Robotic Laparoscopic Radical Prostatectomy for Biopsy Gleason 8 to 10: Prediction of Favorable Pathologic Outcome with Preoperative Parameters

Clinical and oncological outcomes of robot-assisted radical prostatectomy with nerve sparing vs. non-nerve sparing for high-risk prostate cancer cases

Robot-assisted radical prostatectomy (RARP) is one of the most widely used procedures for localized prostate cancer (PCa). In the present study, the clinical and oncological outcomes of RARP with bilateral or unilateral nerve sparing (NS) for D'Amico high-risk PCa cases were assessed. Among the 767 cases who received RARP at Fujita Health University Hospital between August 2009 and December 2016, 230 high-risk PCa cases who were observed for >6 months comprised the retrospective study cohort. Bilateral NS was performed with the bilateral neurovascular bundle in eight, unilateral in 125 and none in 97 cases. Perioperative parameters [surgery time, console time, estimated blood loss, pathological stage, positive lymph node metastases [pN (+)], and surgical margin positivity] did not exhibit significant differences between the NS and non-NS cohorts. During a median follow-up time of 25 months, the 1- and 3-year biochemical recurrence (BCR)-free survival rates in the NS/non-NS cohorts were 84.4/86.0 and 72.7/75.0%, respectively. There were no significant differences identified between the two groups at each time period. According to multivariate analysis, the resection margin was an important factor for time to BCR, regardless of the NS technique used. The numbers of pads used daily at 3 and 6 months after RARP between the NS/non-NS cohorts were 1.1/1.5 and 0.6/1.0, respectively (P=0.045 and P=0.009), suggesting that the NS technique resulted in significantly improved outcomes regarding urinary continence recovery. In selected high-risk PCa cases, the NS technique resulted in equivalent oncological outcomes and improved urinary continence compared with the non-NS RARP group.

Robotic radical prostatectomy in high-risk prostate cancer: current perspectives

Around 20%–30% of patients diagnosed with prostate cancer (PCa) still have high-risk PCa disease (HRPC) that requires aggressive treatment. Treatment of HRPC is controversial, and multimodality therapy combining surgery, radiation therapy, and androgen deprivation therapy have been suggested. There has been a trend toward performing radical prostatectomy (RP) in HRPC and currently, robot-assisted laparoscopic RP (RARP) has become the most common approach. Number of publications related to robotic surgery in HRPC is limited in the literature. Tissue and Tumor characteristics might be different in HRPC patients compared to low-risk group and increased surgical experience for RARP is needed. Due to the current literature, RARP seems to have similar oncologic outcomes including surgical margin positivity, biochemical recurrence and recurrence-free survival rates, additional cancer therapy needs and lymph node (LN) yields with similar complication rates compared to open surgery in HRPC. In addition, decreased blood loss, lower rates of blood transfusion and shorter duration of hospital stay seem to be the advantages of robotic surgery in this particular patient group. RARP in HRPC patients seems to be safe and technically feasible with good intermediate-term oncologic results, acceptable morbidities, excellent short-term surgical and pathological outcomes and satisfactory functional results.

Safety of selective nerve sparing in high risk prostate cancer during robot-assisted radical prostatectomy

