Prediction of functional outcomes after nerve-sparing radical prostatectomy: results of conditional survival analyses

The Association Between Low Preoperative Serum Testosterone and Post-radical Prostatectomy Urinary Function

OBJECTIVE

To determine if hypogonadism leads to delayed urinary function recovery post-radical prostatectomy (RP) by studying the effect of preoperative factors including age, membranous urethral length, radiation therapy, and Body Mass Index on urinary continence in patients with or without hypogonadism.

MATERIALS AND METHODS

We identified 1209 patients treated by RP with both pretreatment T and post-treatment urinary outcome. We assessed whether there was an association between low preoperative T level (prenoon T ≤ 300 ng/dL) and continence (using ≤1 pad/d) at 6 and 12months post-RP. Patient-reported continence was used when available, otherwise, surgeon-assessed continence was used. Logistic regression models were used, adjusted for age at RP and nerve-sparing status.

RESULTS

Median age at RP was 61 (Intraquatile Range (IQR) 56, 66), 92% of patients had at least one nerve spared and 99% were continent at baseline. Continence in patients with low T was nonsignificantly lower at 6months (odds ratio 0.69, 95% confidence interval 0.44, 1.06; P = .10) and nonsignificantly higher at 12months (odds ratio 1.07, 95% confidence interval 0.71, 1.58; P = .8). Sensitivity analyses excluding patients with preoperative metastasis or treated with androgen deprivation therapy (ADT) and including testosterone as a continuous predictor were consistent with the primary analysis; similarly finding no evidence of an association.

CONCLUSION

Although we cannot rule out an effect on early continence, overall the evidence does not suggest that low serum testosterone adversely impacts urinary function recovery after RP. This finding can be used to counsel patients enrolled in neoadjuvant ADT trials or those patients undergoing RP who have had prior ADT, such as in the setting of oligometastatic disease.

Conditional survival does not improve over time in metastatic castration-resistant prostate cancer patients undergoing docetaxel

PURPOSE

To investigate the conditional overall survival (OS) of metastatic castration-resistant prostate cancer (mCRPC) patients receiving docetaxel chemotherapy.

METHODS

We used deidentified patient-level data from the Prostate Cancer DREAM Challenge database and the control arm of the ENTHUSE 14 trial. We identified 2158 chemonaïve mCRPC patients undergoing docetaxel chemotherapy in the five randomized clinical trials. The 6-month conditional OS was calculated at times 0, 6, 12, 18, and 24 months from randomization. Survival curves of each group were compared using the log-rank test. Patients were then stratified into low- and high-risk groups based on the median predicted value of our recently published nomogram predicting OS in mCRPC patients.

RESULTS

Nearly half (45%) of the study population was aged between 65 and 74 years. Median interquartile range prostate-specific antigen for the overall cohort was 83.2 (29.6-243) ng/mL, and 59% of patients had bone metastasis with or without lymph node involvement. The 6-month conditional survival rates at 0, 6, 12, 18, and 24 months for the entire cohort were 93% (95% confidence interval [CI]: 92-94), 82% (95% CI: 81-84), 76% (95% CI: 73-78), 75% (95% CI: 71-78), and 71% (95% CI: 65-76). These rates were, respectively, 96% (95% CI: 95-97), 92% (95% CI: 90-93), 84% (95% CI: 81-87), 81% (95% CI: 77-85), and 79% (95% CI: 72-84) in the low-risk group and 89% (95% CI: 87-91), 73% (95% CI: 70-76), 65% (95% CI: 60-69), 64% (95% CI: 58-70), and 58% (95% CI: 47-67) in the high-risk group.

CONCLUSION

The conditional OS for patients undergoing docetaxel chemotherapy tends to plateau over time, with the main drop in conditional OS happening during the first year from initiating docetaxel treatment. That is the longer a patient survives, the more likely they are to survive further. This prognostic information could be a useful tool for a more accurate tailoring of both follow-up and therapies.

PATIENT SUMMARY

In this report, we looked at the future survival in months of patients with metastatic castration resistant prostate cancer on chemotherapy who have already survived a certain period. We found that the longer time that a patient survives, the more likely they will continue to survive. We conclude that this information will help physicians tailor follow-ups and treatments for patients for a more accurate personalized medicine.

Development of a Nomogram to Predict the Outcome for Patients with Soft Tissue Sarcoma

Soft tissue sarcomas (STSs) are common cutaneous or subcutaneous neoplasms in dogs. Most STSs are initially treated by surgical excision, and local recurrence may develop in almost 20% of patients. Currently, it is difficult to predict which STS will recur after excision, but this ability would greatly assist patient management. In recent years, the nomogram has emerged as a tool to allow oncologists to predict an outcome from a combination of risk factors. The aim of this study was to develop a nomogram for canine STSs and determine if the nomogram could predict patient outcomes better than individual tumour characteristics. The current study provides the first evidence in veterinary oncology to support a role for the nomogram to assist with predicting the outcome for patients after surgery for STSs. The nomogram developed in this study accurately predicted tumour-free survival in 25 patients but failed to predict recurrence in 1 patient. Overall, the sensitivity, specificity, positive predictive, and negative predictive values for the nomogram were 96%, 45%, 45%, and 96%, respectively (area under the curve: AUC = 0.84). This study suggests a nomogram could play an important role in helping to identify patients who could benefit from revision surgery or adjuvant therapy for an STS.

Defining the relevance of surgical margins. Part two: Strategies to improve prediction of recurrence risk

Due to the complex nature of tumour biology and the integration between host tissues and molecular processes of the tumour cells, a continued reliance on the status of the microscopic cellular margin should not remain our only determinant of the success of a curative-intent surgery for patients with cancer. Based on current evidence, relying on a purely cellular focus to provide a binary indication of treatment success can provide an incomplete interpretation of potential outcome. A more holistic analysis of the cancer margin may be required. If we are to move ahead from our current situation - and allow treatment plans to be more intelligently tailored to meet the requirements of each individual tumour - we need to improve our utilisation of techniques that either improve recognition of residual tumour cells within the surgical field or enable a more comprehensive interrogation of tumour biology that identifies a risk of recurrence. In the second article in this series on defining the relevance of surgical margins, the authors discuss possible alternative strategies for margin assessment and evaluation in the canine and feline cancer patient. These strategies include considering adoption of the residual tumour classification scheme; intra-operative imaging systems including fluorescence-guided surgery, optical coherence tomography and Raman spectroscopy; molecular analysis and whole transcriptome analysis of tissues; and the development of a biologic index (nomogram). These techniques may allow evaluation of individual tumour biology and the status of the resection margin in ways that are different to our current techniques. Ultimately, these techniques seek to better define the risk of tumour recurrence following surgery and provide the surgeon and patient with more confidence in margin assessment.

The development and assessment of a predicting nomogram for the recovery of immediate urinary continence following laparoscopic radical prostatectomy

Purpose

This study aimed to develop a nomogram to predict the recovery of immediate urinary continence in laparoscopic radical prostatectomy (LRP) patients.

Methods

A prediction model was developed based on a dataset of 154 LRP patients. Immediate urinary continence was defined as free from using pads within 7 days after the removal of the urinary catheter. The least absolute shrinkage and selection operator regression (LASSO) model was applied to screen the features. Multivariate logistic regression analysis was used to establish prediction model integrating the features selected from the LASSO regression analysis. Receiver operating curve (ROC), calibration and decision curve analysis (DCA) were used to assess the model's discrimination, calibration and clinical utility.

