Outcomes assessment in men undergoing open retropubic radical prostatectomy, laparoscopic radical prostatectomy, and robotic-assisted radical prostatectomy

Nanoparticle Therapy for Prostate Cancer: Overview and Perspectives

Traditional prostate cancer therapy and especially chemotherapy has faced many challenges. Low accumulation levels, rapid clearance or drug resistance at the tumor site have been central to why the effect of chemotherapy drugs has declined. Applications of nanotechnology to biomedicine have enabled the development of nanoparticle therapeutic carriers suited for the delivery of chemotherapeutics in cancer therapy. This review describes the current nature of nanoparticle therapeutic carriers for prostate cancer. It describes typical nanocarriers commonly used for the delivery of chemotherapy or for imaging examination. Targeting strategies and related influencing factors are investigated to find ways of enhancing treatment effects of nanoparticles. The overall purpose of this review is to further understanding and to offer recommendations on the design and development of therapeutic nanoparticles for prostate cancer.

da Vinci and Open Radical Prostatectomy: Comparison of Clinical Outcomes and Analysis of Insurance Costs

PURPOSE

To assess clinical outcomes and reimbursement costs of open and robotic-assisted radical prostatectomies in Germany.

METHODS

Perioperative data of 499 open (2003-2006) and 932 (2008-2010) robotic-assisted radical prostatectomies as well as longitudinal reimbursement costs of an anonymized health insurance research database from Germany containing data of patients who underwent robotic-assisted or open radical prostatectomy were retrospectively analysed in a single-centre study.

RESULTS

Significantly better outcomes after robotic-assisted vs. open prostatectomy were observed in regards to positive surgical margins (13.3 vs. 22.4%; p < 0.0001), intraoperative transfusions (0.1 vs. 2.6%; p < 0.0001), hospitalization (8.7 vs. 15.2 days; p < 0.0001) and duration of catheter (6.6 vs. 12.8 days; p < 0.0001). Operating time was significantly longer with robotic-assisted radical prostatectomy when compared to open surgery (184.4 vs. 128.0 min; p < 0.0001), while intraoperative complications showed a similar occurrence between both groups. Significant fewer postoperative complications were observed after robotic-assisted radical prostatectomy (26.5 vs. 42.5%; p < 0.0001) and rate of re-admission was lower for the robotic patients (13.6 vs. 19.4%; p = 0.0050). While insurance costs were higher in the 2 years before radical prostatectomy for the patients who underwent a robotic procedure (4,241.60 vs. 3,410.23 €; p = 0.202), additive costs of care of the year of surgery plus the 2 following years were less for the robotic cohort when compared to the costs incurred by the open group (21,673.71 vs. 24,512.37 €; p = 0.1676).

CONCLUSIONS

The observed clinical advantages of robotic-assisted radical prostatectomy seem to result in reduced health insurance cost postoperatively when compared to open surgery. This should be taken into consideration regarding reimbursement and implementation of a clinically superior method.

Contemporary urologic minilaparoscopy: indications, techniques, and surgical outcomes in a multi-institutional European cohort

OBJECTIVES

To provide an analytical overview of contemporary indications, techniques, and outcomes of urologic minilaparoscopy (ML) in multiple European centers.

METHODS

Data of patients who had undergone a minilaparoscopic urologic procedure at nine European institutions between 2009 and 2012 were retrospectively gathered. Surgical procedures were classified as upper or lower urinary tract and as ablative or extirpative and reconstructive. The main surgical outcome parameters were analyzed and relevant operative data related to the surgical technique were recorded.

RESULTS

Overall, 192 patients (mean age 45.25±17.8 years) were included in the analysis. Most of them were nonobese (mean body mass index [BMI] 24.7±3.6 kg/m(2)) at low estimated surgical risk (mean American Society of Anesthesiologists [ASA] 1.69±0.68). Indications for surgery were mostly nononcologic (132 cases, 68.8%). Most of the procedures were done in the upper urinary tract (133 cases, 69.2%) and were mostly with a reconstructive intent (109 cases, 56.7%). Overall operative time was 132.7±52.3 minutes with an estimated blood loss of 60.9±47.6 mL while the mean hospital stay was 5±2.1 days. Most of the postoperative complications were low Clavien grade (1 and 2), with only one (0.5%) grade 3 and one (0.5%) grade 4 complications recorded.

CONCLUSIONS

A broad range of common procedures can be safely and effectively performed with ML techniques. By duplicating the principles of standard laparoscopy, but potentially offering less surgical scar and trauma, ML can be regarded as a viable option when looking for a virtually "scarless" surgery.

Benchmarks for operative outcomes of robotic and open radical prostatectomy: results from the Health Professionals Follow-up Study

BACKGROUND

Robot-assisted laparoscopic radical prostatectomy (RALP) has become increasingly common; however, there have been no nationwide, population-based, non-claims-based studies to evaluate differences in outcomes between RALP and open radical retropubic prostatectomy (RRP).