D'Amico high risk prostate cancer is associated with higher incidence of extra prostatic disease. It is recommended to avoid nerve sparing in high risk patients to avoid residual cancer. We report our intermediate term oncologic and functional outcomes in patients with preoperative D'Amico high risk prostate cancer, who underwent selective nerve sparing robot-assisted radical prostatectomy (RARP). Between Jan 2008 till June 2013, 557 patients underwent RARP for D'Amico high risk prostate cancer. The criteria for nerve sparing were as follows-complete: non palpable disease with <3 cores involvement on prostate biopsy; partial: non palpable disease with <4 cores involvement on prostate biopsy; none: clinically palpable disease with ≥4 cores involvement on prostate biopsy and intraoperative visual cues of locally advanced disease (loss of dissection planes, focal bulge of prostatic capsule). Degree of nerve sparing (NS) was graded intraoperatively by the surgeon independently at either side as side specific margins were assessed to predict subjectivity of the intraoperative judgment. Various data were collected and analyzed. Of 557 patients who underwent RARP 140 underwent complete (group 1), 358 patients underwent partial (group 2), and 59 patients underwent non-nerve-sparing procedure (group 3). There were no difference in preoperative characteristic between the groups (p = 0.678), but group 3 had higher Gleason score sum (p = 0.001), positive cores on biopsy (p = 0.001) and higher t stage (p = 0.001). Postoperatively Extra prostatic extension (p = 0.001), seminal vesicle invasion (p = 0.001), and tumor volume (p < 0.001) were higher in Group 3. Side specific positive surgical margins (PSMs) rates were higher for non-nerve-sparing compared to partial and complete nerve sparing RARP (p < 0.001; overall PSMs = 25.2 %). On univariate and multivariate analysis, nerve sparing did not affect PSMs (p > 0.05). The overall biochemical recurrence (BCR) rate at mean follow-up of 24.3 months was 19.21 %. The continence rate at 3 month was significantly higher in complete NS group in comparison to non-NS group (p = 0.020), however, this difference was not statistically significant at 1 year. Similarly, mean time to continence was significantly lower in complete NS group in comparison to non-NS group (p = 0.030). The potency rate was significantly higher and mean time to potency was significantly lower in complete NS group in comparison to non-NS group (p = 0.010 and 0.020, respectively). In high risk prostate cancer patients, selective nerve sparing during RARP, using the preoperative clinical variables (clinical stage and positive cores on biopsy) and surgeon's intraoperative perception, could provide reasonable intermediate term oncologic, functional outcomes (continence and potency) with acceptable perioperative morbidity and positive surgical margins rate. Use of these preoperative factors and surgeon's intraoperative judgment can appropriately evaluate high risk prostate cancer patients for nerve sparing RARP.

Role of robot-assisted radical prostatectomy in the management of high-risk prostate cancer

We aimed to evaluate the role of robot-assisted radical prostatectomy (RARP) in the management of high-risk prostate cancer (PCa), with a focus on oncological, functional and perioperative outcomes. Further, we also aimed to briefly describe our novel modification to conventional RARP that allows immediate organ retrieval and examination for intra-operative surgical margin assessment. A literature search of PubMed was performed for articles on the management of high-risk PCa. Papers written in English and concerning clinical outcomes following RARP for locally advanced and high-risk PCa were selected. Outcomes data from our own center were also included. A total of 10 contemporary series were evaluated. Biopsy Gleason score ≥ 8 was the most common cause for classification of patients into the high-risk PCa group. Biochemical failure rate, in the few series that looked at long-term follow-up, varied from 9% to 26% at 1 year. The positive surgical margin rate varied from 12% to 53.3%. Urinary continence rates varied from 78% to 92% at 1 year. The overall complication rates varied from 2.4% to 30%, with anastomotic leak and lymphocele being the most common complications. Long-term data on oncological control following RARP in high-risk patients is lacking. Short-term oncological outcomes and functional outcomes are equivalent to open radical prostatectomy (RP). Safety outcomes are better in patients undergoing RARP when compared with open RP. Improved tools for predicting the presence of organ-confined disease (OCD) are available. High-risk patients with OCD would be ideal candidates for RARP and would benefit most from surgery alone.

Are active surveillance criteria sufficient for predicting advanced stage prostate cancer patients?

OBJECTIVES

To examine the treatment outcomes of the prostate cancer (PCa) patients treated by radical prostatectomy (RP) who could be good candidates for active surveillance (AS) and test the confidence and reliability of the AS criterias for predicting advanced stage disease (RP Gleason score≥7 or Pathological stage T3).

METHODS

Between 2005 and 2012 the records of the 401 patients who underwent RP with a diagnosis of PCa were examined. Of these patients, 173 were found to be candidates of AS. The inclusion criteria were as follows; clinical stage T2a or less, PSA<10ng/ml, 2 or fewer cores involved with cancer, no single core with 50% or greater maximum involvement of cancer, and no Gleason grade greater than 3 in the specimen.

