Postoperative complications of contemporary open and robot-assisted laparoscopic radical prostatectomy using standardised reporting systems

Impact of COVID-19 on the time to counseling and treatment of prostate cancer

PURPOSE

This study investigates how the COVID-19 pandemic (CP) impacted the timeline between initial diagnosis (ID) of prostate carcinoma and subsequent therapy consultation (TC) or radical prostatectomy (RP) due to the implementation of a "minimal contact concept," which postponed clinical examinations until the day of admission.

METHODS

We analyzed patient data from a tertiary care center from 2018 to September 2021. The focus was on comparing the time intervals from ID to TC and from ID to RP before and during the CP.

RESULTS

Of 12,255 patients, 6,073 (61.6%) were treated before and 3,791 (38.4%) during the CP. The median time from ID to TC reduced from 37 days (IQR: 21 - 58d) pre-CP to 32 days (IQR: 20 - 50d) during CP (p < 0.001). Similarly, the time from ID to RP decreased from 98 days (IQR: 70 - 141d) to 75 days (IQR: 55 - 108d; p < 0.001) during the CP. There was a significant decrease in low-risk tumor cases at ID (18.9% vs. 21.4%; p = 0.003) and post-RP (4% vs. 6.7%; p < 0.001) during the CP.

CONCLUSION

Our findings suggest that the COVID-19 pandemic facilitated more timely treatment of prostate cancer, suggesting potential benefits for both low-risk and aggressive tumor management through expedited clinical procedures.

Outcomes of Cytoreductive Radical Prostatectomy for Oligometastatic Prostate Cancer on Prostate-specific Membrane Antigen Positron Emission Tomography: Results of a Multicenter European Study

BACKGROUND

De novo oligometastatic prostate cancer (omPCa) on prostate-specific membrane antigen (PSMA) positron emission tomography (PET) is a new disease entity and its optimal management remains unknown.

OBJECTIVE

To analyze the outcomes of patients treated with cytoreductive radical prostatectomy (cRP) for omPCa on PSMA-PET.

DESIGN, SETTING, AND PARTICIPANTS

Overall, 116 patients treated with cRP at 13 European centers were identified. Oligometastatic PCa was defined as miM1a and/or miM1b with five or fewer osseous metastases and/or miM1c with three or fewer lung lesions on PSMA-PET.

INTERVENTION

Cytoreductive radical prostatectomy.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Thirty-day complications according to Clavien-Dindo, continence rates, time to castration-resistant PCa (CRPC), and overall survival (OS) were analyzed.

RESULTS AND LIMITATIONS

Overall, 95 (82%) patients had miM1b, 18 (16%) miM1a, and three (2.6%) miM1c omPCa. The median prebiopsy prostate-specific antigen was 14 ng/ml, and 102 (88%) men had biopsy grade group ≥3 PCa. The median number of metastases on PSMA-PET was 2; 38 (33%), 29 (25%), and 49 (42%) patients had one, two, and three or more distant positive lesions. A total of 70 (60%) men received neoadjuvant systemic therapy, and 37 (32%) underwent metastasis-directed therapy. Any and Clavien-Dindo grade ≥3 complications occurred in 36 (31%) and six (5%) patients, respectively. At a median follow-up of 27 mo, 19 (16%) patients developed CRPC and eight (7%) patients died. The 1-yr urinary continence rate was 82%. The 2-yr CRPC-free survival and OS were 85.8% (95% confidence interval [CI] 78.5-93.7%) and 98.9% (95% CI 96.8-100%), respectively. The limitations include retrospective design and short-term follow-up.

CONCLUSIONS

Cytoreductive radical prostatectomy is a safe and feasible treatment option in patients with de novo omPCa on PSMA-PET. Despite overall favorable oncologic outcomes, some of these patients have a non-negligible risk of early progression and thus should be considered for multimodal therapy.

PATIENT SUMMARY

We found that patients treated at expert centers with surgery for prostate cancer, with a limited number of metastases detected using novel molecular imaging, have favorable short-term survival, functional results, and acceptable rates of complications.

Role of cytoreductive radical prostatectomy in men with oligometastatic prostate cancer on molecular imaging

PURPOSE OF REVIEW

The implementation of PET with prostate-specific membrane antigen (PSMA) tracer as primary staging tool occurred recently. Since its introduction, a novel category of patients emerged, with negative staging at conventional imaging, and positive molecular imaging. Local treatment in these patients might be associated with improved oncological outcomes when combined with systemic therapy. However, its impact on oligometastatic prostate cancer (omPCa) remains unknown. In this review, we aimed at investigating the role of cytoreductive radical prostatectomy (cRP) in oligometastatic disease at molecular imaging.

