Variations in surgeon volume and use of pelvic lymph node dissection with open and minimally invasive radical prostatectomy

Comparison of surgical approaches to radical prostatectomy in our series beyond oncological and functional outcomes

OBJECTIVES

To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) compared to those of open (ORP) and laparoscopic (LRP) surgery. The interest lies fundamentally in the quality-of-life (QoL) evaluation, postoperative recovery, and personal satisfaction of patients with the intervention (PS) beyond oncological and functional outcomes.

METHODS

Six hundred eighty-five RPs were performed in our center between 2011-2018 (17,8% ORP, 22,2% LRP and 60% RARP). Patients were prospectively assessed through follow-up until April 2020 and a multiple questionnaire at 12-months post-RP that included ICIQ-SF, SHIM, IPSS, IQL and questions about pain, postoperative recovery and PS. Also baseline and postoperative patient- and treatment-related data were collected, and binomial logistic regressions were performed for the 1 vs.1 comparisons (ORP vs. RARP and LRP vs. RARP).

RESULTS

RARP patients have overall fewer comorbidities, less tumor aggressiveness, more operative time requirements and more positive surgical margins than ORP and LRP patients. Nevertheless, RARP outperforms ORP in: hospital stay (days) (OR 0,86; 95% CI: 0,80-0,94), hemoglobin loss (OR 0,38; 95% CI: 0,30-0,47), transfusion rate (OR 0,18; 95% CI: 0,09-0,34), early complications (p = 0,001), IQL (OR 0,82; 95% CI: 0,69-0,98), erectile function (OR 0,41; 95% CI: 0,21-0,79), pain control (OR 0,82; 95% CI: 0,75-0,89), postoperative recovery (p < 0,001) and choice of a different approach (OR 5,55; 95% CI: 3,14-9,80). RARP is superior to LRP in: urinary continence (OR 0,55; 95% CI: 0,37-0,82), IPSS (OR 0,96; 95% CI: 0,93-0,98), IQL (OR 0,76; 95% CI: 0,66-0,88), erectile function (OR 0,52; 95% CI: 0,29-0,93), postoperative recovery (p = 0,02 and 0,004), PS (p = 0,005; 0,002; and 0,03) and choice of a different approach (OR 7,79; 95% CI: 4,63-13,13).

CONCLUSIONS

The findings of our study globally endorse a positive effectiveness of RARP over ORP and/or LRP, both on functional issues, postoperative recovery, QoL and PS. Oncologic results should still be improved.

Comparing Oncological Outcomes and Surgical Complications of Hand-Assisted, Laparoscopic and Robotic Nephroureterectomy for Upper Tract Urothelial Carcinoma

Purpose

This study aimed to compare the oncological outcomes and surgical complications of patients with upper tract urothelial carcinoma (UTUC) treated with different minimally invasive techniques for nephroureterectomy.

Methods

From the updated data of the Taiwan UTUC Collaboration Group, a total of 3,333 UTUC patients were identified. After excluding ineligible cases, we retrospectively included 1,340 patients from 15 institutions who received hand-assisted laparoscopic nephroureterectomy (HALNU), laparoscopic nephroureterectomy (LNU) or robotic nephroureterectomy (RNU) between 2001 and 2021. Kaplan-Meier estimator and Cox proportional hazards model were used to analyze the survival outcomes, and binary logistic regression model was selected to compare the risks of postoperative complications of different surgical approaches.

Results

Among the enrolled patients, 741, 458 and 141 patients received HALNU, LNU and RNU, respectively. Compared with RNU (41.1%) and LNU (32.5%), the rate of lymph node dissection in HALNU was the lowest (17.4%). In both Kaplan-Meier and univariate analysis, the type of surgery was significantly associated with overall and cancer-specific survival. The statistical significance of surgical methods on survival outcomes remained in multivariate analysis, where patients undergoing HALNU appeared to have the worst overall (p = 0.007) and cancer-specific (p = 0.047) survival rates among the three groups. In all analyses, the surgical approach was not related to bladder recurrence. In addition, HALNU was significantly associated with longer hospital stay (p = 0.002), and had the highest risk of major Clavien-Dindo complications (p = 0.011), paralytic ileus (p = 0.012), and postoperative end-stage renal disease (p <0.001).