Results

The identified features of the prediction model included age, body mass index (BMI) and three pelvic anatomic parameters measured by MRI: membranous urethral length (MUL), intravesical prostatic protrusion length (IPPL) and puborectalis muscle width (PMW). The nomogram showed good discrimination with an are under the curve(AUC) of 0.914 (95% CI, 0.865-0.959, p < 0.001). Moreover, good calibration was showed in the model. Lastly, DCA showed that the nomogram was clinically useful.

Conclusion

The developed novel nomogram that can predict the possibility for post-prostatectomy patients to recover immediate urinary continence could be used as a counseling tool to explain urinary incontinence to patients after LRP.

Prediction of Incontinence after Robot-Assisted Radical Prostatectomy: Development and Validation of a 24-Month Incontinence Nomogram

Simple Summary

Many men fear urinary leakage after radical surgery for prostate cancer and may even choose against operation for unrealistic fears of leakage. Many urologists are unaware of their own results, and some urologists who collect their results do so in different ways. We collected urinary leakage data from 680 men in a uniform and simple way at 6, 12, and 24 months after operation: no pads, 1–2 pads, or ≥3 pads required daily. We used many patient characteristics to identify the key factors that predict recovery of urinary control after operation: age, race, height and weight, and preoperative erectile function. Easy-to-use nomograms were constructed that should be tested by other urologists to make sure they perform equally well in their patients. Nomograms like these allow men and the urologists counseling them to share patient-specific information about the timeline for, and the chance of, recovery of urinary control after operation.

Abstract

Incontinence after robot-assisted radical prostatectomy (RARP) is feared by most patients with prostate cancer. Many risk factors for incontinence after RARP are known, but a paucity of data integrates them. Prospectively acquired data from 680 men who underwent RARP January 2008–December 2015 and met inclusion/exclusion criteria were queried retrospectively and then divided into model development (80%) and validation (20%) cohorts. The UCLA-PCI-Short Form-v2 Urinary Function questionnaire was used to categorize perfect continence (0 pads), social continence (1–2 pads), or incontinence (≥3 pads). The observed incontinence rates were 26% at 6 months, 7% at 12 months, and 3% at 24 months. Logistic regression was used for model development, with variables identified using a backward selection process. Variables found predictive included age, race, body mass index, and preoperative erectile function. Internal validation and calibration were performed using standard bootstrap methodology. Calibration plots and receiver operating curves were used to evaluate model performance. The initial model had 6-, 12-, and 24-month areas under the curves (AUCs) of 0.64, 0.66, and 0.80, respectively. The recalibrated model had 6-, 12-, and 24-month AUCs of 0.52, 0.52, and 0.76, respectively. The final model was superior to any single clinical variable for predicting the risk of incontinence after RARP.

Applications of artificial intelligence in the diagnosis and prediction of erectile dysfunction: a narrative review

Despite the high prevalence of erectile dysfunction, patients are reluctant to seek medical advice, which leads to low diagnostic rates in clinical practice. Artificial intelligence has been widely applied in the diagnosis of many diseases and may alleviate the situation. However, the applications of artificial intelligence in erectile dysfunction have not been reviewed to date. Therefore, the assistance from artificial intelligence needs to be summarized. In this review, 418 publications before January 10, 2021, regarding artificial intelligence applications in diagnosing and predicting erectile dysfunction, were retrieved from five databases, including PubMed, EMBASE, the Cochrane Library, and two Chinese databases (WANFANG and CNKI). In addition, the reference lists of the included studies or relevant reviews were checked to avoid bias. Finally, 30 articles were reviewed to summarize the current status, merits, and limitations of applying artificial intelligence in diagnosing and predicting erectile dysfunction. The results showed that artificial intelligence contributed to developing novel diagnostic questionnaires, equipment, expert systems, classifiers by images and predictive models. However, most of the included studies were not subjected to external validations, resulting in doubt on the generalizability. In the future, more rigorously designed studies with high-quality datasets for erectile dysfunction are required.

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.

[Künstliche Harnsphincter zur Behandlung von Stress-Harninkontinenz - eine oft nicht ausgelastete Behandlungsoption in Deutschland]

ABSTRAKT

Harninkontinenz ist in Deutschland weit verbreitet und betrifft Millionen von Frauen und Männern. Vor allem Männer, die postoperativ dauerhaft inkontinent sind, werden hierzulande trotz der ausreichenden Verfügbarkeit chirurgischer Optionen unterbehandelt. Der künstliche Schließmuskel wird seit Jahrzehnten erfolgreich zur Behandlung angeborener und erworbener Stress-Harninkontinenz bei Männern und Frauen sowie neurogener Harninkontinenz eingesetzt und wird in Form neuer Modelle weiterentwickelt. Aufgrund der guten Ergebnisse, Es gilt jetzt als Standardtherapie für Männer mit anhaltender, mittelschwerer bis schwerer Harninkontinenz. Die operationstechnische Technik ist anspruchsvoll, kann aber erlernt werden. Die meisten Komplikationen können in erfahrenen Händen deutlich reduziert werden. Patientenzufriedenheit mit künstlichen Harnsphinctern (AUS) ist hoch und korreliert mit der Kontinenzrate und nicht mit der relativ hohen Revisionsrate, weshalb diese Behandlungsoption in Deutschland zunehmend mehr Patienten mit mittelschwerer bis schwerer Harninkontinenz angeboten werden sollte. Urologen in der allgemeinen Praxis spielen in diesem Zusammenhang eine zentrale Rolle.

Dynamic contrast enhancement in prostate MRI as predictor of erectile function and recovery after radical prostatectomy

PURPOSE

To analyze routine preoperative prostate MRI to predict erectile function (EF) before and after radical prostatectomy (RP).

METHODS

Patients who underwent RP with an existing preoperative MRI including dynamic contrast-enhanced images and completed International Index of Erectile Function (IIEF-5) questionnaires at baseline and 12 months postoperative. They were divided into four erectile dysfunction (ED) groups according to preoperative IIEF-5 score. The perfusion quality was measured in the peripheral zone of the prostate by the ratio of signal increase 120 s after wash-in of contrast agent (Ratio120) in preoperative MRI and compared between the ED groups.

RESULTS

Ratio120 showed differences among the preoperative ED groups (p = .020) in 97 patients. According to IIEF-5 at 12 months postoperative, 43 patients were dichotomized into "no to mild" (≥17 points) and "moderate to severe" (≤16) ED groups. Ratio120 revealed differences among the postoperative ED groups (128.84% vs. 101.95%; p = .029) and stayed an independent predictor for ED in the multivariable regression analysis (adjusted for age, nerve-sparing and preoperative IIEF-5). ROC curves demonstrated an additional diagnostic benefit.

CONCLUSIONS

Preoperative MRI of the prostate may be used for the prediction of EF and postsurgical recovery after RP. This may serve as important tool in preoperative patient counseling and management of expectations.

The Effect of Adverse Patient Characteristics on Perioperative Outcomes in Open and Robot-Assisted Radical Prostatectomy

Objective: To analyze the effect of adverse preoperative patient and tumor characteristics on perioperative outcomes of open (ORP) and robot-assisted radical prostatectomy (RARP).