RECENT FINDINGS

After comprehensive review of literature, two retrospective studies highlighted the feasibility, safety, and potential benefits of surgery in omPCA patients at molecular imaging. They showed that 72% of patients achieved PSA less than 0.01 ng/ml following cRP as part of a multimodal approach, 17% experienced radiographic progression, and 7% died at 27-month median follow-up. Moreover, complications postcRP after PSMA PET were modest, with a 40% rate of any adverse event, and 5% of grade more than 3. The 1-year urinary continence after cRP rate was 82%. The oncological, functional outcomes and the complication rate aligned with those observed in series of cRP after conventional imaging.

SUMMARY

cRP is feasible, well tolerated, and effective in selected patients with omPCa at PSMA PET.

High-volume surgeons decrease operating time in robot-assisted radical prostatectomy: results in 1229 patients

BACKGROUND

The aim is to evaluate factors impacting operating time (OT) during robot-assisted radical prostatectomy (RARP) with or without extended pelvic lymph node dissection (ePLND) for prostate cancer.

METHODS

Overall, 1289 patients underwent RARP from January 2013 to December 2021. ePLND was performed in 825 cases. Factors potentially associated with OT variations were assessed. Three low-volume (LVS) and two high-volume surgeons (HVS) performed the procedures. A linear regression model was computed to assess associations with OT variations.

RESULTS

When RARP was performed by HVS an OT decrease was observed independently by significant clinical (Body Mass Index [BMI]; prostate volume [PV]) and anatomical/perioperative features (prostate weight [PW]; intraoperative blood loss [BL]) both in clinical (change in OT: -42.979 minutes; 95% CI: -51.789; -34.169; P<0.0001) and anatomical/perioperative models (change in OT: -40.020 minutes; 95% CI: -48.494; -31.587; P<0.0001). A decreased OT was observed in clinical (change in OT: -27.656 minutes; 95% CI: -33.449; -21.864; P<0.0001) and anatomical/perioperative (change in OT: -24.935 minutes; 95% CI: -30.562; -19.308; P<0.0001) models also in case of RARP with ePLND performed by HVS, independently by BMI, PV, PSA as well as for PW, seminal vesicle invasion, positive surgical margins, and BL.

CONCLUSIONS

In a tertiary academic referral center, OT decreased when RARP was performed by HVS, independently of adverse clinical and anatomical/perioperative factors. Available OT loads can be planned to optimize waiting lists, teaching tasks, operative costs, and surgeon's volume.

Suitability of the MP1000 Platform for Robot-assisted Prostatectomy: A Prospective Randomised Controlled Trial

Background and objective

Robot-assisted radical prostatectomy (RARP) is widely used because of the many advantages of a robotic approach. The da Vinci Si robot is one of the most commonly used surgical robot systems, but it may be associated with higher costs owing to the use of consumable surgical supplies. Our aim was to conduct a preliminary investigation of the capability of the MP1000 system for RARP.

Methods

In this prospective, multicentre, single-blinded study, we randomly assigned 42 patients scheduled to undergo RARP between April and September 2021 to a da Vinci Si group (control) or an MP1000 group (intervention). Patients underwent RARP performed using the assigned robotic system and were followed up at 3-mo intervals. The primary outcome was the rate of conversion to open/laparoscopic surgery. Secondary outcomes were installation and operation times, intraoperative blood loss, postoperative surgical margin status, hospital stay, incontinence, complications, safety indicators, and surgeon ergonomics.

Key findings and limitations

All procedures were successfully completed without conversion to open/laparascopic surgery or major complications. Secondary outcomes, including oncological and ergonomic indicators, did not differ significantly between the groups over the study period. One patient in the control group experienced dysuria (Clavien-Dindo grade 3). No patients had incontinence at 3 mo. A limitation of the study is the small sample size.

Conclusions and clinical implications

RARP with the MP1000 system is feasible, safe, and effective in the management of localised prostate cancer.

Patient summary

We assessed the effectiveness and safety of the new MP1000 robot system for robot-assisted removal of the prostate in comparison to the da Vinci Si robot. We found no difference in effectiveness or safety among 42 patients with prostate cancer who were assigned randomly to one of the two systems. We conclude that the MP1000 is a suitable robot for this surgery.

