A large prostate at radical retropubic prostatectomy does not adversely affect cancer control, continence or potency rates

Effects of Bony Pelvic and Prostate Dimensions on Surgical Difficulty of Robot-Assisted Radical Prostatectomy: An Original Study and Meta-analysis

BACKGROUND

Due to the deep location of the prostate within the pelvic cavity, procedures of robot-assisted radical prostatectomy (RARP) might be challenged by the prostate size and the limited pelvic cavity space. This study aimed to investigate the roles of bony pelvic and prostate dimensions in RARP procedures by an original study coupled with a meta-analysis.

METHODS

In the original study, patients undergoing multiport RARP between 2021 and 2022 were consecutively assessed. The associations of anatomic features with operative time (OT), estimated blood loss (EBL), and positive surgical margin (PSM) were evaluated using linear and logistic regression analyses as well as restricted cubic spline (RCS) analysis. Based on machine-learning algorithms, this study established predictive models for surgical difficulty and interpreted the model using SHapley Additive exPlanation (SHAP). In the meta-analysis, three databases were searched for eligible studies. Quantitative syntheses were subsequently performed.

RESULTS

Overall, 219 patients were enrolled in the original study. Prostate volume (PV) and the prostate volume-to-pelvic cavity index (PCI) ratio (PV-to-PCI ratio) were significantly associated with longer OT (P < 0.05). In the RCS models, U-shaped associations were observed between the prostate anteroposterior diameter (PAD) and OT, and between the prostate height (PH) and EBL, and an L-shaped association was observed between the anteroposterior diameter of the pelvic inlet (API) and EBL. The XGBoost model was superior to the logistic regression model in predicting prolonged OT. The meta-analysis demonstrated that greater PV was significantly associated with longer OT (β = 0.20; 95% confidence interval [CI] 0.12-0.27; odds ratio [OR] = 1.05; 95% CI 1.00-1.11), and a smaller PV could increase the risk of PSM (OR = 0.82; 95% CI 0.77-0.88).

CONCLUSIONS

A large prostate within a narrow and deep pelvis might suggest increased surgical difficulty of RARP. The size of the pelvic inlet also had a great impact on RARP. For PAD and PH, there seemed to be an optimal range with the lowest surgical difficulty. Machine-learning models based on the XGBoost algorithm could be successfully applied to predict the surgical difficulty of RARP.

The Impact of Prostate Volume in Open Radical Prostatectomy: A Single Centre Experience

BACKGROUND

Even the most experienced surgeons experience technical difficulties and challenges when operating on very large prostates, regardless of surgical technique. Our goal was to determine whether preoperative prostate volume has an impact on functional and oncological outcomes after open radical prostatectomy.

MATERIALS AND METHODS

We reviewed the records of 909 patients who underwent open radical prostatectomy by a single surgeon at our institution. Variables were compared across quartile distributions of prostate volume as defined by preoperative transrectal ultrasound examination, including group A with prostate volume < 30ccm 3, group B with prostate volume ≥ 30ccm 3 and < 50ccm 3, group C with prostate volume ≥ 50ccm 3 and < 70ccm 3 and group D with prostate volume ≥ 70ccm3. Factors assessed in this analysis were patient age, preoperative prostate specific antigen (p-PSA), Gleason score, pathological stage, margin status, operative time, cystography leakage, early continence, biochemical recurrence (BCR)-free, and overall-survival (OS). The complication rates were classified using Clavien Dindo classification.

RESULTS

There were no statistically relevant differences between the groups considering preoperative factors such as age, p-PSA, Gleason score, and tumor stadium. Patients with a very large prostate had slightly higher percentage of anastomosis leakage, severe Clavien Dindo complication rates (≥ 3), longer operation time and severe early incontinence (IV°) rates, simultaneously having lower positive margin rates. Nevertheless, the early continence rates, BCR-free and OS were similar regardless of the prostate size.

CONCLUSIONS

open radical prostatectomy for patients with very large prostate is a viable therapy option with slightly higher urinary leakage-, early incontinence- and complication-rates that takes slightly more operation time. However, the functional and oncological outcomes are similar when compared to smaller prostates.

Functional and Oncological Outcomes Following Robot-Assisted and Laparoscopic Radical Prostatectomy for Localized Prostate Cancer With a Large Prostate Volume: A Retrospective Analysis With Minimum 2-Year Follow-Ups

Objective

We aimed to analyze the perioperative, functional, and oncologic outcomes following robot-assisted radical prostatectomy (RARP) and laparoscopic radical prostatectomy (LRP) for patients with localized prostate cancer (PCa) characterized by a large prostate volume (PV; ≥50 ml) over a minimum of 2 years follow-up.

Materials and Methods

Patients undergoing RARP and LRP for localized PCa with a large PV were included in the final analysis. The perioperative, functional, and oncologic outcomes were analyzed between the two groups.

Results

All operations were successfully completed without open conversion in both groups. The mean operative time and estimated blood loss in the RARP group were significantly decreased compared to those in the LRP group (139.4 vs. 159.0 min, p = 0.001, and 124.2 vs. 157.3 ml, p = 0.003, respectively). Patients in the RARP arm had significantly lower proportions of grade II or lower and of higher than grade II postoperative complications compared with those in the LRP group (7.9% vs. 17.1%, p = 0.033, and 1.6% vs. 6.7%, p = 0.047, respectively). No significant differences in terms of the rates of pT3 disease, positive surgical margin, and positive lymph node were noted between the two groups. Moreover, no significant difference in the median specimen Gleason score was observed between the RARP and LRP groups (6 vs. 7, p = 0.984). RARP vs. LRP resulted in higher proportions of urinary continence upon catheter removal (48.4% vs. 33.3%, p = 0.021) and at 3 (65.1% vs. 50.5%, p = 0.025) and 24 (90.5% vs. 81.0%, p = 0.037) months post-operation. The median erectile function scores at 6 and 24 months post-operation in the RARP arm were also significantly higher than those in the LRP arm (15 vs. 15, p = 0.042, and 15 vs. 13, p = 0.026, respectively). Kaplan–Meier analyses indicated that the biochemical recurrence-free survival and accumulative proportion of continence were statistically comparable between the two groups (p = 0.315 and p = 0.020, respectively).

Conclusions

For surgically managing localized PCa with a large prostate (≥50 ml), RARP had a tendency toward a lower risk of postoperative complications and better functional preservation without cancer control being compromised when compared to LRP.

A matter of size? Health-related quality of life after radical prostatectomy for patients with giant prostates

BACKGROUND

Evidence regarding the impact of giant prostate volume (PV) on outcome after radical prostatectomy (RP) is controversial with a lack of evidence on the impact of PV on health-related quality of life (HRQOL). We aimed to assess the impact of giant PV on HRQOL and functional outcomes for men with prostate cancer (PC) undergoing RP.

METHODS

Giant PV was defined based on the 95th percentile of PV measured by specimen weight of 3929 patients that underwent RP between 2013 and 2018 in a large tertiary care center. A propensity score-matched analysis of 929 men treated with RP for PC (n = 184 with PV ≥ 100 cm³ , n = 745 with PV < 100 cm³ ) was conducted. Primary endpoint was the impact of giant PV on HRQOL (based on EORTC QLQ-C30) assessed with binary logistic regression and Cox proportional hazard model. Secondary endpoint was the impact of PV on oncological- and functional outcome.

