULTS

Geographic region as an instrument was relatively common, with 22 eligible studies identified, many of which were published in high-impact journals. Treatment rates did not vary greatly by geographic region. Covariates were not balanced by the instrument in the majority of studies. Eight out of eleven studies found statistically significant effects of treatment on multivariable analysis but not for instrumental variables, with the central estimates of the instrumental variables analysis generally being closer to the null.

CONCLUSIONS

We recommend caution and an investigation of IV assumptions when considering the use of geographic region as an instrument in observational studies of cancer treatments. The value of geographic region as an instrument should be critically evaluated in other areas of medicine.

Strategies to minimize readmission rates following major urologic surgery

Readmissions after major surgical procedures are prevalent across multiple disciplines. Specifically, in urology, with incorporation of early discharge and recovery pathways, readmissions are emerging as an important problem and effecting an epidemic proportion of urology patients. As expected, readmissions have garnered the attention of major healthcare payers in the United States who see readmissions as easy targets because of the association with astronomical costs. More importantly, readmissions have a significant negative impact on patient sense of wellbeing, and places economic and other hardships on the doors of our patients and their families. Here, we explore the reasons patients are readmitted, using radical cystectomy as a case study, and means to decrease the incidence of readmissions. Since time to readmission for most major urologic oncology surgeries is within the first 2 weeks after discharge, this time frame is critical for efforts to improve symptom identification and reduce the total number and severity of readmissions. Readmission reduction to zero is unlikely for any major surgery, but with effective coordinated strategies, we must strive to reduce the rates as much as possible, as a means to improve the care continuum for our patients.

Role of robot-assisted radical prostatectomy in locally advanced prostate cancer

Locally advanced prostate cancer is regarded as a very high-risk disease with a poor prognosis. Although there is no definitive consensus on the definition of locally advanced prostate cancer, radical prostatectomy for locally advanced prostate cancer as a primary treatment or part of a multimodal therapy has been reported. Robot-assisted radical prostatectomy is currently carried out even in high-risk prostate cancer because it provides optimal outcomes. However, limited studies have assessed the role of robot-assisted radical prostatectomy in patients with locally advanced prostate cancer. Herein, we summarize and review the current knowledge in terms of the definition and surgical indications of locally advanced prostate cancer, and the surgical procedure and perisurgical/oncological outcomes of robot-assisted radical prostatectomy and extended pelvic lymphadenectomy for locally advanced prostate cancer.

Laparoscopic and robotic-assisted versus open radical prostatectomy for the treatment of localised prostate cancer

BACKGROUND

Prostate cancer is commonly diagnosed in men worldwide. Surgery, in the form of radical prostatectomy, is one of the main forms of treatment for men with localised prostate cancer. Prostatectomy has traditionally been performed as open surgery, typically via a retropubic approach. The advent of laparoscopic approaches, including robotic-assisted, provides a minimally invasive alternative to open radical prostatectomy (ORP).

OBJECTIVES

To assess the effects of laparoscopic radical prostatectomy or robotic-assisted radical prostatectomy compared to open radical prostatectomy in men with localised prostate cancer.

SEARCH METHODS

We performed a comprehensive search using multiple databases (CENTRAL, MEDLINE, EMBASE) and abstract proceedings with no restrictions on the language of publication or publication status, up until 9 June 2017. We also searched bibliographies of included studies and conference proceedings.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) with a direct comparison of laparoscopic radical prostatectomy (LRP) and robotic-assisted radical prostatectomy (RARP) to ORP, including pseudo-RCTs.

DATA COLLECTION AND ANALYSIS

Two review authors independently classified studies and abstracted data. The primary outcomes were prostate cancer-specific survival, urinary quality of life and sexual quality of life. Secondary outcomes were biochemical recurrence-free survival, overall survival, overall surgical complications, serious postoperative surgical complications, postoperative pain, hospital stay and blood transfusions. We performed statistical analyses using a random-effects model and assessed the quality of the evidence according to GRADE.

