Radical Prostatectomy After Previous Prostate Surgery: Clinical and Functional Outcomes

Does previous transurethral resection of the prostate affect the outcomes in robotic assisted radical prostatectomy?

PURPOSE

Transurethral resection of the prostate (TURP) is one of the surgical options for treating enlarged prostates with lower urinary symptoms (LUTS). In this older group of patients, concomitant prostate cancer is not uncommon. However, the fibrosis and distortion of the prostate anatomy by prior TURP can potentially hinder surgical efficacy at robotic-assisted radical prostatectomy (RARP). We aim to evaluate functional, and oncologic outcomes of RARP in patients with and without previous TURP.

METHODS

231 men with previous TURP underwent RARP (TURP group). These men were propensity score matched using clinicopathological characteristics to men without previous TURP who underwent RARP (Control group). Perioperative and postoperative variables were analysed for significant differences in outcomes between groups. Variables analysed included estimated blood loss (EBL), operative time, catheter time, hospitalization time, postoperative complications, positive surgical margins (PSM) rates, cancer status, biochemical recurrence (BCR), potency, and continence rates.

RESULTS

Patients in the TURP group showed no statistically significant differences in operative safety measures including median EBL, operative time, catheter time, hospitalization time or postoperative complications. No significant difference between the groups in terms of potency rates and continence rates. Furthermore, there were no statistically significant differences in oncological outcomes, including PSM rates (15% vs 18%, P = 0.3) and BCR.

CONCLUSION

In RARP after TURP there is often noticeable distortion of the surgical anatomy. For an experienced team the procedure is safe and provides similar oncologic control and functional outcomes to RARP in patients without previous TURP.

Outcomes of robot-assisted radical prostatectomy in men after trans-urethral resection of the prostate: a matched-pair analysis

Prior history of transurethral resection of the prostate (TURP) can complicate Robot-assisted radical prostatectomy (RARP). Very few studies analyse the outcomes of RARP in men with a prior history of TURP. We analysed the oncological and functional outcomes of RARP in post-TURP men from our prospectively maintained database. We included the RARP data from January 2016 to January 2022. Thirty men who had RARP with a prior history of TURP were identified (Group 2). They were matched using R software and propensity score matching to 90 men with no previous TURP (Group-1). The groups were matched for age, body mass index (BMI), Gleason score, stage, PSA and D'Amico risk category in a 1:3 ratio. The two-year oncological and functional outcomes were compared. Overall, the study found no significant difference between the groups in the preoperative parameters, such as BMI, age, Gleason grade, clinical stage, PSA, prostate volume, and D'amico risk grouping. There was no difference in the estimated blood loss. The TURP group had a lower chance of having a nerve spare (p = 0.03). The median console time was longer in the TURP group (140 min (120,180) versus 168 (129,190) p = 0.058). The postoperative complications (Clavien-Dindo 3a 2% versus 6.7%) and hospital stay (median of 2 days), positive surgical margins, continence, and biochemical recurrence rates at 3, 12, and 24 months were not statistically different between the groups. In high-volume centres, the oncological and continence outcomes of RARP post-TURP are not inferior to that of men without prior TURP.

Does previous transurethral resection of the prostate negatively influence subsequent robotic-assisted radical prostatectomy in men diagnosed with prostate cancer? A systematic review and meta-analysis

It is not uncommon to incidentally discover prostate cancer during the transurethral resection of the prostate (TURP) for the treatment of benign prostatic hyperplasia and necessitate a subsequent robotic-assisted radical prostatectomy (RARP). The study aims to evaluate whether TURP have negative influence on subsequent RARP. Through a literature search using MEDLINE, EMBASE and the Cochrane Library, 10 studies with 683 patients who underwent RARP after previous TURP and 4039 patients who underwent RARP only were identified for the purposes of the meta-analysis. Compared to standard RARP, RARP after TURP was related to longer operative time (WMD: 29.1 min, 95% CI: 13.3-44.8, P < 0.001), more blood loss (WMD: 49.3 ml, 95% CI: 8.8-89.7, P = 0.02), longer time to catheter removal (WMD: 0.93 days, 95% CI: 0.41-1.44, P < 0.001), higher rates of overall (RR: 1.45, 95% CI: 1.08-1.95, P = 0.01) and major complications (RR: 3.67, 95% Cl: 1.63-8.24, P = 0.002), frequently demand for bladder neck reconstruction (RR: 5.46, 95% CI: 3.15-9.47, P < 0.001) and lower succeed in nerve sparing (RR: 0.73, 95% CI: 0.62-0.87, P < 0.001). In terms of quality of life, there are worse recovery of urinary continence (RR of incontinence rate: RR: 1.24, 95% CI: 1.02-1.52, P = 0.03) and potency (RR: 0.8, 95% CI: 0.73-0.89, P < 0.001) at 1 year in RARP with previous TURP. In addition, the RARP with previous TURP had greater percentage positive margins (RR: 1.24, 95% CI: 1.02-1.52, P = 0.03), while there is no difference in length of stay and biochemical recurrence rate at 1 year. RARP is feasible but challenging after TURP. It significantly increases the difficulty of operation and compromises surgical, functional and oncological outcomes. It is important for urologists and patients to be aware of the negative impact of TURP on subsequent RARP and establish treatment strategies to lessen the adverse effects.

Retzius-sparing robot-assisted radical prostatectomy after previous trans-urethral resection of the prostate: Assessment of functional and oncological outcomes

BACKGROUND

no data exist concerning functional and oncological outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP), in patients previously treated with trans-urethral resection of the prostate (p-TURP), for benign prostate obstruction. Our study addressed the impact of p-TURP on immediate and 12-months urinary continence recovery (UCR), as well as peri-operative outcomes and surgical margins, after RS-RARP.

METHODS

all patients treated with RS-RARP for prostate cancer at a single high-volume European institution, between 2010 and 2021, were identified and stratified according to p-TURP status. Logistic, Poisson and Cox regression models were performed.

RESULTS

Of 1386 RS-RARP patients, 99 (7%) had history of p-TURP. Between p-TURP and no-TURP patients no differences were detected regarding both intra- and post-operative complications (p values = 0.9). The rates of immediate UCR were 40 vs 67% in p-TURP vs no-TURP patients (p < 0.001). At 12 months from RS-RARP, the rates of UCR were 68 vs 94% in p-TURP vs no-TURP patients (p < 0.001). At multivariable logistic and Cox regression models, p-TURP was independently associated, respectively, with lower immediate (odds ratio [OR]: 0.32, p < 0.001) and 12-months UCR (hazard ratio: 0.54, p < 0.001). At multivariable Poisson analyses, p-TURP predicted longer operative time (rate ratio: 1.08, p < 0.001) but not longer length of stay or time to catheter removal (p values > 0.05). Positive surgical margins rates were 23 vs 17% in p-TURP vs no-TURP patients (p = 0.1), which translated in a non-statistically significant multivariable OR of 1.14 (p = 0.6).

CONCLUSIONS

p-TURP does not increase surgical morbidity but portends longer operative time and worse urinary continence after RS-RARP.

Functional and oncological outcomes after radical prostatectomy in patients with history of surgery for lower urinary tract symptoms related to benign prostatic enlargement: A systematic review with meta-analysis

BACKGROUND

Outcomes of radical prostatectomy (RP) in men with history of lower urinary tract symptoms related to benign prostatic enlargement (LUTS/BPE) surgery represents a controversial issue. We performed an updated systematic review and meta- analysis evaluating oncological and functional outcomes of RP in this subset of patients.

METHODS

Eligible studies were identified from MEDLINE, Web of Science and the Scopus databases. The following outcomes were evaluated: incidence of positive surgical margins (PSM), incidence of biochemical recurrence (BCR), 3-mo and 1-year urinary continence (UC) rates, incidence of nerve-sparing (NS) procedures, 1-year erectile function (EF) recovery rates. We estimated pooled Odds ratios (OR) and 95% confidence intervals (CI) using random effects models. Sub-analyses were performed according to the type of RP and LUTS/BPE surgery.