Conclusions

Minimally invasive surgery can be safe and feasible. We proved that compared with the HALNU group, the LNU and RNU groups have better survival rates and fewer surgical complications. It is crucial to uphold strict oncological principles with sophisticated technique to improve outcomes. Further prospective studies are needed to validate our findings.

External Validation of the Briganti Nomogram to Predict Lymph Node Invasion in Prostate Cancer-Setting a New Threshold Value

(1) Introduction: The study aimed to test and validate the performance of the 2012 Briganti nomogram as a predictor for pelvic lymph node invasion (LNI) in men who underwent radical prostatectomy (RP) with extended pelvic lymph node dissection (PLND) to examine their performance and to analyse the therapeutic impact of using a different nomogram cut-off. (2) Material and Methods: The study group consisted of 222 men with clinically localized prostate cancer (PCa) who underwent RP with ePLND between 01/2012 and 10/2018. Measurements included: preoperative PSA, clinical stage (CS), primary and secondary biopsy Gleason pattern, and the percentage of positive cores. The area under the curve (AUC) of the receiver operator characteristic analysis was appointed to quantify the accuracy of the primary nomogram model to predict LNI. The extent of estimation associated with the use of this model was graphically depicted using calibration plots. (3) Results: The median number of removed lymph nodes was 16 (IQR 12–21). A total of 53 of 222 patients (23.9%) had LNI. Preoperative clinical and biopsy characteristics differed significantly (all p < 0.005) between men with and without LNI. A nomogram-derived cut-off of 7% could lead to a reduction of 43% (95/222) of lymph node dissection while omitting 19% (10/53) of patients with LNI. The sensitivity, specificity, and negative predictive value associated with the 7% cut-off were 81.1%, 50.3%, and 96.3%, respectively. (4) Conclusions: The analysed nomogram demonstrated high accuracy for LNI prediction. A nomogram-derived cut-off of 7% confirmed good performance characteristics within the first external validation cohort from Poland.

External validation of Memorial Sloan Kettering Cancer Center nomogram and prediction of optimal candidate for lymph node dissection in clinically localized prostate cancer

Introduction

The aim of our study was to evaluate the external validity of the online Memorial Sloan Kettering Cancer Center (MSKCC) nomogram as a predictor for pelvic lymph node invasion (LNI) in men who underwent radical prostatectomy (RP) with pelvic lymph node dissection (PLND).

Material and methods

The study cohort consisted of 679 men with clinically localized prostate cancer (PCa) who underwent RP with PLND between 2005 and 2017. The area under curve (AUC) of the receiver operator characteristic analysis was used to quantify the accuracy of MSKCC nomogram to predict LNI. The specificity, sensitivity and negative predictive value were calculated to assess LNI probability cut-off.

Results

A total of 81 of 679 patients had LNI (11.9%). The AUC of MSKCC nomogram was 79%. Using the cut-off value of 7% (sensitivity 88.9%, specificity 45.2% and NPV 96.8%) a PLND could be omitted in 41% (279/679) of men. However, 3.2% (9/279) of men with LNI would be missed. MSKCC nomogram showed good calibration characteristics and high net benefit at decision curve analysis.

Conclusions

MSKCC nomogram in patients with PCa undergoing PLND has 79% discriminated accuracy for prediction of LNI in our cohort. Using a 7% nomogram cut-off, roughly 40% of men would be spared PLND with minimal risk to miss LNI.

Prostate specific antigen (PSA) persistence 6 weeks after radical prostatectomy and pelvic lymph node dissection as predictive factor of radiographic progression in node-positive prostate cancer patients

Purpose: To evaluate the prognostic value of early postoperative prostate specific antigen (PSA) levels after radical prostatectomy (RP) and pelvic lymph node dissection (PLND) in prostate cancer patients with lymph node invasion (LNI).