RESULTS

Median follow-up was 24 months. Median PV, measured by specimen-weight, was 58 cm³ . We found no significant differences in median general HRQOL (p = .183), giant PV was not associated with better HRQOL (odds ratio [OR], 1.54; 95% confidence interval [CI], 0.96-2.47; p = .075). No significant differences were found regarding continence recovery (hazard ratio [HR], 0.956; 95% CI, 0.771-1.185; p = .682), median International Consultation of Incontinence Questionnaire-Short-Form (ICIQ-SF) scores (p = .062) or potency rates (p = .151). Giant PV did not significantly impair biochemical recurrence-free survival (HR, 0.968; 95% CI, 0.651-1.439; p = .871).

CONCLUSIONS

For patients undergoing RP, giant PV was not associated with adverse HRQOL outcomes. We found no significant impact of PV on continence rates, potency rates, and biochemical recurrence-free survival. Hence, RP is an efficient cancer treatment for men even with giant PV.

The association between prostate weight and positive surgical margins in prostate cancer: A meta-analysis

There have been some conflicting claims whether larger prostate weight (PW) reduces the risk of positive surgical margins (PSMs). This study aims to examine the associations between PW and PSMs. PubMed, Web of Science and Cochrane library were systematically retrieved. Relative risks (RRs) and the corresponding 95% confidence intervals (CIs) were synthesised utilising random-effect models. Ultimately, 22 cohort studies met criteria were enrolled in this meta-analysis, of which 18 studies reporting the RR of the highest VS lowest category of PW yielded the combined RR of PSMs of 0.61 (95% CI 0.50-0.74). Subgroup analysis showed that geographic region and surgical modalities were considered as potential confounders of influence of PW on PSMs. The nonlinear dose-response relationship demonstrated that PSM risk decreased by 1% (RR = 0.99, 95% CI, 0.98-0.99) for every one gram increment in PW. This study suggests PW has a negative association with risk of PSMs, and having a appropriate PW is very important.

Impact of prostate volume on oncologic, perioperative, and functional outcomes after radical prostatectomy

BACKGROUND

The impact of prostate volume (PV) on oncologic, perioperative and functional outcomes after radical prostatectomy (RP) remains controversial, as recent studies present inconsistent results. We studied the influence of PV on outcomes in a large single center dataset and summarized the existing literature.

METHODS

5,477 patients who underwent RP between January 2008 and December 2011 were analyzed. The impact of PV on biochemical recurrence (BCR) and metastasis-free survival (MFS) was assessed using Kaplan-Meier curves and multivariate Cox proportional hazard model. Uni- and multivariate logistic regressions were used to estimate the impact of PV on surgical margin (SM), 1-week, 3-months and 12-months continence and 3-months and 12-months potency. Finally, the impact of PV on intraoperative blood loss was analyzed using uni- and multivariate linear regressions.

RESULTS

Median follow-up was 36.1 months. Overall, 16.5% of patients recurred during the follow-up period. The mean preoperative PV was 43.3 ml. One-week, 3-months and 12-months continence rates were 55.6%, 69.3%, and 87.4% for patients with PV ≥ 70 compared to 64.4%, 78.3%, and 92.1% for patients with PV < 30, respectively. Three-months and 12-months potency rates were 37.1% and 54.8% for men with large glands (≥70) and 56.3% and 65.0% for men with PV < 30. In multivariate analysis, continence at 1 week, 3 months and 12 months was significantly worse in patients with glands ≥70 ml, while potency was not influenced by PV in multivariate analysis. There was a higher mean blood loss (P < 0.001) in patients with larger glands. In univariate analysis, higher PV was significantly associated with lower BCR (P = 0.019), but not with metastasis free survival (P = 0.112).

CONCLUSIONS

PV significantly influences BCR-free survival only in univariate analysis. Especially early (1-week and 3-months) postoperative continence is negatively affected by higher PV in multivariate analysis, while PV did not influence potency after adjusting for further covariates in a specialized high-volume institution.

Efficacy of Duloxetine in the Early Management of Urinary Continence after Radical Prostatectomy

AIM

To evaluate the efficacy of early duloxetine therapy in stress urinary incontinence occurring after radical prostatectomy (RP).

MATERIAL AND METHOD

Patients that had RP were randomly divided into 2 groups following the removal of the urinary catheter. Group A patients (n = 28) had pelvic floor exercise and duloxetine therapy. Group B patients (n = 30) had only pelvic floor exercise. The incontinence status of the patients and number of pads were recorded and 1-hour pad test and Turkish validation of International Consultation on Incontinence Questionnaire-Short Form test were applied to the patients at the follow-up.

RESULTS

When the dry state of the patients was evaluated, 5, 17, 3, and 2 of 28 Group A patients stated that they were completely dry in the 3rd, 6th, 9th and 12th month respectively and pad use was stopped. There was no continence in 30 Group B in the first 3 months. Twelve, 6, and 8 patients stated that they were completely dry in the 6th, 9th and 12th month, respectively. But 3 of 4 patients in whom dryness could not be provided were using a mean of 7.6 pads in the first day and a mean of 1.3 pads after 1 year. When pad use of the patients was evaluated, the mean monthly number of pad use was determined to be 6.2 (4-8) in the initial evaluation, 2.7 (0-5) in the in 3rd month, 2 (0-3) in the 6th month and 1.6 (0-2) pad/d in the 9th month in the group taking medicine. The mean monthly number of pads used was determined to be 5.8 (4-8) in the initial evaluation, 4.3 (3-8) in the 3rd month, 3 (0-6) in the 6th month and 1.6 (0-6) pad/d in the 9th month in the group not taking medicine.

CONCLUSION

According to the results, early duloxetine therapy in stress urinary incontinence that occurred after RP provided early continence.

Importance of prostate volume in the stratification of patients with intermediate-risk prostate cancer

OBJECTIVES

To evaluate the role of prostate volume assessed at final pathology in the risk of biochemical recurrence in patients with clinically localized prostate cancer treated with radical prostatectomy.

METHODS

Overall, 5637 patients treated with radical prostatectomy between January 1993 and August 2013 were identified. Multivariable Cox regression analyses tested the association between prostate volume and biochemical recurrence in the overall population and after stratifying patients according to the D'Amico risk groups.

RESULTS

Mean (median) prostate volume was 50.61 mL (46 mL). When patients were stratified according to D'Amico risk groups, mean (median) prostate volume was 51.7 mL (48 mL), 49.8 mL (45 mL) and 50.6 mL (46 mL) in low-, intermediate-, and high-risk prostate cancer, respectively (P = 0.04). Overall, the 5-year biochemical recurrence-free survival rate was 87.9%. In multivariable Cox regression analyses, prostate volume was associated with a lower risk of biochemical recurrence (hazard ratio 0.99, 95% confidence interval 0.99-1.00), after accounting for disease characteristics. However, when patients were stratified according to D'Amico risk groups, prostate volume represented an independent predictor of biochemical recurrence only in individuals with intermediate-risk disease (hazard ratio 0.99, 95% confidence interval 0.99-1.00). Conversely, prostate volume was not associated with the risk of experiencing biochemical recurrence in patients with low- and high-risk disease.

CONCLUSIONS

Smaller prostates are associated with increased risk of biochemical recurrence after surgery only in men with intermediate-risk disease. In this category, the preoperative assessment of prostate volume might be helpful in order to identify patients at higher risk of biochemical recurrence after surgery. Additionally, prostate volume might be used to individualize follow-up schedules after radical prostatectomy.

Impact of prostate size on urinary quality of life scores after open radical prostatectomy: a single-center experience

OBJECTIVE

The aim of this study was to assess the effects of prostate size on long-term health-related quality of life (HRQoL) and functional outcomes after radical prostatectomy (RP).