RESULTS

Twenty-five retrospective studies including 11,101 patients undergoing RP were included in the analysis (2113 with history of LUTS/BPE surgery, and 8898 controls). PSM rate was significantly higher in patients with history of LUTS/BPE surgery (OR 1.39, 95% CI 1.18-1.63, p < 0.001). No statistically significant difference in terms of BCR emerged between patients with or without history of LUTS/BPE surgery (OR 1.46, 95% CI 0.97-2.18, p = 0.066). Three-months and 1-year UC rates were significantly lower in patients with previous LUTS/BPE surgery (OR 0.48, 95% CI 0.34-0.68, p < 0.001 and OR 0.44, 95% CI 0.31-0.62, p < 0.001; respectively). Although not statistically significant differences between the two groups emerged in terms of adoption of NS procedures (OR 0.59, 95% CI 0.32-1.12, p = 0.107), 1-year EF recovery was significantly lower in patients with history of LUTS/BPE procedures (OR 0.60, 95% CI 0.40-0.89, p = 0.010).

CONCLUSIONS

In conclusions, RP in patients with history of previous LUTS/BPE surgery is associated with increased incidence of PSM, lower UC rates at both 3-months and 1-year follow-up as well as lower rates of EF recovery at 1-year follow-up.

Perioperative, functional, and oncologic outcomes in patients undergoing robot-assisted radical prostatectomy previous transurethral resection of prostate: a systematic review and meta-analysis of comparative trials

The influence of robot-assisted radical prostatectomy (RARP) on patients who have previously undergone transurethral resection of the prostate (TURP) versus TURP-naive patients is still debatable. The present study aimed to compare perioperative, functional, and oncologic outcomes of RARP between TURP and Non-TURP groups. We systematically searched the databases such as Science, PubMed, Embase, Web of Science, and the Cochrane Library database to identify relevant studies published in English up to August 2022. Review Manager was used to compare various parameters. The study was registered with PROSPERO (CRD42022378126). Eight comparative trials with a total of 4186 participants were conducted. The TURP group had a longer operative time (WMD 22.22 min, 95% CI 8.48, 35.95; p = 0.002), a longer catheterization time (WMD 1.32 day, 95% CI 0.37, 2.26; p = 0.006), a higher estimated blood loss (WMD 23.86 mL, 95% CI 2.81, 44.90; p = 0.03), and higher bladder neck reconstruction rate (OR 8.02, 95% CI 3.07, 20.93; p < 0.0001). Moreover, the positive surgical margin (PSM) was higher in the TURP group (OR 1.49, 95% CI 1.12, 1.98 p = 0.007). However, there was no difference between the two groups regarding the length of hospital stay, transfusion rates, nerve-sparing status, complication rates, long-term continence, potency rates and biochemical recurrence (BCR). Performing RARP on patients who have previously undergone TURP is a safe procedure. Furthermore, the current findings demonstrated that the TURP group had comparable oncologic and long-term functional outcomes to the Non-TURP group.

Prevalence and risk factors of incidental prostate cancer in certain surgeries for benign prostatic hyperplasia: A systematic review and meta-analysis

BACKGROUND

This study aimed to explore the prevalence and clinical risk factors in patients diagnosed with incidental prostate cancer (IPC) during certain surgeries (transurethral resection of the prostate [TURP], open prostatectomy [OP], and holmium laser enucleation of the prostate [HoLEP]) after clinically suspected benign prostatic hyperplasia (BPH).

MATERIALS AND METHODS

Literature search of the MEDILINE, Web of Science, Embase, and Cochrane Library databases was performed to identify eligible studies published before June 2021. Multivariate adjusted odds ratios (ORs) and associated 95% confidence intervals (CIs) of the prevalence and clinical risk factors of IPC were calculated using random or fixed-effect models.

RESULTS

Twenty-three studies were included in the meta-analysis. Amongst the 94.783 patients, IPC was detected in 24.715 (26.1%). Results showed that the chance of IPC detection (10%, 95% CI: 0.07-4.00; P<0.001; I2=97%) in patients treated with TURP is similar to that of patients treated with HoLEP (9%, 95% CI: 0.07-0.11; P<0.001; I2=81.4%). However, the pooled prevalence estimate of patients treated with OP was 11% (95% CI: -0.03-0.25; P=0.113; I2=99.1%) with no statistical significance. We observed increased incidence of IPC diagnosis after BPH surgery amongst patients with higher prostate-specific antigen (PSA) level (OR: 1.13, 95% CI: 1.04-1.23; P=0.004; I2=89%), whereas no effect of age (OR: 1.02, 95% CI: 0.97-1.06; P=0.48; I2=78.8%) and prostate volume (OR: 0.99, 95% CI: 0.96-1.03; P=0.686; I2=80.5%) were observed.

CONCLUSIONS

The prevalence of IPC was similar amongst patients undergoing TURP, HoLEP, and OP for presumed BPH. Interestingly, increased PSA level was the only independent predictor of increasing risk of IPC after BPH surgery rather than age and prostate volume. Hence, future research should focus on predictors which accurately foretell the progression of prostate cancer to determine the optimal treatment for managing patients with IPC after BPH surgery.

Technical Tips in Managing Large Median Lobes During Robot-assisted Radical Prostatectomy

Prostate cancer surgeons are commonly faced by a technically challenging situation dealing with prostate cancer having large median lobes. Patients with large median lobes often have larger prostates, which makes it difficult to visualize anatomical planes during robot-assisted radical prostatectomy (RARP). Herein, we described our experience in dealing with large median lobes during RARP. We have focused on technical tips to avoid complications and facilitate a smooth procedure in patients with large median lobes during RARP. A total of 2671 patients who underwent RARP were divided into two groups based on the presence or absence of a protruded median lobe (PML): group A (2411 patients without a PML) and group B (260 patients with a PML). All patients underwent preoperative magnetic resonance imaging and final intraoperative confirmation for the presence of a PML. Pre-, intra-, and postoperative parameters were compared in two groups using the Student t test and two-proportion t test as appropriate. Patients in group B have statistically significantly higher median prostate-specific antigen (PSA; 7.7 vs 5.8 ng/dl), PSA density (0.17 vs 0.09), and International Prostate Symptom Score (19.5 vs 7.2); longer median console time (114 vs 134 min) and surgery time (145 vs 170 min); and higher blood loss (150 vs 175 ml) than those in group A. There were no statistically significant differences in pathological stages (T2, T3; 87%, 13% vs 88%, 12%) and rates of positive surgical margins (7% vs 8.5%) between groups A and B. Single-center and retrospective design was the major limitation of our study. We conclude that understanding the key steps to facilitate bladder neck dissection is vital to avoid serious intraoperative events and to maximize outcomes.

Patient summary

In this report, we looked at our robotic radical prostatectomy cohort with large median lobes. We found that surgery in these patients requires more time and blood loss, but similar cancer control. We conclude that following the key steps are important to avoid complications.

Robotic Assisted Radical Prostatectomy After Prior Transurethral Resection of Prostate: An Analysis of Perioperative, Functional, Pathologic, and Oncological Outcomes

BACKGROUND

We performed a retrospective comparison of surgical, oncological, and functional outcomes following robotic assisted radical prostatectomy between patients who have undergone prior TURP to TURP naïve patients.

METHODS

Past robotic prostatectomy hospital data was scrutinized to form two matched groups of patients: those who have undergone prior TURP and TURP naïve patients. The perioperative and pathological data, along with functional and oncological outcomes, over a period of 3 years were compared between groups.

RESULTS

Compared to TURP-naïve patients, prior TURP patients experienced longer RALP times (p<.001), increased incidence of bladder neck reconstruction (p=0.03), greater blood loss (p= 0.0001), and lesser nerve sparing (p<0.01). Complication rates (p=0.3), positive surgical margin (p=0.4), extracapsular disease (p=0.3), or seminal vesicle invasion (p=0.1) were comparable between groups. Continence (p=0.5) and potency (p=0.1) at 1 year were not different between groups. Biochemical recurrence rates were not different at 3 years (p=0.9). Diabetes slowed recovery of continence in patients with prior TURP compared to TURP naïve patients until 6 months after surgery.

CONCLUSION

Although prior TURP makes subsequent robotic prostatectomy more technically demanding, it can be safely performed by experienced surgeons without compromising long term functional or oncological outcomes.

Tri‐modality therapy with i‐125 brachytherapy, external beam radiation therapy, and short‐term hormone therapy for high‐risk prostate cancer after holmium laser enucleation of the prostate

Introduction

We present tri‐modality therapy with i‐125 brachytherapy for high‐risk prostate cancer after holmium laser enucleation of the prostate.