Material and Methods: We retrospectively analyzed 656 patients who underwent ORP or RARP according to intraoperative blood loss (BL), operation time (OR time), neurovascular bundle preservation (NVBP) and positive surgical margins (PSM). Univariable and multivariable logistic regression models were used to identify risk factors for impaired perioperative outcomes.

Results: Of all included 619 patients, median age was 66 years. BMI (<25 vs. 25-30 vs. ≥30) had no influence on blood loss. Prostate size >40cc recorded increased BL compared to prostate size ≤ 40cc in patients undergoing ORP (800 vs. 1200 ml, p < 0.001), but not in patients undergoing RARP (300 vs. 300 ml, p = 0.2). Similarly, longer OR time was observed for ORP in prostates >40cc, but not for RARP. Overweight (BMI 25-30) and obese ORP patients (BMI ≥30) showed longer OR time compared to normal weight (BMI <25). Only obese patients, who underwent RARP showed longer OR time compared to normal weight. NVBP was less frequent in obese patients, who underwent ORP, relative to normal weight (25.8% vs. 14.0%, p < 0.01). BMI did not affect NVPB at RARP. No differences in PSM were recorded according to prostate volume or BMI in ORP or RARP. In multivariable analyses, patient characteristics such as prostate volume and BMI was an independent predictor for prolonged OR time. Moreover, tumor characteristics (stage and grade) predicted worse perioperative outcome.

Conclusion: Patients with larger prostates and obese patients undergoing ORP are at risk of higher BL, OR time or non-nervesparing procedure. Conversely, in patients undergoing RARP only obesity is associated with increased OR time. Patients with larger prostates or increased BMI might benefit most from RARP compared to ORP.

A novel tool to predict functional outcomes after robot-assisted radical prostatectomy and the value of additional surgery for incontinence

OBJECTIVES

To develop and validate a model to predict 12-month continence status after robot-assisted radical prostatectomy (RARP) from preoperative and 3-month postoperative data; this model could help in informing patients on their individualised risk of urinary incontinence (UI) after RP in order to choose the best treatment option.

PATIENTS AND METHODS

Data on 9421 patients in 25 Belgian centres were prospectively collected (2009-2016) in a compulsory regional database. The primary outcome was the prediction of continence status, using the International Consultation on Incontinence Urinary Incontinence Short Form (ICIQ-UI-SF) at 12-months after RARP. Linear regression shrinkage was used to assess the association between preoperative 3-month postoperative characteristics and 12-month continence status. This association was visualised using nomograms and an online tool.

RESULTS

At 12 months, the mean (sd) score of the ICIQ-UI-SF questionnaire was 4.3 (4.7), threefold higher than the mean preoperative score of 1.4. For the preoperative model, high European Association of Urology risk classification for biochemical recurrence (estimate [Est.] 0.606, se 0.165), postoperative radiotherapy (Est. 1.563, se 0.641), lower preoperative European Organisation for Research and Treatment of Cancer quality of life questionnaire 30-item core (EORCT QLQ-C30)/quality of life (QoL) score (Est. -0.011, se 0.003), higher preoperative ICIQ-UI-SF score (Est 0.214, se 0.018), and older age (Est. 0.058, se 0.009), were associated with a higher 12-month ICIQ-UI-SF score. For the 3-month model, higher preoperative ICIQ-UI-SF score (Est. 0.083, se 0.014), older age (Est. 0.024, se 0.007), lower 3-month EORCT QLQ-C30/QoL score (Est. -0.010, se 0.002) and higher 3-month ICIQ-UI-SF score (Est. 0.562, se 0.009) were associated with a higher 12-month ICIQ-UI-SF score.

CONCLUSIONS

Our models set the stage for a more accurate counselling of patients. In particular, our preoperative model assesses the risk of UI according to preoperative and early postoperative variables. Our postoperative model can identify patients who most likely would not benefit from conservative treatment and should be counselled on continence surgery.

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.

Athermal versus ultrasonic nerve-sparing laparoscopic radical prostatectomy: a comparison of functional and oncological outcomes

PURPOSE

Many urologists emphasize the concept of heat-related damage suggesting the avoidance of any energy to perform nerve-sparing radical prostatectomy. At our institution, both athermal and ultrasonic dissection have been used over the last years to perform a nerve-sparing laparoscopic radical prostatectomy (NSLRP). In this study, we compare functional and oncological outcomes of the two procedures.

METHODS

All charts from patients undergoing NSLRP between January 2009 and June 2015 were reviewed. The International Index of Erectile Function (IIEF-5) was recorded preoperatively and 3, 12 and 24 months after surgery; continence was recorded at 3 and 12 months; PSA was recorded at last follow-up. Uni- and multivariate analyses were performed to assess the association of variables with functional and oncological outcomes.

RESULTS

Ultrasonic NSLRP was used for 120 patients, while athermal NSLRP on 111. The impact of the cutting technique on erection recovery was different at 3 months, favoring athermal dissection (p = 0.002); however, significance was lost at 12 (p = 0.09) and 24 (p = 0.14) months. Continence recovery was comparable at 3 (p = 0.1) and 12 (p = 0.2) months; the rate of positive surgical margins and PSA recurrence were also similar (p = 0.2 and p = 0.06, respectively). At univariate analysis, age, Gleason sum, nerve-sparing laterality, and extension (intra- vs interfascial) were associated with overall erection recovery; only age and nerve-sparing laterality were independent predictors. Age and preoperative TRUS prostate volume were associated with continence recovery, both at uni- and multivariate analysis.

CONCLUSIONS

The use of an ultrasonic device compared to athermal dissection during NSLRP does not affect long-term potency, nor continence and early biochemical recurrence.

Conditional survival after surgery for patients with penile cancer

BACKGROUND

Penile cancer represents a rare pathology whose natural history of treatment is poorly understood.

OBJECTIVE

To illustrate the dynamic survival profiles in surgically treated patients with squamous cell carcinoma of the penis (SCCP) using the conditional survival (CS) estimates.

MATERIALS AND METHODS

Patients with non-metastatic SCCP were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Conditional 3-yr overall survival (OS) rate and 3-yr cancer-specific survival (CSS) rate represented the primary outcomes of interest and were calculated using the Kaplan-Meier method. The multivariable Cox regression model was employed to calculate proportional hazard ratios for the prediction of mortality.

RESULTS

A total of 1887 SCCP patients who had undergone surgeries were identified. Given a 1-, 2-, 3-, 4-, and 5-yr survivorship, the 3-yr OS rates were, respectively, improved by + 9.8 (72.6%), +18.2 (78.1%), +23.4 (81.6%), +27.8 (84.5%), and + 26.6% (83.7%) from those calculated at baseline (time zero). As compared with the baseline calculations, patients who had survived 1, 2, 3, 4, or 5 yr after surgery could, respectively, harvest a + 7.8 (84.7%), +14.8 (90.2%), +19.5 (93.9%), +22.1 (96.0%), and + 22.4% (96.2%) improvement in 3-yr CSS. Patients with the most aggressive disease at baseline ultimately benefited the most from event-free survivorship. Multivariable Cox regression analyses showed that the impact of adverse pathological parameters (G2-3, ≥ pT2, pN+) on OS and CSS mostly showed a decreasing trend over time and some could disappear after a minimum of 1-yr survivorship.