MATERIAL AND METHODS

A total of 207 consecutive patients who underwent RP for localized prostate cancer was stratified by pathological prostate gland weight into group 1, patients with prostate glands weighing less than 30 g; group 2, those with prostates weighing 30-50 g; and group 3, those with prostates weighing more than 50 g. Urinary HRQoL was assessed before surgery and at 1, 3, 6, 12, 18, 24, 36, 48 and 60 months after RP using a Japanese version of the Expanded Prostate Cancer Index Composite (EPIC) questionnaire.

RESULTS

Baseline urinary function was significantly (p < 0.05) reduced in patients with the largest glands (group 3), as demonstrated by EPIC urinary domain summary and subscale scores, including scores for urinary bother, irritation and obstruction, compared with patients with smaller glands (groups 1 and 2). At follow-up ranging from 18 to 36 months, patients in group 3 had improved EPIC urinary domain summary and subscale scores, including scores for urinary irritation and obstruction and urinary bother subscale scores, compared with their baseline scores (p < 0.05).

CONCLUSIONS

In patients with large prostate glands, postoperative improvement was observed in HRQoL and functional outcome after RP. Thus, RP may be beneficial in patients with large prostates.

Five-year oncological outcomes of endoscopic extraperitoneal radical prostatectomy (EERPE) for prostate cancer: results from a medium-volume UK centre

OBJECTIVE

To determine the 5-year oncological outcomes of endoscopic extraperitoneal radical prostatectomy (EERPE) from a medium-volume centre, thereby providing much needed data on outcomes from the UK.

PATIENTS AND METHODS

From January 2006 to January 2012, 575 patients underwent EERPE for localized prostate cancer, performed by a single surgeon who had completed a modular training programme. Follow-up was as per local hospital policy and data were collected in our prospective database. A retrospective review of patient demographics, prostate-specific antigen (PSA) levels, pathological T stages, Gleason scores, surgical margin status and biochemical recurrence (BCR) data was performed. BCR was defined as PSA >0.2 μg/L.

RESULTS

The mean (range) patient age was 62 (40.3-76.5) years and the mean (range) follow-up was 30 (12-72) months. The median (interquartile range [IQR]) operating time was 135 (120-170) min and the median (IQR) blood loss was 200 (100-250) mL. Of the 575 patients, 135 (23.5%) had positive surgical margins (PSMs). The PSM rate for pT2 disease was 66/406 patients (16.3%) and for pT3 disease it was 68/168 patients (40.5%). Overall BCR-free survival at 5-years was 81.5%. Multivariate Cox analysis showed that PSMs, Gleason score, D'Amico risk category and pT stage were independent predictors of BCR-free survival.

CONCLUSIONS

This assessment of the oncological results of EERPE, which included the surgical learning curve, shows that the adoption of EERPE after mentored fellowship training translates into mid-term oncological outcomes in line with those of retropubic/transperitoneal laparoscopic approaches and with large-volume centres worldwide which have pioneered laparoscopic radical prostatectomy. The study shows that EERPE in a medium-volume second generation laparoscopic centre (that introduced EERPE after adequate training in pioneering centres) produces results with good 5-year oncological outcomes, similar to those of other major series, for patients in the UK.

Impact of prostate size on pathologic outcomes and prognosis after radical prostatectomy

Purpose

We investigated prostate size and its correlation with final pathologic outcomes and prognosis.

Materials and Methods

From 1993 to 2009, 830 consecutive patients who underwent radical prostatectomy with follow-up duration of 12 months or more were included in this study. Patients were categorized according to prostate size as follows: group 1, prostate size ≤40 g (n=458), and group 2, prostate size >40 g (n=472). Preoperative parameters and postoperative pathologic outcomes were compared between groups. Multivariate analysis with Cox proportional hazards regression model was used to identify the pathologic and clinical factors affecting biochemical recurrence.

Results

Patients in group 1 had higher pathologic T stage (pT2a=17.7% vs. 23.9%, pT2b=1.1% vs. 0%, pT2c=40.4% vs. 39.8%, pT3a=29.5% vs. 21.0%, pT3b=10.7% vs. 13.2%, p=0.003) and higher positive surgical margin (40.3% vs. 33.1%, p=0.033) than did patients in group 2. Pathologic Gleason score was not significantly different between the two groups. The 5-year biochemical-recurrence-free survival was 62.3% for patients in group 1 and 73.2% for patients in group 2 (p=0.005). Multivariate Cox regression analysis showed that prostate size of 40 g or less (hazard ratio [HR], 1.378; 95% confidence interval [CI], 1.027 to 1.848; p=0.032), extracapsular extension (HR, 1.592; 95% CI, 1.147 to 2.209; p=0.005), positive surgical margin (HR, 2.348; 95% CI, 1.701 to 3.242; p<0.001), and pathologic Gleason sum (HR, 1.507; 95% CI, 1.292 to 1.758; p<0.001) were independent predictors of biochemical recurrence.

Conclusions

Smaller prostate size was associated with increased risk of higher pT stage and positive surgical margin after radical prostatectomy. Also, prostate size less than 40 g was an independent prognostic factor for biochemical recurrence.

Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy

Background

We examined the effect of prostate weight on perioperative data, and the pathological and functional outcomes of robotic-assisted laparoscopic prostatectomy (RALP).

Patients and methods

Data were available from 716 consecutive patients before, during and after undergoing RALP at one institution. Prostate size was arbitrarily stratified by recorded prostate weight into <50, 50–80 and >80 g, corresponding to small, moderate and large glands, respectively. Perioperative data and the histopathological and functional outcomes were compared across these groups by both univariable and multivariable-adjusted analyses.

Results

Increased prostate size was associated with increased age, preoperative prostate-specific antigen levels, body mass index, operative duration, blood loss, lower biopsy and pathological Gleason scores, and lower pathological staging (P < 0.05). The incidence of extensive positive surgical margins was 14.8%, 9.7%, and 5.3% in small, moderate and large prostates, respectively (P < 0.001). However, after multivariable adjustment, only Gleason score and pathological stage were significantly associated with the incidence of positive margins (P < 0.05); prostate weight was not significantly associated. Overall, 78% and 92% of patients were potent and continent at 12 months, respectively, which was not affected by prostate size.

Conclusion

Patients with larger prostates had favourable pathological outcomes after RALP. When controlling for pathological stage, prostate size was not associated with margin positivity. Functionally, neither continence nor potency at 12 months was affected by prostate size.

The impact of prostate size, median lobe, and prior benign prostatic hyperplasia intervention on robot-assisted laparoscopic prostatectomy: technique and outcomes

BACKGROUND

Large prostate size, median lobes, and prior benign prostatic hyperplasia (BPH) surgery may pose technical challenges during robot-assisted laparoscopic prostatectomy (RALP).

OBJECTIVE

To describe technical modifications to overcome BPH sequelae and associated outcomes.

DESIGN, SETTINGS, AND PARTICIPANTS

A retrospective study of prospective data on 951 RALP procedures performed from September 2005 to November 2010 was conducted. Outcomes were analyzed by prostate weight, prior BPH surgical intervention (n=59), and median lobes >1 cm (n=42).

SURGICAL PROCEDURE

RALP.

MEASUREMENTS

Estimated blood loss (EBL), blood transfusions, operative time, positive surgical margin (PSM), and urinary and sexual function were measured.