Case presentation

A 75‐year‐old man had visited our hospital with complaints of dysuria. Holmium laser enucleation of the prostate was performed for benign prostatic hyperplasia. The resected histopathological prostate tissue showed malignancy (Gleason score: 3 + 3 = 6). Two years thereafter, Gleason score progressed (4 + 5 = 9) concomitantly with increased prostate‐specific antigen levels. Therefore, tri‐modality therapy, including brachytherapy, was applied. Combined androgen blockade therapy was conducted over a 9‐month period. One month after brachytherapy, external beam radiation was performed.

Conclusion

Brachytherapy following transurethral prostate surgery is relatively contraindicated because of increased adverse urethral event frequency and seed placement difficulties. A tri‐modality therapy, including brachytherapy, was implemented without any major problems in this patient with high‐risk prostate cancer after holmium laser enucleation of the prostate, following which he had a favorable prognosis without recurrence for 6 years.

Impact of previous transurethral resection of prostate on robot-assisted radical prostatectomy: a matched cohort analysis

We aimed to compare surgical, oncological, and functional outcomes of robot-assisted radical prostatectomy (RARP) in prostate cancer patients with and without prior history of transurethral resection of the prostate (TURP), using a matched cohort analysis. In an IRB-approved protocol, all patients who underwent RARP at our institution between April 2005 and July 2018 with at least 1-year follow-up were included. Among these, patients who had undergone a previous TURP (Group A) were compared with those without TURP (Group B) using the Survival, Continence, and Potency outcomes reporting system. Using propensity score matching for age, PSA and Gleason score, the two cohorts were further subdivided in a 1:2 ratio into Group C (prior TURP from Group A) and Group D (without prior TURP from Group B). Similar comparisons were made between Group C and D. Patients in Group A (n = 40) had lower PSA (p = 0.031) and were more likely to have Gleason grade 1 disease (p = 0.035) than patients in Group B (n = 143). In the propensity-matched group analysis, patients of Group C (n = 38) had higher operative time and blood loss than Group D (n = 76) patients. Group C patients also had lower continence at 3, 6, and 12 months after surgery. However, oncological and potency outcomes were similar in both the groups. We concluded that previous TURP is a predictor for surgical and continence outcomes following RARP. Even though these patients have a potentially lower stage or grade of disease, they are less likely to achieve social continence than men who have not had a previous TURP. This information would be important in counseling them for treatment options.

Does prior transurethral resection of prostate affect the functional and oncological outcomes of robot-assisted radical prostatectomy? A matched-pair analysis

Robot-assisted radical prostatectomy (RARP) is challenging in men with prior history of transurethral resection of the prostate (TURP). Few studies analyze this peculiar group of patients, and hence we sought to investigate the outcome of RARP in post-TURP men. We interrogated our prospectively maintained database containing 643 patients who underwent RARP from January 2012 to December 2020. We matched 36 men with prior history of TURP consecutively to 72 men without prior TURP. The groups were matched for age, body mass index (BMI), Charlson comorbidity index (CCI), serum PSA, International Society of Urological Pathology (ISUP) grade groups and clinical stage. Men with prior history of stricture surgeries, pelvic radiation, ablative laser procedures, Urolift and Rezum were excluded from the study. Fisher's Exact test/Chi-square was used for the comparison of categorical variables. Mann-Whitney test (Independent group/Unpaired data) and Wilcoxon sign rank test (for paired data) were employed to analyze continuous variables. The complication rates, median day of drain removal and length of hospital stay were similar between the groups. The TURP group required bladder neck reconstruction twice as often as the non-TURP group (58.3% versus 29.1%, p = 0.0035) and a longer duration of postoperative catheterization (10 versus 8 days, p = 0.0005). The rate of positive surgical margins was higher in the TURP group (30.5% versus 25%, p = 0.5414), albeit statistically insignificant. Biochemical recurrence (BCR) at one year (48.8% versus 60%, p = 0.0644) and zero pad/one safety-pad continence rates at one, three, six and twelve months were also not significantly different (14.3%, 35.4%, 59.2%, 81.6% for non TURP group versus 9.1%, 28.6%, 53.6%, 76.0% for TURP group). On multivariate analysis, prior TURP was not associated with a higher risk of BCR, margin positivity or incontinence. The oncological and functional outcomes of RARP post-TURP are comparable to men without prior TURP.

Evaluation of Risk Factors for Adverse Functional Outcomes after Radical Prostatectomy in Patients with Previous Transurethral Surgery of the Prostate

INTRODUCTION

A history of transurethral surgery of the prostate is generally considered as a risk factor of adverse functional outcomes after radical prostatectomy (RP). We tested whether the risk of postoperative urinary incontinence (UIC) and erectile dysfunction (ED) after RP could be further substantiated in such patients.

MATERIALS AND METHODS

We tested the effect of the following variables on UIC and ED rates 1 year after RP: residual prostate volume after transurethral desobstruction, the time from transurethral desobstruction to RP, the type of transurethral desobstruction (TURP vs. laser enucleation), age, and nerve-sparing surgery (yes vs. no). UIC was defined as usage of any pad except a safety pad. ED was defined as no sexual intercourse possible.

RESULTS

Overall, 216 patients treated with RP between 2010 and 2019 in a tertiary care center were evaluated. All patients had previously undergone transurethral desobstruction. Regarding UIC analyses, only time from transurethral desobstruction to RP significantly influenced UIC rates (p = 0.003). Regarding ED rates, none of the tested variables reached statistical significance.

CONCLUSION

The risk of UIC and ED after RP is substantial in men who had previously undergone transurethral desobstruction. The time from transurethral desobstruction to RP significantly impacts on the postoperative UIC rates. This observation should be further explored in future studies.

Does prior surgical interventional therapy for BPH affect the oncological or functional outcomes after primary whole-gland prostate cryoablation for localized prostate cancer?

BACKGROUND

To assess whether prior interventional treatment for benign prostatic hyperplasia (BPH) influences oncologic or functional outcomes following primary whole-gland prostate cryoablation.

METHODS

Among 3831 men with prostate cancer who underwent primary whole-gland prostate cryoablation, we identified 160 with a history of prior BPH interventional therapy including transurethral needle ablation (n = 6), transurethral microwave thermotherapy (n = 9), or transurethral resection of the prostate (n = 145). Patients with a history of medically treated or unspecified BPH therapy were excluded from the study. Oncological and functional outcomes were compared between men with and without prior BPH interventional therapy.

RESULTS

In unadjusted analyses, prior interventional BPH therapy was associated with higher risks of postoperative urinary retention (17.5% vs. 9.6%, p = 0.001) and new-onset urinary incontinence (39.9% vs. 19.4%, p > 0.001) compared with no prior therapy. Interventional BPH therapy was not correlated with the risk of developing a rectourethral fistula (p = 0.84) or new-onset erectile dysfunction (ED) at 12 months (p = 0.08) following surgery. On multivariable regression, prior interventional BPH therapy was associated with increased risk of urinary retention (OR 1.9, 95%, p = 0.015) and new-onset urinary incontinence (OR 2.13, p < 0.001). The estimated 5 years Kaplan-Meier survival analysis showed no statistically significant difference (p = 0.3) in biochemical progression free survival between those who underwent interventional BPH therapy compared with those who did not. Local disease recurrence assessed by post cryoablation positive for-cause prostate biopsy showed no significant difference between the two groups (25.4% vs. 28.7%, p = 0.59).

CONCLUSIONS

Prior interventional BPH therapy did not affect the oncologic outcomes nor did it increase the risk of rectourethral fistula or ED in sexually performing patients prior to cryosurgery. Prior interventional BPH therapy was associated with increased risk of urinary retention and incontinence after primary whole-gland prostate cryoablation for prostate cancer.

Initial Experience with Radical Prostatectomy Following Holmium Laser Enucleation of the Prostate

BACKGROUND

Although an increasing number of prostate cancer (PCa) patients received holmium laser enucleation of the prostate (HoLEP) previously for benign prostatic obstruction (BPO), there is still no evidence regarding the outcomes of radical prostatectomy (RP) in this setting.

OBJECTIVE

To assess functional and oncological results of RP in PCa patients who received HoLEP for BPO previously in a contemporary multi-institutional cohort.