MAIN RESULTS

We included two unique studies with 446 randomised participants with clinically localised prostate cancer. The mean age, prostate volume, and prostate-specific antigen (PSA) of the participants were 61.3 years, 49.78 mL, and 7.09 ng/mL, respectively. Primary outcomes We found no study that addressed the outcome of prostate cancer-specific survival. Based on data from one trial, RARP likely results in little to no difference in urinary quality of life (MD -1.30, 95% CI -4.65 to 2.05) and sexual quality of life (MD 3.90, 95% CI -1.84 to 9.64). We rated the quality of evidence as moderate for both quality of life outcomes, downgrading for study limitations. Secondary outcomes We found no study that addressed the outcomes of biochemical recurrence-free survival or overall survival.Based on one trial, RARP may result in little to no difference in overall surgical complications (RR 0.41, 95% CI 0.16 to 1.04) or serious postoperative complications (RR 0.16, 95% CI 0.02 to 1.32). We rated the quality of evidence as low for both surgical complications, downgrading for study limitations and imprecision.Based on two studies, LRP or RARP may result in a small, possibly unimportant improvement in postoperative pain at one day (MD -1.05, 95% CI -1.42 to -0.68 ) and up to one week (MD -0.78, 95% CI -1.40 to -0.17). We rated the quality of evidence for both time-points as low, downgrading for study limitations and imprecision. Based on one study, RARP likely results in little to no difference in postoperative pain at 12 weeks (MD 0.01, 95% CI -0.32 to 0.34). We rated the quality of evidence as moderate, downgrading for study limitations.Based on one study, RARP likely reduces the length of hospital stay (MD -1.72, 95% CI -2.19 to -1.25). We rated the quality of evidence as moderate, downgrading for study limitations.Based on two study, LRP or RARP may reduce the frequency of blood transfusions (RR 0.24, 95% CI 0.12 to 0.46). Assuming a baseline risk for a blood transfusion to be 8.9%, LRP or RARP would result in 68 fewer blood transfusions per 1000 men (95% CI 78 fewer to 48 fewer). We rated the quality of evidence as low, downgrading for study limitations and indirectness.We were unable to perform any of the prespecified secondary analyses based on the available evidence. All available outcome data were short-term and we were unable to account for surgeon volume or experience.

AUTHORS' CONCLUSIONS

There is no high-quality evidence to inform the comparative effectiveness of LRP or RARP compared to ORP for oncological outcomes. Urinary and sexual quality of life-related outcomes appear similar.Overall and serious postoperative complication rates appear similar. The difference in postoperative pain may be minimal. Men undergoing LRP or RARP may have a shorter hospital stay and receive fewer blood transfusions. All available outcome data were short-term, and this study was unable to account for surgeon volume or experience.

Patient driven care in the management of prostate cancer: analysis of the United States military healthcare system

Background

Patient preferences are assumed to impact healthcare resource utilization, especially treatment options. There is limited data exploring this phenomenon. We sought to identify factors associated with patients transferring care for prostatectomy, from military to civilian facilities, and the receipt of minimally invasive radical prostatectomy (MIRP).

Methods

Retrospective review of 2006-2010 TRICARE data identified men diagnosed with prostate cancer (ICD-9 185) receiving open radical prostatectomy (ORP; ICD-9: 60.5) or MIRP (ICD-9 60.5 + 54.21/17.42). Patients diagnosed at military facilities but underwent surgery at civilian facilities were defined as “transferring care”. Logistic regression models identified predictors of transferring care for patients diagnosed at military facilities. A secondary analysis identified the predictors of MIRP receipt at civilian facilities.

Results

Of 1420 patients, 247 (17.4%) transferred care. These patients were more likely to undergo MIRP (OR = 7.83, p < 0.01), and get diagnosed at low-volume military facilities (OR = 6.10, p < 0.01). Our secondary analysis demonstrated that transferring care was strongly associated with undergoing MIRP (OR = 1.51, p = 0.04).

Conclusions

Patient preferences induced a demand for greater utilization of MIRP and civilian facilities. Further work exploring factors driving these preferences and interventions tailoring them, based on evidence and cost considerations, is required.

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.

[CCAFU french national guidelines 2016-2018 on prostate cancer]

OBJECTIVES

The purpose of the guidelines national committee CCAFU was to propose updated french guidelines for localized and metastatic prostate cancer (PCa).

METHODS

A Medline search was achieved between 2013 and 2016, as regards diagnosis, options of treatment and follow-up of PCa, to evaluate different references with levels of evidence.