DISCUSSION AND CONCLUSION

The survival probability of SCCP patients increases with post-operative survival. Patients with aggressive disease at baseline ultimately benefit the most from event-free survivorship and may expect a better prognosis once they survive the critical few years after surgery. The recorded observations have crucial implications regarding patient counseling and follow-up.

Concurrent Penile Prosthesis and Artificial Urinary Sphincter versus Penile Prosthesis and Male Sling: A National Multi-Institutional Analysis of National Surgical Quality Improvement Program Database Comparing Postoperative Morbidity

Purpose

We aimed to assess the 30-day morbidity in patients undergoing combined insertion of penile prosthesis (PP) and artificial urinary sphincter (AUS) vs. PP and male sling (MS).

Materials and Methods

The National Surgical Quality Improvement Program database was queried to identify patients who underwent placement of AUS or MS combined with PP. Patient demographics, postoperative morbidity including complications, readmission and reoperation rates were recorded. Student t-test and chi-square or Fischer's exact test were used as appropriate.

Results

Forty-one patients met selection criteria between 2010 and 2016. Overall, 26 patients received PP and AUS vs. 15 that received PP and MS. Average age was similar in both groups (64.8±6.6 years vs. 62.3±6.3 years, p=0.254). Diabetes mellitus was more prevalent in PP+MS group compared to AUS+PP group (46.7% vs. 11.5%, p=0.022). Average length of stay was higher in PP+AUS group compared to PP+MS group (2.2±0.6 days vs. 1.8±0.4 days, p=0.017). Postoperative morbidity was reported in four patients in PP+AUS group. No reported complications in PP+MS group. In PP+AUS group, complications included one patient who developed urinary tract infection, one developed surgical site infection, readmission in two for postoperative infection, and one return to the operating room. No reported prosthesis explantation or revision in either groups.

Conclusions

Our results showed that 30-day morbidity was recorded in the PP+AUS group and none in the PP+MS group. The complication and readmission rates remain comparable to the previous reports in both groups.

Conditional disease-free survival in high-risk renal cell carcinoma treated with sunitinib

BACKGROUND

Disease-free survival (DFS) did not reflect accurate individual prognosis after initial diagnosis. As conditional DFS (CDFS) could provide dynamic prognostic information, we evaluated CDFS in these patients treated with or without sunitinib.

RESULTS

A total of 1329 patients with median follow-up 6.54 years were enrolled. CDFS improved continuously with disease-free survivorship increasing in both sunitinib and placebo group with minimal difference. In placebo arm, the CDFS of surviving to five year after living 1, 2, 3, and 4 years were 65%, 78%, 87%, and 95% (observed 5-year DFS: 51%). Dynamic changes of HR showed adjuvant sunitinib decrease relapse risks during the first 1.5 years after surgery (P < 0.03).

CONCLUSIONS

Our study provided contemporary data of CDFS and change of relapse HR in high-risk ccRCC patients after adjuvant sunitinib or placebo. The remarkable improvement in CDFS highlighted the importance of disease-free interval as a strong indicator in patient counseling and surveillance planning.

MATERIALS AND METHODS

The primary end point was CDFS and the second end point was smooth hazard ratios (HR) for the prediction of relapses. The differences of conditional survival were compared with the calculation of d value.

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”.

Postoperative dynamic survival of gastric cancer patients: A multi-institutional, international analysis of 22 265 patients

BACKGROUND

How to best evaluate the disease-specific survival (DSS) of gastric cancer (GC) survivors over time is unclear.

METHODS

Clinicopathological data from 22 265 patients who underwent curative intend resection for GC were retrospectively analyzed. Changes in the patients' 3-year conditional disease-specific survival (CS3) were analyzed. We used time-dependent Cox regression to analyze which variables had long-term effects on DSS and devised a dynamic predictive model based on the length of survival.

RESULTS

Based on 1-, 3-, and 5-year survivorships, the CS3 of the population increased gradually from 62% to 68.1%, 83.7%, and 90.6%, respectively. Subgroup analysis showed that the CS3 of patients who had poor prognostic factors initially demonstrated the greatest increase in postoperative survival time (eg, N3b: 26.6%-84.1%, Δ57.5% vs N0: 84.1%-93.3%, Δ9.2%). Time-dependent Cox regression analysis showed the following predictor variables constantly affecting DSS: age, the number of examined lymph nodes (LNs), T stage, N stage, and site (P < .05). These variables served as the basis for a dynamic prediction model.

CONCLUSIONS

The influence of prognostic factors on DSS and CS3 changed dramatically over time. We developed an effective model for predicting the DSS of patients with GC based on the length of survival time.

Causes of Death and Conditional Survival of Renal Cell Carcinoma

Background: As conditional survival could provide more relevant prognostic information at each follow-up time, the present study aimed to assess conditional overall survival (COS) based on two cohorts and assess the risks of death due to renal cell carcinoma (RCC) vs. other causes. Methods: The Fudan University Shanghai Cancer Center (FUSCC) and Surveillance, Epidemiology, and End Results (SEER) database were used as the source of data for our analysis. COS and cancer-specific survival were evaluated using the Kaplan-Meier method. Results: A total of 90,927 patients (SEER cohort = 88,807, FUSCC cohort = 2,120) were enrolled. Our results suggest that hazards of other causes-related death were always higher than that of cancer-specific death in low-risk RCC patients, but lower in metastatic RCC patients. It exceeded that of cancer-specific death by 8 years in high-risk RCC patients. Only in metastatic RCC patients, the COS improved markedly with survivorship increasing. After surviving 1, 2, 3, 4, and 5 years, the 5 years COS increased by +10, +18, +23, +29, and 35% (the observed 5 years OS: 12%), respectively. Conclusions: COS can better help patients with metastatic RCC rather than other RCC patients. Additionally, COS brings optimism for metastatic RCC patients with expected poorer prognosis psychologically.

A long-term conditional survival analysis for gastric cancer based on 7th and 8th TNM classification in Eastern and Western populations

BACKGROUND

To compare the power to predict the 5-year conditional disease-specific survival (CS5) between the 7th and 8th editions of the TNM for gastric cancer (GC) patients.

METHOD

This retrospective study recruited 20,548 patients who underwent GC surgery from the databases of the Surveillance, Epidemiology, End Results and a center in Asia. The CS5 was evaluated with the 7th and 8th TNM classification.

RESULTS

A two-step model showed that at the 3-5th postoperative years, the 8th staging remained an independent risk factor, whereas there was no significant difference for 7th -edition staging. Further analysis of the ability to predict CS5 indicated that there were significant differences in the CS5 of 7th -edition stages IIb and IIIa at baseline and at the postoperative 1-4th years (all p < 0.05, Cohen's d > 0.5). However, the CS5 of the fifth year was similar between them (p = 0.307, Cohen's d = 0.35). Meanwhile, the results indicated that the 8th -edition staging could effectively determine the CS5 among stages Ⅰa, Ⅰb, Ⅱa, Ⅱb, Ⅲa, and Ⅲb at baseline and at the postoperative 1-5th years (all p < 0.05). However, neither the 7th - nor the 8th -edition staging could predict the CS5 for stages Ⅲb and Ⅲc from the postoperative third to fifth years (all p > 0.05).