Extended pelvic lymph node dissection in robot-assisted radical prostatectomy is an independent risk factor for major complications

The aim of this study is to evaluate the major postoperative complication rate after robot-assisted radical prostatectomy (RARP) and to identify related risk factors. A consecutive series of patients who underwent RARP between September 2016 and May 2021, with or without extended pelvic lymph node dissection (ePLND) were analyzed for postoperative complications that occurred within 30 days following surgery. Potential risk factors related to complications were identified by means of a multivariate logistic analysis. Electronic medical records were retrospectively reviewed for the occurrence of major complications (Clavien-Dindo grade III or higher) on a per patient level. A multivariate logistic regression with risk factors was performed to identify contributors to complications. In total, 1280 patients were included, of whom 79 (6.2%) experienced at least 1 major complication. Concomitant ePLND was performed in 609 (48%) of patients. The majority of all complications were likely related to the surgical procedure, with anastomotic leakage and lymphoceles being the most common. Upon multivariate analysis, performing ePLND remained the only significant risk factor for the occurrence of major complications (OR 2.26, p = 0.001). In contrast to robot-assisted radical prostatectomy alone, the combination with extended pelvic lymph node dissection (ePLND) has a substantial risk of serious complications. Since the ePLND is performed mainly for staging purpose, the clinical contribution of the ePLND has to be reconsidered with the present use of the PSMA-PET/CT.

Robot-Assisted Surgery and Racial and Ethnic Disparities in Post-Prostatectomy Outcomes Among Prostate Cancer Patients

BACKGROUND

We sought to determine whether the differences in short-term outcomes between patients undergoing robot-assisted radical prostatectomy (RARP) and those treated with open radical prostatectomy (ORP) differ by race and ethnicity.

METHODS

This observational study used New York State Cancer Registry data linked to discharge records and included patients undergoing radical prostatectomy for localized prostate cancer during 2008-2018. We used logistic regression to examine the association between race and ethnicity (non-Hispanic White [NHW], non-Hispanic Black [NHB], Hispanic), surgical approach (RARP, ORP), and postoperative outcomes (major events, prolonged length of stay [pLOS], 30-day re-admission). We tested interaction between race and ethnicity and surgical approach on multiplicative and additive scales.

RESULTS

The analytical cohort included 18,926 patients (NHW 14,215 [75.1%], NHB 3195 [16.9%], Hispanic 1516 [8.0%]). The average age was 60.4 years (standard deviation 7.1). NHB and Hispanic patients had lower utilization of RARP and higher risks of postoperative adverse events than NHW patients. NHW, NHB, and Hispanic patients all had reduced risks of adverse events when undergoing RARP versus ORP. The absolute reductions in the risks of major events and pLOS following RARP versus ORP were larger among NHB {relative excess risk due to interaction (RERI): major events -0.32 [95% confidence interval (CI) -0.71 to -0.03]; pLOS -0.63 [95% CI -0.98 to -0.35]) and Hispanic (RERI major events -0.27 [95% CI -0.77 to 0.09]; pLOS -0.93 [95% CI -1.46 to -0.51]) patients than among NHW patients. The interaction was absent on the multiplicative scale.

CONCLUSIONS

RARP use has not penetrated and benefited all racial and ethnic groups equally. Increasing utilization of RARP among NHB and Hispanic patients may help reduce disparities in patient outcomes after radical prostatectomy.

Robotic-assisted radical prostatectomy: a multicenter experience with the Senhance Surgical System

PURPOSE

Robotic-assisted surgery for radical prostatectomy is becoming a standard treatment, and respective implementations are expanding. The Senhance Surgical System is a robotic system with existing but limited data on radical prostatectomy, including a lack of multicenter study experiences. The TRUST study aims to fill this gap and explores observations for radical prostatectomy with the Senhance Surgical System.

METHODS

Between August 2019 and November 2022, 375 patients met inclusion criteria from two European sites. Patients' surgical procedure times, data on conversion, malfunction, adverse events, and pain scores were registered and evaluated. Outcomes were calculated for both sides, combined as a total and compared between the initial (1st-150th case) and later (> 150th case) period.