Materials and Methods: The retrospective analysis involved 96 patients who had a diagnosis of LNI with available data on the first PSA level at postoperative 6 weeks after RP and PLND between 2002 and 2014 at our institution. PSA persistence was defined as PSA ≥ 0.1 ng/ml at 6 weeks after surgery. Radiographic progression was defined as positive imaging during follow-up after the onset of biochemical recurrence, consisting of a bone scan and/or computed tomography (CT) and/or magnetic resonance imaging and/or 18F-(2-deoxy-2-fluoro-D-glucose positron emission tomography/CT scan. Comparative analysis of patients with and without PSA persistence was done, and Kaplan-Meier curve analysis with log-rank test and Cox proportional hazard regression models assessed radiographic progression free survival (PFS).

Results: Fifty two (54.2%) patients displayed PSA persistence. Kaplan-Meier curve analysis showed significantly decreased 5-year radiographic PFS (64.2% vs. 93.2%, log-rank, p=0.009) in the PSA persistence group compared to the no PSA persistence group. In a multivariate analysis, PSA persistence was a statistically significant predictor of radiographic PFS.

Conclusions: Early assessment of PSA after surgery is important for predicting radiographic progression in node-positive prostate cancer patients. Risk stratification based on the early PSA value after surgery would be helpful to identify patients who may benefit from early adjuvant therapies.

National cohort study comparing severe medium-term urinary complications after robot-assisted vs laparoscopic vs retropubic open radical prostatectomy

OBJECTIVES

To evaluate the occurrence of severe urinary complications within 2 years of surgery in men undergoing either robot-assisted radical prostatectomy (RARP), laparoscopic radical prostatectomy (LRP) or retropubic open radical prostatectomy (ORP).

PATIENTS AND METHODS

We conducted a population-based cohort study in men who underwent RARP (n = 4 947), LRP (n = 5 479) or ORP (n = 6 873) between 2008 and 2012 in the English National Health Service (NHS) using national cancer registry records linked to Hospital Episodes Statistics, an administrative database of admissions to NHS hospitals. We identified the occurrence of any severe urinary or severe stricture-related complication within 2 years of surgery using a validated tool. Multi-level regression modelling was used to determine the association between the type of surgery and occurrence of complications, with adjustment for patient and surgical factors.

RESULTS

Men undergoing RARP were least likely to experience any urinary complication (10.5%) or a stricture-related complication (3.3%) compared with those who had LRP (15.8% any or 5.7% stricture-related) or ORP (19.1% any or 6.9% stricture-related). The impact of the type of surgery on the occurrence of any urinary or stricture-related complications remained statistically significant after adjustment for patient and surgical factors (P < 0.01).

CONCLUSION

Men who underwent RARP had the lowest risk of developing severe urinary complications within 2 years of surgery.

Lymphadenectomy in Gleason 7 prostate cancer: Adherence to guidelines and effect on clinical outcomes

BACKGROUND

To examine usage trends, guideline adherence, and survival data for patients undergoing lymphadenectomy (LND) at the time of radical prostatectomy (RP) for Gleason 7 prostate cancer (PCa).

METHODS

The SEER database was queried for all patients with nonmetastatic biopsy Gleason 7 PCa from 2004 to 2013. Distribution and trends of LND were analyzed. The Memorial-Sloan Kettering Cancer Center nomogram was applied to stratify patients based on risk of nodal disease at time of RP (<5% risk or ≥5% risk). Analyses were performed to determine covariates associated with LND receipt at time of RP and cancer-specific mortality (CSM).

RESULTS

A total of 78,641 patients with either G34 or G43 PCa underwent RP (59,194 and 19,447, respectively). Of these patients, 61.2% of G34 and 73.5% of G43 patients underwent LND. During this 10-year period, the proportion of G43 patients undergoing LND remained relatively stable, whereas the proportion of G34 patients undergoing LND ranged between 55.9% and 67.9%. Regional differences were a predictor of LND receipt regardless of risk stratification, but did not translate to higher risk of CSM. Receipt of LND was not predictive of improved CSM in any of the cohorts analyzed.