RESULTS AND LIMITATIONS

In unadjusted analysis, men with larger prostates and median lobes experienced higher EBL (213.5 vs 176.5 ml; p<0.001 and 236.4 vs 193.3 ml; p=0.002), and larger prostates were associated with more transfusions (4 vs 1; p=0.037). Operative times were longer for men with larger prostates (164.2 vs 149.1 min; p=0.002), median lobes (185.8 vs 155.0 min; p=0.004), and prior BPH surgical interventions (170.2 vs 155.4 min; p=0.004). Men with prior BPH interventions experienced more prostate base PSM (5.1% vs 1.2%; p=0.018) but similar overall PSM. In adjusted analyses, the presence of median lobes increased both EBL (p=0.006) and operative times (p<0.001), while prior BPH interventions also prolonged operative times (p=0.014). However, prostate size did not affect EBL, PSM, or recovery of urinary or sexual function.

CONCLUSIONS

Although BPH characteristics prolonged RALP procedure times and increased EBL, prostate size did not affect PSM or urinary and sexual function.

Prostate size is not associated with recovery of sexual function after minimally invasive radical prostatectomy

OBJECTIVES

To investigate the association of prostate weight with recovery of sexual function after minimally invasive radical prostatectomy.

METHODS

Between April 2001 and September 2007, two surgeons performed 856 consecutive laparoscopic radical prostatectomies for clinically localized prostate cancer. Patients were stratified into three groups by prostate weight: <35 g, 35-70 g, and >70 g. Sexual and urinary outcomes were assessed prospectively using the Expanded Prostate Cancer Index Composite (EPIC) questionnaire. Patients who underwent nerve sparing (unilateral or bilateral) with complete preoperative EPIC data, a minimum preoperative Sexual Health Inventory for Men score ≥21, and a minimum of 3 months of complete postoperative EPIC data were included in the analysis.

RESULTS

Of the cohort of 856 men, 324 (38%) had complete, evaluable data and met the inclusion criteria for this study. Preoperatively, there were no significant differences by prostate weight in the EPIC sexual function or bother subscale scores or the proportion of patients participating in sexual intercourse. Postoperatively, we observed statistically similar returns to baseline EPIC sexual function and bother subscale scores and participation in sexual intercourse across all gland weight groups at all time points. EPIC sexual domain scores and the proportions of patients participating in sexual intercourse continued to increase up to 24 months postoperatively, but no group returned to preoperative function at any sampling point.

CONCLUSIONS

Prostate size is not associated with postoperative recovery of sexual function in men undergoing minimally invasive radical prostatectomy.

Does robotic technology mitigate the challenges of large prostate size?

OBJECTIVES

For radical prostatectomy, the advantages of robotic surgery may facilitate precise dissection and improve functional outcomes. However, patients with larger prostates may still pose increased challenges because of impaired visualization and mobility in the pelvis. For this reason, we undertook a study to better understand the relationships between large prostate size and robotic prostatectomy outcomes with respect to intraoperative and pathologic factors.

METHODS

Patients undergoing robotic-assisted radical prostatectomy from 2003 to 2008 at our institution were included in this retrospective study. Prostate size was categorized into 3 groups (< 50, 50-100, > 100 g). We compared surgical and quality of life (Expanded Prostate Cancer Index Composite [EPIC] scores) outcomes among groups using generalized linear models and chi-square testing.

RESULTS

Patients with the largest prostates had longer operative times (> 100 vs < 50 g, 250 vs 232 minutes, P < .01) and more blood loss (> 100 vs < 50 g, 250 vs 155 mL, P = .01). Conversely, these patients had fewer positive surgical margins and lower Gleason sums (both P < .01). Despite worse baseline irritative symptoms (> 100 vs < 50 g, 79.7 vs 90.0, P < .001) and sexual function (> 100 vs < 50 g, 38.2 vs 77.9, P < .001), these differences resolved at 3 months (P = .92, P = .88, respectively). Recovery of continence was relatively sluggish compared with that in patients with the smallest prostates (> 100 vs < 50 g; 44.0, 62.2, P = .03).

CONCLUSIONS

Not surprisingly, larger prostate size was associated with increased operative times and blood loss, although of questionable clinical significance. While these patients appeared to benefit regarding irritative symptoms, recovery of continence was delayed. Longer follow-up is needed to further assess recovery.

Detection rates of nonpalpable prostate cancer in Korean men with prostate-specific antigen levels between 2.5 and 4.0 ng/mL

OBJECTIVE

To evaluate the detection rate and pathology of cancer in Korean men with low levels of prostate-specific antigen (PSA), 2.5-4.0 ng/mL.

METHODS

We examined 1097 patients with PSA level of 2.5-10.0 ng/mL, who underwent transrectal ultrasonography-guided prostate needle biopsies between January 2008 and March 2009. Of the 1097 biopsy patients, 815 met our criteria of benign findings by digital rectal examination and the absence of cancerous lesions by TRUS. Clinical characteristics and detection rates of prostate cancer, as well as the pathology of specimens obtained by needle biopsies and prostatectomies, were evaluated in these patients.

RESULTS

Of the 815 patients, 349 had group 1 (PSA level, 2.5-4.0 ng/mL) and 466 had group 2 (PSA level, 4.0-10.0 ng/mL). The percentage of patients diagnosed with prostate cancer was not statistically different between the 2 groups (21.8% in group 1, and 20.2% in group 2). In group 1, 70.7% of patients had a pathologic Gleason score of 7 or higher and 91.4% had organ-confined tumors (pT2). The pathologic characteristics, including Gleason score, pathologic stage, and percentage of insignificant cancer were similar in prostatectomy specimens between group 1 and group 2.

CONCLUSIONS

Detection rates of nonpalpable prostate cancer in Korean men were 21.8% in group 1 and 20.2% in group 2 without statistically significant difference. Pathologic characteristics of prostatectomy specimens also were similar between group 1 and group 2. These results suggest that a lower PSA level might be considered as an indication for prostate biopsy.

Tumor volume, tumor percentage involvement, or prostate volume: which is predictive of prostate-specific antigen recurrence?

OBJECTIVES

To compare the effects of tumor volume (TV), tumor percentage involvement (TPI), and prostate volume (PV) on prostate-specific antigen (PSA) recurrence (PSAR) after radical prostatectomy (RP).

METHODS

A cohort of 3528 patients receiving RP between 1988 and 2008 was retrieved from the Duke Prostate Center. Patients were stratified by TV (< 3, 3-6, > 6 cm(3)), TPI (< 10%, 10%-20%, > 20%), and PV (< 35, 35-45, > 45 cm(3)) and their effects on PSAR evaluated using Kaplan-Meier analysis. Clinicopathologic variables included in univariate analysis were age at surgery, race, year of surgery, PSA, pathologic Gleason score, pathologic tumor stage, margin status, extracapsular extension, and seminal vesicle invasion. The effects of TV, TPI, and PV (as continuous and categorical variables) on PSAR were compared using Cox analysis.

RESULTS

TPI, TV, and PV were predictive of PSAR (P <.05) in Kaplan-Meier analysis. In multivariate analysis as continuous variables, TPI and PV were predictive of PSAR (hazard ratio [HR] = 1.16 and HR = 0.65, P <.05). As categorical variables, TPI > 20% and PV 10-35 cm(3) were predictive of PSAR (HR = 1.45 and OR = 1.25, P <.05). TV was not predictive of PSAR in either analysis. Pathologic Gleason score > or = 7, PSA, positive margins, seminal vesicle invasion, and tumor stage T3/T4 were found to be predictors of PSAR (P <.05).

CONCLUSIONS

TV, TPI, and PV were predictive of PSAR in univariate analysis, but in multivariate analysis, only TPI and PV were predictive of PSAR. TPI and PV should be considered when evaluating, assessing, and counseling patients regarding PSAR risk.