DESIGN, SETTING, AND PARTICIPANTS

A total of 95 patients who underwent RP between 2011 and 2019 and had a history of HoLEP were identified in two institutions. Functional as well as oncological follow-up was prospectively assessed and retrospectively analyzed.

INTERVENTION

RP following HoLEP compared with RP without previous transurethral surgery.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Patients with complete follow-up data were matched with individuals with no history of BPO surgery using propensity score matching. Complications were assessed using the Clavien-Dindo scale.

RESULTS AND LIMITATIONS

The median follow-up was 50.5 mo. We found no significant impact of previous HoLEP on positive surgical margin rate (14.0% [HoLEP] vs 18.8% [no HoLEP], p =  0.06) and biochemical recurrence-free survival (hazard ratio 0.74, 95% confidence interval [CI] 0.32-1.70, p =  0.4). Patients with a history of HoLEP had increased 1-yr urinary incontinence rates after RP. After adjusting for confounders, no significant impact of previous HoLEP was found (odds ratio [OR] 0.87, 95% CI 0.74-1.01; p = 0.07). Previous HoLEP did not hamper 1-yr erectile function recovery (OR 1.22, 95% CI 1.05-1.43; p =  0.01). Limitations include retrospective design and small sample size.

CONCLUSIONS

RP after previous HoLEP is surgically feasible, with low complication rates and no negative impact on biochemical recurrence-free survival. However, in a multivariable analysis, we observed significantly worse 1-yr continence rates in patients after previous HoLEP.

PATIENT SUMMARY

In the current study, we assessed the oncological and functional outcomes of radical prostatectomy in patients who underwent holmium laser enucleation of the prostate (HoLEP) previously due to prostatic bladder outlet obstruction. A history of HoLEP did not hamper oncological results, 1-yr continence, and erectile function recovery.

[Pre-, intra- and postoperative predictors of functional outcome following radical prostatectomy]

Maintaining continence and erectile function is crucial for quality of life after radical prostatectomy. This review provides an overview of available evidence concerning preoperative risk stratification as well as intra- and postoperative factors determining functional outcomes after radical prostatectomy.Current data indicate that patient factors including age, baseline erectile function, prostate size, body-mass index and comorbidity status are valid predictors of functional outcome after prostatectomy. While surgical methods do not seem to have any influence, intraoperative procedures like nerve-sparing techniques, the extent of pelvic floor reconstruction as well as surgeons' experience have a significant impact on postoperative potency and continence. Rehabilitation consisting of pelvic floor training and use of PDE-5 inhibitors also contributes significantly to the recovery of erectile function and urinary continence.In summary, numerous adjustments of treatment can help to improve functional results and thus the quality of life after prostatectomy. A careful preoperative selection of suitable patients by urologists and integration of knowledge of periprostatic nerve and fascial structures into the surgical procedure are decisive factors.

Impact of previous transurethral prostate surgery on health-related quality of life after radical prostatectomy: Does the interval between surgeries matter?

PURPOSE

To assess the impact of previous transurethral surgery for benign prostate enlargement (BPE) and time interval between procedures on functional outcomes and health-related quality of life (HRQOL) after radical prostatectomy (RP).

METHODS

A propensity score-matched patient cohort [n = 685, (513 without previous BPE surgery, 172 with BPE surgery)] was created and HRQOL was pre- and postoperatively assessed using validated questionnaires (EORTC QLQ-C30). Urinary continence was measured via ICIQ-SF questionnaire and pad usage. Multivariable analysis included binary logistic and Cox regression models (p < 0.05).

RESULTS

Median follow-up was 18 months. There was no significant difference in recurrence-free survival in multivariate analysis (HR 0.66, 95%CI 0.40-1.07, p = 0.093). We observe higher mean ICIQ-SF scores (5.7 vs. 8.2, p < 0.001) and daily pad usage (1.3 vs. 2.5, p < 0.001), and decreased continence recovery (OR 0.46, 95%CI 0.30-0.71, p < 0.001) for patients with BPE surgery. Postoperative general HRQOL scores were significantly lower for patients with previous BPE surgery (70.6 vs. 63.4, p = 0.003). In multivariate analysis, continence recovery (OR 5.19, 95%CI 3.10-8.68, p < 0.001) but not previous BPE surgery (0.94, 0.57-1.54, p = 0.806) could be identified as independent predictors of good general HRQOL. There was no significant correlation between time interval between both surgeries and continence (p = 0.408), and HRQOL (p = 0.386) outcomes.

CONCLUSIONS

We observe favourable continence outcomes for patients without previous BPE surgery. Our results indicate that RP can be safely performed after transurethral BPE surgery, regardless of the time interval between both interventions.

The Management of Patients Diagnosed with Incidental Prostate Cancer: Narrative Review

5–14% of patients underwent surgery for benign prostate hyperplasia harboring prostate cancer (PCa) focus. The best management of incidental prostate cancer (iPCa) has been debated. The decision “treatment or no treatment” should be determined by predictors which accurately foretell PCa progression after transurethral resection of the prostate (TURP). The purpose of this study is to review the available data that can be useful in daily clinical judgment. Transrectal ultrasound prostate biopsy (TRUSBx) did not provide further Gleason score (GS) data in most patients diagnosed with iPCa. TRUSBX may be useful before active surveillance, but not in all following radical prostatectomy. The decision “treatment or no treatment” should be dependent on the expected chance of having residual cancer and clinical progression. Prostate-specific antigen (PSA) levels before and after TURP are good predictors of residual cancer after TURP. Pathological report of T0 is most likely seen in patients with low PSA density after TURP and indistinguishable lesion on multiparametric magnetic resonance imaging. The decision “treatment vs no treatment” is judged by life expectancy, tumor characteristic in the pathology report of TURP sample and PSA level following TURP. Active surveillance should be contemplated in patients with iPCa who have both prostate-specific antigen density ≤0.08 after TURP and indistinguishable cancer lesion on multiparametric magnetic resonance imaging. Patients who do not meet the criteria for active surveillance are candidates for radical prostatectomy or radiotherapy (RT). Radical prostatectomy could be peacefully done after TURP with somewhat greater morbidity. RT in patients who had a history of TURP could be safely done and is associated with acceptable quality of life.

Serving as a bedside surgeon before performing robotic radical prostatectomy improves surgical outcomes

INTRODUCTION

To evaluate the influence of previous experience as bedside assistants on patient selection, perioperative and pathological results in robot assisted laparoscopic radical prostatectomy.

MATERIALS AND METHODS

The first 50 cases of two robotic surgeons were reviewed retrospectively. Group 1 consisted of the first 50 cases of the surgeon with previous experience as a robotic bedside assistant between September 2016-July 2018, while group 2 included the first 50 cases of the surgeon with no bedside assistant experience between February 2009-December 2009. Groups were examined in terms of demographics, prostate volume, presence of median lobe, prostate specific antigen (PSA), preoperative Gleason score, positive core number, clinical stage, console surgery time, estimated blood loss, postoperative Gleason score, pathological stage, positive surgical margin rate, postoperative complications, length of hospital stay and biochemical recurrence rate.

RESULTS

Previous abdominal surgery and the presence of median lobe hypertrophy rates were higher in Group 1 than in Group 2 (20% vs. 4%, p=0.014; 24% vs. 6%, p=0.012; respectively). In addition, patients in Group 1 were in a higher clinical stage than those in Group 2 (cT2: 70% vs. 28%, p=0.001). Median console surgery time and median length of hospital stay was significantly shorter in Group 1 than in Group 2 (170 min vs. 240 min, p=0.001; 3 vs. 4, p=0.022; respectively). Clavien grade 3 complication rate was higher in Group 2 but was statistically insignificant.

CONCLUSION

Our findings might reflect that previous bedside assistant experience led to an increase in self-confidence and the ability to manage troubleshooting and made it more likely for surgeons to start with more difficult cases with more challenging patients. It is recommended that novice surgeons serve as bedside assistants before moving on to consoles.