CONCLUSIONS

The role of LND for Gleason 7 prostate adenocarcinoma is not yet standardized, as indicated by the variability of LND dissection rates. Receipt of LND did not improve CSM, and in G43 patients, it predicted higher CSM. As the effect of LND on CSM is uncertain, further evaluation of oncologic benefit in this patient population is warranted.

Current technique and results for extended pelvic lymph node dissection during robot-assisted radical prostatectomy

The practice of extended pelvic lymph node dissection (ePLND) remains one of the most controversial topics in the management of clinically localized prostate cancer. Although most urologists agree on its benefit for staging and prognostication, the role of the ePLND in cancer control continues to be debated. The increased perioperative morbidity makes it unpalatable, especially in patients with low likelihood of lymph node disease. With the advent of robotic assisted laparoscopic prostatectomy, many surgeons were slow to adopt ePLND in the robotic setting. In this study, we summarize the evidence for the prognostic and therapeutic roles of ePLND, review the clinical tools used for lymph node metastasis prediction and survey the numerous experiences of ePLND compiled by robotic urologic surgeons over the years.

Perioperative Blood Transfusion as a Significant Predictor of Biochemical Recurrence and Survival after Radical Prostatectomy in Patients with Prostate Cancer

Purpose

There have been conflicting reports regarding the association of perioperative blood transfusion (PBT) with oncologic outcomes including recurrence rates and survival outcomes in prostate cancer. We aimed to evaluate whether perioperative blood transfusion (PBT) affects biochemical recurrence-free survival (BRFS), cancer-specific survival (CSS), and overall survival (OS) following radical prostatectomy (RP) for patients with prostate cancer.

Materials and Methods

A total of 2,713 patients who underwent RP for clinically localized prostate cancer between 1993 and 2014 were retrospectively analyzed. We performed a comparative analysis based on receipt of transfusion (PBT group vs. no-PBT group) and transfusion type (autologous PBT vs. allogeneic PBT). Univariate and multivariate Cox-proportional hazard regression analysis were performed to evaluate variables associated with BRFS, CSS, and OS. The Kaplan-Meier method was used to calculate survival estimates for BRFS, CSS, and OS, and log-rank test was used to conduct comparisons between the groups.

Results

The number of patients who received PBT was 440 (16.5%). Among these patients, 350 (79.5%) received allogeneic transfusion and the other 90 (20.5%) received autologous transfusion. In a multivariate analysis, allogeneic PBT was found to be statistically significant predictors of BRFS, CSS, and OS; conversely, autologous PBT was not. The Kaplan-Meier survival analysis showed significantly decreased 5-year BRFS (79.2% vs. 70.1%, log-rank, p = 0.001), CSS (98.5% vs. 96.7%, log-rank, p = 0.012), and OS (95.5% vs. 90.6%, log-rank, p < 0.001) in the allogeneic PBT group compared to the no-allogeneic PBT group. In the autologous PBT group, however, none of these were statistically significant compared to the no-autologous PBT group.

Conclusions

We found that allogeneic PBT was significantly associated with decreased BRFS, CSS, and OS. This provides further support for the immunomodulation hypothesis for allogeneic PBT.

Retropubic, laparoscopic, and robot-assisted radical prostatectomy: surgical, oncological, and functional outcomes: a systematic review

OBJECTIVES

Despite the wide diffusion of minimally invasive approaches, such as laparoscopic (LRP) and robot-assisted radical prostatectomy (RALP), few studies compare the results of these techniques with the retropubic radical prostatectomy (RRP) approach. The aim of this study is to compare the surgical, functional, and oncological outcomes and cost-effectiveness of RRP, LRP, and RALP.

METHODS

A systematic review of the literature was performed in the PubMed and Embase databases in December 2013. A 'free-text' protocol using the term 'radical prostatectomy' was applied. A total of 16,085 records were found. The authors reviewed the records to identify comparative studies to include in the review.