Prostate size is associated with surgical difficulty but not functional outcome at 1 year after radical prostatectomy

PURPOSE

We assessed the impact of prostate size on operative difficulty as measured by estimated blood loss, operating room time and positive surgical margins. In addition, we assessed the impact on biochemical recurrence and the functional outcomes of potency and continence at 1 year after radical prostatectomy as well as postoperative bladder neck contracture.

MATERIALS AND METHODS

From 1998 to 2007, 3,067 men underwent radical prostatectomy by 1 of 5 dedicated prostate surgeons with no neoadjuvant or adjuvant therapy. Pathological specimen weight was used as a measure of prostate size. Cox proportional hazards and logistic regression analysis was used to study the association between specimen weight, and biochemical recurrence and surgical margin status, respectively, controlling for adverse pathological features. Continence and potency were analyzed controlling for age, nerve sparing status and surgical approach.

RESULTS

With increasing prostate size there was increased estimated blood loss (p = 0.013) and operative time (p = 0.004), and a decrease in positive surgical margins (84 of 632 [14%] for 40 gm or less, 99 of 862 [12%] for 41 to 50 gm, 78 of 842 [10%] for 51 to 65 gm, 68 of 731 [10%] for more than 65 gm, p <0.001). Biochemical recurrence was observed in 186 of 2,882 patients followed postoperatively and was not significantly associated with specimen weight (p = 0.3). Complete continence was observed in 1,165 of 1,422 patients (82%) and potency in 425 of 827 (51%) at 1 year. Specimen weight was not significantly associated with potency (p = 0.8), continence (p = 0.08) or bladder neck contracture (p = 0.22).

CONCLUSIONS

Prostate size does not appear to affect biochemical recurrence or 1-year functional results. However, estimated blood loss and operative time increased with larger prostate size, and positive surgical margins are more often observed in smaller glands.

Prostate volume and the incidence of extraprostatic extension: is there a relation?

BACKGROUND AND PURPOSE

Extraprostatic extension (EPE) of tumor is an important prognostic indicator that has an impact on long-term survival after radical prostatectomy. We investigated whether the prostate size has any association with the tumor volume and the incidence of EPE.

PATIENTS AND METHODS

Seven hundred consecutive robot-assisted radical prostatectomy procedures performed by a single surgeon at a single center were studied. Preoperative parameters (demographic details, prostate-specific antigen (PSA) level, biopsy characteristics, and tumor volume) and the postoperative histopathologic details of the specimen (prostate volume, Gleason sum, EPE, and surgical margin status) were compared among the small prostate (< 40 cc), intermediate size (40-70 cc), and large prostate (> 70 cc) groups. Chi-square analysis was performed for comparison of groups with nominal variables while continuous variables were compared using analysis of variance. A double-sided P value of less than 0.05 was considered statistically significant.

RESULTS

A greater proportion of patients in the large prostate group had T(1c) tumor compared with those in the small prostate group (90.2% v 78.3%). Younger men and smaller prostates had lower preoperative PSA levels (P < 0.001). A significantly higher PSA density (0.16 v 0.07) and cancer density (0.0102 v 0.0025), however, was observed in patients with small prostates compared with those with large prostates. A total of 102 (14.6%) patients had EPE on the final pathologic analysis while 8.6% of the patients had positive surgical margins. Greater incidence of EPE was observed in the group with smaller prostates compared to those in the large prostate group (16.7% v 7.3%).

CONCLUSION

Small prostates have a higher cancer density and a greater incidence of EPE of tumor.

Nerve-sparing prostatectomy and urinary function: a prospective analysis using validated quality-of-life measures

OBJECTIVES

To prospectively study whether urinary function and bother are directly related to neurovascular bundle preservation at radical prostatectomy using validated quality-of-life questionnaires.

METHODS

A total of 91 consecutive patients undergoing radical prostatectomy were prospectively studied using the University of California, Los Angeles, Prostate Cancer Index and the International Prostate Symptom Score. The patients were divided into 2 groups (>50% nerve sparing vs <or=50% nerve sparing). To control for differences in the 2 groups, linear mixed models were performed to adjust for the time after surgery, preoperative sexual ability, and urinary function.

RESULTS

Of the 91 patients, 62 (68%) had >50% nerve-sparing during prostatectomy. Their mean age at surgery was 59 +/- 6 years, and the mean follow-up was 16 +/- 9 months. Of the 91 patients, 29 (32%) had <or=50% nerve sparing during prostatectomy. Their mean age at surgery was 64 +/- 8 years, and the mean follow-up was 13 +/- 7 months. Increased nerve sparing was associated with better urinary function (P = .014) and less urinary bother (P = .043). After adjusting for preoperative variables, the increased nerve-sparing group scored 8.4 points (95% confidence interval 1.3-15.4) higher for urinary function and 8.5 points (95% confidence interval 0.3-16.8) higher for urinary bother compared with the group. The International Prostate Symptom Score improved in both groups of patients, and no significant differences were found between the 2 groups.

CONCLUSIONS

The results of our study have shown that nerve-sparing prostatectomy is associated with improvement in urinary function and bother. This improvement was modest and is of unknown clinical significance.

The first 1000 cases of laparoscopic radical prostatectomy in the UK: evidence of multiple 'learning curves'

OBJECTIVE

To report the initial experience of one surgeon, with contemporary experience of both open radical prostatectomy (ORP) and reconstructive laparoscopy, in laparoscopic radical prostatectomy (LRP) in 1000 patients, and to investigate the rate of change of various outcome variables for this procedure with time.

PATIENTS AND METHODS

Between March 2000 and December 2007, 1000 consecutive patients with clinical stage T < or = 3aN0M0 prostate cancer underwent LRP, either supervised (17%) or performed (83%), by one surgeon. The median prostate-specific antigen (PSA) level was 7.0 (1-50) ng/mL and median Gleason sum 6 (4-10); the clinical stage was T1 in 46.9%, T2 in 49.8% and T3 in 3.3%.

RESULTS

The median (range) operative duration was 177 (78-600) min. There was one conversion (patient 8) to open surgery. The median blood loss was 200 (10-1300) mL and four patients were transfused (0.4%). The median postoperative hospital stay was 3.0 (3-28) nights. The median catheterization time was 10.0 (0.8-120) days. There were 48 complications (4.8%) requiring surgical intervention in 33 (3.3%) patients, 58% of these as a day-case admission. The positive margin rates according to d'Amico risk groups were: low, 9.1%; intermediate, 20.3%; and high, 36.8%. The overall positive margin rate was 13.3%. The PSA level was < or =0.1 mg/L at 3 months in 99.1% of patients. At a mean follow-up of 27.7 (3-72) months, 96.1% of patients were free of biochemical recurrence. In patients with a follow-up of > or =24 months potency rates peaked in the series at 86% for all men and 94% for men aged < or =65 years, and continence rates at 98% before declining thereafter in men with a shorter follow-up.

CONCLUSION

The learning curve for operating time and blood loss was overcome within the first 100-150 cases, but complication and continence rates took 150-200 cases to reach a plateau. The longest learning curve was for potency, which did not stabilize until 700 cases. These learning curves are likely to be considerably shorter when surgeons are taught in departments with a high throughput of cases but both surgeons and patients should be aware of them. In view of these findings, the authors recommend that LRP should not be self-taught and should be learned within an immersion teaching programme. Even then, a large surgical volume is likely to be needed to maintain clinical outcomes at the highest level.

The association between prostate size and Gleason score upgrading depends on the number of biopsy cores obtained: results from the Shared Equal Access Regional Cancer Hospital Database

OBJECTIVE

To test the hypothesis that the association between prostate size and risk of Gleason grade upgrading varies as a function of sampling.