RESULTS

The median operating time was 190 min (IQR: 167.5-215.0) and the median docking time was 3 min (IQR: 2.0-5.0). Eighteen cases (4.8%) were converted to standard laparoscopy and two (0.5%) to open. Two perioperative (0.5%) and eleven postoperative adverse events (2.9%) occurred, mostly (83.3%) categorized as mild. Pain scores were reduced from an average of 3.4 (± 1.4) on the postoperative day to 0.9 (± 0.7) at discharge. Compared to our previous data and based on a comparison between our initial and later period, operating time seems to plateau. However, docking time, complication, and conversion rates were successfully reduced.

CONCLUSION

We demonstrate progressing safety and efficiency for robotic-assisted radical prostatectomy with the Senhance Surgical System.

Cardiovascular Disease and Chronic Pulmonary Disease Increase the Risk of Short-Term Major Postoperative Complications after Robotic-Assisted Radical Prostatectomy

Background and objectives: Certain comorbidities may be associated with a higher risk of complications after robotic-assisted radical prostatectomy. Material and Methods: Relying on a tertiary care database, we identified robotic-assisted radical prostatectomy patients (January 2014-March 2023). Short-term major postoperative complications were defined according to Clavien Dindo as ≥IIIa within 30 days after robotic-assisted radical prostatectomy. Results: Of 1148 patients, the rates of postoperative Clavien Dindo IIIa, Clavien Dindo IIIb, Clavien Dindo IVa, and Clavien Dindo IVb complications were 3.3%, 1.4%, 0.3%, and 0.2%, respectively. Of those, 28 (47%) had lymphoceles, and 8 (13%) had bleeding-associated complications. Patients with cardiovascular disease (8 vs. 4%) or chronic pulmonary disease (13 vs. 5%) were more likely to have complications. In multivariable logistic regression models, cardiovascular disease (odds ratio: 1.78; p = 0.046) and chronic pulmonary disease (odds ratio: 3.29; p = 0.007) remained associated with an increased risk of postoperative complications. Conclusions: Complications after robotic-assisted radical prostatectomy are predominantly manageable without anesthesia. Concomitant cardiovascular disease and chronic pulmonary disease were both associated with a higher risk of postoperative complications.

Prevention of thromboembolic events after radical prostatectomy in patients with hereditary thrombophilia due to a factor V Leiden mutation by multidisciplinary coagulation management

Objective

To examine the perioperative impact of factor V Leiden mutation on thromboembolic events' risk in radical prostatectomy (RP) patients. With an incidence of about 5%, factor V Leiden mutation is the most common hereditary hypercoagulability among Caucasians and rarer in Asia. The increased risk of thromboembolic events is three- to seven-fold in heterozygous and to 80-fold in homozygous patients.

Methods

Within our prospectively collected database, we analysed 33 006 prostate cancer patients treated with RP between December 2001 and December 2020. Of those, patients with factor V Leiden mutation were identified. All patients received individualised recommendation of haemostaseologists for perioperative anticoagulation. Thromboembolic complications (deep vein thrombosis and pulmonary embolism) were assessed during hospital stay, as well as according to patient reported outcomes within the first 3 months after RP.

Results

Overall, 85 (0.3%) patients with known factor V Leiden mutation were identified. Median age was 65 (interquartile range: 61-68) years. There was at least one thrombosis in 53 (62.4%) patients and 31 (36.5%) patients had at least one embolic event in their medical history before RP. Within all 85 patients with factor V Leiden mutation, we experienced no thromboembolic complications within the first 3 months after surgery.

Conclusion

In our cohort of patients with factor V Leiden mutation, no thromboembolic events were observed after RP with an individualised perioperative coagulation management concept. This may reassure patients with this hereditary condition who are counselled for RP.

Robot-assisted versus open radical prostatectomy: a systematic review and meta-analysis of prospective studies

