Short- and Long-term Functional Outcomes and Quality of Life after Radical Prostatectomy: Patient-reported Outcomes from a Tertiary High-volume Center

Value-Based Health Care for Prostate Cancer Centers by Implementing Specific Key Performance Indicators Using a Balanced Score Card

BACKGROUND

Prostate cancer (PC) is the most common cancer in men in 112 countries, and accounts for 15% of cancers. Because it cannot be prevented, the rise in cases is inevitable, and improvements in diagnostic pathways and treatments are needed, as there is still a shortage of cost-effective diagnostics and widespread oncologically safe treatment options with measurable quality. As part of the implementation of a Full Cycle of Care, instruments have been developed to achieve value-based medicine, such as consistent commitment to measurability. One of these instruments is the Balanced Scorecard (BSC). Here, we propose the first BSC for prostate cancer (PC) treatment.

METHODS

BSCs are used to assess performance in healthcare organizations across four dimensions: financial, patient and referrer, process, and learning and development. This study aimed to identify Key Performance Indicators (KPIs) for each perspective. A systematic literature search was conducted according to PRISMA guidelines using multiple databases and specific search terms to identify KPIs for PC care, excluding case reports and conference abstracts. In total, 44 reports were included in analyses and development of the PC-specific BSC.

RESULTS

In the present study, a PC-specific BSC and KPIs were defined for the four classic perspectives, as well as for a newly developed PC-Specific Disease and Outcome perspective, including patient-related parameters from the German Cancer Society and the International Consortium for Health Outcomes Measurement. In addition, the Process perspective includes KPIs of fulfillment of continuing education of residents and the metrics of structured training of the radical prostatectomy procedure in the Learning and Development perspective.

CONCLUSIONS

The developed BSC provides a comprehensive set of perspectives for an Integrated Practice Unit or center in PC care, ensuring that the indicators remain manageable and applicable. The BSC facilitates value creation in line with Porter's Full Cycle of Care by systematically collecting and providing economic, personnel, and medical results, actions, and indicators. In particular, this BSC includes KPIs of structured training of practitioners and metrics of the German Cancer Society, that recently proved to improve PC patients outcomes.

Differences in Quality of Life between German and Dutch Patients with Prostate Cancer Treated with Robot-assisted Radical Prostatectomy: Implications for International Multicenter Randomized Controlled Trials

BACKGROUND

As a local treatment for prostate cancer (PCa), robot-assisted radical prostatectomy (RARP) may have a quality of life (QoL) benefit over open surgery. Recent analyses revealed substantial between-country differences in the function and symptom scale scores for the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), which is typically used to assess patient-reported QoL. Such differences could have implications for multinational studies in PCa.

OBJECTIVE

To examine whether nationality is significantly associated with patient-reported QoL.

DESIGN, SETTING, AND PARTICIPANTS

The study cohort comprised Dutch and German patients with PCa treated with RARP in a single high-volume prostate center from 2006 to 2018. Analyses were restricted to patients who were preoperatively continent with at least one follow-up time point.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

QoL was measured in terms of the global Quality of Life (QL) scale score and the overall summary score for the EORTC QLQ-C30. Linear mixed models for repeated-measures multivariable analyses (MVAs) were used to examine the association between nationality and both the global QL score and the summary score. MVAs were further adjusted for QLQ-C30 baseline values, age, Charlson comorbidity index, preoperative prostate-specific antigen, surgical expertise, pathological tumor and nodal stage, Gleason grade, degree of nerve-sparing, surgical margin status, 30-d Clavien-Dindo grade complications, urinary continence recovery, and biochemical recurrence/postoperative radiotherapy.

RESULTS AND LIMITATIONS

For Dutch (n = 1938) versus German (n = 6410) men, the mean baseline scores were 82.8 versus 71.9 for the global QL scale score and 93.4 versus 89.7 for the QLQ-C30 summary score. Urinary continence recovery (QL: +8.9, 95% confidence interval [CI] 8.1-9.8; p < 0001) and Dutch nationality (QL: +6.9, 95% CI 6.1-7.6; p < 0001) were the strongest positive contributors to the global QL and summary scores, respectively. The main limitation is the retrospective study design. In addition, our Dutch cohort may not be representative of the general Dutch population and reporting bias cannot be ruled out.

CONCLUSIONS

Our findings provide observational evidence under specific conditions involving the same setting for patients of two different nationalities suggesting that cross-national patient-reported QoL differences appear to be real and may need to be taken into consideration in multinational studies.

PATIENT SUMMARY

We observed differences in the quality-of-life scores reported by Dutch and German patients with prostate cancer after they underwent robot-assisted removal of the prostate. These findings should be taken into consideration in cross-national studies.

Individualized center-based analysis of urinary and sexual functional outcome after radical prostatectomy based on the prostate cancer outcome study: a post hoc pathway to patient outcome measurement analysis for quality improvement

PURPOSE

We evaluate differences of patient-reported outcome measurements (PROM) based urinary continence and sexual function 12 months after radical prostatectomy (RPE) based on perioperative, surgical, and patient-specific characteristics in a large European academic urology center.

MATERIALS AND METHODS

All men enrolled in the Prostate Cancer Outcome Study (PCO) study who were treated with RPE between 2017 and 2021 completed EPIC-26 information surveys before and 12 months after RPE. Survey data were linked to clinical data of our institution. Logistic regression analyses were performed to examine the correlation between individual surgeons, patient characteristics, patient clinical data, and their urinary continence and sexual function.

RESULTS

In total, data of 429 men were analyzed: unstratified mean (SD) EPIC-26 domain score for urinary function decreased from 93.3 (0.7) to 60.4 (1.5) one year after RPE, respectively for sexual function from 64.95 (1.6) to 23.24 (1.1). Patients with preoperative adequate urinary function (EPIC-26 score > 80) reported significantly different mean urinary function scores between 53.35 (28.88) and 66.25 (25.15), p= 0.001, stratified by surgeons experience. On binary logistic regression analyses, only nerve sparing techniques (OR: 1,83, 95% CI: 1.01;3.21; p = 0.045) and low body mass index (OR: 0.91, CI: 0.85;0.99, p= 0.032) predicted adequate postoperative urinary function.

CONCLUSIONS

The results show how using provider-specific data from a larger cohort study enables to develop institution-specific analysis for functional outcomes after RPE. These models can be used for internal quality improvement as well as enhanced and provider-specific patient communication and shared decision making.

Urinary Symptoms Change and Quality of Life After Robotic Radical Prostatectomy: A Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

To present the patient-reported quality of life (QoL) outcomes from a prospective, randomized controlled trial comparing the use of pelvic floor muscle training (PFMT) and duloxetine after robot-assisted radical prostatectomy (RARP).

METHODS

We identified 213 men with organ-confined disease having post-RARP urinary incontinence who were randomly assigned to received PFMT, duloxetine, combined PFMT-duloxetine and pelvic floor muscle home exercises. Urinary symptoms burden was measured by marked clinical important difference improvement (MCID) defined by using the International Prostate Symptom Score (IPSS) difference of - 8 points (ΔIPSS ≤-8). QoL was assessed according to Visual Analog Scale (VAS), King's Health Questionnaire (KQH), and International Index of Erectile Function (IIEF-5). Multivariable regression analyses aimed to predict MCID, burden of urinary symptoms (IPSS ≥8), and patients reporting to be satisfied (IPSS QoL ≤2) or comfortable (VAS ≤1) post-RARP.