RESULTS

Epidemiology, classification, staging systems, diagnostic evaluation are reported. Disease management options are detailed. Recommandations are reported according to the different clinical situations. Active surveillance is a major option in low risk PCa. Radical prostatectomy remains a standard of care of localized PCa. The three-dimensional conformal radiotherapy is the technical standard. A dose of > 74Gy is recommended. Moderate hypofractionation provides short-term biochemical control comparable to conventional fractionation. In case of intermediate risk PCa, radiotherapy can be combined with short-term androgen deprivation therapy (ADT). In case of high risk disease, long-term ADT remains the standard of care. ADT is the backbone therapy of metastatic disease. In men with metastases at first presentation, upfront chemotherapy combined with ADT should be considered as a new standard. In case of metastatic castration-resistant PCa (mCRPC), new hormonal treatments and chemotherapy provide a better control of tumor progression and increase survival.

CONCLUSIONS

These updated french guidelines will contribute to increase the level of urological care for the diagnosis and treatment for prostate cancer. © 2016 Elsevier Masson SAS. All rights reserved.

Community-based Outcomes of Open versus Robot-assisted Radical Prostatectomy

BACKGROUND

Identifying the optimal surgical approach for patients with localized prostate cancer (PCa) managed in the community setting remains controversial due to the lack of robust, prospective data.

OBJECTIVE

To assess surgical outcomes and changes in urinary and sexual quality of life (QOL) over time in patients undergoing radical prostatectomy (RP).

DESIGN, SETTING, AND PARTICIPANTS

Our study included patients enrolled in Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), a large, prospective, mostly community-based, nationwide PCa registry, who underwent RP between 2004 and 2016.

INTERVENTION

Open (ORP) versus robot-assisted radical prostatectomy (RARP) for localized PCa.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Demographic and clinicopathologic data and surgical outcomes were compared between ORP and RARP. Self-reported, validated questionnaires (scaled 0-100 with higher numbers indicating better function) were used to evaluate urinary and sexual QOL at different time points. Repeated measures mixed-models assessed changes in function and bother over time in each domain.

RESULTS AND LIMITATIONS

Among 1892 men (n = 1137 ORP; n = 755 RARP), Cancer of the Prostate Risk Assessment score, Gleason grade at biopsy and RP, and pT-stage were lower in ORP patients (all p < 0.01). Men undergoing RARP had comparable surgical margin rates, lymph node yields, and biochemical recurrence rates. In a subset analysis with 1451 men reporting baseline and follow-up QOL data, ORP patients reported superior scores in urinary incontinence (ORP mean ± standard deviation 69 ± 26 vs RARP 62 ± 27) and bother (ORP 75±29 vs RARP 68±28, both p < 0.01) only in the 1st yr after RP. Differences in sexual outcomes did not differ between groups, nor did any QOL scores beyond 1 yr. Limitations include a decrease in the rate of questionnaire response during follow-up, potential selection biases in terms of patient assignment to ORP versus RARP and survey completion rates, and the fact that RARP cases likely included the initial learning curve for the CaPSURE surgeons.

CONCLUSIONS

Most patients experienced changes in urinary and sexual QOL in the 1st 3 yr following RP. The pattern of recovery over time was similar between ORP and RARP groups. Patients should not expect different oncologic or QOL outcomes based on surgical approach.

PATIENT SUMMARY

Aside from a small, early, and temporary advantage in terms of urinary incontinence and bother favoring open surgery, minimal differences in outcomes are observed when comparing men who undergo open versus robot-assisted prostatectomy in the community setting.

Comparative effectiveness of prostate cancer treatments for patient-centered outcomes: A systematic review and meta-analysis (PRISMA Compliant)

BACKGROUND

In the context of prostate cancer (PCa) characterized by the multiple alternative treatment strategies, comparative effectiveness analysis is essential for informed decision-making. We analyzed the comparative effectiveness of PCa treatments through systematic review and meta-analysis with a focus on outcomes that matter most to newly diagnosed localized PCa patients.

METHODS

We performed a systematic review of literature published in English from 1995 to October 2016. A search strategy was employed using terms "prostate cancer," "localized," "outcomes," "mortality," "health related quality of life," and "complications" to identify relevant randomized controlled trials (RCTs), prospective, and retrospective studies. For observational studies, only those adjusting for selection bias using propensity-score or instrumental-variables approaches were included. Multivariable adjusted hazard ratio was used to assess all-cause and disease-specific mortality. Funnel plots were used to assess the level of bias.