The study aims to synthesize all available prospective comparative studies and reports the latest systematic analysis and updated evidence comparing robot-assisted radical prostatectomy (RARP) with open radical prostatectomy (ORP) for perioperative, functional, and oncological outcomes in patients with clinically localized prostate cancer (PCa). PubMed, Embase, Web of Science, and the Cochrane Library were retrieved up to March 2023. Only randomized controlled trials (RCTs) and prospective comparative studies were included, and weighted mean differences (WMD) and odds ratios (OR) were used to evaluate the pooled results. Twenty-one articles were included in the present meta-analysis. The results indicated that compared to ORP, RARP had longer operative time (OT) (WMD: 51.41 min; 95%CI: 28.33, 74.48; p < 0.0001), reduced blood loss (WMD: -516.59 mL; 95%CI: -578.31, -454.88; p < 0.00001), decreased transfusion rate (OR: 0.23; 95%CI: 0.18, 0.30; p < 0.00001), shorter hospital stay (WMD: -1.59 days; 95%CI: -2.69, -0.49; p = 0.005), fewer overall complications (OR: 0.61; 95%CI: 0.45, 0.83; p = 0.001), and higher nerve sparing rate (OR: 1.64; 95%CI: 1.26, 2.13; p = 0.0003), as well as was more beneficial to postoperative erectile function recovery and biochemical recurrence (BCR). However, no significant disparities were noted in major complications, postoperative urinary continence recovery, or positive surgical margin (PSM) rates. RARP was superior to ORP in terms of hospital stay, blood loss, transfusion rate, complications, nerve sparing, postoperative erectile function recovery, and BCR. It is a safe and effective surgical approach to the treatment of clinically localized PCa.

Association of Urinary Incontinence and Depression: Findings From the National Health and Nutrition Examination Survey

OBJECTIVE

To evaluate the association between urinary incontinence and depression. An estimated 21 million adults in the United States (U.S.) reported at least one major depressive episode. Urinary incontinence has a well-described negative impact on quality of life.

METHODS

We included respondents aged ≥20 who participated in the 2017 - March 2020 National Health and Nutrition Examination Survey cycles. Our dichotomous outcomes were depression and clinical depression. The predictor variable urinary incontinence was assessed using the validated incontinence severity index. We fitted an adjusted multivariable logistic regression and performed interaction analysis for urinary incontinence and our variable of interest.

RESULTS

Among a weighted sample of 233.5 million people (unweighted 8256), 19.9 million (8.5%) reported depression (P < .001). The weighted population was 48.6% male, 55.2% married, and 63.4% non-Hispanic White (all P < .001). Moderate and severe urinary incontinence was associated with depression (adjusted odds ratio [aOR] 2.3; 95%CI [1.5-3.3]; aOR 3.8; 95%CI [2.5-3.3]; P < .001). No association was observed between urinary incontinence and clinical depression. Interaction analysis showed that men (aOR 3.62; 95%CI [2.13-6.15]; Pint<.001) and participants at the lowest socioeconomic status (aOR 2.2; 95%CI [1.3-3.71]; Pint=.005) with moderate/severe urinary incontinence had higher odds of depression than their continent counterparts.

CONCLUSION

We report that urinary incontinence is an independent predictor of depression in a nationally representative survey for men and those in the lowest socioeconomic tier. The association is most prominent among men and the socioeconomically disadvantaged population. This suggests that treatment for urinary incontinence may be important tool to reduce depression in the general population.

Outcome of patients with epithelialized cavity formation after excessive vesicourethral anastomotic leak post radical prostatectomy

PURPOSE

Excessive vesicourethral anastomotic leak (EVAL) is a rare but severe complication after radical prostatectomy (RP). Epithelialized vesicourethral cavity formation (EVCF) usually develops during prolonged catheterization. To our knowledge, there is no description of postoperative outcomes, complications, or functional assessment of these patients who received conservative therapy after EVAL.

METHODS

We identified 70 patients (0.56%) with radiographic evidence of EVCF out of 12,434 patients who received RP in 2016-2020 at our tertiary care center. Postoperative radiographic cystograms (CG) were retrospectively re-examined by two urologists individually. We assessed urinary continence (UC), the need for intervention due to anastomotic stricture formation, urinary tract infection (UTI), and symphysitis during the first year of follow-up post-RP.

RESULTS

The median age was 66 years [interquartile range (IQR) 61-70 years], the median body mass index was 27.8 kg/m2 (IQR 25.5-30.3 kg/m2), and the median prostate specific antigen before RP was 7.1 ng/ml (IQR 4.7-11.8 ng/ml). The median catheter insertion time was 44.5 days (IQR 35.2-54 days). One-year continence follow-up was available for 27 patients (38.6%), of which 22 (81.5%) reported the use of ≤ one pad, two patients reported the use of two (7.4%) pads/24 h, and three (11.1%) patients reported use > two pads/24 h. Overall, four (5.7%) patients needed surgical reintervention for anastomotic stricture, eight (11.5%) patients presented with symphysitis, and 55 (77.1%) presented with UTI.

CONCLUSION

UC in 81.5% 1-year post-RP suggests that conservative treatment in EVAL is a treatment option with an acceptable outcome on UC and should be considered before reintervention for anastomotic insufficiency.