RESULTS

Moderate to severe urinary symptoms decreased from 48% preoperatively to 40%, 34%, and 23% at 3, 6, and 12months post-RARP. After surgery, MCID improvement was observed in 19% of patients, and deterioration in 3.3%. Large prostate was the only factor associated to MCID (OR 1.03 [95%CI 1.01-1.05], P = .005). At 6months, patients reached the same degree of preoperative satisfaction. Neurovascular bundle preservation was the only predictor of being comfortable regarding urinary symptoms postoperatively (OR 12.8 [CI95% 1.47-111.7], P = .02 at 3months) and was also associated to higher median postoperative IIEF-5.

CONCLUSION

Despite urinary incontinence following RARP, patients with larger prostates experience a reduction of lower urinary tract symptoms within a year, which subsequently elevates QoL. Furthermore, nerve-sparing surgery augments erectile function and urinary outcomes, shaping postoperative QoL.

Pathway for post-prostatectomy urinary incontinence: impact on patient confidence and satisfaction

BACKGROUND

Between 8 and 87% of prostatectomies result in urinary incontinence, with around half of patients using incontinence pads daily at 6 months. Specialist urology continence nurses at the Norfolk and Norwich University Hospitals (NNUH) NHS Foundation Trust created a pre- and post-surgical care pathway formalising support for these patients, which involves the provision of TENA Men (Essity) male incontinence pads.

AIMS

This audit aimed to assess patient satisfaction with this pathway and TENA Men pads.

METHODS

Patients who underwent a radical prostatectomy at NNUH between 27 April and 9 November 2021 and who required continence pads were invited to fill out an online anonymous mixed-method (mainly qualitative) survey.

RESULTS

Of 28 respondents, 71% reported incontinence after their surgical catheter was removed. Most (89%) were satisfied with the preoperative advice. Of 19 respondents to questions on confidence and satisfaction, 16 were confident that the pads they had been prescribed were helping them to manage urinary leakage, and 16 were confident or very confident that they could manage their incontinence themselves. Generally, respondents were confident that their overall and mental health had improved, and most were confident or very confident that they had less anxiety. However, less than a quarter of respondents were 'very confident' about going out, meeting people or exercising. All but one respondent found TENA Men pads easy to fit, and the most used words in the free-text explanations of what they most liked, included 'easy', 'discreet', 'comfortable' and 'unobtrusive'.

CONCLUSION

The clinical pathway helped give patients undergoing radical prostatectomy confidence in their ability to manage post-surgery incontinence themselves and could be of value in other hospitals. Easy access to incontinence pads designed for the male anatomy has an important part in this.

Outcome of patients with epithelialized cavity formation after excessive vesicourethral anastomotic leak post radical prostatectomy

PURPOSE

Excessive vesicourethral anastomotic leak (EVAL) is a rare but severe complication after radical prostatectomy (RP). Epithelialized vesicourethral cavity formation (EVCF) usually develops during prolonged catheterization. To our knowledge, there is no description of postoperative outcomes, complications, or functional assessment of these patients who received conservative therapy after EVAL.

METHODS

We identified 70 patients (0.56%) with radiographic evidence of EVCF out of 12,434 patients who received RP in 2016-2020 at our tertiary care center. Postoperative radiographic cystograms (CG) were retrospectively re-examined by two urologists individually. We assessed urinary continence (UC), the need for intervention due to anastomotic stricture formation, urinary tract infection (UTI), and symphysitis during the first year of follow-up post-RP.

RESULTS

The median age was 66 years [interquartile range (IQR) 61-70 years], the median body mass index was 27.8 kg/m2 (IQR 25.5-30.3 kg/m2), and the median prostate specific antigen before RP was 7.1 ng/ml (IQR 4.7-11.8 ng/ml). The median catheter insertion time was 44.5 days (IQR 35.2-54 days). One-year continence follow-up was available for 27 patients (38.6%), of which 22 (81.5%) reported the use of ≤ one pad, two patients reported the use of two (7.4%) pads/24 h, and three (11.1%) patients reported use > two pads/24 h. Overall, four (5.7%) patients needed surgical reintervention for anastomotic stricture, eight (11.5%) patients presented with symphysitis, and 55 (77.1%) presented with UTI.

CONCLUSION

UC in 81.5% 1-year post-RP suggests that conservative treatment in EVAL is a treatment option with an acceptable outcome on UC and should be considered before reintervention for anastomotic insufficiency.

Impact of Age on Long-Term Urinary Continence after Robotic-Assisted Radical Prostatectomy

Aim and Objectives: We aimed to test the impact of age on long-term urinary continence (≥12 months) in patients undergoing robotic-assisted radical prostatectomy. Methods and Materials: We relied on an institutional tertiary-care database to identify the patients who underwent robotic-assisted radical prostatectomy between January 2014 and January 2021. Patients were divided into three age groups: age group one (≤60 years), age group two (61-69 years) and age group three (≥70 years). Multivariable logistic regression models tested the differences between the age groups in the analyses addressing long-term urinary continence after robotic-assisted radical prostatectomy. Results: Of the 201 prostate cancer patients treated with robotic-assisted radical prostatectomy, 49 (24%) were assigned to age group one (≤60 years), 93 (46%) to age group two (61-69 years) and 59 (29%) to age group three (≥70 years). The three age groups differed according to long-term urinary continence: 90% vs. 84% vs. 69% for, respectively, age group one vs. two vs. three (p = 0.018). In the multivariable logistic regression, age group one (Odds Ratio (OR) 4.73, 95% CI 1.44-18.65, p = 0.015) and 2 (OR 2.94; 95% CI 1.23-7.29; p = 0.017) were independent predictors for urinary continence, compared to age group three. Conclusion: Younger age, especially ≤60 years, was associated with better urinary continence after robotic-assisted radical prostatectomy. This observation is important at the point of patient education and should be discussed in informed consent.

Anterior Sphincter-sparing Suturing of the Vesicourethral Anastomosis During Robotic-assisted Laparoscopic Radical Prostatectomy

Background

Continence is an important functional outcome after robotic-assisted laparoscopic radical prostatectomy (RARP), and modifications of the surgical technique may improve outcomes.

Objective

To illustrate a novel RARP technique and to describe the observed continence outcomes.

Design setting and participants

A retrospective study of men treated with RARP between 2017 and 2021 was conducted.

Surgical procedure

During RARP, periprostatic structures are preserved, the intraprostatic urethra is partially spared, and the anterior anastomosis stitches involve the plexus structures but not the anterior urethra.

Measurements

A descriptive analysis of the pathological, functional, and short-term oncological outcomes was performed.

Results and limitations

Of 640 men, 448 (70%) with at least 1 yr of follow-up and a median age of 66 yr were included. The median operative time was 270 min and the prostatic volume 52 ml. The transurethral catheter was removed after a median of 3 d, and leakage of urine in the first 24 h after catheter removal was observed in 66/448 patients (15%). Positive surgical margins were reported in 104/448 (23%). Prostate-specific antigen persistence after prostatectomy was observed in 26/448 (6%). During a median follow-up of 2 yr (interquartile range 1-3 yr), the biochemical recurrence after prostatectomy was observed in 19/448 patients (4%). One year after prostatectomy, 406/448 patients (91%) were continent and required no pad at all, while 42/448 (9%) required at least one pad per day.

