Use of a modified American Urological Association Symptom Score for the evaluation of the quality of life of patients with prostate cancer

Nerve spare robot assisted laparoscopic prostatectomy with amniotic membranes: medium term outcomes

INTRODUCTION

dHACM is a source of factors including cytokines that allow anti-inflammatory and proliferative elements to be utilized for wound and ulcer management. We present our experience of using dHACM in a cohort of patients undergoing nerve-sparing (NS) robot-assisted laparoscopic prostatectomy (RALP). Our objective is to investigate the functional and oncological outcomes of NS after placing amniotic or dehydrated human amnion/chorion membrane (dHACM) on preserved neurovascular bundles (NVBs). From 2013 to 2019, our institution performed transperitoneal multi-port da Vinci robotic prostatectomy. The NVBs are spared by releasing their fascial planes posteriorly, followed by an anterior release of the plane at a similar level. Once the retrograde release of the NVB is performed then 599 patients underwent placement of dHACM graft (AmnioFix by MiMedx, Marietta, GA, USA). The graft was cut into two 4 × 1 cm pieces and laid over the NVB as a wrap. In order to inform the urological community of oncological and functional outcomes, we excluded patients with less than 12 months follow up (n = 64), benign prostatic hyperplasia (n = 5), and unilateral NS (n = 1). 529 (88%) patients were included in this study who underwent a partial or full bilateral NS with dHACM. 529 patients were followed-up for a median (IQR) of 42 months (25-89). Demographics include median (IQR) age 57 years (52-62), median preoperative SHIM score of 24 (21-15), and AUASS of 5 (2-11). Full NS was performed in 74% (391/529). Pathological staging was pT2 = 399 (75%), pT3a = 107 (20%), pT3b = 19 (4%) and pT4 = 4 (1%) with N1 = 3 (0.6%). The number of patients with PSM was 86 (16%), and the overall BCR in the entire cohort was 10%. Postoperatively, 434 (82%) were sexually active. Median time to potency was 119 (37-420) days and time to continence was 42 (23-91) days. Regarding full vs partial NS: median post op SHIM score 18 (13-20) vs 15 (6-20), median time to potency 92 (35-365) days vs 184 (42-560) days, and median time to continence 42 (23-91) days vs 44 (30-92) days. Age > 55 vs ≤ 55 years: median post op SHIM score 18 (12-20) vs 15 (10-20), median time to potency 167 days (42-549) vs 80 (35-288) days, and median time to continence 42 (25-116) days vs 42 (29-76) days. In our series the application of amniotic membrane/dHACM has led to acceptable post RALP outcomes. The BCR rate of 10% in addition to the recovery of potency at a median time of 3 months and continence at 6 weeks is an encouraging result of dHACM. Our findings indicate that dHACM allowed for an even faster period for continence recovery which was independent of grade of NS. Future comparative studies may further assess the impact of new amniotic membrane types on the functional and oncological outcomes after RALP.

Measuring symptoms in localized prostate cancer: a systematic review of assessment instruments

It is critical for prostate cancer researchers and clinicians to have access to comprehensive, sensitive and simple-to-use symptom measures that allow them to understand and quantify the subjective patient experience. The purpose of the current review is to provide a comprehensive review, detailed tool descriptions and objectively defined quality criteria to facilitate tool choices for patients with localized prostate cancer. Using a systematic web-based literature search, we found n=29 prostate symptom measures described in n=35 validation studies. To be recommended, tools needed to meet four criteria: broad domain coverage, ability to differentiate objective and subjective experience, good internal consistency and validation in at least two populations and/or having achieved two types of validations. Of the 29 tools reviewed, n=7 meet our criteria for recommendation, and three in particular (the EPIC-26 (Expanded Prostate Cancer Index Composite)-26, PC-QOL (Prostate Cancer-Quality of Life) and the UCLA-PCI (UCLA Prostate Cancer Index)) showed the strongest psychometrics. There is a reasonable number of measures to choose from that meet criteria for good psychometrics.

Prostate Cancer Chemoprevention Targeting Men with High-Grade Prostatic Intraepithelial Neoplasia (HGPIN) and Atypical Small Acinar Proliferation (ASAP): Model for Trial Design and Outcome Measures

In spite of the large number of nutrient-derived agents demonstrating promise as potential chemopreventive agents, most have failed to prove effectiveness in clinical trials. Critical requirements for moving nutrient-derived agents to recommendation for clinical use include adopting a systematic, molecular-mechanism based approach and utilizing the same ethical and rigorous methods such as are used to evaluate other pharmacological agents. Preliminary data on a mechanistic rationale for chemoprevention activity as observed from epidemiological, in vitro and preclinical studies, phase I data of safety in suitable cohorts, duration of intervention based on time to progression of preneoplastic disease to cancer and the use of a valid panel of biomarkers representing the hypothesized carcinogenesis pathway for measuring efficacy must inform the design of phase II clinical trials. The goal of this paper is to provide a model for evaluating a well characterized agent- Polyphenon E- in a phase II clinical trial of prostate cancer chemoprevention.