Perioperative Morbidity of Radical Prostatectomy After Intensive Neoadjuvant Androgen Blockade in Men With High-Risk Prostate Cancer: Results of Phase II Trial Compared to a Control Group

INTRODUCTION

Recent studies about intense neoadjuvant therapy followed by Radical Prostatectomy (RP) lack standardized criteria regarding surgical complications and comparison to a group of patients who underwent RP without the use of neoadjuvant therapy. The aim of this study is to describe and compare the perioperative complication rates.

MATERIALS AND METHODS

This was a prospective, single-center phase II trial in patients with high-risk prostate cancer (HRPCa). The control group included HRPCa patients who underwent RP outside the clinical trial during the same study recruitment period. The interventional group was randomized (1:1) to receive neoadjuvant androgen deprivation therapy plus abiraterone with or without apalutamide followed by RP. Complications observed up to 30 days of surgery were classified based on the Clavien-Dindo classification. Uni- and multivariate analyses were carried out to assess predictive factors associated with perioperative complications.

RESULTS

In total, 124 patients with HRPCa were underwent to RP between May 27, 2019 and August 6, 2021, including 61 patients in the intervention group and 63 patients in the control group. The general and major complications in the intervention group reached 29.6% and 6.6%, respectively, and 39.7% and 7.9% in the control group, respectively. There was no significant difference between groups. We observed 4.9% of thromboembolic event in the neoadjuvant group.

CONCLUSIONS

There was no significant increase in morbidity rate in RP after intense neoadjuvant therapy. The association of intense androgen deprivation neoadjuvant therapy with RP and extended pelvic lymphadenectomy may increase the risk of a perioperative thromboembolic events.

American Society of Anesthesiologists' (ASA) Physical Status System and Risk of Major Clavien-Dindo Complications After Robot-Assisted Radical Prostatectomy at Hospital Discharge: Analysis of 1143 Consecutive Prostate Cancer Patients

Objective

To test the hypothesis of associations of preoperative physical status system with major postoperative complications at hospital discharge in prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy (RARP).

Materials and Methods

In a period ranging from January 2013 to October 2020, 1143 patients were evaluated. The physical status was assessed by the American Society of Anesthesiologists' (ASA) system, which was computed trained anesthesiologists. The Clavien-Dindo system was used to classify postoperative complications, which were coded as major if greater than 1.

Results

ASA physical status system included class I in 102 patients (8.9%), class II in 934 subjects (81.7%), and class III in 107 cases (9.4%). Clavien-Dindo complications were distributed as follows: grade 1: 141 cases (12.3%), grade 2: 108 patients (9.4%), grade 3a: 5 subjects (0.4%), grade 3b: 9 patients (0.8%), and grade 4a: 3 cases (0.3%). Overall, major complications were detected in 125 cases (10.9%). On multivariate analysis, major Clavien-Dindo complications were predicted by ASA score grade II (adjusted odds ratio, OR = 2.538; 95%CI 1.007-6.397; p = 0.048) and grade III (adjusted OR 3.468; 95%CI 1.215-9.896; p = 0.020) independently by pelvic lymph node dissection (PLND) and/or blood lost.

Conclusion

In RARP surgery, the risk of major postoperative Clavien-Dindo complications increased as the physical status system deteriorated independently by performing or not a PLND and/or large intraoperative blood lost. The ASA score system was an effective predictor of major Clavien-Dindo complications, which delayed LOHS in RARP surgery. Confirmatory studies are required.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-022-01577-9.

Population based study of morbidity and mortality rates associated to radical prostatectomy cases in Spain

INTRODUCTION

There is no population-based study that accounts for the number of radical prostatectomies (RP) carried out in Spain, nor regarding the morbidity and mortality of this intervention. Our objective is to study the morbidity and mortality of RP in Spain from 2011 to 2015 and to evaluate the geographic variation.

MATERIAL AND METHODS

We designed a retrospective observational study of all patients submitted to RP in Spain during five consecutive years (2011-2015). The data was extracted from the «Conjunto Mínimo Básico de Datos» (CMBD). We have evaluated geographic variations in terms of morbidity and hospital stay, and the impact of the mean annual surgical volume for each center on these variables.