RESULTS

Our search strategy yielded 58 articles, of which 29 were RCTs, 6 were prospective studies, and 23 were retrospective studies. The studies provided moderate data for the patient-centered outcome of mortality. Radical prostatectomy demonstrated mortality benefit compared to watchful waiting (all-cause HR = 0.63 CI = 0.45, 0.87; disease-specific HR = 0.48 CI = 0.40, 0.58), and radiation therapy (all-cause HR = 0.65 CI = 0.57, 0.74; disease-specific HR = 0.51 CI = 0.40, 0.65). However, we had minimal comparative information about tradeoffs between and within treatment for other patient-centered outcomes in the short and long-term.

CONCLUSION

Lack of patient-centered outcomes in comparative effectiveness research in localized PCa is a major hurdle to informed and shared decision-making. More rigorous studies that can integrate patient-centered and intermediate outcomes in addition to mortality are needed.

Early clinical experience with the da Vinci Xi Surgical System in general surgery

The da Vinci Xi Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) has been released in 2014 to facilitate minimally invasive surgery. Novel features are targeted towards facilitating complex multi-quadrant procedures, but data is scarce so far. Perioperative data of patients who underwent robotic general surgery with the da Vinci Xi system within the first 6 month after installation were collected and analyzed. The gastric bypass procedures performed with the da Vinci Xi Surgical System were compared to an equal amount of the last procedures with the da Vinci Si Surgical System. Thirty-one foregut (28 Roux-en-Y gastric bypasses), 6 colorectal procedures and 1 revisional biliary procedure were performed. The mean operating room (OR) time was 221.8 (±69.0) minutes for gastric bypasses and 306.5 (±48.8) for colorectal procedures with mean docking time of 9.4 (±3.8) minutes. The gastric bypass procedure was transitioned from a hybrid to a fully robotic approach. In comparison to the last 28 gastric bypass procedures performed with the da Vinci Si Surgical System, the OR time was comparable (226.9 versus 230.6 min, p = 0.8094), but the docking time significantly longer with the da Vinci Xi Surgical System (8.5 versus 6.1 min, p = 0.0415). All colorectal procedures were performed with a single robotic docking. No intraoperative and two postoperative complications occurred. The da Vinci Xi might facilitate single-setups of totally robotic gastric bypass and colorectal surgeries. However, further comparable research is needed to clearly determine the significance of this latest version of the da Vinci Surgical System.

Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study

BACKGROUND

The absence of trial data comparing robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy is a crucial knowledge gap in uro-oncology. We aimed to compare these two approaches in terms of functional and oncological outcomes and report the early postoperative outcomes at 12 weeks.

METHOD

In this randomised controlled phase 3 study, men who had newly diagnosed clinically localised prostate cancer and who had chosen surgery as their treatment approach, were able to read and speak English, had no previous history of head injury, dementia, or psychiatric illness or no other concurrent cancer, had an estimated life expectancy of 10 years or more, and were aged between 35 years and 70 years were eligible and recruited from the Royal Brisbane and Women's Hospital (Brisbane, QLD). Participants were randomly assigned (1:1) to receive either robot-assisted laparoscopic prostatectomy or radical retropubic prostatectomy. Randomisation was computer generated and occurred in blocks of ten. This was an open trial; however, study investigators involved in data analysis were masked to each patient's condition. Further, a masked central pathologist reviewed the biopsy and radical prostatectomy specimens. Primary outcomes were urinary function (urinary domain of EPIC) and sexual function (sexual domain of EPIC and IIEF) at 6 weeks, 12 weeks, and 24 months and oncological outcome (positive surgical margin status and biochemical and imaging evidence of progression at 24 months). The trial was powered to assess health-related and domain-specific quality of life outcomes over 24 months. We report here the early outcomes at 6 weeks and 12 weeks. The per-protocol populations were included in the primary and safety analyses. This trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), number ACTRN12611000661976.