Changes in continence and health-related quality of life after curative treatment and watchful waiting of prostate cancer

OBJECTIVES

To investigate the long-term changes in health-related quality of life (HRQOL), continence, and sexual function after curative therapy (CT) and watchful waiting (WW) for prostate cancer.

METHODS

A self-reported questionnaire of HRQOL and continence was administered to patients with prostate cancer who were candidates for CT and WW. The questionnaire was re-administered during follow-up. The pretreatment and posttreatment HRQOL burden scores were compared and correlated with the treatment, continence, and sexual function.

RESULTS

Of the 61 patients, 41 chose CT (26 chose prostatectomy and 15 radiotherapy). The average follow-up for the CT patients was 24.3 +/- 13.3 months. The pretreatment incontinence score was 0.38 +/- 0.9 and the HRQOL burden score was 16.3 +/- 8.8 (CT versus WW, P = 0.55). On follow-up, 23 (56%) of 41 CT patients were continent. The HRQOL burden score after treatment was similar between the CT and WW patients (20.4 +/- 9.6 versus 18.4 +/- 9.0, P = 0.45). The continent patients had a significantly lower HRQOL burden compared with the post-CT incontinent patients (17.41 +/- 7.4 versus 24.2 +/- 10.8, P = 0.02). The HRQOL burden score after treatment for CT patients who maintained sexual activity and CT patients who lost their sexual activity was similar (P = 0.28).

CONCLUSIONS

The HRQOL after CT of prostate cancer was related to patients' self-perception of continence. Incontinence, either urinary or fecal, was associated with an increased self-reported HRQOL burden, although reduced sexual function was not associated with such a change. The WW patients maintain their HRQOL. Separating the continent and incontinent patients during the analysis of the posttreatment HRQOL brought to light the adverse outcomes associated with post-CT incontinence.

Incontinence severity and QOL scales for fecal incontinence

This article reviews self-reporting instruments to measure severity and quality of life in fecal incontinence. Severity instruments assess the frequency, type, and amount of stool loss and the impact of fecal incontinence on coping mechanisms and lifestyle/behavioral change. Non-weighted instruments use simple numerical totals to gauge severity; however, the use of vague quantifiers to describe severity can make the results highly subjective. In weighted surveys, every possible response (indicating the frequency of each type of incontinence) is multiplied by a weight that reflects the average severity assigned by a representative group of patients (or physicians), and the weighted responses are added to compile a total score. When variables such as coping mechanisms and lifestyle changes are included in severity questionnaires, the results tend to reflect patient functioning more than severity and should be interpreted cautiously. Quality-of-life scales assess variables that are not directly observable and are highly subjective. Quality-of-life scales are divided into 3 categories: (1) generic scales permit the measurement of gross change and compare the experience of the target population to other populations; (2) specialized scales are most useful in trying to isolate effects of specific variables, such as depression; and (3) condition-specific quality-of-life scales measure the relationship between specific medical conditions or treatments, and quality of life outcomes. Future research should focus on the need for weighting, further evaluation of the use of coping mechanisms as an indicator of severity, and how to integrate measures of urgency. In the area of quality of life, "modules" are needed that can be appended to established instruments to help assess and compare the experience of specific populations.

Permanent Prostate Brachytherapy in Men with Clinically Localised Prostate Cancer

Permanent prostate brachytherapy techniques are associated with excellent biochemical control for patients with localised prostate cancer. Ten-year data show that permanent prostate brachytherapy is compatible with external beam irradiation or radical prostatectomy. However, treatment protocols and techniques for prostate brachytherapy vary between centres and there is little conformity of treatment protocols. The selection of patients for monotherapy or combined external beam irradiation and brachytherapy is controversial. The role of neoadjuvant androgen deprivation also remains unanswered in patients with localised prostate cancer. In addition, post-implant dosimetry may in fact be more significant for predicting outcome than the addition of adjuvant therapies, and should be a requirement when performing prostate brachytherapy. Data now seem to support specific computed tomography (CT)-based criteria to evaluate implant quality and delivered dose to the prostate. Unfortunately, prostate oedema and poor imaging techniques are limiting factors for evaluating implant dosimetry. Treatment planning techniques that use new treatment planning computers may assist in improving the implant procedure and dosimetry and are now available.