PATIENTS AND METHODS

We examined the association between pathological prostate weight, prostate biopsy scheme and Gleason upgrading (Gleason > or =7 at radical prostatectomy, RP) among 646 men with biopsy Gleason 2-6 disease treated with RP between 1995 and 2007 within the Shared Equal Access Regional Cancer Hospital Database using logistic regression. In all, 204 and 442 men had a sextant (six or seven cores) or extended-core biopsy (eight or more cores), respectively. Analyses were adjusted for centre, age, surgery, preoperative prostate-specific antigen level, clinical stage, body mass index, race, and percentage of cores positive for cancer.

RESULTS

In all, 281 men (44%) were upgraded; a smaller prostate was positively associated with the risk of upgrading in men who had an extended-core biopsy (P < 0.001), but not among men who had a sextant biopsy (P = 0.22). The interaction between biopsy scheme and prostate size was significant (P interaction = 0.01).

CONCLUSIONS

These data support the hypothesis that the risk of upgrading is a function of two opposing contributions: (i) a more aggressive phenotype in smaller prostates and thus increased risk of upgrading; and (ii) more thorough sampling in smaller prostates and thus decreased risk of upgrading. When sampled more thoroughly, the phenotype association dominates and smaller prostates are linked with an increased risk of upgrading. In less thoroughly sampled prostates, these opposing factors nullify, resulting in no association between prostate size and risk of upgrading. These findings help to explain previously published disparate results of the importance of prostate size as a predictor of Gleason upgrading.

Prostate weight and early potency in robot-assisted radical prostatectomy

OBJECTIVES

Using an athermal technique for nerve preservation we noted that approximately 40% are potent compared with approximately 60% who are not at 3 months after robot-assisted laparoscopic prostatectomy (RLP). In an attempt to understand this difference, we examine factors potentially influencing potency at 3 months.

METHODS

Of 300 consecutive RLPs, we identified 139 men who met preoperative inclusion criteria: age <or= 65 years with International Index of Erectile Function (IIEF-5) scores of 22-25. All men were instructed to take 5'-phosphodiesterase inhibitors postoperatively. All data were collected and entered prospectively into an electronic database. Sexual outcomes were obtained via self-administered validated questionnaires. We defined potency by affirmative answers to the following questions: Were erections adequate for penetration, and were they satisfactory?

RESULTS

At 3 months, 53 subjects (38%) were potent. Univariate and multivariate analysis demonstrated no effect for IIEF-5 score, body mass index, nerves spared, estimated blood loss, hypertension, diabetes, use of cholesterol-lowering agents, and lifestyle issues. Prostate weight (43.3 vs 51.4 g, P = .038) and age (55 vs 57, P = .03) were significant in univariate analysis. In multivariate analysis only prostate weight was predictive of potency (P = .04). To ascertain a possible relation between traction nerve injury and prostate weight, analysis between prostate weight groups and potency demonstrated an inverse relationship.

CONCLUSIONS

Low prostate weight was the only factor found to correlate with early return of potency. Our data also suggest that increasing prostate weight increases the risk of delay in potency recovery.

The impact of prostate gland weight in robot assisted laparoscopic radical prostatectomy

PURPOSE

We determined whether prostate weight has an impact on the pathological and operative outcomes of robot assisted laparoscopic radical prostatectomy.

MATERIALS AND METHODS

We reviewed the records of 1,847 consecutive patients who underwent robot assisted laparoscopic radical prostatectomy at our institution. Variables were compared across quartile distributions of prostate size as defined by weight, including group 1-less than 30 gm, group 2-30 to 49.9, group 3-50 to 69.9 and group 4-70 or greater. Factors assessed in this analysis were patient age, body mass index, prostate specific antigen, Gleason score, pathological stage, margin status, operative time, blood loss, transfusion rate, length of stay and rehospitalization rate.

RESULTS

Patients with a larger prostate (group 4) were older (mean age 66.2 years), had higher pretreatment prostate specific antigen (median 6.5 ng/ml), lower Gleason score (mean 6.3), longer operative time (mean 3.2 hours), higher estimated blood loss (median 250 cc) and longer hospital stay (p = 0.0002). There was a trend toward higher risk disease based on D'Amico risk stratification and positive margin status in group 1, although evidence of extracapsular extension was more common in groups 2 and 3. There was no association between prostate size and body mass index, lymph node status, blood transfusion rate, seminal vesicle involvement and rehospitalization rate.

CONCLUSIONS

Robot assisted laparoscopic radical prostatectomy in patients with an enlarged prostate is feasible with slightly longer operative time, urinary leakage rates and hospital stay. Pathologically larger prostates are generally associated with lower Gleason score and risk group stratification. One-year continence rates and biochemical recurrence rates are similar across all groups.

Race and prostate weight as independent predictors for biochemical recurrence after radical prostatectomy

We hypothesized that factors beyond pathological stage, grade, PSA and margin status would be important predictors of biochemical recurrence (BCR) after radical prostatectomy (RP). A cohort of 3194 patients who underwent RP between 1988 and 2007 and who had neither neoadjuvant therapy nor postoperative adjuvant hormonal therapy was retrieved from the Duke Prostate Center database. Age, prostate-specific antigen (PSA), pathological Gleason score (pG), lymph node status, seminal vesicle invasion (SVI), extracapsular extension (ECE), positive surgical margin (PSM) status, year of surgery, race, adjuvant radiation therapy (XRT), percent tumor involvement in the RP specimen and prostate weight were evaluated as possible predictors of BCR in multivariate Cox regression analysis. BCR was defined as a PSA of 0.2 ng ml(-1) or higher at least 30 days after surgery. A nomogram was developed from the Cox model. Predictive accuracy was obtained by calculating bias-corrected Harrell's c and by bootstrap calibration. In multivariate analysis, PSA (hazard ratio 1.39 (95% confidence interval 1.29-1.51)), ECE (1.22 (1.04-1.44)), pG score (1.38 (1.14-1.68), 2.23 (1.76-2.84), 2.69 (2.12-3.40) for pG 3+4, 4+3, >7, respectively), SVI (1.72 (1.40-2.12)), PSM (2.05 (1.73-2.42)), year of surgery (0.65 (0.54-0.77)), African-American race (1.37 (1.13-1.66)), adjuvant XRT (0.19 (0.11-0.34)) and prostate weight (0.83 (0.76-0.92)) were identified as independent predictors of BCR (P< or =0.018 for all factors). Predictive accuracy of the nomogram was 0.75. Race and prostate weight were independent predictors for BCR after RP. By incorporating these variables, we developed a nomogram, which provides a highly accurate means for estimating risk of BCR after RP.

Association of Prostate Size and Tumor Grade in Korean Men with Clinically Localized Prostate Cancer

OBJECTIVES

To investigate the association of prostate size with aggressiveness of prostate cancer in Korean men who received radical retropubic prostatectomy (RRP) for clinically localized prostate cancer.

METHODS

We evaluated the association of RRP specimen weight and prostate volume measured by transrectal ultrasound (TRUS) with pathologic tumor grade, extraprostatic extension of disease, surgical margin status, and seminal vesicle invasion by reviewing data of 346 consecutive patients who underwent RRP for clinically localized prostate cancer at our institution without receiving preoperative radiation or hormonal treatment.