RESULTS

44 comparative studies were identified. With regard to the perioperative outcome, LRP and RALP were more time-consuming than RRP, but blood loss, transfusion rates, catheterisation time, hospitalisation duration, and complication rates were the most optimal in the laparoscopic approaches. With regard to the functional and oncological results, RALP was found to have the best outcomes.

CONCLUSION

Our study confirmed the well-known perioperative advantage of minimally invasive techniques; however, available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. On the contrary, cost comparison clearly supports RRP.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTION

Radical prostatectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

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

RESULTS AND LIMITATIONS

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

CONCLUSIONS

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

PATIENT SUMMARY

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

A systematic review of the volume-outcome relationship for radical prostatectomy

CONTEXT

Due to the complexity and challenging nature of radical prostatectomy (RP), it is likely that both short- and long-term outcomes strongly depend on the cumulative number of cases performed by the surgeon as well as by the hospital.

OBJECTIVE

To review systematically the association between hospital and surgeon volume and perioperative, oncologic, and functional outcomes after RP.

EVIDENCE ACQUISITION

A systematic review of the literature was performed, searching PubMed, Embase, and Scopus databases for original and review articles between January 1, 1995, and December 31, 2011. Inclusion and exclusion criteria comprised RP, hospital and/or surgeon volume reported as a predictor variable, a measurable end point, and a description of multiple hospitals or surgeons.

EVIDENCE SYNTHESIS

Overall 45 publications fulfilled the inclusion criteria, where most data originated from retrospective institutional or population-based cohorts. Studies generally focused on hospital or surgeon volume separately. Although most of these analyses corroborated the impact of increasing volume with better outcomes, some failed to find any significant effect. Studies also differed with respect to the proposed volume cut-off for improved outcomes, as well as the statistical means of evaluating the volume-outcome relationship. Five studies simultaneously compared hospital and surgeon volume, where results suggest that the importance of either hospital or surgeon volume largely depends on the end point of interest.

CONCLUSIONS

Undeniable evidence suggests that increasing volume improves outcomes. Although it would seem reasonable to refer RP patients to high-volume centers, such regionalization may not be entirely practical. As such, the implications of such a shift in practice have yet to be fully determined and warrant further exploration.

Pelvic lymph node dissection during robot-assisted radical prostatectomy: efficacy, limitations, and complications-a systematic review of the literature

CONTEXT

Pelvic lymph node dissection (PLND) in prostate cancer is the most effective method for detecting lymph node metastases. However, a decline in the rate of PLND during radical prostatectomy (RP) has been noted. This is likely the result of prostate cancer stage migration in the prostate-specific antigen-screening era, and the introduction of minimally invasive approaches such as robot-assisted radical prostatectomy (RARP).

OBJECTIVE

To assess the efficacy, limitations, and complications of PLND during RARP.

EVIDENCE ACQUISITION

A review of the literature was performed using the Medline, Scopus, and Web of Science databases with no restriction of language from January 1990 to December 2012. The literature search used the following terms: prostate cancer, radical prostatectomy, robot-assisted, and lymph node dissection.

EVIDENCE SYNTHESIS

The median value of nodal yield at PLND during RARP ranged from 3 to 24 nodes. As seen in open and laparoscopic RP series, the lymph node positivity rate increased with the extent of dissection during RARP. Overall, PLND-only related complications are rare. The most frequent complication after PLND is symptomatic pelvic lymphocele, with occurrence ranging from 0% to 8% of cases. The rate of PLND-associated grade 3-4 complications ranged from 0% to 5%. PLND is associated with increased operative time. Available data suggest equivalence of PLND between RARP and other surgical approaches in terms of nodal yield, node positivity, and intraoperative and postoperative complications.

CONCLUSIONS

PLND during RARP can be performed effectively and safely. The overall number of nodes removed, the likelihood of node positivity, and the types and rates of complications of PLND are similar to pure laparoscopic and open retropubic procedures.

