Oncological effect of palliative transurethral resection of the prostate in patients with advanced prostate cancer: a propensity score matching study

The Role of Transurethral BPH Surgeries in Management of Urinary Symptoms in Prostate Cancer Patients, Narrative Review

PURPOSE OF REVIEW

Prostate cancer and benign prostate hyperplasia (BPH) are two ubiquitous pathologies that may coexist. A significant percentage of patients with different stages of prostate cancer suffer lower urinary tract symptoms (LUTS) due to associated BPH. We aimed to review the literature regarding the role of transurethral surgeries in the management of prostate cancer patients and the different available management options.

RECENT FINDINGS

The evidence in literature for the use of BPH surgeries in prostate cancer patients is based mainly on low-quality retrospective studies. In patients on active surveillance, BPH surgeries are beneficial in relieving LUTS without oncological risk and can eliminate the contribution of adenoma to PSA level. In patients with advanced prostate cancer, palliative BPH surgery can relieve LUTS and urinary retention with unclear oncological impact; however some reports depict that the need for BPH surgery in advanced prostate cancer is associated with poorer prognosis. In patients receiving radiotherapy, various studies showed that transurethral resection of prostate (TURP) is associated with increased radiotoxicity despite some recent reports encouraging the use of Holmium Laser Enucleation of the Prostate (HoLEP) to improve urinary symptom scores before radiotherapy. The most commonly reported techniques utilized are TURP, photoselective vaporization of prostate (PVP) and HoLEP. The use of BPH surgery is justified for relieving LUTS in selected prostate cancer patients on active surveillance or in advanced stages, however the use in the pre-radiotherapy settings remains controversial. Future prospective and randomized controlled trials are required for validating the benefits and assessing potential hazards.

[Palliative urologic surgery for metastatic prostate cancer: what needs to be considered in the future?]

Androgen deprivation in combination with novel hormonal agents, docetaxel or the combination of abiraterone/prednisone plus docetaxel or darolutamide plus docetaxel represent the standard therapeutic approach in metastatic hormone-sensitive prostate cancer (mHSPC). Patients with low-risk prostate cancer also benefit from additional radiation therapy or radical prostatectomy in terms of progression-free and overall survival. Despite favourable response rates, basically all patients will develop castration-resistant prostate cancer (CRPC) within 2.5 to 4 years. Systemic chemotherapy, second-line hormonal treatment or systemic application of radionuclides such as Radium-223 or 177Lu-PSMA represent salvage management options. As the new medical treatment options have led to an improved oncological outcome with significantly prolonged survival times, about 50% to 65% of patients will develop symptoms due to local progression of prostate cancer. The management of such symptomatic local progression will become more important in upcoming years, which means that all uro-oncologists need to be aware of the various surgical management options. If complications of the lower urogenital tract occur, for example repetitive gross haematuria with or without bladder clotting and with the necessity for red blood cell transfusions, subvesical obstruction, acute urinary retention or rectourethral or rectovesical fistulas, these may be managed by palliative surgery such as palliative TURP, radical cystectomy, radical cystoprostatectomy with urinary diversion, and pelvic exenteration. Symptomatic or asymptomatic obstruction of the upper urinary tract can be managed by endoluminal or percutaneous urinary diversion, ureteral reimplantation, ileal ureter replacement, or implantation of a Detour system. However, an individualised and risk-adapted treatment strategy needs to be developed for each single patient to achieve an optimal therapeutic outcome with improvement of both symptoms and quality of life. In specific clinical situations, best supportive care may be an adequate option.

Transurethral prostate surgery in prostate cancer patients: A population-based comparative analysis of complication and mortality rates

Objective

Prostate cancer (PCa) patients might experience lower urinary tract symptoms as those diagnosed with benign prostatic hyperplasia (BPH). Some of them might be treated for their lower urinary tract symptoms instead of PCa. We aimed to test the effect of PCa versus BPH on surgical outcomes after transurethral prostate surgery, namely complication and mortality rates.

Methods

Within the American College of Surgeons National Surgical Quality Improvement Program database (2011-2016), we identified patients who underwent transurethral resection of the prostate, photoselective vaporization, or laser enucleation. Patients were stratified according to postoperative diagnosis (PCa vs. BPH). Univariable and multivariable logistic regression models evaluated the predictors of perioperative morbidity and mortality. A formal test of interaction between diagnosis and surgical technique used was performed.

Results

Overall, 34 542 patients were included. Of all, 2008 (5.8%) had a diagnosis of PCa. The multivariable logistic regression model failed to show statistically significant higher rates of postoperative complications in PCa patients (odds ratio: 0.9, 95% confidence interval: 0.7-1.1; p=0.252). Moreover, similar rates of perioperative mortality (p=0.255), major acute cardiovascular events (p=0.581), transfusions (p=0.933), and length of stay of more than or equal to 30 days (p=0.174) were found. Additionally, all tests failed to show an interaction between post-operative diagnosis and surgical technique used.