CONCLUSIONS

For patients with stages IIB and IIIA GC, the 8th TNM has a higher discriminatory value than the 7th edition for CS5 after the postoperative fourth year. However, a more detailed classification system is still needed to predict conditional survival for GC.

Prediction of Conditional Probability of Survival After Surgery for Gastric Cancer: A Study Based on Eastern and Western Large Data Sets

BACKGROUND

The dynamic prognosis of patients who have undergone curative surgery for gastric cancer has yet to be reported. Our objective was to devise an accurate tool for predicting the conditional probability of survival for these patients.

METHODS

We analyzed 11,551 gastric cancer patients from the Surveillance, Epidemiology, and End Results database. Two-thirds of the patients were selected randomly for the development set and one-third for the validation set. Two nomograms were constructed to predict the conditional probability of overall survival and the conditional probability of disease-specific survival, using conditional survival methods. We then applied these nomograms to the 4,001 patients in the database from Fujian Medical University Union Hospital, Fuzhou, China, one of the most active Chinese institutes.

RESULTS

The 5-year conditional probability of overall survival of the patients was 41.6% immediately after resection and increased to 52.8%, 68.2%, and 80.4% at 1, 2, and 3 years after gastrectomy. The 5-year conditional probability of disease-specific survival "increased" from 48.9% at the time of gastrectomy to 59.8%, 74.7%, and 85.5% for patients surviving 1, 2, and 3 years, respectively. Sex; race; age; depth of tumor invasion; lymph node metastasis; and tumor size, site, and grade were associated with overall survival and disease-specific survival (P <.05). Within the Surveillance, Epidemiology, and End Results validation set, the accuracy of the conditional probability of overall survival nomogram was 0.77, 0.81, 0.82, and 0.82 at 1, 3, 5, and 10 years after gastrectomy, respectively. Within the other validation set from the Fujian Medical University Union Hospital (n = 4,001), the accuracy of the conditional probability of overall survival nomogram was 0.76, 0.79, 0.77, and 0.77 at 1, 3, 5, and 10 years, respectively. The accuracy of the conditional probability of disease-specific survival model was also favorable. The calibration curve demonstrated good agreement between the predicted and observed survival rates.

CONCLUSION

Based on the large Eastern and Western data sets, we developed and validated the first conditional nomogram for prediction of conditional probability of survival for patients with gastric cancer to allow consideration of the duration of survivorship.

Preoperative Urine Culture Results Correlate Poorly With Bacteriology of Urologic Prosthetic Device Infections

INTRODUCTION

Although preoperative negative urine culture results and treatment of urinary tract infections are generally advised before artificial urinary sphincter (AUS) and penile prosthesis (PP) surgery to prevent device infection, limited evidence exists to support this practice.

AIM

To evaluate the relation between preoperative urine culture results and the bacteriology of prosthetic device infections.

METHODS

Men undergoing AUS and/or PP placement at a tertiary referral center from 2007 through 2015 were analyzed. A total of 713 devices were implanted in 681 patients (337 AUSs in 314 patients and 376 PPs in 367 patients), of whom 259 (36%) did not have preoperative urine culture and were excluded. The remaining 454 patients received standard broad-spectrum perioperative antibiotics. Two patient groups were identified based on preoperative urine cultures: group 1 had negative urine culture results and group 2 had untreated asymptomatic positive urine culture results identified postoperatively.

MAIN OUTCOME MEASURES

Device infection was diagnosed clinically and cultures obtained from the explanted device and tissue spaces were compared with preoperative urine culture results.

RESULTS

Although multivariate analysis showed that patients undergoing AUS placement had a 4.5-fold greater risk of positive urine culture results (114 of 250, 45%) compared with those undergoing PP placement (36 of 204, 18%; P < .001), infection rates between device types were similar (8 of 250 for AUSs [3%] and 7 of 204 for PPs [3%]; P = .89). At a median follow-up of 15 months, device infection occurred in 15 of 454 devices (3%) implanted and no differences in infection rates were noted between urine culture groups (10 of 337 in group 1 [3.3%] and 5 of 117 in group 2 [4.3%]; P = .28). Remarkably, only 1 of 15 device infections (7%) had the same organism present at preoperative urine culture.

CONCLUSIONS

Despite the finding that patients with AUS placement had a 4.5 times higher rate of positive urine culture results than patients with PP placement, preoperative urine culture results appeared to show little correlation with the bacteriology of prosthetic device infections.

Are Urine Cultures Necessary Prior to Urologic Prosthetic Surgery?

INTRODUCTION

A preoperative negative urine culture is generally advised before implantation of urologic prosthetics to prevent device infection. However, a review of the medical literature indicates sparse evidence to support this practice.

AIM

To describe outcomes for patients undergoing prosthetic implantation without preoperative urine cultures.

METHODS

The cases of men undergoing artificial urinary sphincter (AUS) and/or inflatable penile prosthesis (IPP) placement at a tertiary care center from 2007 through 2015 were reviewed. Of 713 devices implanted in 681 patients (337 AUSs in 314 patients, 376 IPPs in 367), 259 cases without preoperative urine cultures were analyzed (41%). Patients received standard perioperative antibiotics.

MAIN OUTCOME MEASURES

Device infection was diagnosed clinically. Average follow-up was 15 months.

RESULTS

Device infection occurred in 4 of 259 patients (1.5%) with no difference noted in infection rate between device groups (AUS = 3 of 174 [2%]; IPP = 1 of 85 [1%]; P = .99); this rate appears to be consistent with the infection rate of numerous other published prosthetic series. Common skin organisms were implicated as the infectious agents in half the infected devices. Only one patient (0.4%) developed an Escherichia coli infection.

CONCLUSION

This study suggests that prosthetic urologic surgery can be safely performed without preoperative urine cultures. Kavoussi NL, Viers BR, Pagilara TL, et al. Are Urine Cultures Necessary Prior to Urologic Prosthetic Surgery? Sex Med Rev 2018;6:157-161.

Functional outcomes of clinically high-risk prostate cancer patients treated with robot-assisted radical prostatectomy: a multi-institutional analysis

BACKGROUND

To ascertain 3-year urinary continence (UC) and sexual function (SF) recovery following robot-assisted radical prostatectomy (RARP) for clinically high-risk prostate cancer (PCa).

METHODS

Retrospective analyses of a prospectively maintained database for 769 patients with D'Amico high-risk PCa undergoing RARP at two tertiary care centers in the United States and Europe between 2001 and 2014. The association between time since RARP and recovery of UC (defined as 0 pad/one safety liner per day) and SF (defined as sexual health inventory for men (SHIM) score ⩾17) was tested in separate preoperative and post-operative Cox-proportional hazards regression models. Sensitivity analyses were conducted using continence 0 pad per day and erection sufficient for intercourse as end points for UC and SF recovery, respectively.