External validation of the updated Briganti nomogram to predict lymph node invasion in prostate cancer patients undergoing extended lymph node dissection

PURPOSE

We aimed to test accuracy and generalizability of a recently updated nomogram to assess the probability of lymph node invasion (LNI), when applied to a different European cohort of men undergoing radical prostatectomy (RP) with extended pelvic lymph node dissection (ePLND).

MATERIALS AND METHODS

The study cohort consisted of 1,282 men with clinically localized PCa who underwent RP and ePLND, including removal of obturator, external iliac, and hypogastric lymph nodes, between 01/2007 and 08/2011. Descriptive measurements included preoperative clinical and biopsy variables, such as prostate-specific antigen (PSA), clinical stage (CS), primary and secondary biopsy Gleason pattern, and percentage of positive cores. We used the area under curve (AUC) of the receiver operator characteristic analysis to quantify accuracy of the model to predict LNI. The extent of over- or under-estimation was explored graphically within loess calibration plots.

RESULTS

The median number of removed lymph nodes was 15 with an interquartile range of 12-20. Twelve percent (n = 155) of men had LNI. Preoperative clinical and biopsy characteristics differed significantly (all P ≤ 0.002) between men with LNI and those without. External validation of the previously reported updated LNI nomogram showed very good accuracy (AUC: 0.829). A nomogram-derived cut-off of 4% could lead to a reduction of 48% of lymph node dissection, while missing 10% of patients with LNI.

CONCLUSIONS

We report the external validation of an updated LNI nomogram, demonstrating accuracy and applicability in a different European cohort. A nomogram-derived cut-off of 4% confirmed good performance characteristics within a different external validation cohort.

Feasibility of minimally invasive lymphadenectomy in bladder and prostate cancer surgery

With the rapid and widespread adoption of minimally invasive procedures (laparoscopic and robotic) for the treatment of prostate and bladder cancers in the last decade, concerns have been raised regarding whether the technique can emulate the time-tested gold standard open procedures. This article briefly reviews the indications for lymph node dissection for bladder and prostate cancer, and reviews the role of extended lymphadenectomy in each procedure. Much of the focus of this review is on minimally invasive approaches and the technical aspects of the procedures, the feasibility of the robotic technique, and early oncologic outcomes.

Temporal trends and predictors of pelvic lymph node dissection in open or minimally invasive radical prostatectomy

BACKGROUND

Pelvic lymph node dissection (PLND) is an important component of prostate cancer staging and treatment, especially for surgical patients who have high-risk tumor features. It is not clear how the shift from open radical prostatectomy (ORP) to minimally invasive radical prostatectomy (MIRP) has affected the use of PLND. The objectives of this study were to identify predictors of PLND and to assess the impact of surgical technique in a contemporary, population-based cohort.

METHODS

In Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked with Medicare claims, the authors identified men who underwent ORP or MIRP for prostate cancer during 2003 to 2007. The impact of surgical approach on PLND was evaluated, and interactions were examined between surgical procedure, prostate-specific antigen (PSA), and Gleason score with the analysis controlled for patient and tumor characteristics.

RESULTS

Of 6608 men who underwent ORP or MIRP, 70% (n = 4600) underwent PLND. The use of PLND declined over time both overall and within subgroups defined by procedure type. PLND was 5 times more likely in men who underwent ORP than in men who underwent MIRP when the analysis was controlled for patient and tumor characteristics. Elevated PSA and biopsy Gleason score, but not clinical stage, were associated with a greater odds of PLND in both the ORP group and the MIRP group. However, the magnitude of the association between these factors and PLND was significantly greater for patients in the ORP group.

CONCLUSIONS

PLND was less common among men who underwent MIRP, independent of tumor risk factors. A decline in PLND rates was not fully explained by an increase in MIRP. The authors concluded that these trends may signal a surgical approach-dependent disparity in prostate cancer staging and therapy.