RESULTS

Univariate analyzes revealed that patients with advanced stage disease have higher prostate specific antigen density (PSAD), higher maximum percent (max%) in positive cores and higher RP tumor volumes. In multivariate analyzes PSAD, max% in positive cores and RP tumor volumes were statistically significant determinants for advanced stage disease. ROC analyzes revealed that the RP tumor volume is a good test on advanced stage disease.

CONCLUSIONS

Decreasing the cutoff values for PSAD and max% in positive cores should be considered for AS inclusion criteria. If we could calculate the tumor volume before RP, we can minimize the treatment failures (over or undertreatment) of PCa. Perhaps new biopsy protocols, tissue biomarkers, and molecular imaging technology may refine AS criteria.

Results of surgery for high-risk prostate cancer

PURPOSE OF REVIEW

Surgery for high-risk prostate cancer (PCa) is applied frequently nowadays. Nevertheless, this approach is still surrounded by many controversies. The present review discusses the most recent literature regarding surgery for high-risk PCa.

RECENT FINDINGS

As there is no standard definition of high-risk PCa, outcome comparison between series and treatment approaches is hampered. Nevertheless, recent radical prostatectomy series have shown excellent cancer-specific survival in patients with high-risk PCa. Even for very-high-risk PCa (cT3b-T4 or any cT, N1), surgery may be applied to highly selected patients as a first step of a multimodality approach. Recent experience with robot-assisted surgery opens new possibilities for a minimally invasive approach in this field.Patient selection for surgery was also addressed in recent studies. Excellent cancer-specific survival is seen when specimen-confined PCa is found at final histopathology; a recently published nomogram enables the prediction of specimen-confined disease. Another issue in high-risk PCa is the impact of age and comorbidities on cancer-specific and overall mortality. In a recent study, it was shown that patients with low comorbidity scores, even when at least 70 years old, had a significant risk of dying from their cancer and may benefit most from a surgical approach. A modified extended pelvic lymphadenectomy template was presented, providing optimal removal of positive lymph nodes.

SUMMARY

Radical prostatectomy with extended pelvic lymphadenectomy delivers very good cancer-related outcomes in high-risk and very-high-risk PCa, often within a multimodal approach. Minimally invasive surgery and improved patient selection will be key to further improve oncological and functional outcomes.

Laparoscopic radical prostatectomy monotherapy, a more aggressive yet less invasive option, is oncologically effective in selected men with high-risk prostate cancer having only one D'Amico risk factor: experience from an Asian tertiary referral center

PURPOSE

To present oncologic results of laparoscopic radical prostatectomy (LRP) monotherapy for men with high-risk, localized prostate cancer, and to find factors associated with a good prognosis via surgery alone.

PATIENTS AND METHODS

Between 2002 and 2009, 241 men underwent LRP at an Asian tertiary referral center. Among them, we retrospectively identified 85 (35.3%) men who met the D'Amico's high-risk criteria: Prostate-specific antigen level >20 ng/mL, Gleason score of 8 to 10, or clinical stage ≥T2c. Perioperative parameters were analyzed against biochemical recurrence (BCR)-free survival.

RESULTS

At a median follow-up of 54 months, BCR developed in 28 (34.1%), with an actuarial BCR-free survival rate of 63.3% at 5 years. Pathologically, 37.6% of the men had organ-confined (OC) disease. Positive surgical margins (PSM) were identified in 49.4% of the patients. A favorable pathologic outcome, defined as OC(+)PSM(-), was observed in 24 patients and associated with a 5-year BCR-free survival rate of 87.0%, compared with 100%, 54.0%, and 46.4% in men with OC(+)PSM(+), OC(-)PSM(-) and OC(-)PSM(+) disease (log-rank, P=0.008). The overall positive lymph node rate was 14.1%. Men (65.9%) with only one D'Amico risk factor had a 5-year BCR-free survival rate of 76.9%, compared with 34.6% in men (34.1%) with ≥2 risk factors (log-rank, P<0.001).