Robot-Assisted Radical Prostatectomy in Patients with a History of Holmium Laser Enucleation of the Prostate: The Indiana University Experience

Introduction: We sought to update our experience of oncologic and functional outcomes of robot-assisted radical prostatectomy (RARP) for prostate cancer in patients with history of holmium laser enucleation of the prostate (HoLEP). Patients and Methods: Twenty-seven patients with previous HoLEP who underwent RARP were matched 1:1 with RARP patients with no history of transurethral surgery. Demographic, operative, oncologic, continence, and erectile function outcomes were analyzed. Results: Median time between HoLEP and RARP was 31 months with a mean prostate-specific antigen doubling time of 4.28 ng/mL/year. Operative times were significantly longer with higher bladder neck reconstruction rates and similarly low complication rates. Biochemical recurrence was relatively low (7%) in the HoLEP group, identical to the comparative group. Continence at last follow-up was not statistically significant between groups, although time to continence favored the non-HoLEP cohort. Erectile function recovery was generally poor in the post-HoLEP cohort (11%), although bilateral nerve sparing was rarely performed (11%). Compared with our initial experience, there were significant improvements in time to continence (16 vs 36 weeks). No T2 post-HoLEP RARP since 2010 has had a positive surgical margin. Conclusions: Post-HoLEP prostatectomy remains feasible with similar perioperative and oncologic outcomes compared with matched cohorts. Functional recovery remains slowed yet may continue to improve with technical familiarity.

Radical prostatectomy after previous transurethral resection of the prostate: a systematic review and meta-analysis

Background

The influence of a previous transurethral resection of the prostate (TURP) on the outcomes of radical prostatectomy (RP) is still controversial. Therefore, we performed a meta-analysis to evaluate the perioperative, functional and oncological outcomes of RP with or without a previous TURP.

Methods

We conducted a computerized literature search of PubMed, Embase, and the Cochrane Library and included 15 retrospective studies evaluating RPs with or without a previous TURP in this meta-analysis.

Results

Fifteen studies, including 6,840 cases, were analyzed. RP after a previous TURP were related to smaller prostate volumes (WMD: -6.93 cm³; 95% CI, -10.89 to -2.97; P<0.001), lower preoperative prostate-specific antigen (PSA) levels (WMD: -1.51; 95% CI, -2.49 to -0.53; P=0.002), longer operative times (WMD: 13.22 min; 95% CI, 4.55 to 21.89 min; P=0.003), more blood loss (WMD: 55.38 mL; 95% CI, 12.35 to 98.41 mL; P=0.01), higher overall complication rates (OR =1.98; 95% CI, 1.27 to 3.08; P=0.002), longer hospital stays (WMD: 1.16 days; 95% CI, 0.65 to 1.67; P<0.001), longer duration of catheter (WMD: 0.60 days; 95% CI, 0.56 to 0.64; P<0.001), higher positive surgical margin rates (OR =1.30; 95% CI, 1.09 to 1.55; P=0.004), lower complete continence rates at 3 months (OR =0.67; 95% CI, 0.56 to 0.81; P<0.001), 6 months (OR =0.52; 95% CI, 0.31 to 0.88; P=0.01), 12 months (OR =0.59; 95% CI, 0.46 to 0.74; P<0.001), and lower potency rates at 12 months (OR =0.62; 95% CI, 0.51 to 0.77; P<0.001). Subgroup analysis indicated that open RP after previous TURP could achieve better outcomes.

Conclusions

RP after a previous TURP leads to worse perioperative, oncological, and functional outcomes. For these patients an open procedure is recommended. Due to the low number of studies and known biases, further large-scale studies are needed to support this result.

Radical prostatectomy after previous transurethral resection of the prostate: oncological, surgical and functional outcomes-a meta-analysis

BACKGROUND

The current study aimed to carry out a comprehensive meta-analysis on the existing evidence to quantify and compare the oncological, surgical and functional outcomes following radical prostatectomy between TURP group and Non-TURP group.

METHODS

A systematic literature search was conducted using EMBASE, PubMed and Cochrane databases to identify relevant studies published in English up to March 2019. A meta-analysis was conducted using Review Manager.

RESULTS

There were 13 studies included in the present study. Our results suggest that TURP group demonstrates a significantly higher positive surgical margin rate, bladder neck reconstruction rate and overall complication rate compared with Non-TURP group (OR = 1.31, 95% CI 1.09-1.58, P = 0.004, I² = 0%; OR = 14.36, 95% CI 2.93-70.45, P = 0.001, I² = 81%; OR = 2.63, 95% CI 1.87-3.71, P < 0.00001, I² = 0%); whereas TURP group demonstrates a significantly lower nerve sparing rate compared with Non-TURP group (OR = 0.30, 95% CI 0.22-0.43, P < 0.00001, I² = 40%); the operation time, blood loss and 1-year urinary continence rate are same between TURP group and Non-TURP group (MD = 4.25, 95% CI - 0.13 to 8.63, P = 0.06, I² = 34%; MD = 27.29, 95% CI - 10.31 to 64.90, P = 0.15, I² = 39%; OR = 0.68, 95% CI 0.43-1.06, P = 0.09, I² = 0%).

CONCLUSION

This meta-analysis demonstrates that Non-TURP group may have a great advantage over TURP group in terms of positive surgical margin rate, bladder neck reconstruction rate, overall complication rate and sparing rate. The operation time, blood loss and 1-year urinary continence rate are comparable between TURP group and Non-TURP group. Therefore, important information should be given to those patients at risk of prostate cancer that TURP procedure may increase perioperative complications in case of a following radical prostatectomy. In the meantime, our meta-analysis found that each of these four subgroups (RARP, LRP, ORP and RARP/ORP) has its own advantages or disadvantages in every pool results. So when radical prostatectomy is performed on patients with TURP history, the appropriate operation method should be selected as per the conditions of patients, doctors and hospitals.

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

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

When should we use urodynamic testing? Recommendations of the Italian Society of Urodynamics (SIUD). Part 2 - Male and neurogical population

Recent studies in literature, have raised some doubts on the routine use of urodynamic testing. Many physicians and articles recommend a selective use of this tool, considering carefully risks and benefits. These recommendations are intended to guide clinicians in the right selection of the male and neurological patients to submit to a urodynamic evaluation. This is the second part of a previous article regarding the urodynamic recommendations in the female population. We reviewed the literature, regarding the use of UDS in male and neurological population with lower urinary tract symptoms (LUTS). Specifically, we analyzed and compared the guidelines and recommendations of the most important urology and urogynecology international scientific societies. These publications were used to create the evidence basis for characterizing the recommendations to perform urodynamic testing. A panel of 10 experts was composed and Delphi process was followed to obtain the panelist consensus. The final recommendations were approved by the unanimous consensus of the panel and compared with the best practice recommendations available in the literature. The recommendations are provided for diagnosis and management of common LUTS in male and neurological population. This review provides a summary of the most effective utilization of urodynamic studies for the global evaluation of patients with LUTS, and how to use them when really needed, avoiding unnecessary costs and patient inconveniences.

Radical prostatectomy after previous TUR-P: Oncological, surgical, and functional outcomes

OBJECTIVES

To examine oncological, surgical, and functional outcomes of radical prostatectomy (RP) in patients with history of transurethral resection of the prostate (TUR-P).

MATERIALS AND METHODS

Retrospective analysis of 18,681 RP-patients including 470 patients with previous TUR-P at a single institution (2002-2015). Kaplan-Meier as well as multivariable Cox and logistic regression analyses compared surgical, oncological, and functional outcomes between TUR-P and non-TUR-P patients after propensity score matching (nearest neighbor in a 1:3 fashion).

RESULTS

After propensity score adjustment, pathological and surgical results were similar between both groups. Specifically, rates of positive surgical margins and nerve-sparing (NS) procedure did not differ between groups (positive surgical margins: 18.5% vs. 17.2%, P = 0.7; nerve-sparing: 89.4% vs. 91.6%, P = 0.5). In addition, there was no difference in mean operating room time (185 vs. 184 minutes, P = 0.6), blood loss (710 vs. 666 ml, P = 0.1), and catheterization time (12 days, P = 0.3). In multivariable analyses, TUR-P patients did not exhibit higher risk of biochemical recurrence, metastatic progression, or mortality (all P > 0.05). However, TUR-P patients exhibited higher risk for urinary incontinence at third month (OR: 1.47; 95% confidence interval [CI] 1.01-2.12, P = 0.04) and first year (OR: 2.06; 95% CI 1.23-3.42, P = 0.006) and worse 1-year erectile function recovery (OR: 0.48; 95% CI 0.27-0.86, P = 0.02).