OBJECTIVE

To determine surgical, oncologic, and health-related quality of life (HRQOL) outcomes following RALP and RRP in a nationwide cohort.

DESIGN, SETTING, AND PARTICIPANTS

We identified 903 men in the Health Professionals Follow-up Study diagnosed with prostate cancer between 2000 and 2010 who underwent radical prostatectomy using RALP (n=282) or RRP (n=621) as primary treatment.

INTERVENTION

Radical prostatectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We compared patients undergoing RALP or RRP across a range of perioperative, oncologic, and HRQOL outcomes.

RESULTS AND LIMITATIONS

Use of RALP increased during the study period, constituting 85.2% of study subjects in 2009, up from 4.5% in 2003. Patients undergoing RALP compared to RRP were less likely to have a lymph node dissection (51.5% vs 85.4%; p<0.0001), had less blood loss (207.4 ml vs 852.3 ml; p<0.0001), were less likely to receive blood transfusions (4.3% vs 30.3%; p<0.0001), and had shorter hospital stays (1.8 d vs 2.9 d; p<0.0001). Surgical, oncologic, and HRQOL outcomes did not differ significantly among the groups. In multivariate logistic regression models, there were no significant differences in 3- or 5-yr recurrence-free survival comparing RALP versus RRP (hazard ratios: 0.98 [95% confidence interval (CI), 0.46-2.08] and 0.75 [95% CI, 0.18-3.11], respectively).

CONCLUSIONS

In a nationwide cohort of patients undergoing surgical treatment for prostate cancer, RALP was associated with shorter hospital stay, and lower blood loss and transfusion rates than RRP. Surgical oncologic and HRQOL outcomes were similar between groups.

PATIENT SUMMARY

We studied men throughout the United States with prostate cancer who underwent surgical removal of the prostate. We found that robot-assisted laparoscopic radical prostatectomy resulted in shorter hospital stay, less blood loss, and fewer blood transfusions than radical retropubic prostatectomy. There were no differences in cancer control or health-related quality of life.

Development of urologic laparoscopy in Germany, Austria, and Switzerland: a survey among urologists

PURPOSE

Laparoscopy introduction has dramatically changed urology. Novel techniques, such as laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES), might also have substantial influence. This 2012 survey evaluated present laparoscopy use, its appraisal among urologic surgeons, laparoscopy training, and use of new techniques. Results were compared to the previous surveys, demonstrating the 10-year development of laparoscopy.

METHODS

A detailed questionnaire regarding demographic data, laparoscopy use, attitudes concerning laparoscopy, and novel techniques was send to 424 departments in Germany, Austria, and Switzerland. Procedures performed in 25 indications were quantitatively evaluated.

RESULTS

The response rate was 63 % (269). Eighty-six percent of the respondents reported performing laparoscopy, compared to 54 % in 2002. Only 16 % expected economic advantages with laparoscopy, whereas 67 % expected shorter hospitalization. Seventy percent of responders anticipated comparable functional and oncological results between laparoscopic procedures and open surgery. Slow learning curves (81 %) and insufficient training facilities (32 %) were reported to impair laparoscopic surgery. On average, laparoscopic and non-laparoscopic surgical teams consisted of 2.5 and 3.5 members, respectively. LESS procedures were performed at 15 % of institutions. Twenty-two percent of respondents considered NOTES techniques valuable for future urology. Few indications (laparoscopic prostatectomies or nephrectomies) were performed frequently in specialized centers, and the rapidly increasing procedure numbers observed between 2002 and 2007 had dropped to a mild accretion. The results demonstrate broad acceptance of laparoscopy in German urologic surgery, depict the need for structured training facilities, and indicate limited impact of novel techniques (LESS and NOTES).

CONCLUSIONS

The survey demonstrates the 10-year development of urologic laparoscopy and the broad acceptance of laparoscopic techniques.

Long-term oncological and functional results of extraperitoneal laparoscopic radical prostatectomy: one surgical team's experience on 1,600 consecutive cases

PURPOSE

To determine the oncologic and functional outcomes of ELRP on a single surgical team's series.

METHODS

A total of 1,600 consecutive ELRP patients were recorded with a 2-year follow-up. In 778 patients, a 5-year follow-up was available.

RESULTS

The mean operative time was 125,6 min (PLND not included) and 150,9 min (PLND included). Postoperative stage was pT2a in 282 patients (17.6 %), pT2b in 877 (54.8 %), pT2c in 18 (1.1 %), pT3a in 241 (15 %), and pT3b in 182 (11.3 %). Positive margins were detected in 7.4 and 13.4 % of pT2 and pT3 tumors, respectively. Overall complication rate was 4 %. PSA levels resulted in <0.2 ng/mL in 96.4, 94.9, 92, 90.9, and 81.5 % of the cases at 3, 12, 24, 36, and 60 months after surgery, respectively. BCRFS rates 5 years after ELRP were 88.7 % for patients staged as pT2, 73.9 % for pT3a, and 62.4 % for pT3b. Complete urinary continence rate resulted in 39 and 92 % after 1 and 12 months, respectively, with a further increase from 92 to 98.4 % at 24-month follow-up. A nerve-sparing procedure was performed in 45 % of patients. The overall potency rate at 12-month follow-up was 38.67 % for UNSS patients and 75 % for BNSS patients. Potency recovery was age-dependent, with patients aged <55 years who resulted potent in 46.8 % of UNSS and 95.8 % of BNSS after 24 months.