RESULTS

Between 2011-2015, a total of 37,725 RPs were performed in 221 Spanish public hospitals. The mean age of the series was 63.9±3.23 years. Of all RPs, 50% were performed through an open approach, and 43.4% have been operated on in hospitals with <500 beds. We observed an important variability in the distribution of the cases operated on in the different regions. The regions that perform more RPs are Andalusia, Catalonia, Galicia, and Madrid. Our study shows a complication rate of 8.6%, with hemorrhage and the need for transfusion being the most frequent (5.3 and 4%, respectively). There are significant differences in bleeding rates and hospital stay among regions, which are maintained after adjusting for patient characteristics and type of hospital. When studying the annual surgical volume of each hospital, we find that the impact on the rate of hemorrhage or transfusion is linear; however, hospital stay remains stable at around 5 days from 60 RPs/year.

CONCLUSIONS

In national terms, morbidity and mortality rates after RP are comparable to those described in the literature. This study reveals a clear dispersion in the hospitals that carry out this intervention, showing clear differences in terms of morbidity and hospital stay between the different regions.

Comparison of early oncologic and functional results of open and robot-assisted laparoscopic radical prostatectomy

Aim: Radical prostatectomy (RP) has undergone a remarkable transformation from open surgery to minimally invasive surgery over the past two decades. In our study, we aimed to compare patients who underwent open (ORRP) and robot-assisted laparoscopic radical prostatectomy (RARP) for localized prostate cancer in terms of early oncological and functional outcomes. Material and Methods: Our study included 537 patients who were diagnosed with prostate cancer and underwent RP between January 2009 and January 2014. (Open retropubic radical prostatectomy (ORRP)=387, robot-assisted laparoscopic radical prostatectomy (RARP)=150). Demographic data, perioperative and postoperative results of the patients were compared between the two groups. Results: The mean age of the patients was 62.9 (46-76) in the ORRP group and 61.1 (42-76) years in the RARP group. It was observed that the mean hospital stay, urethral catheterization time, and blood transfusion requirement were significantly shorter in the RARP group. Surgical margin positivity rates were 16.3% and 20% (p=0.412) for the ORRP and RARP groups, respectively, in those with pT2 stage, and 40.9% and 68.8% in the ORRP and RARP groups, respectively, in patients with pT3 stage (p= 0.05). The mean follow-up period was 30.6 (3-64) months in the ORRP group and 11.3 (1-24) months in the RARP group. At follow-up, anastomotic stricture and biochemical recurrence were observed to be less in the RARP group (3.9% vs. 29.9% p

A novel radical prostatectomy specific index (PSI) for the prediction of major cardiovascular events following surgery

PURPOSE

Prostate cancer patients tend to be older with multiple comorbidities and are thus at increased risk for postoperative cardiovascular events after radical prostatectomy (RP). Thus, proper patient selection strategies are essential to decide for or against a surgical approach. We aimed to derive a prostatectomy specific index (PSI) for patients undergoing RP and compare its performance to universally used indices.

METHODS

The cohort was derived from National Surgical Quality Improvement Program database between 2005 and 2012. The primary outcome was incidence of major adverse cardiovascular events at 30 days post-surgery including: death, myocardial infarction, or stroke. A multivariable logistic regression model was constructed, performance and calibration were evaluated using a ROC analysis and the Hosmer-Lemeshow test, the PSI index was derived and compared to the RCRI and AUB-HAS2 indices.

RESULTS

A total of 17,299 patients were included in our cohort, with a mean age of 62 ± 7.4 years. Seventy three patients had a cardiac event post RP. The final PSI index encompassed six variables: history of heart disease, age, anemia, American society of anesthesiology class, surgical approach, and hypertension. The PSI ROC analysis provided C-statistic = 0.72, calibration R² = 0.99 and proper goodness of fit. In comparison, the C-statistics of RCRI and AUB-HAS2 were found to be 0.57 and 0.65, respectively (p value < 0.001).

CONCLUSION

The PSI model is a procedure tailored index for prediction of major cardiovascular events post RP. It was calibrated using a large national database aiming to optimize treatment selection strategies for prostate cancer patients.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long-Term Complications of Open and Robot-Assisted Laparoscopic Radical Prostatectomy in an Afro-Caribbean Population

Background

With the Afro-Caribbean population increasing in the United States, their complication profiles following open (ORP) and robot-assisted laparoscopic (RALP) radical prostatectomy warrants investigation. The purpose of this pilot study was to evaluate differences in long-term complications between ORP and RALP in Afro-Caribbeans.