CONCLUSIONS

This large series of TUR-P RP patients demonstrated that RP could be safely performed in patients with history of TUR-P without compromising oncological results. However, functional outcomes were worse for patients with previous TUR-P.

Does a previous prostate biopsy-related acute bacterial prostatitis affect the results of radical prostatectomy?

OBJECTIVE

To The standard technique for obtaining a histologic diagnosis of prostatic carcinomas is transrectal ultrasound guided prostate biopsy. Acute prostatitis which might develop after prostate biopsy can cause periprostatic inflammation and fibrosis. In this study, we performed a retrospective review of our database to determine whether ABP history might affect the outcome of RP.

MATERIALS AND METHODS

441 RP patients who were operated in our clinic from 2002 to 2014 were included in our study group. All patients' demographic values, PSA levels, biopsy and radical prostatectomy specimen pathology results and their perioperative/postoperative complications were evaluated.

RESULTS

There were 41 patients in patients with acute prostatitis following biopsy and 397 patients that did not develop acute prostatitis. Mean blood loss, transfusion rate and operation period were found to be significantly higher in ABP patients. Hospitalization period and reoperation rates were similar in both groups. However, post-op complications were significantly higher in ABP group.

CONCLUSION

Even though it does not affect oncological outcomes, we would like to warn the surgeons for potential complaints during surgery in ABP patients.

Artificial Urinary Sphincter: Report of the 2015 Consensus Conference

PURPOSE

The AMS800™ device, by far the most frequently implanted artificial urinary sphincter (AUS) worldwide, is considered to be the "gold-standard" when male incontinence surgical treatment is contemplated. Despite 40 years of experience, it is still a specialized procedure with a number of challenges. Here, we present the recommendations issued from the AUS Consensus Group, regarding indications, management, and follow-up AMS800™ implantation or revision.

MATERIALS AND METHODS

Under ICS auspices, an expert panel met on July 10, 2015 in Chicago, IL, USA in an attempt to reach a consensus on diverse issues related to the AMS800™ device. Participants were selected by the two co-chairs on the basis of their practice in a University hospital and their experience: number of implanted AUSs according to AMS (American Medical System Holdings Inc., Minnetonka, MN) records and/or major published articles. Topics listed were the result of a pre-meeting email brainstorming by all participants. The co-chairs distributed topics randomly to all participants, who then had to propose a statement on each topic for approval by the conference after a short evidence-based presentation, when possible.

RESULTS

A total of 25 urologists were invited to participate, 19 able to attend the conference. The present recommendations, based on the most recent and relevant data available in literature as well as expert opinions, successively address multiple specific and problematic issues associated with the AMS800™ trough a eight-chapter structure: pre-operative assessment, pre operative challenges, implantation technique, post-operative care, trouble-shooting, outcomes, special populations, and the future of AUSs.

CONCLUSION

These guidelines undoubtedly constitute a reference document, which will help urologists to carefully select patients and apply the most adapted management to implantation, follow-up and trouble-shooting of the AMS800™.

Robot-Assisted Radical Prostatectomy After Previous Prostate Surgery

Background and Objectives:

Our objective is to clarify the effect of previous transurethral resection of the prostate (TURP) or open prostatectomy (OP) on surgical, oncological, and functional outcomes after robot-assisted radical prostatectomy (RARP).

Methods:

Between August 1, 2009, and March 31, 2013, 380 patients underwent RARP. Of these, 25 patients had undergone surgery for primary bladder outlet obstruction (TURP, 20 patients; OP, 5 patents) (group 1). A match-paired analysis was performed to identify 36 patients without a history of prostate surgery with equivalent clinicopathologic characteristics to serve as a control group (group 2). Patients followed up for 12 months were assessed.

Results:

Both groups were similar with respect to preoperative characteristics, as mean age, body mass index, median prostate-specific antigen, prostate volume, clinical stage, the biopsy Gleason score, D'Amico risk, the American Society of Anesthesiologists (ASA) classification score, the International Prostate Symptom Score, continence, and potency status. RARP resulted in longer console and anastomotic time, as well as higher blood loss compared with surgery-naive patients. We noted a greater rate of urinary leakage (pelvic drainage, >4 d) in group 1 (12% vs 2,8%). The anastomotic stricture rate was significantly higher in group 1 (16% vs 2.8%). No difference was found in the pathologic stage, positive surgical margin, and nerve-sparing procedure between the groups. Biochemical recurrence was observed in 12% (group 1) and 11.1% (group 2) of patients, respectively. No significant difference was found in the continence and potency rates.

Conclusions:

RARP after TURP or OP is a challenging but oncologically promising procedure with a longer console and anastomosis time, as well as higher blood loss and higher anastomotic stricture rate.

Does previous transurethral prostate surgery affect oncologic and continence outcomes after RARP?

We examined the effect of previous transurethral resection of the prostate (TURP) on multiple oncologic and continence outcomes after robotic-assisted radical prostatectomy (RARP). We performed a retrospective cohort study of a total of 2693 patients from 2007 to 2014 who underwent RARP. Patients were stratified into 49 patients who had previous TURP prior to RARP (group 1) and 2644 patients who had no TURP prior to RARP (group 2). We collected operative variables including estimated blood loss, operative time, and positive surgical margin (PSM) rates. Urinary continence, defined as 0 pads per day (PPD), and social continence, defined as 1-PPD, were also assessed. American Urological Association Symptoms Score (AUASS), overall ability to function sexually, and Expanded Prostate Cancer Index Composite (EPIC) questionnaire were evaluated at 3 and 12 months after RARP. Weakness of urinary stream (EPIC #4d) at 12 months imposed a greater problem for group 1 patients with prior TURP compared to group 2 patients without prior TURP (p = 0.012). PSM was not statistically significant between the two groups (p = 0.110). Group 1 patients had a greater PSM rate (30.61 %) as compared to group 2 (20.95 %). PSM locations in group 1 patients showed the most common locations at the posterior and apex. The difference between the two groups for AUASS, overall sexual function, estimated blood loss, operative time, urinary continence, and social continence was not statistically significant. We examined the effect of previous TURP on postoperative RARP continence and oncologic outcomes. This data can be used to counsel those with prior TURP before RARP.

Laparoscopic radical prostatectomy after previous transurethral resection of prostate using a catheter balloon inflated in prostatic urethra: Oncological and functional outcomes from a matched pair analysis

OBJECTIVES

To explore the surgical, oncological and functional outcomes of laparoscopic radical prostatectomy in patients who have undergone transurethral resection of the prostate, using a catheter balloon inflated in the prostatic urethra.

METHODS

A total of 25 patients were randomly assigned to the no balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy group (n = 12) and the with balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy group (n = 13). Two matched pairs analyses were carried out to identify the 12 (control A) and 13 (control B) surgery-naïve patients. The outcomes were compared between the groups with previous transurethral resection of the prostate (no balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy and with balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy groups) and the controls. The rate of intra- and postoperative complications was assessed. The International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form and the International Index of Erectile Function 5 were used for symptoms evaluation.

RESULTS

The mean blood loss was higher in patients submitted to transurethral resection of the prostate, with statistically insignificant reduced blood loss in the with balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy group. The no balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy group had longer operative time compared with both the with balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy and control A groups (P < 0.05). International Index of Erectile Function 5 showed a significant difference between no balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy and its control group; the International Consultation on Incontinence Questionnaire showed a statistically significant difference (P < 0.05) between the no balloon previous transurethral resection of the prostate laparoscopic radical prostatectomy and control A groups.

CONCLUSION

The use of a catheter balloon inflated in the prostatic urethra seems to facilitate laparoscopic radical prostatectomy in patients with previous transurethral resection of the prostate, ultimately reducing the rate of perioperative complications. These findings warrant further investigation on a larger case series with a longer follow up.

Robotic or open radical prostatectomy after previous open surgery in the pelvic region

PURPOSE

We sought to evaluate the feasibility and safety of open or robotic radical prostatectomy (RP) after rectum, sigmoid, or colon surgery.