CONCLUSIONS

Radical prostatectomy monotherapy performed laparoscopically or robotically appears to be an option for high-risk prostate cancer, especially in men with a single D'Amico risk factor. Men with ≥2 risk factors are more prone for BCR to develop after surgery and may need second-line therapy.

Oncologic outcomes following radical prostatectomy in the active surveillance era

OBJECTIVE

In this study, we examine the oncologic outcomes of men with low, intermediate and high preoperative risk for prostate cancer treated with radical prostatectomy prior to and during the active surveillance era.

METHODS

We analyzed records from patients who underwent radical prostatectomy at our Canadian tertiary care facility from 2000 to 2012. Patients were stratified by D'Amico preoperative risk category and by year of treatment. Biochemical recurrence-free survival was estimated using the Kaplan-Meier method.

RESULTS

We included 2643 consecutive patients in our analysis. The proportion of men with low-risk disease undergoing radical prostatectomy decreased from 2007 onwards coincident with the implementation of an active surveillance strategy in our institution. Men with low-risk and high-risk disease showed significantly worse biochemical outcomes from 2007 to 2012 compared to 2000 to 2006 (p < 0.05), while men with intermediate-risk prostate cancer showed no significant differences (p = 0.27). Within the low-risk cohort, the later treatment group displayed significantly lower age, pre-treatment prostate specific antigen and tumour volume and significantly higher testosterone and body mass index.

CONCLUSIONS

The time period corresponding with the implementation of active surveillance at our institution corresponded with significant deterioration of biochemical outcomes in the low- and high-risk groups. This suggests that the men with most favourable disease deferred treatment, whereas men with worse preoperative disease characteristics were increasingly treated with radical prostatectomy in the past 6 years perhaps to their benefit.

The role of robot-assisted radical prostatectomy and pelvic lymph node dissection in the management of high-risk prostate cancer: a systematic review

CONTEXT

The role of robot-assisted radical prostatectomy (RARP) for men with high-risk (HR) prostate cancer (PCa) has not been well studied.

OBJECTIVE

To evaluate the indications for surgical treatment, technical aspects such as nerve sparing (NS) and lymph node dissection (LND), and perioperative outcomes of men with HR PCa treated with RARP.

EVIDENCE ACQUISITION

A systematic expert review of the literature was performed in October 2012, searching the Medline, Web of Science, and Scopus databases. Studies with a precise HR definition, robotic focus, and reporting of perioperative and pathologic outcomes were included.

EVIDENCE SYNTHESIS

A total of 12 papers (1360 patients) evaluating RARP in HR PCa were retrieved. Most studies (67%) used the D'Amico classification for defining HR. Biopsy Gleason grade 8-10 was the most frequent HR identifier (61%). Length of follow-up ranged from 9.7 to 37.7 mo. Incidence of NS varied, although when performed did not appear to compromise oncologic outcomes. Extended LND (ELND) revealed positive nodes in up to a third of patients. The rate of symptomatic lymphocele after ELND was 3%. Overall mean operative time was 168 min, estimated blood loss was 189 ml, length of hospital stay was 3.2 d, and catheterization time was 7.8 d. The 12-mo continence rates using a no-pad definition ranged from 51% to 95% with potency recovery ranging from 52% to 60%. The rate of organ-confined disease was 35%, and the positive margin rate was 35%. Three-year biochemical recurrence-free survival ranged from 45% to 86%.

CONCLUSIONS

Although the use of RARP for HR PCa has been relatively limited, it appears safe and effective for select patients. Short-term results are similar to the literature on open radical prostatectomy. Variability exists for NS and the template of LND, although ELND improves staging and removes a higher number of metastatic nodes. Further study is required to assess long-term outcomes.

Incidence of upgrading and upstaging in patients with low-volume Gleason score 3+4 prostate cancers at biopsy: finding a new group eligible for active surveillance

INTRODUCTION

The aim of this study was to identify patients with low-volume Gleason score 3+4 (GS3+4) prostate cancer (PCa) who may be candidates for active surveillance (AS) by analyzing the incidence of upgrading and upstaging following radical prostatectomy (RP).