Conclusions

Not stitching the anterior urethra is a novel technical modification and may improve continence outcomes.

Patient summary

We describe a novel way to stitch the bladder neck to the urethra after removal of the prostate using a surgical robotic system. Our technique appeared safe, with promising urinary continence results.

Full functional-length urethral sphincter- and neurovascular bundle preservation improves long-term continence rates after robotic-assisted radical prostatectomy

The objective of the study was to test the impact of implementing standard full functional-length urethral sphincter (FFLU) and neurovascular bundle preservation (NVBP) with intraoperative frozen section technique (IFT) on long-term urinary continence in patients undergoing robotic-assisted radical prostatectomy (RARP). We relied on an institutional tertiary-care database to identify patients who underwent RARP between 01/2014 and 09/2019. Until 10/2017, FFLU was not performed and decision for NVBP was taken without IFT. From 11/2017, FFLU and IFT-guided NVBP was routinely performed in all patients undergoing RARP. Long-term continence (≥ 12 months) was defined as the usage of no or one safety- pad. Uni- and multivariable logistic regression models tested the correlation between surgical approach (standard vs FFLU + NVBP) and long-term continence. Covariates consisted of age, body mass index, prostate volume and extraprostatic extension of tumor. The study cohort consisted of 142 patients, with equally sized groups for standard vs FFLU + NVBP RARP (68 vs 74 patients). Routine FFLU + NVBP implementation resulted in a long-term continence rate of 91%, compared to 63% in standard RARP (p < 0.001). Following FFLU + NVBP RARP, 5% needed 1-2, 4% 3-5 pads/24 h and no patient (0%) suffered severe long-term incontinence (> 5 pads/24 h). No significant differences in patient or tumor characteristics were recorded between both groups. In multivariable logistic regression models, FFLU + NVBP was a robust predictor for continence (Odds ratio [OR]: 7.62; 95% CI 2.51-27.36; p < 0.001). Implementation of FFLU and NVBP in patients undergoing RARP results in improved long-term continence rates of 91%.

Efficacy of pelvic floor muscle exercise or therapy with or without duloxetine: a systematic review and network Meta-analysis

OBJECTIVES

Postprostatectomy urinary incontinence (PPUI) is a serious complication despite surgical advances. Treatment options for PPUI include conservative care like Pelvic floor muscle exercise (PFME), which is a physiotherapy performed by the patients themselves; Pelvic floor muscle therapy (PFMT), a physiotherapy performed under the guidance of a therapist, and duloxetine treatment; and surgical interventions. In this study, network meta-analysis (NMA) was performed for direct comparison of these treatment options.

MATERIALS AND METHODS

The NMA pooled the odds ratios and 95% credible intervals using the number of patients achieving urinary continence and the total number of patients in an intention-to-treat population. The treatments were ranked based on the surface under the cumulative ranking curve (SUCRA) probabilities and the rankograms.

RESULTS

The pooled overall ORs of patients achieving urinary continence compared with no treatment was 1.73 (95% CrI: 0.657, 4.71) in PFME, 2.62 (95% CrI: 0.553, 13.5) in PFME plus Duloxetine, and 4.05 (95% CrI: 1.70, 10.2) in PFMT. The SUCRA values of ranking probabilities for each treatment showed high rates of continence in the order of PFMT, PFME plus Duloxetine, and PFME.

CONCLUSION

The results suggest that patients with PPUI should undergo PFMT and consider duloxetine as an additional treatment option.

Pathway for post-prostatectomy urinary incontinence: impact on patient confidence and satisfaction

BACKGROUND

Between 8% and 87% of prostatectomies result in urinary incontinence, with around half of patients using incontinence pads daily at 6 months. Specialist urology continence nurses at the Norfolk and Norwich University Hospitals NHS Foundation Trust created a pre- and post-surgical care pathway formalising support for these patients, which involves the provision of TENA Men (Essity) male incontinence pads.

AIMS

This audit aimed to assess patient satisfaction with this pathway and TENA Men pads.

METHODS

Patients who underwent a radical prostatectomy at NNUH between 27 April and 9 November 2021 and who required continence pads were invited to fill out an online anonymous mixed-method (mainly qualitative) survey.

RESULTS

Of 28 respondents, 71% reported incontinence after their surgical catheter was removed. Most (89%) were satisfied with the preoperative advice. Of 19 respondents to questions on confidence and satisfaction, 16 were confident that the pads they had been prescribed were helping them to manage urinary leakage, and 16 were confident or very confident that they could manage their incontinence themselves. Generally, respondents were confident that their overall and mental health had improved, and most were confident or very confident that they had less anxiety. However, less than a quarter of respondents were 'very confident' about going out, meeting people or exercising. All but one respondent found TENA Men pads easy to fit, and the most used words in the free-text explanations of what they most included 'easy', 'discreet', 'comfortable' and 'unobtrusive'.

CONCLUSION

The clinical pathway helped give patients undergoing radical prostatectomy confidence in their ability to manage post-surgery incontinence themselves and could be of value in other hospitals. Easy access to incontinence pads designed for the male anatomy has an important part in this.

Long term erectile function results of radical perineal prostatectomy

INTRODUCTION

Although many patients are being treated by radical prostatectomy (RP), there is still insufficient information about the changes in long-term erectile function after RP. Our aim is to examine long term, up to 5 year erectile function status of patients after Radical Perineal Prostatectomy (RPP).

MATERIALS AND METHODS

One hundred and thirty-two patients, who underwent bilateral nerve-sparing Radical Perineal Prostatectomy (RPP) in between January 2012 and January 2017, with preoperative age≤70, prostate volume<80g, transrectal ultrasound (TRUS) guided biopsy Gleason score (GS)<7, prostate specific antigen (PSA) value<10ng/mL, and cT stage≤2 (N0, M0) were included into this study. Exclusion criteria were previous cardiovascular diseases, serious chronic renal and/or hepatic insufficiency, neurological diseases, uncontrolled diabetes mellitus, and severe lung diseases. Patients who received additional treatment (hormonal and/or radiotherapy) after RPP were also excluded from the study group. Erectile function was evaluated before surgery and at postoperative 3rd, 12th, and 60th months. Patients with an "International Index of Erectile Function (IIEF) - 5" score of ≥21 and patients whose IIEF-5 scores were between 16 and 20 but responded as "yes" to the "Sexual Encounter Profile (SEP) - 2" and "SEP-3" questions were accepted as having normal erectile function.

RESULTS

Out of the 132 patients, 96 (72.7%) of the patients were found to be potent in the first postoperative year. A total of 118 patients were evaluated at the end of 5 years. Eighty seven (73.7%) patients had normal erectile function according to our criteria.

DISCUSSION

According to the results of our study, short term and long term erectile function outcomes of patients undergoing RPP were favorable and there was no statistically significant difference between short and long term results.