CONCLUSIONS

ELRP is a standardized and safe procedure that implies advantages of both minimally invasive and extraperitoneal approaches with elevated standards for oncologic and functional outcomes obtained at long-term follow-up.

Recent advances in laparoscopic surgery

Laparoscopic surgery has been widely adopted and new technical innovation, procedures and evidence based knowledge are persistently emerging. This review documents recent major advancements in laparoscopic surgery. A PubMed search was made in order to identify recent advances in this field. We reviewed the recent data on randomized trials in this field as well as papers of systematic review. Laparoscopic cholecystectomy is the most frequently performed procedure, followed by laparoscopic bariatric surgery. Although bile duct injuries are relatively uncommon (0.15%-0.6%), intraoperative cholangiography still plays a role in reducing the cost of litigation. Laparoscopic bariatric surgery is the most commonly performed laparoscopic gastrointestinal surgery in the USA, and laparoscopic Nissen fundoplication is the treatment of choice for intractable gastroesophageal reflux disease. Recent randomized trials have demonstrated that laparoscopic gastric and colorectal cancer resection are safe and oncologically correct procedures. Laparoscopic surgery has also been widely developed in hepatic, pancreatic, gynecological and urological surgery. Recently, SILS and robotic surgery have penetrated all specialties of abdominal surgery. However, evidence-based medicine has failed to show major advantages in SILS, and the disadvantage of robotic surgery is the high costs related to purchase and maintenance of technology. Laparoscopic surgery has become well developed in recent decades and is the choice of treatment in abdominal surgery. Recently developed SILS techniques and robotic surgery are promising but their benefits remain to be determined.

Extraperitoneal laparoscopic radical prostatectomy: A prospective 2-year single-surgeon experience with 171 cases

Objective

To assess the safety and the oncological and functional efficacy of a prospective series of extraperitoneal laparoscopic radical prostatectomy (ELRP).

Patients and methods

This prospective study included 171 consecutive patients (mean age 62.9 years, SD 6.5) who underwent ELRP by one surgeon between January 2008 and December 2009. The variables analysed were operative duration, blood loss, conversion rate, complications, hospital stay, duration of catheterisation, and the oncological results. We also assessed the rates of continence and erectile function.

Results

There were no conversions to open surgery. The mean (SD) operative duration was 112.7 (19.4) min, the blood loss was 372.1 (219.1) mL, the hospital stay was 6.8 (2.0) days, and the duration of catheterisation 6.7 (1.5) days. Collectively, 23.4% (40/171) of patients had positive surgical margins. Urinary continence at 1, 3, 6 and 12 months was achieved in 63.3% (95/150), 88.6% (78/88), in 90.3% (121/134) and 92.1% (117/127) of patients, respectively. The respective percentages for physiological erections after nerve-sparing ELRP at the same times were 11.8% (13/110), 11.8% (13/110), 18.2% (20/110) and 25.5% (28/110). The overall potency recovery rates (including patients on pharmacotherapy) were, respectively, 26.4% (29/110), 35.5% (39/110), 52.7% (58/110) and 69.1% (76/110), for the nerve-sparing procedure.

Conclusion

ELRP gave good oncological and functional results, especially in terms of urinary continence.

Natural orifice (NOTES) transurethral sutureless radical prostatectomy with thulium laser support: first patient report

INTRODUCTION

The aim of this descriptive study was to demonstrate the feasibility and safety of the first true transurethral sutureless radical prostatectomy for prostate cancer in humans using the NOTES technique.

MATERIALS AND METHODS

A 77-year-old man with clinically localized bilateral prostate cancer (Gleason 3 + 4 = 7 in 80% of 12 biopsy cores) and a serum PSA level of 2.1 ng/ml underwent our first natural orifice transurethral radical thulium laser prostatectomy within toto organ retrieval via sectio alta. The surgical procedure is described.

RESULTS

The procedure was completed successfully. Overall operation time was 312 min; laser time was 46 min with 151 KJ. Postoperative hemoglobin was 9.4 g/dl, and the hematocrit was 28%. A cystogram on the 7th postoperative day showed no signs of extravasation and the transurethral catheter was removed, and a flexible cystoscopy on the 9th day demonstrated a sufficient arbitrarily sphincter closure against irrigation flow.

CONCLUSION

The presented descriptive report demonstrates that natural orifice transurethral radical thulium laser prostatectomy for prostate cancer is feasible and safe. Potential candidates include older patients with low-risk cancers and urinary obstruction. Further prospective reports are necessary to evaluate functional and oncological outcome for this innovative technique.