PATIENTS AND METHODS

Of 907 patients who underwent RP at our institute over the last 5 years, 66 men diagnosed with low-volume GS3+4 PCa at needle biopsy were identified. The incidence of upstaging and upgrading was assessed.

RESULTS

The overall rate of upgrading and upstaging was 31.8 and 25.6%, respectively. Preoperative PSA levels were significantly higher in patients who were upgraded (p = 0.015). The optimal preoperative PSA cutoff level for the prediction of upgrading was 4.73 ng/ml (sensitivity 85.7%, specificity 57.8%). Patients with <15% of maximum cores positive had significantly lower upstaging rate than those with >15% of maximum cores positive (p = 0.035). Clinical stage and number of positive cores had marginal association with upgrading and upstaging statistically (p = 0.061 and 0.081, respectively).

CONCLUSIONS

In patients with low-volume GS3+4 PCa at biopsy, underestimation may be effectively avoided when we select patients with PSA <4.73 and % maximum cancer involvement on positive cores <15%.

Contemporaneous comparison of open vs minimally-invasive radical prostatectomy for high-risk prostate cancer

OBJECTIVES

To analyze pathological and short-term oncological outcomes in men undergoing open and minimally-invasive radical prostatectomy (MIRP) for high-risk prostate cancer (HRPC; prostate-specific antigen level [PSA] >20 ng/mL, ≥ cT2c, Gleason score 8-10) in a contemporaneous series.

PATIENTS AND METHODS

In total, 913 patients with HRPC were identified in the Johns Hopkins Radical Prostatectomy Database subsequent to the inception of MIRP at this institution (2002-2011) Of these, 743 (81.4%) underwent open radical retropubic prostatectomy (ORRP), 105 (11.5%) underwent robot-assisted laparoscopic radical prostatectomy (RALRP) and 65 (7.1%) underwent laparoscopic radical prostatectomy (LRP) for HRPC. Appropriate comparative tests were used to evaluate patient and prostate cancer characteristics. Proportional hazards regression models were used to predict biochemical recurrence.

RESULTS

Age, race, body mass index, preoperative PSA level, clinical stage, number of positive cores and Gleason score at final pathology were similar between ORRP and MIRP. On average, men undergoing MIRP had smaller prostates and more organ-confined (pT2) disease (P = 0.02). The number of surgeons and surgeon experience were greatest for the ORRP cohort. Overall surgical margin rate was 29.4%, 34.3% and 27.7% (P = 0.52) and 1.9%, 2.9% and 6.2% (P = 0.39) for pT2 disease in men undergoing ORRP, RALRP and LRP, respectively. Biochemical recurrence-free survival among ORRP, RALRP and LRP was 56.3%, 67.8% and 41.1%, respectively, at 3 years (P = 0.6) and the approach employed did not predict biochemical recurrence in regression models.

CONCLUSIONS

At an experienced centre, MIRP is comparable to open radical prostatectomy for HRPC with respect to surgical margin status and biochemical recurrence.

Robotic-assisted laparoscopic prostatectomy for high-risk prostate cancer: technical considerations and review of the literature

Men with high-risk prostate cancer are at significant risk of progressive, symptomatic disease leading to metastases or death from prostate cancer. Surgery-specifically robotic-assisted laparoscopic prostatectomy (RALP)-is increasingly being considered as a key component of a multimodal strategy to treat these patients. Herein, we review key technical considerations of performing RALP with bilateral pelvic lymphadenectomy in men with high-risk disease. Recent literature supporting the increasing role of surgery either alone or in combination with adjuvant therapies to treat men with high-risk prostate cancer is also reviewed.