RESULTS

Mean age of the cohort was 62.3 years, and 62.1% harbored ⩾PT3a disease. Nerve sparing (unilateral or bilateral) RARP was performed in 87.7% of patients. Kaplan-Meier estimates of UC recovery at 12, 24 and 36 months after surgery was 85.2%, 89.1% and 91.2%, respectively, while 33.8, 52.3 and 69.0% of preoperatively potent men (preoperative SHIM ⩾17; n=548; 71.3%) recovered SF. Similar results were noted in sensitivity analyses. Patient age and year of surgery were associated with UC and SF recovery; additionally, preoperative SHIM score, degree of nerve sparing, pT3b-T4 disease and surgical margins were associated with SF recovery over the period of observation.

CONCLUSIONS

Patients with D'Amico high-risk PCa treated with RARP may continue to recover UC and SF beyond 12 months of surgery and show promising outcomes at 3-year follow-up. Appropriate patient selection and counseling may aid in setting realistic expectations for functional recovery post RARP.

A prognostic model for predicting urinary incontinence after robot-assisted radical prostatectomy

BACKGROUND

The aim of this study is to develop a novel prognostic model for estimating the risk of postoperative urinary incontinence (UI) after robot-assisted radical prostatectomy (RARP).

METHODS

Participants comprised 131 men who underwent RARP at our hospital from 2011 to 2013. Cox regression analyses were performed to evaluate associations between UI and preoperative factors including filling cystometry and pressure-flow study results and magnetic resonance imaging.

RESULTS

Logistic regression analyses revealed significant associations between membranous urethral length or levator thickness and UI at 3 and 6 months. Stratification produced high (membranous urethral length < 9.5 mm or levator thickness < 9.0 mm) and low (membranous urethral length ≥ 9.5 mm and levator thickness ≥ 9.0 mm) UI risk groups. These inter-group differences in UI rate were significant.

CONCLUSIONS

We developed a novel prognostic model based on preoperative patient data that can be used for patient counselling.

Early Postoperative Radiotherapy is Associated with Worse Functional Outcomes in Patients with Prostate Cancer

PURPOSE

The effect of time between radical prostatectomy and radiation therapy on postoperative functional outcomes is still unclear in patients with surgically managed prostate cancer. We hypothesized that a shorter time between radical prostatectomy and radiotherapy might be associated with worse functional recovery rates after radical prostatectomy.

MATERIALS AND METHODS

We retrospectively evaluated 2,190 patients treated with radical prostatectomy and stratified according to radiotherapy schedule (adjuvant radiotherapy, salvage radiotherapy, no radiotherapy). We examined recovery rates for erectile function and urinary function according to adjuvant radiotherapy, salvage radiotherapy and no radiotherapy, and according to time from surgery to radiotherapy. Cox regression analyses were used to evaluate the impact of these predictors on functional outcomes.

RESULTS

Median followup was 48 months. The 3-year erectile function recovery rates were 35.0%, 29.0% and 11.6% in patients who received no radiotherapy, salvage radiotherapy and adjuvant radiotherapy, respectively (p <0.001), and differed significantly according to time to radiotherapy (11.7% vs 34.7% for less than 1 year vs 1 year or more, respectively, p <0.001). The 3-year urinary continence recovery rates were 70.7%, 59.0% and 42.2% in patients who received no radiotherapy, salvage radiotherapy and adjuvant radiotherapy, respectively (p <0.001), and differed according to time to radiotherapy (43.5% vs 62.7% for less than 1 year vs 1 year or more, respectively, p <0.001). Cox regression analyses confirmed the negative impact of early radiotherapy on recovery rates for erectile function and urinary continence.

CONCLUSIONS

Time from radical prostatectomy to radiotherapy has an important role in the recovery of erectile function and urinary continence. Delayed radiotherapy is preferred to improve functional outcomes after surgery.

Short and long-term urodynamic and quality of life assessment after nerve sparing radical hysterectomy: a prospective pilot study

OBJECTIVE

The aim of this study was to compare pre- and postoperative bladder function and quality of life (QoL) in women diagnosed with gynecologic malignancy and treated with nerve sparing radical hysterectomy (NSRH).

STUDY DESIGN

Before and after NSRH for uterine malignancy, bladder function was prospectively assessed in a small cohort of 12 women (39-72 years) suffering from uterine malignancy using urodynamic studies and a validated self-administered condition specific QoL questionnaire. Urodynamic studies were performed one day before (U0) as well as one week (U1) and 22 months (U2) after surgery. The questionnaire was applied at U0 and U2.

RESULTS

Cystometry showed detrusor contractions leading to overactive bladder incontinence in six out of nine women at short-term, which persisted in three women at long-term follow-up leading to a significant impaired QoL. Voiding function and bladder sensation remained uncompromised after surgery.

CONCLUSIONS

NSRH preserves voiding function and bladder sensation. However, short and long-term urodynamic detrusor overactivity and urge incontinence was observed in a significant number of women although symptoms improved over time. These data are important for counselling women and for the design of larger studies to assess the benefits of NSRH versus conventional radical hysterectomy (RH).

Bladder dose-volume parameters are associated with urinary incontinence after postoperative intensity modulated radiation therapy for prostate cancer

PURPOSE

Urinary incontinence is a potential side effect of prostatectomy and intensity modulated radiation therapy (IMRT) for prostate cancer. There are limited data on dosimetric parameters that may predict for poor continence recovery in men who receive postoperative IMRT.

METHODS AND MATERIALS

Eighty-seven men with nonmetastatic prostate cancer who underwent prostatectomy followed by adjuvant (13%) or salvage (87%) IMRT were identified. The Expanded Prostate Cancer Index composite questionnaire was prospectively collected at baseline, 6 weeks, and 6, 12, 18, 24, 36, and 48 months post-IMRT. Relevant critical structures were contoured and dose-volume metrics collected. The primary endpoint was urinary continence global score. Longitudinal analysis using a generalized estimating equation model was performed.

RESULTS

There was no statistically significant change in Expanded Prostate Cancer Index composite urinary continence global scores over time as compared with baseline (all P > .05). In univariate analysis, bladder volume receiving 70 Gy (V70 Gy) and penile bulb V70 Gy were associated with urinary continence (odds ratio, 0.82; P < .05). In a multivariable model that included body mass index, distance between vesicourethral junction and genitourinary diaphragm, time from surgery, use of antihypertensive medications, age, diabetes, and bladder V70 Gy, only bladder V70 Gy (odds ratio, 0.82; P = .03) was associated with outcome. After 2 years, there was a significant difference in global score for those with V70 Gy < 42.27 versus ≥42.27 mL (all P < .05 at 2 and 3 years post-IMRT).

CONCLUSION

There was no significant change in patient-reported urinary continence scores after postprostatectomy IMRT. Bladder V70 Gy was independently associated with a decrease in urinary continence scores. Further evaluation is necessary to optimize quality of life in these men.

Real-Time MRI-Guided Focused Ultrasound for Focal Therapy of Locally Confined Low-Risk Prostate Cancer: Feasibility and Preliminary Outcomes

OBJECTIVE

Focal therapy is an emerging approach to the treatment of localized prostate cancer. The purpose of this study was to report the 6-month follow-up oncologic and functional data of the initial phase 1 trial of patients treated with focal transrectal MRI-guided focused ultrasound in North America.