Urethral Sphincter Length but Not Prostatic Apex Shape in Preoperative MRI Is Associated with Mid-Term Continence Rates after Radical Prostatectomy

Background: To test the impact of urethral sphincter length (USL) and anatomic variants of prostatic apex (Lee-type classification) in preoperative multiparametric magnet resonance imaging (mpMRI) on mid-term continence in prostate cancer patients treated with radical prostatectomy (RP). Methods: We relied on an institutional tertiary-care database to identify patients who underwent RP between 03/2018 and 12/2019 with preoperative mpMRI and data available on mid-term (>6 months post-surgery) urinary continence, defined as usage 0/1 (-safety) pad/24 h. Univariable and multivariable logistic regression models were fitted to test for predictor status of USL and prostatic apex variants, defined in mpMRI measurements. Results: Of 68 eligible patients, rate of mid-term urinary continence was 81% (n = 55). Median coronal (15.1 vs. 12.5 mm) and sagittal (15.4 vs. 11.1 mm) USL were longer in patients reporting urinary continence in mid-term follow-up (both p < 0.01). No difference was recorded for prostatic apex variants distribution (Lee-type) between continent vs. incontinent patients (p = 0.4). In separate multivariable logistic regression models, coronal (odds ratio (OR): 1.35) and sagittal (OR: 1.67) USL, but not Lee-type, were independent predictors for mid-term continence. Conclusion: USL, but not apex anatomy, in preoperative mpMRI was associated with higher rates of urinary continence at mid-term follow-up.

Two-year quality of life after robot-assisted radical prostatectomy according to pentafecta criteria and cancer of the prostate risk assessment (CAPRA-S)

The quality of life (QoL) of men with optimal outcomes after robot-assisted radical prostatectomy (RARP) is largely unexplored. Thus we assessed meaningful changes of QoL measured with the EORTC QLQ-C30 24 months after RARP according to postsurgical Cancer of the Prostate Risk Assessment score (CAPRA-S) and pentafecta criteria. 2871 prostate cancer (PCa) patients with completed EORTC QLQ-C30 were stratified according to CAPRA-S, pentafecta (erectile function recovery, urinary continence recovery, biochemical-recurrence-free survival (BFS), negative surgical margins) and 90-day Clavien–Dindo-complications (CDC) ≤ 3a. Multivariable logistic regression analyses (LRM) aimed to predict improvement of EORTC QoL. Mean preoperative QoL values did not significantly differ between CAPRA-S low- (LR) vs. high-risk (HR, 75.7 vs. 75.2; p = 0.7) and pentafecta vs. non-pentafecta groups (75.6 vs. 75.2; p = 0.6). After RARP, stable QoL rates for CAPRA-S LR vs. HR and pentafecta were 30, 26 and 30%, respectively. Corresponding improved QoL rates were 44, 32 and 47%. In LRM, CAPRA-S and pentafecta criteria were independent predictors of improved QoL. We conclude that most favourable combined outcomes after RARP might confer stable or even improved QoL but up to one third of patients might experience deterioration. This warrants further investigation how to capture the underlying cause and to address and potentially solve these perceived negative effects despite successful RARP.

Correlation of Urine Loss after Catheter Removal and Early Continence in Men Undergoing Radical Prostatectomy

BACKGROUND

To determine the correlation between urine loss in PAD-test after catheter removal, and early urinary continence (UC) in RP treated patients.

METHODS

Urine loss was measured by using a standardized, validated PAD-test within 24 h after removal of the transurethral catheter, and was grouped as a loss of <1, 1-10, 11-50, and >50 g of urine, respectively. Early UC (median: 3 months) was defined as the usage of no or one safety-pad. Uni- and multivariable logistic regression models tested the correlation between PAD-test results and early UC. Covariates consisted of age, BMI, nerve-sparing approach, prostate volume, and extraprostatic extension of tumor.

RESULTS

From 01/2018 to 03/2021, 100 patients undergoing RP with data available for a PAD-test and early UC were retrospectively identified. Ultimately, 24%, 47%, 15%, and 14% of patients had a loss of urine <1 g, 1-10 g, 11-50 g, and >50 g in PAD-test, respectively. Additionally, 59% of patients reported to be continent. In multivariable logistic regression models, urine loss in PAD-test predicted early UC (OR: 0.21 vs. 0.09 vs. 0.03; for urine loss 1-10 g vs. 11-50 g vs. >50 g, Ref: <1 g; all p < 0.05).

CONCLUSIONS

Urine loss after catheter removal strongly correlated with early continence as well as a severity in urinary incontinence.

Hospital volume and outcomes after radical prostatectomy: a national population-based study using patient-reported urinary continence and sexual function

BACKGROUND

Improvements in short-term outcomes have been reported for hospitals with higher radical prostatectomy (RP) volumes. However, the association with longer-term functional outcomes is unknown.

METHODS

All patients diagnosed with non-metastatic prostate cancer in the English NHS between 2014 and 2016 who underwent RP (N = 10,089) were mailed a survey ≥18 months after diagnosis. Differences in patient-reported urinary continence and sexual function (EPIC-26 on scale from 0 to 100) by hospital volume group (≤60, 61-100, 101-140, >140 RPs/year) were estimated using multilevel linear regression.

RESULTS

Overall, 7702 men (76.3%) responded. There were no statistically significant differences in urinary continence (p = 0.08) or sexual function scores with increasing volume group (p = 0.2). When modelled as a linear function, we found a non-significant increase of 0.70 (95% CI -0.41 to 1.80; p = 0.22) in urinary continence and a significant increase of 1.54 (0.62-2.45; p = 0.001) in sexual function scores for a 100-procedure increase in hospital volume, which did not meet the threshold for a minimal clinically important difference (10-12 points). The results were similar for robotic-assisted RP (5529 men [71.8%]).

CONCLUSIONS

These results do not support further centralisation of RP services beyond levels in England where four in five hospitals perform >60 RPs/year.

Influence of anticancer agents on sexual function: an in Vivo study based on the US FDA Adverse Event Reporting System

Background

Patients with cancer are treated with chemotherapeutics that cause adverse effects, including erectile dysfunction (ED).

Objectives

We investigated erectile function in rats after the administration of anticancer agents based on data retrieved through mining of the US Food and Drug Administration (FDA) Adverse Event Reporting System (AERS) database.

Materials and methods

The statistical signal strength for the association between anticancer drugs and ED was calculated using the reporting odds ratio (ROR). A drug–event combination was detected when the lower limit of the 95% confidence interval (CI) of the ROR exceeded 1.00. Rats were administered anticancer agents detected in the FDA AERS analysis. Erectile function was assessed using intracavernous pressure (ICP) and mean arterial pressure (MAP) analysis after electrical stimulation of the cavernous nerve. Statistical significance was determined using Welch's t‐test or two‐way ANOVA.

Results

Melphalan (L‐PAM; ROR = 4.72, 95% CI = 2.78–8.00), vincristine (VCR; ROR = 2.47, 95% CI = 1.54–3.97), docetaxel (DTX; ROR = 2.25, 95% CI = 1.28–3.95), methotrexate (MTX; ROR = 1.96, 95% CI = 1.39–2.75), and doxorubicin (DOX; ROR = 1.82, 95% CI = 1.07–3.19) enhanced ED risk. L‐PAM and MTX decreased the ICP/MAP ratio 1 week after administration. VCR and DOX decreased erectile function 4 weeks after administration. DTX decreased erectile function at all assessed time points.

Discussion and conclusion

Certain anticancer agents should be considered risk factors for ED.