FINDINGS

Between Aug 23, 2010, and Nov 25, 2014, 326 men were enrolled, of whom 163 were randomly assigned to radical retropubic prostatectomy and 163 to robot-assisted laparoscopic prostatectomy. 18 withdrew (12 assigned to radical retropubic prostatectomy and six assigned to robot-assisted laparoscopic prostatectomy); thus, 151 in the radical retropubic prostatectomy group proceeded to surgery and 157 in the robot-assisted laparoscopic prostatectomy group. 121 assigned to radical retropubic prostatectomy completed the 12 week questionnaire versus 131 assigned to robot-assisted laparoscopic prostatectomy. Urinary function scores did not differ significantly between the radical retropubic prostatectomy group and robot-assisted laparoscopic prostatectomy group at 6 weeks post-surgery (74·50 vs 71·10; p=0·09) or 12 weeks post-surgery (83·80 vs 82·50; p=0·48). Sexual function scores did not differ significantly between the radical retropubic prostatectomy group and robot-assisted laparoscopic prostatectomy group at 6 weeks post-surgery (30·70 vs 32·70; p=0·45) or 12 weeks post-surgery (35·00 vs 38·90; p=0·18). Equivalence testing on the difference between the proportion of positive surgical margins between the two groups (15 [10%] in the radical retropubic prostatectomy group vs 23 [15%] in the robot-assisted laparoscopic prostatectomy group) showed that equality between the two techniques could not be established based on a 90% CI with a Δ of 10%. However, a superiority test showed that the two proportions were not significantly different (p=0·21). 14 patients (9%) in the radical retropubic prostatectomy group versus six (4%) in the robot-assisted laparoscopic prostatectomy group had postoperative complications (p=0·052). 12 (8%) men receiving radical retropubic prostatectomy and three (2%) men receiving robot-assisted laparoscopic prostatectomy experienced intraoperative adverse events.

INTERPRETATION

These two techniques yield similar functional outcomes at 12 weeks. Longer term follow-up is needed. In the interim, we encourage patients to choose an experienced surgeon they trust and with whom they have rapport, rather than a specific surgical approach.

FUNDING

Cancer Council Queensland.

Radical Prostatectomy in Men with Oligometastatic Prostate Cancer: Results of a Single-institution Series with Long-term Follow-up

In the absence of data from randomized trials, the role of local treatment in metastatic prostate cancer (PCa) is gaining interest. Our study aimed to assess perioperative and long-term oncologic outcomes of radical prostatectomy (RP) in a selected cohort of 11 patients with oligometastatic disease treated with RP and extended pelvic lymph node dissection between 2006 and 2011. Oligometastatic disease was defined as the presence of five or fewer bone lesions at bone scan with or without suspicious pelvic or retroperitoneal nodal involvement at preoperative imaging. The minimum follow-up for survivors was 5 yr. Perioperative outcomes, clinical progression, and cancer-specific mortality (CSM) were evaluated. Median age was 72 yr. Median operative time, blood loss, and length of hospitalization were 170min, 750ml, and 13 d, respectively. Overall, two patients (18%) experienced grade 3 complications in the postoperative period, and eight (73%) received blood transfusions. Overall, 10 (91%) and 8 (73%) patients had lymph node invasion and positive surgical margins, respectively. Adjuvant androgen deprivation therapy was administered to 10 patients (91%). Median follow-up for survivors was 63 mo. The 7-yr clinical progression- and CSM-free survival rates were 45% and 82%, respectively. Our findings support the safety and effectiveness of RP in a highly selected cohort of PCa patients with bone metastases and long-term follow-up.

PATIENT SUMMARY

We evaluated the outcomes of patients with oligometastatic prostate cancer treated with radical prostatectomy with a minimum of 5-yr follow-up. This surgical procedure performed with a multimodal approach might represent a safe and feasible option in selected men and provide acceptable oncologic outcomes at long-term follow-up.

Prostate Cancer Registries: Current Status and Future Directions

CONTEXT

Disease-specific registries that enroll a considerable number of patients play a major role in prostate cancer (PCa) research.

OBJECTIVE

To evaluate available registries, describe their strengths and limitations, and discuss the potential future role of PCa registries in outcomes research.

EVIDENCE ACQUISITION

We performed a literature review of the Medline, Embase, and Web of Science databases. The search strategy included the terms prostate cancer, outcomes, statistical approaches, population-based cohorts, registries of outcomes, and epidemiological studies, alone or in combination. We limited our search to studies published between January 2005 and January 2015.

EVIDENCE SYNTHESIS

Several population-based and prospective disease-specific registries are currently available for prostate cancer. Studies performed using these data sources provide important information on incidence and mortality, disease characteristics at presentation, risk factors, trends in utilization of health care services, disparities in access to treatment, quality of care, long-term oncologic and health-related quality of life outcomes, and costs associated with management of the disease. Although data from these registries have some limitations, statistical methods are available that can address certain biases and increase the internal and external validity of such analyses. In the future, improvements in data quality, collection of tissue samples, and the availability of data feedback to health care providers will increase the relevance of studies built on population-based and disease-specific registries.

CONCLUSIONS

The strengths and limitations of PCa registries should be carefully considered when planning studies using these databases. Although randomized controlled trials still provide the highest level of evidence, large registries play an important and growing role in advancing PCa research and care.