Conclusion

Patients diagnosed with PCa do not experience higher perioperative morbidity or mortality after transurethral prostate surgery when compared to their BPH counterparts. Moreover, the diagnosis seems to not influence surgical technique outcomes.

Simultaneous thulium laser resection of the prostate and transperineal prostate biopsy in clinically diagnosed metastatic prostate cancer with bladder outlet obstruction

Metastatic prostate cancer (mPCa) patients complicated with bladder outlet obstruction (BOO) are often referred to a urologist. Androgen deprivation therapy (ADT) combined with indwelling catheter usually be the initial management. To retrospectively analysis the safety and efficacy of simultaneous thulium laser resection of the prostate (TmLRP) and transperineal prostate biopsy in metastatic prostate cancer with bladder outlet obstruction. From January 2016 to December 2021, 67 clinically diagnosed mPCa with BOO patients were included in this study. All patients were preoperatively assessed with international prostate symptom score (IPSS), QoL, serum prostate-specific antigen (PSA), prostate volume evaluation by transrectal ultrasound, postvoid residual urine volume (PVR), and maximum flow rate (Qmax). Preoperative and perioperative parameters at 1-, 3-, and 6-month follow-up were also evaluated. All complications were recorded. Simultaneous TmLRP and transperineal prostate biopsy had obvious advantages for clinically diagnosed mPCa patients with BOO, including short overall operation time (52 ± 23.3 min), little hemoglobin decrease (0.6 ± 0.7 g/l), and short hospital stay (average 3.8 days). In addition, simultaneous TmLRP and transperineal prostate biopsy also brought them significant improvement on IPSS, QoL score, Qmax, and PVR volume (P < 0.001) at 1-, 3-, and 6-month follow-up after operation compared to preoperative parameters. Complications were in a low incidence. Simultaneous TmLRP and transperineal prostate biopsy is a bloodless operation with immediate effect and little perioperative complication. Importantly, it is a promising technology in the diagnosis and treatment of clinically diagnosed mPCa patients with BOO.

Relationships between holmium laser enucleation of the prostate and prostate cancer

Holmium laser enucleation of the prostate (HoLEP) is a size-independent surgical option for treating benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) with excellent, durable functional outcomes. The prevalence of LUTS secondary to BPH and prostate cancer both increase with age, although the two diseases develop independently. Urologists often face a diagnostic dilemma, as men with LUTS secondary to BPH might also present with an elevated PSA and, therefore, need a diagnostic work-up to exclude prostate cancer. Nevertheless, ~15% of men with a negative elevated PSA work-up will undergo HoLEP and will be diagnosed with incidental prostate cancer at the time of HoLEP. Indeed, prostate cancer is often found in men undergoing HoLEP, and this situation can be challenging to manage. Variables associated with the detection of incidental prostate cancer, strategies to reduce incidental prostate cancer, as well as the natural history and management of this condition have been extensively studied, but further work in this area is still needed.

The Impact of Palliative Transurethral Resection of the Prostate on the Prognosis of Patients With Bladder Outlet Obstruction and Metastatic Prostate Cancer: A Population-Matched Study

Objective: This study aimed to evaluate the survival outcomes of patients with bladder outlet obstruction (BOO) and metastatic prostate cancer (mPCa) after having a palliative transurethral resection of the prostate (pTURP) surgery. Methods: We identified patients with mPCa between 2004 and 2016 in the Surveillance, Epidemiology, and End Results (SEER) database. Patients who received pTURP and non-surgical therapy were identified. A propensity-score matching was introduced to balance the covariate. Kaplan-Meier analysis and COX regression were conducted to evaluate the overall survival (OS) and cancer-specific survival (CSS) outcomes. Results: A total of 36,003 patients were identified; 2,823 of them were in the pTURP group and 33,180 were in the non-surgical group. The survival curves of the overall cohort showed that the pTURP group was associated with worse outcomes in both OS (HR: 1.12, 95% CI: 1.07-1.18, p < 0.001) and CSS (HR: 1.08, 95% CI: 1.02-1.15, p = 0.004) compared with the non-surgical group. The mean survival time in the overall cohort of the pTURP group was shorter than the non-surgical group in both OS [35.13 ± 1.53 vs. 40.44 ± 0.59 months] and CSS [48.8 ± 1.27 vs. 55.92 ± 0.43 months]. In the matched cohort, the pTURP group had significantly lower survival curves for both OS (HR: 1.25, 95% CI: 1.16-1.35, p < 0.001) and CSS (HR: 1.23, 95% CI: 1.12-1.35, p < 0.001) than the non-surgical group. pTURP significantly reduced the survival months of the patients (36.49 ± 0.94 vs. 45.52 ± 1.23 months in OS and 50.1 ± 1.49 vs. 61.28 ± 1.74 months in CSS). In the multivariate COX analysis, pTURP increased the risk of overall mortality (HR: 1.19, 95% CI: 1.09-1.31, p < 0.001) and cancer-specific mortality CSS (HR: 1.23, 95% CI: 1.14-1.33, p < 0.001) compared with the non-surgical group. Conclusions: For mPCa patients with BOO, pTURP could reduce OS and CSS while relieving the obstruction.