Our results provide possible treatment strategies for maintaining erectile function in cancer survivors, including careful erectile function monitoring after treatment.

Patient reported outcome measures concerning urinary incontinence after robot assisted radical prostatectomy: development and validation of an online prediction model using clinical parameters, lower urinary tract symptoms and surgical experience

The prediction of post-prostatectomy incontinence (PPI) after robot-assisted radical prostatectomy (RARP) depends on multiple clinical, anatomical and surgical factors. There are only few risk formulas, tables or nomograms predicting PPI that may assist clinicians and their patients in adequate risk counseling on postoperative side-effects. Prospective data collection of 1814 patients who underwent RARP between 2009 and 2017 was done. Pre-operative parameters were age, body mass index (BMI), prostate volume, the American Society of Anesthesiologists (ASA) score, severity of Lower Urinary Tract Symptoms (LUTS), type of planned nerve-sparing surgery and surgical experience. The continence status was reported using Patient Reported Outcome Measurements (PROMs) using the validated pad-use questionnaire EPIC26. Continence was defined as either the use of zero pads or one safety pad. Multivariable logistic regression analysis was performed to identify predictors of PPI within one year after RARP. An online prediction tool was developed and validated. The median follow-up was 36 months (range 12-108). The response rate was high at 85.2%. A total of 85% (1537/1814) of patients was continent on follow-up. One-year continence rate was 80.1% (95% CI 78.3-81.9%) (1453/1814) and increased to 87.4% (95% CI 85.4-89.4%) after 5 years. On multivariable analysis, severity of LUTS (OR = 0.56 p = 0.004), higher age (OR = 0.73 p = 0.049), extend of nerve-sparing surgery (OR = 0.60 p = 0.001) and surgeon experience (OR = 1.48 p = 0.025) were significant independent predictors for PPI. The online prediction model performed well in predicting continence status with poor discrimination and good calibration. An intuitive online tool was developed to predict PPI after RARP that may assist clinicians and their patients in counseling of treatment.

Live implant dosimetry may be an effective replacement for postimplant computed tomography in localized prostate cancer patients receiving low dose rate brachytherapy

PURPOSE

To determine if Live Implant Dosimetry (LIDO) utilizing intraoperative transrectal ultrasound (TRUS) is equivalent to postimplant CT dosimetry (either day 0 or day 30) in patients with localized prostate cancer (PC) treated with low dose rate (LDR) prostate seed brachytherapy.

METHODS AND MATERIALS

The treated population consisted of 628 men with localized (T1-T2) PC. All d'Amico risk categories (low, intermediate, and high) were included, and 437 patients were treated with monotherapy (160 Gy) [low and low tier intermediate], and the remainder (191) [high tier intermediate and high risk] with an implant boost (106 Gy) post external beam radiation, to a volume including the prostate and seminal vesicles (46 Gy). LIDO with intraoperative TRUS, postimplant CT (day 0 and day 30) were performed in all cases. Prostate volumes (V), V₁₀₀ (prostate) and dose (D) D₉₀ (prostate), D₃₀ (urethra), and Rectum D_2cc, were recorded. No urinary catheter was used on Day 30 CT.

RESULTS

More than 91.33% of monotherapy patients reached the target D₉₀ according to LIDO while only 82.99% of Day 0 CT and 92.82% of Day 30 CT achieved target D₉₀. When considering V₁₀₀, monotherapy patients recorded target dosimetry in 90.93%, 82.31%, and 92.02% of cases assessed by LIDO, Day 0 CT and Day 30 CT, respectively. Strong correlations are observed in D₉₀, Rectum D_2cc and Urethra D₃₀ across imaging modalities but V₁₀₀ and V₁₅₀ were poorly correlated due to the relative quantification of this parameter and high degree of error in measurement. Of all monotherapy patients with satisfactory dosimetry on LIDO, 94.82% reached target D₉₀ at day 30 CT and 94.19% reached target V₁₀₀.

CONCLUSIONS

LIDO and CT are both effective tools for assessing postimplant dosimetry. Patients with satisfactory LIDO dosimetry are highly likely to have equivalent dosimetry on CT at follow-up, indicating that postimplant CT may be eliminated in PC a patients implanted with this technique.

Options for Curative Treatment of Localized Prostate Cancer

BACKGROUND

Prostate cancer is the most frequently occurring malignancy among men in Germany, with 60 000 new cases each year. Three of every four tumors are detected at an early, localized stage, when various curative treatment strategies are possible.

METHODS

A selective search of the literature in PubMed accompanied by consideration of guidelines from Germany and other countries.

RESULTS

Owing to the usually prolonged natural course of localized prostate cancer, local treatment is recommended for patients with a life expectancy of at least 10 years. The established treatments with curative intent are radical prostatectomy, percutaneous radiotherapy, and brachytherapy, with active surveillance as a further option for patients with low-risk disease. The eventual choice of treatment is determined by tumor stage, risk group, comorbidities, and patient preference. Conversations with the patient must cover not only the oncological outcome but also the potential adverse effects of the different treatment options. Depending on the procedure, urinary incontinence, erectile dysfunction, and inflammation of the bladder and/or rectum may be frequently occurring complications.

CONCLUSION

A number of curative and other treatments are available for patients with localized prostate cancer. The goal is to identify the appropriate option for each individual patient by means of detailed discussion.

Health-related quality of life and self-reported cognitive function in patients with delayed neurocognitive recovery after radical prostatectomy: a prospective follow-up study

Background

Delayed neurocognitive recovery (DNCR) is a common and serious complication after radical prostatectomy. We hypothesized that patients with DNCR in the early postoperative period would report reduced health-related quality of life (HRQoL) and more cognitive failures 12 months after surgery, compared with patients without DNCR.

Methods

We performed a 12-month follow-up on 367 patients who had been enrolled in a prospective observational trial to study the incidence of DNCR after radical prostatectomy. Patients were screened for preoperative cognitive impairment and depression. We defined DNCR as a decline in cognitive function between days 3 and 5 after surgery, compared with baseline assessments. We evaluated HRQoL and cognitive failures 12 months after surgery with the 36-item Short Form Health Survey and the Cognitive Failures Questionnaire. General linear models were used to analyze associations of DNCR with HRQoL and cognitive failures.

Results

Delayed neurocognitive recovery in the early postoperative period was significantly associated with self-reported cognitive failures (B for no DNCR =  − 0.411 [95% CI: − 0.798;0.024], p = 0.038), but not with physical (B = 0.082 [95% CI: − 0.021;0.186], p = 0.118) or mental HRQoL (B =  − 0.044 [95% CI: − 0.149;0.062], p = 0.417) 12 months after surgery. Preoperative depression screening scores were significantly associated with self-reported cognitive failures and both physical and mental HRQoL 12 months after surgery.

Conclusions

Delayed neurocognitive recovery in the early period after radical prostatectomy has a long-term impact on patients’ daily lives by impairing memory, attention, action, and perception. Therefore, prevention of DNCR must be a priority for physicians and researchers. Consequent preoperative screening for depressive symptoms may facilitate early psycho-oncological intervention to improve postoperative HRQoL.

Trials registrationDRKS00010014, date of registration: 21.03.2016, retrospectively registered.