Role of surgery in high-risk localized prostate cancer

Men with high-risk localized prostate cancer (PCa) remain a challenge for clinicians. Until recently, surgery was not the preferred approach, in part because risk of subclinical metastatic disease, elevated rates of positive surgical margins, absence of randomized studies, and suboptimal cancer control did not justify the morbidity of surgery. No randomized data comparing surgery with radiation therapy are yet available. Data for and comparisons between treatment options should therefore be analyzed with extreme caution.When selecting the best treatment for patients with clinically localized high-risk PCa, considerations should include the life expectancy of the patient, the natural history of PCa, the curability of the disease, and the morbidity of treatment. High-grade PCa managed with noncurative intent greatly reduces life expectancy, but overall, it must also be remembered that radical prostatectomy (RP) and radiotherapy (RT) appear to have similar effects on quality of life. In this population, RP necessitates an extended pelvic lymph node dissection (PLND), but in selected cases, nerve-sparing is a therapeutic possibility and may offer a significant advantage over rt in terms of local control and-although absolutely not yet proved-maybe even in survival. One clear advantage is the ease of administering adjuvant or salvage external-beam rt (EBRT) after rp; conversely, salvage rp after failed EBRT is an exceedingly difficult surgery, with major complications. Surgery therefore has its place, but must be considered in the context of multimodality treatment and the risk of micrometastatic disease. Awaited trial results will help to further refine management in this group of patients.

Inverse stage migration in patients undergoing radical prostatectomy: results of 8916 European patients treated within the last decade

OBJECTIVE

• To investigate the stage migration patterns during the last decade in European men treated with radical prostatectomy (RP).

PATIENTS AND METHODS

• Between 2000 and 2009, RP was performed in 8916 patients at a single European tertiary-care institution. • Age at diagnosis, clinical and pathological data were prospectively collected, and trends and proportions of preoperative and pathological findings were analysed over time.

RESULTS

• The median (mean) age of patients increased from 62 (62) to 63 (65) years between 2000 and 2009 (P < 0.001). • When patients were stratified based on their clinical findings according to the D'Amico risk groups for disease progression, the proportion of low-risk patients dropped from 66% in 2004 to 35% (P= 0.016) in the final year of the study period. • Similarly, histopathological evaluation of RP specimens showed a decrease of favourable disease (organ confinement and Gleason 3 + 3 grade) from 53 to 17% (P= 0.008). • This trend was accompanied by an increase in the number of patients with non-organ-confined prostate cancer (PCa) from 19% in 2003 to 33% in 2009 (P= 0.008). • The restriction of the analyses in the present study to a single tertiary-care centre could limit the generalizeability of the results.

CONCLUSIONS

• During the last decade, we observed an inverse stage migration trend in those European patients with PCa who were treated with RP. • The recorded increase in patients with non-organ-confined disease after RP could be related to changes in patient selection and the growing adoption of RP in multimodal treatment settings for locally advanced tumours as well as the availability of new treatment alternatives for low-risk disease.

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.

Evolution of Robot-Assisted Radical Prostatectomy

Introduction and Objective:

Open radical prostatectomy (RRP) is the gold standard and most widespread treatment for clinically localized prostate cancer. However, in recent years robot-assisted laparoscopic prostatectomy (RARP) is rapidly gaining acceptance among urologists worldwide. We sought to outline our surgical technique of robotic radical prostatectomy and provide practical recommendations based on available reports and personal experience. We also critically review the current experience on RARP world-wide and compare the available data with the gold standard open RRP series.

Material and Methods:

A systematic review of the literature was performed for all published manuscripts between 1997 and 2008 using the keywords — ‘robotic radical prostatectomy, ‘robot-assisted radical prostatectomy’, ‘laparoscopic radical prostatectomy’ and ‘robotic” using the Medline database.

Results:

A total of 226 original manuscripts on RARP were identified. Manuscripts were selected according to their relevance to the current topic (i.e. original articles, number of patients in the series, prospective data collection) and incorporated into this review.

Conclusions:

Eight years after the first RARP, multiple series are mature enough to demonstrate safety, efficiency and reproducibility of the procedure, as well as oncologic and functional outcomes comparable to its open counterpart. Further prospective, randomized studies comparing both surgical techniques are necessary in order to draw more definitive conclusions.