Efficacy and tolerability of metallic stent in patients with malignant prostatic obstruction secondary to prostatic cancer

OBJECTIVE

To evaluate the efficacy and tolerability of a self-expandable covered metallic stent in patients with malignant prostatic obstruction secondary to prostate cancer (PC).

METHODS

We reviewed 22 cases of insertion of self-expandable covered metallic stents with barbs. Data were collected about PC status. Uroflowmetry variables, residual urine volume, International Prostate Symptom Score (IPSS), quality of life (QOL), and duration from stent insertion to removal were surveyed. These clinical parameters were compared before and after stent insertion.

RESULTS

The patients with PC showed a mean age of 75.5 ± 6.5 years and mean 5.1 ± 1.9 Charlson comorbidity index. The average flow rate (2.4 ± 1.9 vs 5.9 ± 2.4 mL/s, P = .005), peak flow rate (6.9 ± 6.2 vs 14.1 ± 5.5 mL/s, P = .003), flow time (54.6 ± 29.1 vs 23.6 ± 13.7 s, P = .002), residual urine volume (178.7 ± 195.5 vs 7.0 ± 7.1 mL, P = .004), IPSS (26.2 ± 8.1 vs 8.0 ± 6.5 points, P = .001), and QOL (4.7 ± 1.3 vs 2.4 ± 2.1 points, P = .030) improved between before and after stent insertion, respectively. Pain was the most common complication, but 60% of the patients were managed without any intervention. There were hematuria, urinary retention, urinary frequency, obstruction, and urinary incontinence. However, there was no urinary tract infection due to the stent. The median time to stent removal was 5.7 months.

CONCLUSIONS

The stent was maintained for about 6 months with improved objective and subjective outcomes. The patients with PC, who had a poor comorbidity index and advanced PC status showed a tolerable maintenance period. Self-expandable covered metallic stents can be used for PC patients with a short life expectancy and unsuitability for general anesthesia.

Indications and Complications of Androgen Deprivation Therapy

OBJECTIVE

To review the indications for and side effects of androgen deprivation therapy (ADT) in men affected by prostate cancer.

DATA SOURCES

National guidelines, evidence-based summaries, peer-reviewed studies, and websites.

CONCLUSION

Indications for ADT include men with (1) intermediate- to high-risk localised prostate cancer undergoing radiation therapy, (2) biochemical recurrence after radical prostatectomy treated with salvage radiation therapy, or (3) metastatic prostate cancer. Several forms of ADT are available. To support self-management, body weight, diet, physical activity, alcohol consumption, and smoking should be discussed during clinical consultations. Important side effects of ADT may include flare-up phenomena of GnRH analogues, local reactions at injection sites, cardiovascular events, bone loss/fractures, drug-drug interactions, urinary tract dysfunction, hot flashes, cognitive impairment, seizure falls, and liver impairment.

IMPLICATIONS FOR NURSING PRACTICE

Nurses have a role in personalized cancer care and should be familiar with indications, side effects, and interventions to optimize quality of life for men affected by prostate cancer receiving ADT.

Clinical and Histopathological Characteristics of Prostate Cancer Patients Taken to Palliative Transurethral Prostate Resection

Introduction In prostate cancer (PCa) patients who have been treated with radiotherapy and/or androgen deprivation therapy (ADT), palliative transurethral resection of the prostate (TURP) is a management option in the presence of lower urinary tract symptoms (LUTS). The present work seeks to describe the clinical and histopathological characteristics of patients with PCa taken to palliative TURP. Methods An observational, descriptive and retrospective study of patients with PCa who underwent palliative TURP for the relief of obstructive urinary symptoms at an oncology reference center between January 2006 and June 2014 was performed. Among the included patients were those with localized PCa treated with radiotherapy and those with advanced PCa with or without metastasis who had previously received ADT. Results Sixty-six patients with a diagnosis of PCa taken to palliative RTUP were identified. Fifty patients (78.4%) were received some type of ADT, seven patients (10.7%) received curative radiotherapy along with adjuvant ADT, five patients (7.8%) were previously treated with only radiotherapy, and two patients (3.1 %) had received no prior management and thus were taken to bilateral orchiectomy along with palliative TURP in a single surgical act. With regard to the pathology reports, tumor tissue was found in 50 patients (76%), and no tumor was observed in the remaining 16 patients (24%). In one case (1.5%), the Gleason score (GS) could not be determined due to the effects of orchiectomy. Under-staging in the grade group was evidenced in 23 patients (46.9%), over-staging in three patients (6.3%), and no difference in 23 patients (46.9%), when compared to the initial GS at biopsy. The mortality rate and the incidence of TURP syndrome were low (3.1% and 1.5%, respectively). A 46% reduction in the mean serum prostate-specific antigen (PSA) value was documented when the preoperative and postoperative values were compared. Conclusion A decrease in the serum PSA levels was observed after palliative TURP, and despite having received ADT, it was possible to determine tumor pathology in the resected tissue, being able to identify a greater grade group compared the GS at the time of diagnosis. The palliative TURP proved to be a safe procedure to relieve LUTS in patients with advanced PCa, with a low morbidity and mortality rate.