What is the impact of post-radical prostatectomy urinary incontinence on everyday quality of life? Linking Pad usage and International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) for a COMBined definition (PICOMB definition)

AIMS

To identify the definition for urinary continence (UC) after radical prostatectomy (RP) which reflects best patients' perception of quality of life (QoL).

METHODS

Continence was prospectively assessed in 634 patients, 12 months after RP using the International Consultation on Incontinence Questionnaire Short-Form (ICIQ-SF) and the number of pads employed in a 24-hour period (pad usage). We used the one-way ANOVA technique with posthoc pairwise comparisons according to Scheffé's method (homogeneous subsets) for assessing the degree of QoL deficit related to urinary incontinence (UI).

RESULTS

The continence prevalence is 64.4%, 74.1%, 88.3%, and 35.8% using "0 pads," "1 safety pad," "1 pad," and "ICIQ score 0" definitions, respectively. Pad usage is moderately strongly associated with ICIQ 1, 2, and 3 (ρ = 0.744, 0.677, and 0.711, respectively; p < 0.001). Concordance between classical UC definitions is acceptable between "0 pads-ICIQ score 0" (K = 0.466), but poor for "1 safety pad" and "1 pad" (K = 0.326 and 0.137, respectively). Patients with "0 pad usage" have better QoL related to urine leakage than patients with "1 safety pad" or "1 pad" (1.41 vs. 2.44 and 3.11, respectively; p < 0.05). There were no significant differences found regarding QoL between patients with ICIQ score 0 and ICIQ score 2 (1.01 vs. 1.63; p = 0.63).

CONCLUSIONS

Pad usage and the ICIQ-SF's answers provide useful information. We propose a combined definition (0 pads and ICIQ score ≤2) as it is the definition with the least impact on daily QoL.

Open retropubic radical prostatectomy

Radical prostatectomy (RP) is a common treatment choice for localized prostate cancer. While there is increasing utilisation of robotic assisted RP in some centres, open RP (ORP) remains well established and commonly performed in many parts of the world. The goals of modern ORP are to remove the prostate en-bloc with negative surgical margins, while minimising blood loss and preserving urinary continence and erectile function. We present a technical review of ORP incorporating contemporary techniques for control of the deep venous complex, additional haemostatic measures, nerve-sparing and vesicourethral reconstruction.

The importance of anatomical reconstruction for continence recovery after robot assisted radical prostatectomy: a systematic review and pooled analysis from referral centers

INTRODUCTION

Urinary incontinence is one of the most scared sequelae of robot assisted radical prostatectomy (RARP). Therefore, different surgical modifications, aimed to restore the original anatomy, were proposed to overcome this issue. The purpose of this study is to assess which is the best reconstruction technique (posterior only: PR; anterior only: AR; total: TR) compared to the standard approach for continence recovery after RARP in a tertiary care center.

EVIDENCE ACQUISITION

After establishing an a priori protocol, a systematic electronic literature search was conducted in May 2019. The article selection proceeded in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and was registered (PROSPERO registry number 131667). The risk of bias and the quality assessment of the included studies were performed. Simple pooled analysis was performed for continence rates according to the definition of continence (0 pad vs. 0-1 pad) and the different types of reconstruction at 1, 4, 12, 24, 52 weeks after RARP. Complication rate, operative and console time and estimated blood loss were pooled. Two-side test of proportion and T-test were used to compare rates and mean, respectively.

EVIDENCE SYNTHESIS

Six studies meeting the inclusion criteria were found and included in the analysis. All the included studies were of "poor" or "good" quality. A high or moderate risk of bias was recorded. TR showed higher continence recovery rates, compared to their anterior reconstruction counterpart at 1, 4, 12, 24, 52 weeks (P<0.001 at all time-points). At 12 weeks TR showed the highest continence rates (P<0.001), followed by AR and PR. No statistically significant differences were recorded regarding anastomosis-related complication rates (anastomosis stricture P=0.08; urine leakage P=0.1).

CONCLUSIONS

In patients undergoing RARP, TR facilitates a faster and higher continence recovery compared to standard approach or PR or AR only.

Patient reported outcome measures concerning urinary incontinence after robot assisted radical prostatectomy: development and validation of an online prediction model using clinical parameters, lower urinary tract symptoms and surgical experience

The prediction of post-prostatectomy incontinence (PPI) after robot-assisted radical prostatectomy (RARP) depends on multiple clinical, anatomical and surgical factors. There are only few risk formulas, tables or nomograms predicting PPI that may assist clinicians and their patients in adequate risk counseling on postoperative side-effects. Prospective data collection of 1814 patients who underwent RARP between 2009 and 2017 was done. Pre-operative parameters were age, body mass index (BMI), prostate volume, the American Society of Anesthesiologists (ASA) score, severity of Lower Urinary Tract Symptoms (LUTS), type of planned nerve-sparing surgery and surgical experience. The continence status was reported using Patient Reported Outcome Measurements (PROMs) using the validated pad-use questionnaire EPIC26. Continence was defined as either the use of zero pads or one safety pad. Multivariable logistic regression analysis was performed to identify predictors of PPI within one year after RARP. An online prediction tool was developed and validated. The median follow-up was 36 months (range 12–108). The response rate was high at 85.2%. A total of 85% (1537/1814) of patients was continent on follow-up. One-year continence rate was 80.1% (95% CI 78.3–81.9%) (1453/1814) and increased to 87.4% (95% CI 85.4–89.4%) after 5 years. On multivariable analysis, severity of LUTS (OR = 0.56 p = 0.004), higher age (OR = 0.73 p = 0.049), extend of nerve-sparing surgery (OR = 0.60 p = 0.001) and surgeon experience (OR = 1.48 p = 0.025) were significant independent predictors for PPI. The online prediction model performed well in predicting continence status with poor discrimination and good calibration. An intuitive online tool was developed to predict PPI after RARP that may assist clinicians and their patients in counseling of treatment.

Trends in risk-group distribution and Pentafecta outcomes in patients treated with nerve-sparing, robot-assisted radical prostatectomy: a 10-year low-intermediate volume single-center experience

PURPOSE

To evaluate the trends in risk-group distribution and Pentafecta outcomes in patients treated with nerve-sparing (NS), robot-assisted radical prostatectomy (RARP) in a single low-intermediate volume prostate cancer (PCa) center over a 10-year period.

MATERIALS AND METHODS

We queried a prospectively maintained database for patients who underwent NS RARP between 2009 and 2018 in a low-intermediate volume PCa center. Risk-groups were defined according to the D'Amico classification. Pentafecta outcomes referred to the postsurgical presence of potency and continence, and the absence of biochemical recurrence (BCR), positive surgical margins (PSM), and perioperative complications. The Kruskall-Wallis test, the t test and the Mann-Whitney tests were used when appropriate.

RESULTS

603 patients underwent NS RARP and 484 patients were evaluated for Pentafecta outcomes. Median postsurgical follow-up was 28 months. Overall, 137 (22.7%), 376 (62.3%), and 90 (15%) patients were diagnosed in the low-, intermediate-, and high-risk groups, respectively. Patients undergoing NS RARP shifted from 33 to 20% in the low-risk group, from 52 to 62% in the intermediate-risk group, and from 10 to 13% in the high-risk group. Patients reaching Pentafecta increased from 38 to 44%. No postoperative potency was the main reason for non-achieving Pentafecta (71%). BCR strongly limited Pentafecta achievement in the high-risk group (61%), but not in intermediate (24%) and low-risk (30%) groups.