RESULTS

A strong correlation was observed between RRP specimen weight and TRUS-measured prostate volume (Spearman r = 0.76; P <0.001). After adjustment for multiple variables including age, body mass index, and preoperative prostate-specific antigen level, RRP specimen weight was observed to be significantly associated with presence of Gleason pattern 4 or greater at RRP in an inverse fashion (P = 0.03). Regarding other adverse pathologic features, prostate weight was also significantly inversely associated with extraprostatic extension of prostate cancer (P = 0.04) and surgical margin positivity (P = 0.002). When TRUS-measured prostate volume was applied in place of RRP specimen weight, results were the same.

CONCLUSIONS

Our data indicate that prostate size may be a useful predictor of tumor aggressiveness in Korean men with clinically localized prostate cancer. Further efforts should be made to elucidate actual mechanisms behind the association of prostate size and/or in vivo androgenicity with aggressiveness of prostate cancer.

[The low weight of the prostate is an independent risk factor for positive surgical margins on radical prostatectomy specimens]

OBJECTIVE

The presence of positive surgical margins (PSM) on radical prostatectomy specimen is predictive of biological recurrence. Our objective was to analyze the influence of prostate weight on surgical margins status after radical prostatectomy.

PATIENTS AND METHODS

A cohort of 295 patients operated consecutively between 1998 and 2004 at our institution was prospectively studied. The variables significantly associated with the surgical margins status in univariate analysis were used for multivariate analysis.

RESULTS

The overall rate of PSM was 23% (9% for pT2 patients). Parameters significantly associated with surgical margins status were preoperative PSA (p = 0.02), number of positive biopsy cores (p = 0.04), pathological stage (p < 0. 001), and Gleason score on radical prostatectomy specimen (p < 0. 001). In addition, patient age and surgical specimen weight were conversely associated with surgical margins status (p = 0.008 and p = 0.001, respectively). In multivariate analysis, only three parameters were found to be independent factors of PSM: the pathological stage (p < 0. 001), the patient age (p = 0. 02), and the surgical specimen weight (p = 0.02). PSM rates were 6% and 25% in patients with prostate > 70g and < 70g, respectively (p = 0.008), and 15% and 28% in those with prostate weight > or = 50g and < 50g, respectively (p = 0.015).

CONCLUSION

Low prostate weight is an independent risk factor of PSM. Patients with prostate weight > or = 70g should be considered at low risk of PSM, while those with prostate weight < 50g are at high risk of PSM.

Analysis of Risk Factors for Urinary Incontinence after Radical Prostatectomy

INTRODUCTION

Our aim was to identify the independent risk factors associated with urinary incontinence after radical retropubic prostatectomy (RRP).

MATERIALS AND METHODS

Using univariate and multivariate analyses, we examined several pre- and perioperative factors. One hundred and sixty-six patients were divided into three groups: patients who were immediately continent after catheter removal (group I), patients who became continent later (group II) and incontinent patients (group III).

RESULTS

There were 34 patients (20.5%) in group I, 111 (66.9%) in group II, and 21 (12.6%) in group III. The multivariate analysis between the continent and incontinent patients proved that the postoperatively measured total length of the posterior urethra (strongly associated with length of the sphincter, length of the urethral stump and the presence of anastomotic stricture) was the independent risk factor for permanent incontinence or delayed continence following RRP. The age of patients per se represented a risk factor only for delayed continence, but not for permanent incontinence.

CONCLUSIONS

Postoperatively measured shorter posterior urethral length results in an increased risk of urinary incontinence and delays continence after RRP. It seems that older age only delays reaching continence.

Recovery of Urinary Continence Following Radical Prostatectomy: The Impact of Prostate Volume—Analysis of Data From the CaPSURE™ Database

PURPOSE

Improved urinary function following radical prostatectomy due to bladder outlet obstruction from subclinical benign prostatic hyperplasia has been described. We determined if prostate volume determined by preoperative transrectal ultrasound could predict recovery of urinary function and continence following radical prostatectomy.

MATERIALS AND METHODS

We identified all 4,984 patients who underwent radical prostatectomy in the CaPSURE national disease registry of men with prostate cancer. Only the 2,097 men who had data available on preoperative prostate volume by transrectal ultrasound, and complete preoperative and postoperative data available on urinary function using the UCLA-PCI were selected for study. Transrectal ultrasound volume was categorized as less than 25, 25 to 50 cc or greater than 50 cc. Univariate and mixed multivariate analyses were performed to determine the association between transrectal ultrasound based prostate volume and continence, as measured by urinary function scores 6 months to 2 years following radical prostatectomy. Analyses were controlled for baseline urinary function as well as other variables, such as body mass index, time of urinary function assessment and patient age at diagnosis. Total and individual item scores on the urinary function subscale were used as outcome variables in separate models.

RESULTS

Median transrectal ultrasound prostate volume was 35 cc (IQR 27-47.8). In the ANOVA for mixed models patient age, time of urinary function assessment, body mass index and transrectal ultrasound prostate volume were independent predictors of urinary continence. Patients with prostate volume greater than 50 cc had lower rates of continence, as assessed by urinary function scores 6 months and 1 year after radical prostatectomy, but scores equalized across all volume ranges by 2 years after radical prostatectomy. The individual domains most significantly affected were urinary control (p = 0.02), urine leakage during sexual activity (p = 0.0016) and urine leakage frequency (p = 0.0175).

CONCLUSIONS

These data indicate that baseline prostate volume is a predictor of recovery of urinary function after radical prostatectomy. Men with larger volume prostates have lower levels of continence up to 2 years after radical prostatectomy. A potential reason could be subclinical bladder dysfunction related to benign prostatic hyperplasia that manifests after surgery.

Preoperative and Intraoperative Risk Factors for Side-Specific Positive Surgical Margins in Laparoscopic Radical Prostatectomy for Prostate Cancer

OBJECTIVES

Identification of variables predicting positive surgical margins (PSMs) in patients undergoing laparoscopic radical prostatectomy (LRP) for clinically localized prostate cancer is lacking. Our objective was to determine preoperative risk factors and the association of ipsilateral degree of neurovascular bundle dissection (intraoperative factor) with side-specific PSMs in these patients.

MATERIAL AND METHODS

Between October 2002 and April 2005, one surgeon performed LRP on 407 previously untreated patients. Of 814 evaluable prostate sides, 728 harboured prostate cancer in the specimen and composed the study population. For each prostate side, we obtained clinical stage, biopsy Gleason, maximum percentage of tumour in the biopsy, suspected extracapsular extension (ECE) on endorectal coil magnetic resonance imaging (MRI), degree of neurovascular bundle (NVB) dissection, and PSMs. PSM was defined as cancer cells at the inked margins. Logistic regression analyses with random effects were generated.

RESULTS

Of the 728 prostate sides with cancer, 51 (7%) had at least one PSM. In multivariable analysis, higher PSA (p=0.01), Gleason score of 7 compared with < or =6 in the biopsy (p=0.04), lower prostate volume on MRI (p=0.01), and interfascial NVB dissection compared with intrafascial dissection (p=0.01) were associated with an increased risk of side-specific PSMs. Suspected ECE on MRI (p=0.9) and clinical stage (p=0.3) were not significantly associated with side-specific PSMs. A subset analysis of 321 patients with bilateral tumours did not show statistically significant differences in PSMs according to tumour side (p=0.3).

CONCLUSIONS

High serum prostate-specific antigen, biopsy Gleason score of 7, low prostate volume, and interfascial NVB dissection were independently associated with side-specific PSMs after LRP, and should be considered during planning of the LRP surgical strategy.

Impact of Prostate Size in Robot-Assisted Radical Prostatectomy

BACKGROUND AND PURPOSE

A large prostate can complicate an extraperitoneal robot-assisted radical prostatectomy (RARP). We report our experience with RARP and evaluate the effects of prostate size on treatment outcomes after extraperitoneal RARP.