MATERIALS AND METHODS

Sixty-four patients with a median age of 65 years (range, 46-73 years) who underwent RP after previous pelvic surgery were included. Twenty-four patients (38%) underwent robotic RP and 40 patients (62%) underwent open RP. Bilateral lymph node dissection and nerve preservation were performed in 50 patients (78%) and 35 patients (55%), respectively. Variables evaluated included demographic characteristics, perioperative complications, and functional and oncological outcomes. The median hospitalization and follow-up periods were 2 days (range, 1-12 days) and 21 months (range, 1-108 months), respectively.

RESULTS

No conversions from robotic to open surgery were performed and there were no intraoperative complications. Surgical margins were positive in 13 patients (20%), seminal vesicle involvement was detected in 6 patients (9%), and lymph node involvement was found in 2 patients (3%). Postoperative complications included lymphocele in 1 patient, urethral stricture in 1 patient, and bowel obstruction and persistent bladder leakage in 2 patients. Eighty-eight percent of the patients were continent at 7 months and 80% of patients were able to achieve erection with or without medical aid.

CONCLUSIONS

Open or robotic RP can be done safely and effectively in patients who have previously undergone pelvic surgery. Although prior pelvic surgery of the large intestine was associated with increased morbidity, it should not be considered a contraindication for robotic or open RP.

Robot-Assisted Radical Prostatectomy in Patients with a History of Holmium Laser Enucleation of the Prostate: Feasibility and Evaluation of Initial Outcomes

PURPOSE

To evaluate outcomes of post-holmium laser enucleation of the prostate (HoLEP) robot-assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

Using an institutional database, we identified 11 HoLEP patients who subsequently underwent RARP. These were matched 1:2 to RARP patients without a previous transurethral surgical procedure. Variables matched were age, pre-RARP prostate-specific antigen level, and biopsy Gleason score. Urinary continence and sexual function were evaluated by physician questioning, American Urological Association symptom score, and Sexual Health in Men (SHIM) scores. Descriptive statistics were used to compare cohorts.

RESULTS

RARP pathologic outcomes were similar between cases and controls. Twenty-seven percent of previous HoLEP patients reached strict urinary continence (leak free, pad free) at last follow-up compared with 64% of matched controls (P=0.071). The average (range) SHIM score at last follow-up was 2.6 (1-5) for previous HoLEP patients compared with 13.9 (5-20) (P<0.001). The posterior bladder neck and apical dissections were significantly more challenging in the setting of previous HoLEP and necessitated a low threshold for wider resection to minimize positive surgical margins.

CONCLUSIONS

Post-HoLEP RARP is challenging but preliminarily appears safe and feasible when performed by an experienced robotic surgeon. Patients should be counseled regarding expectations of urinary continence and sexual function in this setting.

Robotic radical prostatectomy in patients with previous prostate surgery and radiotherapy

Herein, we will review the available literature about robot-assisted radical prostatectomy in patients who have undergone prostate surgery or radiotherapy. Current data about this topic consists of small case series with limited follow-up. Despite being technically demanding, robot-assisted radical prostatectomy (RARP) can be considered feasible in either setting. Prostate surgery or prostatic irradiation should not be considered as a contraindication for robot-assisted radical prostatectomy. Nevertheless, patient counseling about the possible complications and the need for reintervention is of extreme importance in this patient population. Early oncologic and functional results of RARP performed in case of radiorecurrent prostate cancer look promising. Regarding postprostate surgery RARP, some series have reported comparable results, while some have demonstrated more inferior outcomes than those of naive cases. In order to assess the exact functional and oncologic outcome of RARP in patients with previous prostate surgery and radiotherapy, studies enrolling higher number of patients and providing longer follow-up data are needed.

Robotic assisted laparoscopic radical prostatectomy following transurethral resection of the prostate: perioperative, oncologic and functional outcomes

Purpose:

The aim of this study was to assess surgical, oncologic and functional results after robotic-assisted laparoscopic radical prostatectomy (RALP) with and without previous transurethral resection of the prostate (TURP).

Methods:

Between December 2005 and January 2010, 200 patients underwent RALP, of whom 16 (8%) had received previous TURP and 184 (92%) had not. Perioperative and postoperative data were compared between those with previous TURP (group 1) and those without previous TURP (group 2). All patients included in the study had at least 1-year follow-up.

Results:

Preoperative clinical parameters were comparable between both groups. Group 1 patients were found to have significantly more need for bladder neck reconstruction (93.75 % vs. 15.21%, P <0.001), more rectal injury (18.75% vs. 0%, P <0.001), higher incidence of major complications (18.8% vs. 1.1%, P<0.001), and smaller specimen volume (31.63 mL vs. 45.49 mL, P<0.001) than group 2. The 12-month continence rate was 93.8 % in group 1 and 97.8% in group 2 (P =0.344). A nerve-sparing technique was significantly less successfully performed in group 1 patients than in group 2 (33.3% vs. 92.0 %, P=0.001).

Conclusions:

Performing RALP for prostate cancer in patients who have had previous TURP is a technically demanding procedure and may be potentially associated with a higher perioperative major complication rate in short-term follow-up. Neurovascular bundle preservation is technically more challenging.

Practical evaluation of post-prostatectomy incontinence

For patients undergoing radical prostatectomy, urinary incontinence is not an uncommon postoperative complication. For some, it can resolve over time, while in others the condition persists and requires medical and/or surgical intervention. This summary provides a review of the recommended evaluations to perform in this setting.

Berberine inhibited radioresistant effects and enhanced anti-tumor effects in the irradiated-human prostate cancer cells

The purpose of this study was to elucidate the mechanism underlying enhanced radiosensitivity to ⁶⁰Co γ-irradiation in human prostate PC-3 cells pretreated with berberine. The cytotoxic effect of the combination of berberine and irradiation was superior to that of berberine or irradiation alone. Cell death and Apoptosis increased significantly with the combination of berberine and irradiation. Additionally, ROS generation was elevated by berberine with or without irradiation. The antioxidant NAC inhibited berberine and radiation-induced cell death. Bax, caspase-3, p53, p38, and JNK activation increased, but activation of Bcl-2, ERK, and HO-1 decreased with berberine treatment with or without irradiation. Berberine inhibited the anti-apoptotic signal pathway involving the activation of the HO-1/NF-κB-mediated survival pathway, which prevents radiation-induced cell death. Our data demonstrate that berberine inhibited the radioresistant effects and enhanced the radiosensitivity effects in human prostate cancer cells via the MAPK/caspase-3 and ROS pathways.

Age is predictive of immediate postoperative urinary continence after radical retropubic prostatectomy

INTRODUCTION

Immediate continence is a goal to take into consideration for better patient satisfaction after radical prostatectomy. Factors predicting urinary continence at catheter removal were investigated.

MATERIALS AND METHODS

We evaluated preoperative, operative, clinical, hormonal and pathological variables in a homogeneous series of radical retropubic prostatectomies (RRPs) following the principles of urinary sphincter restoration technique.

RESULTS

The study included 201 patients who underwent RRP. The overall immediate continence rate at catheter removal was 67.7% (136 patients); 28.8% (58 patients) were using one protective pad daily and 3.5% (7 patients) were incontinent. At 6-month follow-up incontinence had reached the lowest level of 2.5% (5 patients) and at 12 months the patients using one pad daily had decreased to 11.9% (24 patients). Multivariate logistic analysis showed that the only two factors independently associated with immediate continence were age <65 years (OR = 2.63, 95% CI 1.13-5.88, p = 0.02) and potency (OR = 3.6, 95% CI 1.2-10.7, p = 0.01) adjusting for D'Amico risk group, surgical margins, extracapsular extension, clinical stage, PSA, testosterone, LH and FSH. No significant association was noted for PSA, hormonal levels, hospital stay, prostate size, clinical stage, risk group, TNM stage, pathological Gleason score or extracapsular extension.

CONCLUSIONS

In our series age <65 years was associated with immediate continence after RRP. Moreover, patients who were immediately continent had a 3.6-fold probability to be potent within 12 months.

Laparoscopic versus open bilateral intrafascial nerve-sparing radical prostatectomy after TUR-P for incidental prostate cancer: surgical outcomes and effect on postoperative urinary continence and sexual potency

OBJECTIVE

To evaluate the surgical and functional outcomes in nerve-sparing laparoscopic radical prostatectomy (nsLRPT) and nerve-sparing retropubic radical prostatectomy (nsRRPT) after TUR-P for incidental prostate cancer.