Determinants of performing radical prostatectomy pelvic lymph node dissection and the number of lymph nodes removed in elderly men

OBJECTIVE

Controversy persists regarding the adequacy of pelvic lymph node dissection (PLND) and cancer control when comparing minimally invasive radical prostatectomy (MIRP) and open radical prostatectomy (RRP). We characterized determinants of performance and extent of PLND during radical prostatectomy in elderly men.

METHODS

A population-based study was conducted comprised of 5448 men ≥65 years undergoing RRP and MIRP during 2004 to 2006 from Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked data. Multivariable logistic regression was used to assess the effect of demographic and tumor characteristics, surgical approach, and surgeon volume on the likelihood of performing PLND.

RESULTS

PLND was performed for 87.6% vs. 38.3% of men undergoing RRP vs. MIRP (P <.001). Among RRP, 82.6% vs. 4.6% underwent extended vs. limited PLND, with a median yield of 4 vs. 3 lymph nodes (P <.001). Median MIRP PLND yield was 3 lymph nodes. In adjusted analyses, men undergoing RRP vs. MIRP (odds ratio [OR] 16.7; 95% confidence interval [CI], 11.1-25.0), those with few vs. multiple comorbidities (OR 1.4, 95% CI 1.02-1.91), intermediate (OR 1.87; 95% CI 1.48-2.37), and high (OR 2.77; 95% CI 2.02-3.78) vs. low-risk features, and men treated by high-volume surgeons (OR 1.008; 95% CI 1.004-1.011) were more likely to undergo PLND. Conversely, Hispanic (OR 0.68, 95% CI 0.49-0.96) vs. white men were less likely to undergo PLND.

CONCLUSIONS

Independent of tumor characteristics, men undergoing RRP vs. MIRP were more likely to undergo PLND with greater lymph node yield and racial variation observed. Further studies are needed to determine the appropriate use of PLND.

Association between ethnicity and prostate cancer outcomes across hospital and surgeon volume groups

OBJECTIVE

We analyzed the association between ethnicity and outcomes among prostate cancer patients across hospital and surgeon volume groups.

METHODS

In this retrospective cohort study using SEER-Medicare databases for the period between 1995 and 2003, prostate cancer cases were identified and retrospectively followed for one year pre- and up to eight years post-diagnosis. Based on volume, hospitals and surgeons were divided into three groups each. For each group, we fitted separate models to analyze the association between ethnicity and outcomes such as complications, eight-year mortality and cost, adjusting for covariates. Poisson (zero inflation), generalized linear model (log-link), and Cox regression models were used.

RESULTS

African American ethnicity was associated with 30-day complications among medium volume hospital group. African American patients receiving care at medium volume hospitals and from medium volume surgeons had higher costs. Hispanic patients receiving care at low and medium volume hospitals had lower cost compared to white patients. Hispanic patients receiving care from a high-volume surgeon experienced increased hazard of long-term mortality.

CONCLUSIONS

Association between ethnicity and outcomes varies across hospital and surgeon volume groups. Thus, volume based policy measures may need further exploration for understanding the interaction between structure, process, volume and outcomes.

[Life without robots : What is left for the urologist?]

The triumphal march of robots in urology seems to be unstoppable. In the meantime, a broadening of the scope for indications in urology can be observed: this applies to pyeloplasty and to a lesser degree also to partial nephrectomy and radical cystectomy. As yet no evidence has been provided that robot-assisted radical prostatectomy (RP) is superior to open surgery. Furthermore, data are available which suggest that the midterm functional results are possibly even worse than those achieved with open RP.

Lymph node dissection during robot-assisted radical prostatectomy: where do we stand?

Since the initial report of robot-assisted laparoscopic prostatectomy (RALP) in 2001, the technique has gained rapid acceptance and utilization. When compared with more traditional forms of surgical intervention, there is still much debate with respect to cost, and impact on potency and continence. Less often is the focus on oncologic outcomes. Pelvic lymph node dissection (PLND) at the time of prostatectomy is an important part of the surgical intervention for prostate cancer and is currently underreported during robotic procedures. Herein, we review the current controversies on the value and extent of PLND and the status of emerging data regarding robot-assisted PLND.