SUBJECTS AND METHODS

Four patients with a prostate-specific antigen (PSA) level of 10 ng/mL or less, tumor classification cT2a or less, and a Gleason score of 6 (3 + 3) were prospectively enrolled in the study and underwent multiparametric MRI and transrectal ultrasound-guided prostate systematic biopsy. Under MRI guidance and real-time monitoring with MR thermography, focused high-frequency ultrasound energy was delivered to ablate the target tissue. The incidence and severity of treatment-related adverse events were recorded along with responses to serial quality-of-life questionnaires for 6 months after treatment. Oncologic outcomes were evaluated with multiparametric MRI and repeat transrectal ultrasound-guided biopsy 6 months after treatment.

RESULTS

Four patients with a total of six target lesions were treated and had complications graded Clavien-Dindo I or less. Quality-of-life parameters were similar between baseline and 6-months. All four patients had normal MRI findings in the treated regions (100%), biopsy showed that three patients (75%) were clear of disease in the treated regions, representing complete ablation of five target lesions (83%). All patients had at least one Gleason 6-positive core outside of the treated zone.

CONCLUSION

MRI-guided focused ultrasound is a feasible method of noninvasively ablating low-risk prostate cancers with low morbidity. Further investigation and follow-up are warranted in a larger patient series with appropriate statistical analysis of oncologic and functional outcome measures.

Unexpected Long-term Improvements in Urinary and Erectile Function in a Large Cohort of Men with Self-reported Outcomes Following Radical Prostatectomy

BACKGROUND

It is generally assumed that if a man does not regain urinary continence or erectile function within 12 mo of radical prostatectomy (RP), then the chance of subsequent recovery is low.

OBJECTIVE

To determine the probability of achieving good urinary function (UF) or erectile function (EF) up to 48 mo postoperatively in men who reported poor UF or EF at 12 mo after RP.

DESIGN, SETTING, AND PARTICIPANTS

We identified 3187 patients who underwent RP from 2007 through 2013 at a tertiary institution and had extended multidisciplinary follow-up with patient-reported UF and EF scores at ≥12 mo.

INTERVENTION

Open or minimally invasive RP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Primary outcome was good UF as defined by a urinary score ≥17 (range: 0-21) or good EF as defined by a modified International Index of Erectile Function-6 score ≥22 (range: 1-30). The probability of functional recovery beyond 12 mo was determined by Kaplan-Meier analyses.

RESULTS AND LIMITATIONS

Among patients incontinent at 12 mo, the probability of achieving good UF at 24, 36, and 48 mo was 30%, 49%, and 59%. In patients experiencing erectile dysfunction at 12 mo, the probability of recovering EF at 24, 36, and 48 mo was 22%, 32%, and 40%. On multivariable analyses, 12-mo functional score and age were associated with recovery, but only score was consistently significant.

CONCLUSIONS

Men with incontinence or erectile dysfunction at 12 mo have higher than anticipated rates of subsequent functional improvement. Probability of recovery is strongly influenced by score at 12 mo. Further research should address the impact of ongoing multidisciplinary follow-up care on our observed rates of recovery.

PATIENT SUMMARY

Many prostate cancer patients continue to recover urinary and erectile function after 12 mo. The level of functional recovery by 12 mo is associated with long-term recovery and should be discussed by the physician and patient when deciding on rehabilitative interventions.

Comparison of Outcomes Between Preoperatively Potent Men Treated with Focal Versus Whole Gland Cryotherapy in a Matched Population

BACKGROUND AND PURPOSE

The refinement in the localization of prostate cancer tumor foci through transperineal template-mapping biopsies and MRI has led to an increased interest in lesion-directed focal prostatic cryoablation. Data are lacking, however, that compare the outcomes of whole-gland (WG) to focal ablation therapy (FT). The aim of our study was to assess both oncologic and functional outcomes between WG and FT cryoablation of the prostate after having matched patients for preoperative characteristics.

PATIENTS AND METHODS

We matched with a 1:1 ratio 317 men who underwent FT with 317 who underwent WG treatment in the Cryo Online Data (COLD) registry between 2007 and 2013. All patients were low-risk according to the D'Amico risk groups and were matched according to age at surgery. We only included preoperatively potent men. Oncologic outcomes were biochemical recurrence (BCR) free-survival defined according to the American Society for Radiation Oncology (ASTRO) and Phoenix criteria and assessed by Kaplan-Meier curves. Only patients with prostate-specific antigen (PSA) nadir data were included in oncologic outcome analysis. Functional outcomes were assessed at 6, 12, and 24 months after the procedure for erectile function (defined as ability to have intercourse with or without erectile aids), urinary continence, urinary retention, and rates of fistula formation.

RESULTS

Median age at the time of the procedure was 66.5 years (standard deviation [SD] 6.6 y), and median follow-up time was 58.3 months. After surgery, 30% (n=95) and 17% (n=55) of the men who received WG and FT, respectively, underwent biopsy, with positive biopsy rates of 11.6% and 14.5%, respectively. BCR-free survival rates at 60 months according to the Phoenix definition were 80.1% and 71.3% in the WG and FT cohorts, respectively, with a hazard ratio of 0.827; according to the ASTRO definition, they were 82.1% and 73%, respectively (all P ≥ 0.1). Erectile function data at 24 months was available for 172 WG and 160 FT treated men. Recovery of erection was achieved in 46.8% and 68.8% of patients in the WG and FT cohorts, respectively (P=0.001). Urinary function data at 24 months was available for 307 WG and 313 FT patients. Continence rates were 98.7% and 100% for WG and FT groups, respectively (P=0.02). Urinary retention at 6, 12, and 24 months was reported in 7.3%, 1.9%, and 0.6%, respectively, in the WG arm, and in 5%, 1.3%, and 0.9%, respectively, in the FT arm. Finally, only one fistula was reported in each group.

CONCLUSIONS

Men with low-risk prostate cancer who underwent FT cryoablation had comparable BCR-survival rates at 60 months to patients treated with WG. However, FT patients had higher erectile function preservation rates at 24 months post-procedure. Urinary continence, retention and fistula rates were similar between the two treatment groups.

Nomograms in oncology: more than meets the eye

Nomograms are widely used as prognostic devices in oncology and medicine. With the ability to generate an individual probability of a clinical event by integrating diverse prognostic and determinant variables, nomograms meet our desire for biologically and clinically integrated models and fulfill our drive towards personalised medicine. Rapid computation through user-friendly digital interfaces, together with increased accuracy, and more easily understood prognoses compared with conventional staging, allow for seamless incorporation of nomogram-derived prognosis to aid clinical decision making. This has led to the appearance of many nomograms on the internet and in medical journals, and an increase in nomogram use by patients and physicians alike. However, the statistical foundations of nomogram construction, their precise interpretation, and evidence supporting their use are generally misunderstood. This issue is leading to an under-appreciation of the inherent uncertainties regarding nomogram use. We provide a systematic, practical approach to evaluating and comprehending nomogram-derived prognoses, with particular emphasis on clarifying common misconceptions and highlighting limitations.

Penile rehabilitation after radical prostatectomy: does it work?

CONTEXT

Erectile dysfunction (ED) represents one of the most common long-term side effects in patients with clinically localized prostate cancer (PCa) undergoing nerve-sparing radical prostatectomy (RP).

OBJECTIVE

To analyze the role of penile rehabilitation in the recovery of erectile function (EF) after nerve-sparing RP.