MATERIALS AND METHODS

Between January 2003 and August 2011, 125 nsLRPT and 128 nsRRPT for incidental prostate cancer diagnosed after TUR-P were performed at our clinic. Demographic data, peri- and postoperative measurements and functional outcomes were compared.

RESULTS

The mean operative time was 153.1 ± 35.4 min for nsLRPT and 122.5 ± 67.5 min for nsRRPT (p = 0.03). The mean catheterization time was 8 ± 1 days in the laparoscopic group and 11 ± 2 days in the open group (p = 0.02). Also, the length of hospitalization presents statistical significant difference in the two groups. Positive margins were detected in 2.4 and 4.7% of patients with pT2c tumours in the laparoscopic and open groups, respectively (p = 0.09). At a mean follow-up of 26.9 ± 9.3 months for the nsLRPT group and of 27.8 ± 9.7 months for the nsRRPT group, all patients were alive with no evidence of tumour recurrence. Twelve months postoperatively, complete continence was reported in 96.8% of patients who underwent an nsLRPT and in 89.4% of patients in the nsRRPT group (p = 0.02). At that time, 74.4% of patients in the nsLRPT group and 53.1% in the nsRRPT group reported the ability to engage in sexual intercourse (p = 0.0004).

CONCLUSION

nsLRPT after TUR-P, performed by expert surgeons, results to be a safe procedure with excellent functional outcomes with regard to the urinary continence and sexual potency.

Robot-assisted laparoscopic radical prostatectomy after previous open transvesical adenomectomy

INTRODUCTION

Robot-assisted laparoscopic radical prostatectomy (RALRP) is one of the best treatment for patients with localized prostate cancer. RALRP is currently performed in patients without previous surgical treatment for benign prostatic hyperplasia. This paper presents a successfully performed RALRP after previous open transvesical adenomectomy (TVA).

CASE REPORT

A 68-year-old patient underwent nerve-sparing RALRP for prostate cancer revealed by transrectal ultrasound guided prostate biopsy, 7 years after TVA.

RESULTS

Postoperatively, a regular diet was allowed on day 1. The Foley catheter was removed on day 7. At 3 months' follow-up, the patient complained of moderate stress incontinence but erectile function was responsive to Tadalafil(®). Serum prostate-specific antigen was undetectable. Quality of life was satisfactory.

CONCLUSIONS

A history of previous prostatic surgery does not appear to compromise the outcome of RALRP. Nerve sparing is still indicated. Long-term follow-up is necessary to define RALRP as a gold standard also in patients with previous TVA.

Retrospective study of laparoscopic radical prostatectomy for localized prostate cancer after transurethral resection of the prostate compared with retropubic radical prostatectomy at the same institution

BACKGROUND

Radical prostatectomy (RP) for localized prostate cancer after transurethral resection of the prostate (TUR-P) is technically difficult because of periprostatic adhesion and changes in the form of the prostate. The advantages of laparoscopic RP (LRP) over retropubic RP (RRP) include a less invasive operation through a small wound, a clearer field of vision, and reduced blood loss, and, therefore, LRP may represent the optimal method for RP after TUR-P. The present study compared clinical, oncological, and pathological outcomes between LRP and RRP after TUR-P at our institution.

METHODS

Twenty patients underwent TUR-P for benign prostatic hyperplasia, followed by LRP (12 patients) or RRP (8 patients) after localized prostate cancer was diagnosed at our institution from November 1998 through December 2006. Median patient age was 67.5 years (range, 52-73 years). The median duration of follow-up was 96 months (range, 60-144 months). Operative time, volume of blood loss, duration of indwelling urethral catheter use, degree of urinary incontinence, pathological findings, oncological outcomes, and complications were compared between LRP and RRP.

RESULTS

No significant difference in operative time or amount blood loss was recognized between LRP and RRP. Urinary incontinence in the early and late postoperative periods was significantly more severe after LRP than after RRP. Oncological outcomes and results of pathological examinations were comparable between LRP and RRP.

CONCLUSION

We found no significant differences in clinical, pathological, and oncological outcomes, except for urinary incontinence, between LRP and RRP.

Successful treatment of incidental prostate cancer by radical transurethral resection of prostate cancer

BACKGROUND

To evaluate the rationale for RTUR-PCa against pT1a/b cancer, we analyzed oncological and functional outcomes.

PATIENTS AND METHODS

Fifty-six patients with incidental prostate cancer were included and the age ranged from 66 to 91 years (mean, 76.6; median, 75.0). Preoperative prostate specific antigen (PSA) levels were between 0.70 and 44.1 ng/mL (mean, 5.90; median, 4.60). We performed 69 RTUR-PCa's by resecting and fulgurating the residual prostate tissues after previous transurethral resection of the prostate. Prostate specific antigen nonrecurrence rate was calculated by Kaplan-Meier method.

RESULTS

Follow-up duration of 51 patients was mean ± SD 64.1 ± 21.6 months (median, 67.8 months; range, 13.8-99.8) excluding 5 patients that were lost to follow-up. Prostate specific antigen failure developed in 3 patients (5.9%). In the other 48 patients, PSA stabilized as follows: PSA ≤ 0.01, 24 cases; ≤ 0.02, 5 cases; ≤ 0.03, 6 cases; ≤ 0.04, 3 cases; ≤ 0.1, 7 cases; and ≤ 0.4, 3 cases. Prostate specific antigen nonrecurrence rates were 100% for pT2a and 91.3% for pT2b at the mean follow-up period of 64.1 months. Nonrecurrence rate grouped by D'Amico classification system were 100% in the low-risk group, 94.7% in the intermediate-risk group, and 88.2% in the high-risk group, respectively. Water intoxication did not develop and no patients required transfusion. Bladder neck contracture, which developed in 22 out of 51 patients (43.1%), was the most frequent postoperative complication. Postoperative incontinence was temporary and disappeared within 3 months in all patients.

CONCLUSION

Satisfactory oncologic and functional results suggest that RTUR-PCa could be a promising option for radical treatment against incidental prostate cancer.

Radical prostatectomy after previous transurethral resection of the prostate: robot-assisted laparoscopic versus open radical prostatectomy in a matched-pair analysis

PURPOSE

To determine whether previous transurethral resection of the prostate (TURP) compromises the surgical outcome and pathologic findings in patient who underwent either radical robot-assisted laparoscopic prostatectomy (RALP) or open retropubic radical prostatectomy (RRP) after TURP, because TURP is reported to complicate radical prostatectomy and there are conflicting data.

PATIENTS AND METHODS

From July 2008 to July 2010, 357 patients underwent RALP. Of these, 19 (5.3%) patients had undergone previous TURP. Operative and perioperative data of patients were compared with those of matched controls selected from a database of 616 post-RRP patients. Matching criteria were age, clinical stage, the level of preoperative prostate-specific-antigen, the biopsy Gleason score, the American Society of Anesthesiologists classification score, and prostate volume assessed during transrectal ultrasonography. All RRP and RALP procedures were performed by experienced surgeons.

RESULTS

Mean time to prostatectomy was 67.4 months in the RALP group and 53.1 months in the RRP group. Mean operative time was 217 ± 51.9 minutes for RALP and 174 ± 57.7 minutes for RRP (P<0.05). The overall positive surgical margin rate was 15.8% in both groups (pT(2) tumors: 10.5% for RALP and 5.3% for RRP; P=1.0). Mean estimated blood loss was 333 ± 144 mL in RALP patients and 1103 ± 636 mL in RRP patients (P<0.001). The difference between preoperative and postoperative hemoglobin levels was 3.22 ± 0.98 g/dL for RALP and 5.85 ± 1.95 g/dL for RRP (P=0.0002). The RALP and RRP groups also differed in terms of hospital stay (8.58 ± 1.17 vs 11.74 ± 5.22 days; P=0.0037), duration of catheterization (7.95 ± 5.69 vs 11.78 ± 6.97 days; P=0.0016), postoperative complications according to the Clavien classification system (6 vs 15 patients; P=0.0027), and transfusion rate (0% vs 10.5%; P<0.001).

CONCLUSION

RALP offers advantages over open radical prostatectomy after previous surgery. Although both techniques are associated with adequate surgical outcomes, RALP appeared to be preferable in our population of patients with previous prostate surgery.