CONCLUSIONS

Low-intermediate volume PCa centers show similar trends to high-volume centers regarding risk group distributions over time in PCa patients undergoing NS RARP. We reported an increase in Pentafecta outcomes achievement over time even for experienced surgeons. Pentafecta outcomes achievement is risk-group dependent.

Deep Learning for Natural Language Processing in Urology: State-of-the-Art Automated Extraction of Detailed Pathologic Prostate Cancer Data From Narratively Written Electronic Health Records

PURPOSE

Entering all information from narrative documentation for clinical research into databases is time consuming, costly, and nearly impossible. Even high-volume databases do not cover all patient characteristics and drawn results may be limited. A new viable automated solution is machine learning based on deep neural networks applied to natural language processing (NLP), extracting detailed information from narratively written (eg, pathologic radical prostatectomy [RP]) electronic health records (EHRs).

METHODS

Within an RP pathologic database, 3,679 RP EHRs were randomly split into 70% training and 30% test data sets. Training EHRs were automatically annotated, providing a semiautomatically annotated corpus of narratively written pathologic reports with initially context-free gold standard encodings. Primary and secondary Gleason pattern, corresponding percentages, tumor stage, nodal stage, total volume, tumor volume and diameter, and surgical margin were variables of interest. Second, state-of-the-art NLP techniques were used to train an industry-standard language model for pathologic EHRs by transfer learning. Finally, accuracy of the named entity extractors was compared with the gold standard encodings.

RESULTS

Agreement rates (95% confidence interval) for primary and secondary Gleason patterns each were 91.3% (89.4 to 93.0), corresponding to the following: Gleason percentages, 70.5% (67.6 to 73.3) and 80.9% (78.4 to 83.3); tumor stage, 99.3% (98.6 to 99.7); nodal stage, 98.7% (97.8 to 99.3); total volume, 98.3% (97.3 to 99.0); tumor volume, 93.3% (91.6 to 94.8); maximum diameter, 96.3% (94.9 to 97.3); and surgical margin, 98.7% (97.8 to 99.3). Cumulative agreement was 91.3%.

CONCLUSION

Our proposed NLP pipeline offers new abilities for precise and efficient data management from narrative documentation for clinical research. The scalable approach potentially allows the NLP pipeline to be generalized to other genitourinary EHRs, tumor entities, and other medical disciplines.

A prospective study of patient reported urinary incontinence among American, Norwegian and Spanish men 1 year after prostatectomy

Objective

To compare pre- and post-radical prostatectomy (RP) responses in the urinary incontinence domain of Expanded Prostate Cancer Index Composite-26 (EPIC-26) in cohorts from the USA, Norway and Spain.

Methods

A prospective study of pre- and 1-year post-treatment responses in American (n=537), Norwegian (n=520) and Spanish (n=111) patients, establishing the prevalence of urinary incontinence defined according to published dichotomization. Thereafter we focused on the response alternatives “occasional dribbling”, pad use and problem experience. A multivariate logistic regression analysis (significance level ≤ 0.01) considered risk factors for “not retaining total control”.

Results

Compared to the European men, the American patients were younger, healthier and more presented with lower risk tumors. Before RP no inter-country differences emerged the prevalence of urinary incontinence (6%). One-year post-treatment urinary incontinence was described by 30% of the American and 41% of the European patients, occasional dribbling being the most frequent type of urinary leakage. In the multivariate analysis the risk of “not retaining total control” increased almost 3-fold in European compared to American patients, with age and co-morbidity being additional independent risk factor.

Conclusion

After RP patients from Spain and Norway reported more unfavorable outcomes by EPIC-26 than the American patients to most of the urinary incontinence items, the difference between the European and American patients remaining in the multivariate analysis. The most frequent post-RP response alternative “occasional dribbling” needs to be validated with pad weighing as “gold standard”.

The EORTC quality of life questionnaire predicts early and long-term incontinence in patients treated with robotic assisted radical prostatectomy: Analysis of a large single center cohort

OBJECTIVES

The aim of our study is to evaluate the role of preoperative quality of life (QL) as a possible risk factor for post robotic assisted radical prostatectomy (RARP) urinary incontinence. The secondary aim is to evaluate the possible effect of preoperative QL on post RARP lower urinary tract symptoms (LUTS) and erectile dysfunction (ED).

METHODS AND MATERIALS

Between 2012 and 2017, all patients undergoing RARP for prostate cancer were enrolled. Patient's demographic, clinical, and histological characteristics were recorded. ED, LUTS, urinary incontinence, and QL were evaluated at baseline and postoperatively at 3, 6, and 12 months. Incontinence was evaluated with the International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form questionnaire and QL with the EORTC QLQ-C30 global health score (QLQ-GHS). Multivariate logistic regression analysis was used to evaluate the risk of postoperative incontinence, moderate/severe incontinence, LUTS, and moderate/severe ED.

RESULTS

Overall 4,603 patients were enrolled. Incontinence rates at 3, 6, and 12 months were respectively 17%, 10%, and 8%. On multivariate analysis, QL was an independent predictor of early incontinence (QLQ-GHS:0.71, CI:0.59-0.86; P= 0.001), severe incontinence (QLQ-GHS:0.65, CI:0.49-0.97; P= 0.006), and LUTS (QLQ-GHS:0.48, CI:0.41-0.57; P= 0.001). Single center design may be considered a limitation.

CONCLUSIONS

In our study a comprehensive evaluation of preoperative patient's QL, assessed by the EORTC QLQ-C30 questionnaire, can predict the early and long-term moderate/severe incontinence risk in RARP treated patients. Further studies should confirm our results.

Post-prostatectomy incontinence: multimodal modern-day management

As the rate of prostate cancer detection increases, so does the rate at which radical prostatectomy is performed. Post-prostatectomy incontinence (PPI) or urine leakage affects around 20% of men who undergo this procedure. Although affected individuals must be supported in maintaining hygiene with the use of urine capture devices, definitive treatment should also be offered if appropriate. A range of management options are available, from incontinence pads to artificial urinary sphincters. However, an understanding of the aetiology of the leak as well as patient factors is vital if the correct treatment option is to be selected. This article describes the potential causes of PPI and explores management options for this condition.

Impact of the baseline study with penile doppler ultrasound in patients with prostate cancer before radical prostatectomy

INTRODUCTION

Given the high prevalence of erectile dysfunction in male population between 40-70 years old and the effect of radical prostatectomy on this domain, it is important to perform a baseline study.

MATERIAL AND METHODS

Prior radical prostatectomy, erectile function has been assessed prospectively in 112 prostate cancer patients using the erectile function (EF) domain of the International Index of Erectile Function (EF-IIEF), Erectile Hardness Score (EHS) and a penile doppler ultrasound (PDUS). Comorbidities and Charlson index were collected. The EORTC QLQ C-30 and PR-25 tests were administered.