PATIENTS AND METHODS

Information on 355 consecutive patients undergoing extraperitoneal RARP was gathered, and patients with prostate weight <75 g (N = 319) were compared with those having glands >or=75 g (N = 36). The factors considered were age, body mass index, total operating time, estimated blood loss, serum prostate specific antigen (PSA) concentration, pathologic stage and Gleason grade, intraoperative and peri-operative complications, margin status, and continence.

RESULTS

A statistically significant difference (P < 0.05) was noted in age (59 v 64 years), PSA concentration (6.07 v 8.9 ng/dL), and blood loss (175 v 226 mL) between patients with smaller v larger prostates. No difference was seen in Gleason score (6 v 6), clinical T stage, operative time (217 v 225 minutes), or total positive-margin rate (13% v 19%). A higher positive-margin rate was seen in patients with stage T(3) disease and larger prostates. The 6-month continence rate in patients with a prostate volume < 75 g was 97% v 84% in patients with larger prostate volumes ( P < 0.05).

CONCLUSION

Although a large prostate volume is associated with a slight increase in short-term urinary complications postoperatively, it should not be considered a contraindication for the experienced surgeon. This higher risk raises the question of a possible need for longer catheterization in this subset of patients.

Minimising Postoperative Incontinence Following Radical Prostatectomy: Considerations and Evidence

OBJECTIVES

To review evidence regarding perioperative predictors of incontinence after radical prostatectomy (RP), related anatomic and patient factors, and surgical techniques used to minimise incontinence.

METHODS

A search of the Pubmed, Cancerlit, Cochrane, and ISI Web of Science databases was performed for the key words prostatectomy, incontinence, and continence. Relevant articles were reviewed, summarised, and analysed.

RESULTS

Enhanced understanding of pelvic anatomy applied to surgical approaches has improved continence rates following RP; however, incontinence remains a potential adverse outcome. Evidence suggests that increasing patient body weight and prostate volume are not associated with continence outcomes, but increasing patient age may be predictive. Behavioural therapy may aid in early return to continence although the timing of therapy and benefit of biofeedback assistance are unclear. Various surgical techniques are used to improve continence, but no evidence overwhelmingly supports any specific technique. At best, evidence supports early return to continence with some techniques. No technique significantly increased margin positivity solely at the experimental anatomic site.

CONCLUSIONS

Despite enhanced knowledge of anatomy and improved surgical approach, incontinence persists as a potential adverse outcome of RP. Urologists may not find an evidence-based rationalisation for any particular surgical technique due to the nature of surgical series, variability in the definition of incontinence, and individual surgical skills, preferences, and techniques. Giving careful consideration to the trial design can potentially improve the resulting level of evidence.

Whole-pelvis, “mini-pelvis,” or prostate-only external beam radiotherapy after neoadjuvant and concurrent hormonal therapy in patients treated in the Radiation Therapy Oncology Group 9413 trial

PURPOSE

The Radiation Therapy Oncology Group (RTOG) 9413 trial demonstrated a better progression-free survival (PFS) with whole-pelvis (WP) radiotherapy (RT) compared with prostate-only (PO) RT. This secondary analysis was undertaken to determine whether "mini-pelvis" (MP; defined as > or = 10 x 11 cm but < 11 x 11 cm) RT resulted in progression-free survival (PFS) comparable to that of WP RT. To avoid a timing bias, this analysis was limited to patients receiving neoadjuvant and concurrent hormonal therapy (N&CHT) in Arms 1 and 2 of the study.

METHODS AND MATERIALS

Eligible patients had a risk of lymph node (LN) involvement > 15%. Neoadjuvant and concurrent hormonal therapy (N&CHT) was administered 2 months before and during RT for 4 months. From April 1, 1995, to June 1, 1999, a group of 325 patients were randomized to WP RT + N&CHT and another group of 324 patients were randomized to receive PO RT + N&CHT. Patients randomized to PO RT were dichotomized by median field size (10 x 11 cm), with the larger field considered an "MP" field and the smaller a PO field.

RESULTS

The median PFS was 5.2, 3.7, and 2.9 years for WP, MP, and PO fields, respectively (p = 0.02). The 7-year PFS was 40%, 35%, and 27% for patients treated to WP, MP, and PO fields, respectively. There was no association between field size and late Grade 3+ genitourinary toxicity but late Grade 3+ gastrointestinal RT complications correlated with increasing field size.

CONCLUSIONS

This subset analysis demonstrates that RT field size has a major impact on PFS, and the findings support comprehensive nodal treatment in patients with a risk of LN involvement of > 15%.

Should Men with Serum Prostate-Specific Antigen ≤4 ng/ml and Normal Digital Rectal Examination Undergo a Prostate Biopsy?

The clinical significance of a prostate cancer (PCa) cannot be determined solely by tumor volume (< or =0.5 cm(3)), as small tumors of higher Gleason grade and tumors occurring in younger men may become clinically significant even though the initial volume at diagnosis is small. A certain number of these minimal cancers are likely to remain clinically insignificant; however, it is unpredictable how many can progress beyond the curable stage by the time there is a rise in serum prostate-specific antigen (PSA) values. Compared to clinically detected PCa, PCa detected exclusively by PSA screening (clinical stage T1c) are less likely to be advanced but no more likely to be insignificant in terms of volume, pathologic stage, and Gleason pattern. Only 10-15% of PSA-detected cancers have the features of PCa found at autopsy or in cystoprostatectomy specimens. Actually, 25-30% of PCa are detected with PSA values between 2.5 and 4 ng/ml, and most of these cancers are clinically significant. Evidence from both retrospective and longitudinal studies has shown that the risk of a PCa is dependent on the patient's age and the initial serum PSA. This allows an individualized approach to PCa screening programs, and PSA cutoff values for biopsy indication may be lowered in selected patients.

Post-robotic prostatectomy urinary continence: characterization of perfect continence versus occasional dribbling in pad-free men

OBJECTIVES

To review and characterize two groups of men who report being pad-free after robot-assisted laparoscopic prostatectomy (RLRP): those with occasional incontinence and those with complete control.

METHODS

The study included 106 out of a total of 195 men who underwent RLRP. Inclusion requirements were adequate follow-up and no-pad continence status. All patients completed self-administered American Urological Association symptom score (AUAss) and continence questionnaires and underwent measurement of peak urinary flow rates, postvoid residual volumes, and voided volumes (VV) before and 3 months after surgery. All data and standard clinical characteristics were entered prospectively into an electronic database.

RESULTS

Two distinct groups reported wearing no pads: the "perfect" group (n = 32) reported never leaking, and the "imperfect" group (n = 74) reported occasional leakage but did not wear pads. Preoperatively, the "imperfect" group was older (62.2 versus 59 years) and had more urinary symptoms (all P < 0.05). Postoperatively, the "imperfect" group took longer to achieve a pad-free status (median 39.8 versus 19.3 days), had larger prostates (mean 50.9 versus 43.2 g), had lower VV (324 versus 405 mL), and more urinary symptoms (AUAss 7.4 versus 4.3; all P < 0.05).

CONCLUSIONS

Sixty-nine percent of men who attain "pad-free continence" after RLRP have occasional urinary leakage. Preoperatively, these men are characteristically older and have larger prostates, AUAss, and bother scores. Postoperatively, the "imperfect" group takes longer to achieve pad-free status and has smaller bladder capacities and more urinary symptoms. These results suggest that an overactive detrusor is the likely contributing etiology.