EVIDENCE SYNTHESIS

Penile rehabilitation is defined as the use of any intervention or combination with the goal not only to achieve erections sufficient for satisfactory sexual intercourses, but also to return EF to preoperative levels. The concept of rehabilitation is based on the implementation of protocols aimed at improving oxygenation, preserving endothelial structure, and preventing smooth muscle structural alterations. Nowadays, the most commonly adopted approaches for penile rehabilitation after nerve-sparing RP are represented by the administration of phosphodiesterase type-5 inhibitors (PDE5-Is), intracorporeal injection therapy, vacuum erection devices (VED), and the combination of these therapies. Several basic science studies support the rational for the adoption of penile rehabilitation protocols. Particularly, rehabilitation, set as early as possible, seems to be better than leaving the erectile tissues unassisted. On the other hand, results from solid prospective randomized trials finally assessing the long-term beneficial effects of PDE5-Is, intracavernosal injections, or VED on EF recovery after surgery are still lacking.

CONCLUSIONS

Although preclinical evidences support the rationale for penile rehabilitation after nerve-sparing RP, clinical studies reported conflicting results regarding its efficacy on long-term EF recovery. Nowadays, which is the optimal rehabilitation program still represents a matter of debate.

Urinary Incontinence and Erectile Dysfunction After Robotic Versus Open Radical Prostatectomy: A Prospective, Controlled, Nonrandomised Trial

BACKGROUND

Robot-assisted laparoscopic radical prostatectomy (RALP) has become widely used without high-grade evidence of superiority regarding long-term clinical outcomes compared with open retropubic radical prostatectomy (RRP), the gold standard.

OBJECTIVE

To compare patient-reported urinary incontinence and erectile dysfunction 12 mo after RALP or RRP.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective, controlled, nonrandomised trial of patients undergoing prostatectomy in 14 centres using RALP or RRP. Clinical-record forms and validated patient questionnaires at baseline and 12 mo after surgery were collected.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSES

Odds ratios (ORs) were calculated with logistic regression and adjusted for possible confounders. The primary end point was urinary incontinence (change of pad less than once in 24h vs one time or more per 24h) at 12 mo. Secondary end points were erectile dysfunction at 12 mo and positive surgical margins.

RESULTS AND LIMITATIONS

At 12 mo after RALP, 366 men (21.3%) were incontinent, as were 144 (20.2%) after RRP. The unadjusted OR was 1.08 (95% confidence interval [CI], 0.87–1.34). Erectile dysfunction was observed in 1200 men (70.4%) 12 mo after RALP and 531 (74.7%) after RRP. The unadjusted OR was 0.81 (95% CI, 0.66–0.98).

CONCLUSIONS

In a Swedish setting, RALP for prostate cancer was modestly beneficial in preserving erectile function compared with RRP, without a statistically significant difference regarding urinary incontinence or surgical margins.

PATIENT SUMMARY

We compared patient-reported urinary incontinence after prostatectomy with two types of surgical technique. There was no statistically significant improvement in the rate of urinary leakage, but there was a small improvement regarding erectile function after robot-assisted operation.

Urinary Continence Outcomes after Puboprostatic Ligament Preserving Open Retropubic Radical Prostatectomy at a Sub-Saharan Hospital

Background. Open retropubic radical prostatectomy is a commonly performed procedure for clinically localized prostate cancer. The demand for high level functional outcomes after therapy is increasing especially for young age patients; in this regard refinements in the surgical technique have been made. There is limited data to show the success of some of these refinements in resource limited settings. Methods. A retrospective clinical study was performed over a 2-year period at Mengo Hospital, Urology Unit. Men with clinically localized prostate cancer and who consented to the procedure were eligible and were recruited. Consequently excluded were those that turned out to have advanced disease and those with severe comorbidities. Patients were followed up for 3 months after surgery. Data was entered using SPSS version 17 and analyzed. Results. A total of 24 men with clinically localized prostate cancer underwent open retropubic puboprostatic ligament preserving radical prostatectomy technique. Mean age was 66, range 54–75 years. Outcome. Two patients had stress incontinence and three were incontinent at 3 months. The urinary continence recovery rate was 19/24 (79%) at 3 months. Conclusion. Preservation of the puboprostatic ligament in open retropubic radical prostatectomy was associated with rapid and a high rate of return to urinary continence among men with clinically localized disease.

Counseling the post-radical prostatectomy patients about functional recovery: high predictiveness of current status

OBJECTIVE

To develop prediction models to help counsel post-radical prostatectomy patients about functional recovery.

METHODS

The study included 2162 patients undergoing radical prostatectomy at a major cancer center, who reported urinary and erectile function at 1 year or at 2 years and at least 1 prior follow-up at 3, 6, 9, or 12 months. We created logistic regression models predicting function at one or 2 years on the basis of function at 3, 6, 9, and 12 months (2 years only), with the additional predictors of age, stage, grade, prostate-specific antigen levels, nerve-sparing status and baseline functional score.

RESULTS

No variable other than current functional score had a consistent statistically significant relationship with outcome. The area under the curves for predicting function at 2 years based on current function alone at 3, 6, 9, and 12 months were respectively 0.796, 0.831, 0.882, and 0.885 for erectile function and 0.789, 0.862, 0.869, and 0.876 for urinary function. Patients using 1 pad at 6 months had only a 50% probability of being pad free at 2 years; this dropped to 36% for patients using 2 pads. This suggests that there is an opportunity for early identification and possible referral of patients likely to have long-term urinary dysfunction.

CONCLUSION

Assessment of urinary and erectile function in the first postoperative year is strongly predictive of long-term outcome and can guide patient counseling and decisions about rehabilitative treatments.

Measuring and predicting prostate cancer related quality of life changes using EPIC for clinical practice

PURPOSE

We expanded the clinical usefulness of EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice) by evaluating its responsiveness to health related quality of life changes, defining the minimally important differences for an individual patient change in each domain and applying it to a sexual outcome prediction model.

MATERIALS AND METHODS

In 1,201 subjects from a previously described multicenter longitudinal cohort we modeled the EPIC-CP domain scores of each treatment group before treatment, and at short-term and long-term followup. We considered a posttreatment domain score change from pretreatment of 0.5 SD or greater clinically significant and p ≤ 0.01 statistically significant. We determined the domain minimally important differences using the pooled 0.5 SD of the 2, 6, 12 and 24-month posttreatment changes from pretreatment values. We then recalibrated an EPIC-CP based nomogram model predicting 2-year post-prostatectomy functional erection from that developed using EPIC-26.

RESULTS

For each health related quality of life domain EPIC-CP was sensitive to similar posttreatment health related quality of life changes with time, as was observed using EPIC-26. The EPIC-CP minimally important differences in changes in the urinary incontinence, urinary irritation/obstruction, bowel, sexual and vitality/hormonal domains were 1.0, 1.3, 1.2, 1.6 and 1.0, respectively. The EPIC-CP based sexual prediction model performed well (AUC 0.76). It showed robust agreement with its EPIC-26 based counterpart with 10% or less predicted probability differences between models in 95% of individuals and a mean ± SD difference of 0.0 ± 0.05 across all individuals.

CONCLUSIONS

EPIC-CP is responsive to health related quality of life changes during convalescence and it can be used to predict 2-year post-prostatectomy sexual outcomes. It can facilitate shared medical decision making and patient centered care.