PATIENT SUMMARY

Several population-based and prospective disease-specific registries for prostate cancer are currently available. Analyses of data from these registries yield information that is clinically relevant for the management of patients with prostate cancer.

Robot-assisted Radical Prostatectomy and Extended Pelvic Lymph Node Dissection in Patients with Locally-advanced Prostate Cancer

BACKGROUND

Limited data are available on the role of robot-assisted radical prostatectomy (RARP) in patients with locally advanced prostate cancer (PCa).

OBJECTIVE

To describe our surgical technique of extrafascial RARP and extended pelvic lymph node dissection (ePLND) in locally advanced PCa.

DESIGN, SETTING, AND PARTICIPANTS

Ninety-four patients with clinical stage ≥T3 undergoing RARP with ePLND at three European centers between 2011 and 2015 were retrospectively evaluated.

SURGICAL PROCEDURE

Surgery was performed using the DaVinci Si system. The anatomically defined ePLND included nodes overlying the external iliac axis, those in the obturator fossa, and around the internal iliac artery up to the ureter. RARP was performed using an extrafascial approach where the Denonvillers' fascia was dissected free and left on the posterior surface of the seminal vesicles.

MEASUREMENTS

Perioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values ≥0.2ng/ml. Kaplan-Meier analyses assessed time to BCR and clinical recurrence. Multivariable Cox regression analyses assessed predictors of BCR.

RESULTS AND LIMITATIONS

Median operative time, blood loss, and length of hospital stay were 230min, 200ml, and 6 d. Overall, 12 (12.7%) patients experienced complications and five (5.3%), four (4.3%), and three (3.2%) patients had Clavien I, II, and III/IV complications. Overall, 72 (76.6%), 35 (37.2%), and 30 (32.3%) patients had pT3/4, pN1, and positive margins. The median number of nodes removed was 16. Overall, 19 (20.2%) and 21 (22.3%) patients received adjuvant radiotherapy and hormonal therapy. The median follow-up was 23.5 mo. At 3-yr follow-up, the BCR- and clinical recurrence-free survival rates were 63.3% and 95.8%. Pathologic stage, Gleason score, and positive margins represented predictors of BCR (all p≤0.03). Our study is limited by its retrospective nature and by the follow-up duration.

CONCLUSIONS

RARP represents a well-standardized, safe, and oncological effective option in patients with locally advanced PCa. Pathologic stage, Gleason score, and positive margins should be considered to select patients for multimodal approaches.

PATIENT SUMMARY

Robot-assisted surgery represents a well-standardized, safe, and oncological effective option in men with locally advanced prostate cancer. Two out of three patients treated with this approach are free from recurrence at 3-yr follow-up. Pathologic stage, Gleason score, and positive surgical margins represent predictors of BCR and should be considered to select patients for multimodal approaches.

Using big data for quality assessment in oncology

There is increasing attention in the US healthcare system on the delivery of high-quality care, an issue central to oncology. In the report 'Crossing the Quality Chasm', the Institute of Medicine identified six aims for improving healthcare quality: safe, effective, patient-centered, timely, efficient and equitable. This article describes how current big data resources can be used to assess these six dimensions, and provides examples of published studies in oncology. Strengths and limitations of current big data resources for the evaluation of quality of care are also discussed. Finally, this article outlines a vision where big data can be used not only to retrospectively assess the quality of oncologic care, but help physicians deliver high-quality care in real time.

Teaching Hospitals and the Disconnect Between Technology Adoption and Comparative Effectiveness Research: The Case of the Surgical Robot

The surgical robot, a costly technology for treatment of prostate cancer with equivocal marginal benefit, rapidly diffused into clinical practice. We sought to evaluate the role of teaching in the early adoption phase of the surgical robot. Teaching hospitals were the primary early adopters: data from the Healthcare Cost and Utilization Project showed that surgical robots were acquired by 45.5% of major teaching, 18.0% of minor teaching and 8.0% of non-teaching hospitals during the early adoption phase. However, teaching hospital faculty produced little comparative effectiveness research: By 2008, only 24 published studies compared robotic prostatectomy outcomes to those of conventional techniques. Just ten of these studies (41.7%) were more than minimally powered, and only six (25%) involved cross-institutional collaborations. In adopting the surgical robot, teaching hospitals fulfilled their mission to innovate, but failed to generate corresponding scientific evidence.