Transurethral resection of the prostate is an independent risk factor for biochemical recurrence after radical prostatectomy for prostate cancer

Biochemical recurrence (BCR) is important for measuring the oncological outcomes of patients who undergo radical prostatectomy (RP). Whether transurethral resection of the prostate (TURP) has negative postoperative effects on oncological outcomes remains controversial. The primary aim of our retrospective study was to determine whether a history of TURP could affect the postoperative BCR rate. We retrospectively reviewed patients with prostate cancer (PCa) who had undergone RP between January 2009 and October 2017. Clinical data on age, prostate volume, serum prostate-specific antigen levels (PSA), biopsy Gleason score (GS), metastasis stage (TNM), D'Amico classification, and American Society of Anesthesiologists (ASA) classification were collected. Statistical analyses including Cox proportional hazard models and sensitivity analyses which included propensity score matching, were performed, and the inverse-probability-of-treatment-weighted estimator and standardized mortality ratio-weighted estimator were determined. We included 1083 patients, of which 118 had a history of TURP. Before matching, the non-TURP group differed from the TURP group with respect to GS (P = 0.047), prostate volume (mean: 45.19 vs 36.00 ml, P < 0.001), and PSA level (mean: 29.41 vs 15.11 ng ml⁻¹, P = 0.001). After adjusting for age, PSA level, T stage, N stage, M stage, and GS, the TURP group showed higher risk of BCR (hazard ratio [HR]: 2.27, 95% confidence interval [CI]: 1.13–3.94, P = 0.004). After matching (ratio 1:4), patients who underwent TURP were still more likely to develop BCR according to the adjusted propensity score (HR: 2.00, 95% CI: 1.05–3.79, P = 0.034). Among patients with PCa, those with a history of TURP were more likely to develop BCR after RP.

Palliative Transurethral Resection of the Prostate in Patients with Metastatic Prostate Cancer: A Prospective Study of 188 Patients

Purpose: Palliative transurethral resection of the prostate (pTURP) in metastatic prostate cancer (mPCa) is reported to be rarely applied in clinics. We prospectively evaluated the ability of pTURP to achieve tumor control in patients with mPCa. Patients and Methods: A prospective study of patients with mPCa from 2011 to 2018 was conducted. The patients were divided into two groups: a pTURP + androgen deprivation therapy (ADT) group and an ADT group. Castration-resistant prostate cancer (CRPC)-free survival and cancer-specific survival (CSS) were analyzed as research endpoints between the groups using a Kaplan-Meier estimator. Results: A total of 188 patients with mPCa were enrolled in the study from our center, of which 110 patients were in the pTURP + ADT group, and 78 patients were in the ADT group. The basic clinical characteristics were comparable between the groups. There were no reoperations or severe complications in the pTURP + ADT group. The median follow-up was 29 months. The median CRPC-free survival was significantly increased when the 7-month prostate-specific antigen (PSA) was <4 ng/mL (34 vs 6, p < 0.01) and bone metastasis was ≤5 (25 vs 10, p < 0.01) but not in the pTURP + ADT group (16 vs 12, p = 0.267). The 3-year CSS was higher in the pTURP + ADT group than that in the ADT group (95.9% vs 64.9%, p = 0.004), as well as when the 7-month PSA was <4 ng/mL compared to ≥4 ng/mL (90.7% vs 36.6%, p < 0.01) and when bone metastasis was ≤5 compared to >5 (82.2% vs 63.2%, p < 0.01). In subgroup analysis, pTURP + ADT could significantly improve patients' CSS when PSA ≥65 ng/mL, Gleason Score (GS) ≥8, and bone metastasis ≤5. Conclusions: We used our center-based cancer database to analyze survival in patients with mPCa undergoing pTURP. In the study population, pTURP + ADT was indicated to benefit CSS and shown to be safe. Moreover, we suggest that mPCa patients with PSA ≥65 ng/mL, GS ≥8, and bone metastasis ≤5 may perform pTURP before ADT.