RESULTS

According to EF-IIEF questionnaire, 50.9% of patients showed normal EF and EHS grade 3-4 erection was achieved in the 75.9%. PDUS was normal only in 28.6% of patients and 51.8% showed arterial insufficiency. We found a significant association (P<.0001) between categorized EF-IIEF (normal, mild/moderate/severe) and the EHS value. Between PDUS (normal vs. pathologic) and EHS (3-4 vs. 1-2) statistically significant association (P=.005) was found. Just 35.3% of patients with EHS 3-4 showed normal PDUS. Correlation between the PDUS and the EF-IIEF (≥26 vs.<26) was statistically significant (P=.043). Moreover, only 38.6% of patients with EF-IIEF≥26 had a normal PDUS.

CONCLUSIONS

In order to predict EF recovery after surgery, global assessment is required. Solely self-administered tests are not enough. In this baseline study, PDUS can play an important role.

Patient Reported Outcome Measures for Transperineal Template Prostate Mapping Biopsies in the PICTURE Study

PURPOSE

Transperineal template prostate mapping biopsy is an increasingly used method of procuring tissue from men with suspected prostate cancer. We report patient related outcome measures and adverse events in men in the PICTURE trial (ClinicalTrials.gov NCT01492270) who underwent this diagnostic test.

MATERIALS AND METHODS

A total of 249 men underwent multiparametric magnetic resonance imaging followed by transperineal template prostate mapping biopsy as a validation study. Functional outcomes before and after transperineal template prostate mapping were prospectively collected and recorded with questionnaires, including the I-PSS (International Prostate Symptom Score), the I-PSS-QoL (Quality of Life), the IIEF-15 (International Index of Erectile Function-15) and the EPIC (Expanded Prostate Cancer Index Composite) urinary function.

RESULTS

Mean age was 62 years, median prostate specific antigen was 6.8 ng/ml and median gland size was 37 ml. At transperineal template prostate mapping biopsy a median of 49 cores (IQR 40-55) were taken. Mean time to complete the post-procedure patient related outcome measure questionnaires was 46 days. Adverse events included post-procedure acute urinary retention in 24% of patients, rectal pain in 26% and perineal pain in 41%. Transperineal template prostate mapping biopsy resulted in a statistically significant increase in scores on the I-PSS from 10.9 to 11.8 (p = 0.024) and the I-PSS-QoL from 1.57 to 1.76 (p = 0.03). The IIEF-15 erectile function score decreased by 23.2% from 47.7 to 38.7 (p <0.001). Significant deterioration was noted in all 5 of IIEF-15 functional domains, including erectile and orgasmic function, sexual desire, and intercourse and overall satisfaction (p <0.001). EPIC urinary scores showed no overall change from baseline.

CONCLUSIONS

Transperineal template prostate mapping biopsy causes a high urinary retention rate and a detrimental impact on genitourinary functional outcomes, including deterioration in urinary flow and sexual function. Our findings can be used to ensure adequate counseling about transperineal template prostate mapping biopsies. The results point to a need for strategies such as multiparametric magnetic resonance imaging and targeted biopsies to minimize the harms of transperineal template prostate mapping biopsy.

Indications, surgical technique, and long-term results of nerve sparing

Radical prostatectomy is frequently performed as a curative approach for clinically localized prostate cancer. In order to reduce the adverse effects of this operation on erectile function, preservation of neurovascular bundles was introduced as part of this operation. The decision of nerve sparing must be carefully tailored in each patient according to the stage of the disease. Patient selection has a critical importance in performing nerve sparing radical prostatectomy. In organ-confined cancers a nerve sparing surgery can be performed in the majority of the cases without jeopardizing tumor control. Individualized decision making in each case may allow more patients to receive a nerve sparing approach, and therefore, better functional outcomes. However, it continues to be difficult to predict postoperative functional outcomes accurately due to many influencing factors.

Psychotherapeutic Interventions Targeting Prostate Cancer Patients: A Systematic Review of the Literature

CONTEXT

Psychological counseling is a rarely discussed need for patients diagnosed with prostate cancer (PCa).

OBJECTIVE

To systematically review studies that investigated the effectiveness and feasibility of professional psychotherapeutic support for PCa patients.

EVIDENCE ACQUISITION

A systematic search was carried out using electronic databases, including PubMed, Web of Science, PsycInfo, and the Cochrane library. The search was performed up to September 1, 2017; only articles published in English were considered. The combination of the search words "prostate cancer" with "psychotherapy" was used. Inclusion criteria were: (1) studies with psychotherapy interventions that included PCa patients; (2) patients with localized or advance disease; and (3) professional psychotherapeutic support.

EVIDENCE SYNTHESIS

We identified a total of ten studies (1067 participants). Six studies investigated cognitive behavioral therapy (CBT; 713 participants). Two studies used supportive psychotherapy (88 participants) and two used cognitive essential couple therapy (133 couples). Most studies came from the USA (5 studies). CBT seemed to be beneficial in African Americans, Hispanics, men with higher interpersonal sensitivity, and those with relatively high levels of stress in single studies. Couples therapies seemed beneficial for patients and their partners. Supportive psychotherapy was usually integrated into multimodal supportive treatments.

CONCLUSIONS

Despite the limitations of the available studies, there is promising early evidence that specialized psychotherapeutic support for PCa patients is feasible and beneficial. Psychological intervention can significantly improve PCa patients' wellbeing after therapy. Further multicenter randomized controlled trials should focus on assessing which patients need psychotherapeutic help and which are most likely to benefit from such support, and which type of interventions are the most appropriate for each patient.

PATIENT SUMMARY

We report on studies comparing psychological outcomes in prostate cancer patients treated with psychotherapeutic interventions. Psychotherapeutic support is feasible and improves overall wellbeing and cancer-related distress in some prostate cancer patients.

Refined nomogram incorporating standing cough test improves prediction of male transobturator sling success

AIMS

To develop a decision aid in predicting sling success, incorporating the Male Stress Incontinence Grading Scale (MSIGS) into existing treatment algorithms.

METHODS

We reviewed men undergoing first-time transobturator sling for stress urinary incontinence (SUI) from 2007 to 2016 at our institution. Patient demographics, reported pads per day (PPD), and Standing Cough Test (SCT) results graded 0-4, according to MSIGS, were assessed. Treatment failure was defined as subsequent need for >1 PPD or further procedures. Parameters associated with failure were included in multivariable logistic models, compared by area under the receiver-operating characteristic curves. A nomogram was generated from the model with greatest AUC and internally validated.

RESULTS

Overall 203 men (median age 67 years, IQR 63-72) were evaluated with median follow-up of 45 months (IQR 11-75 months). A total of 185 men (91%) were status-post radical prostatectomy and 29 (14%) had pelvic radiation history. Median PPD and SCT grade were both two. Eighty men (39%) failed treatment (use of ≥1 PPD or subsequent anti-incontinence procedures) at a median of 9 months. History of radiation (P = 0.03), increasing MSIGS (P < 0.0001) and increasing preoperative PPD (P < 0.0001) were associated with failure on univariate analysis. In a multivariable model with AUC 0.81, MSIGS, and PPD remained associated (P = 0.002 and <0.0001 respectively, and radiation history P = 0.06), and was superior to models incorporating PPD and radiation alone (AUC 0.77, P = 0.02), PPD alone (AUC 0.76, P = 0.02), and a cutpoint of >2 PPD alone (AUC 0.71, P = 0.0001).

CONCLUSIONS

MSIGS adds prognostic value to PPD in assessing success of transobturator sling for treatment of SUI.