Methods

A retrospective review of patients undergoing ORP or RALP between April 2010 and August 2019 at an academic medical center and county hospital was conducted. Patients who identified as Afro-Caribbean with complete data were analyzed. Complications were classified using the Clavien-Dindo system. Age, transrectal ultrasound prostate volume, preoperative prostate-specific antigen, Gleason scores, and long-term complications (persisting to at least 18 months postoperatively) were compared between procedures using the Mann-Whitney U test or Fisher’s exact test for statistical significance. Multivariable logistic regression was used to assess the odds of complications.

Results

This study included 53 Afro-Caribbean patients (mean age±SD; 65.9±6.8 years, 30 ORP, and 23 RALP). Patients treated by RALP were younger and had lower Gleason scores. Patients who were treated by RALP had a lower association to having ≥1 complications compared to those treated by ORP (OR=0.28, 95%CI 0.09-0.89, p=0.024). In addition, >60% of complications had a Clavien-Dindo grade≤II for both procedures. RALP resulted in fewer grade II complications compared to ORP (OR=0.25, 95%CI 0.08-0.81, p=0.046).

Conclusions

Treatment of Afro-Caribbeans with RALP allows for fewer complications, especially Clavien-Dindo Grade II complications. While previous investigations show that Black populations experience more complications when treated with ORP or RALP compared to other groups, their complication profile is likely not homogenous when considering their sub-ethnic background and must be investigated to understand optimal interventions for prostate cancer.

[The Onkonet database: taking stock of an Internet-based, multi-centre database on surgical prostate cancer treatment]

BACKGROUND

 The Onkonet database has been developed and coordinated by the Berliner Tumorzentrum e. V. (http://www.prostata-ca.net) and contains data on pre-, peri- and postoperative parameters of radical prostatectomy documented since January 2005. With its user-friendly interface and its integrated benchmarking tool, the main goal of Onkonet was to outline and improve the surgical care of prostate cancer patients in Germany. This study aimed to analyse all Onkonet data documented from the beginning of the project until June 2018. We focused on the completeness and plausibility of data to investigate and define the possibilities and limits of further analyses.

PATIENTS AND METHODS

 All patients who underwent radical prostatectomy in one of the urological clinics participating in this project until June 2018 were included in this retrospective study. The completeness of all documented patient data was analysed using Excel 2013. The statistical analysis was descriptive.

RESULTS

 A total of 21 474 patients were documented in Onkonet. 58,6 % (12 591) of them had a complete dataset including date of birth, date of surgery, dates of hospitalisation and discharge, initial PSA value, Gleason score of the biopsy, clinical T stage, pathological T stage, pathological Gleason score, as well as information on the surgical technique. Mean completeness of pre-operative parameters was 26,8 %, of hospitalisation parameters 64,5 %, and of pathological parameters 58,1 %. Amongst these, the documentation of the pathological T stage was complete in 80,1 %, documentation of N stage in 78,8 %, of M stage in 74,8 %, of pathological Gleason Score in 78,7 %, and of R1 status in 78,7 %. Completeness of follow-up data was 8,1 %, with PSA data being available in 27,2 %, continence data in 23,0 %, and potency data in 13,9 %.

CONCLUSIONS

 Comprising 21 474 documented patients and over 200 parameters, Onkonet is one of the most comprehensive clinical registers for the documentation of prostate cancer patients in Germany. The data analysis showed that the limitations of such a database are mainly due to the high number of parameters and the high susceptibility to errors due to manual data submission.

Predictors of complications occurring after open and robot-assisted prostate cancer surgery: a retrospective evaluation of 1062 consecutive patients treated in a tertiary referral high volume center

To investigate factors associated with the risk of major complications after radical prostatectomy (RP) by the open (ORP) or robot-assisted (RARP) approach for prostate cancer (PCa) in a tertiary referral center. 1062 consecutive patients submitted to RP were prospectively collected. The following outcomes were addressed: (1) overall postoperative complications: subjects with Clavien-Dindo System (CD) one through five versus cases without any complication; (2) moderate to major postoperative complications: cases with CD < 2 vs.  ≥ 2, and 3) major post-operative complications: subjects with CDS CD ≥  3 vs.  < 3. The association of pre-operative and intra-operative factors with the risk of postoperative complications was assessed by the logistic regression model. Overall, complications occurred in 310 out of 1062 subjects (29.2%). Major complications occurred in 58 cases (5.5%). On multivariate analysis, major complications were predicted by PCa surgery and intraoperative estimated blood loss (EBL). ORP compared to RARP increased the risk of major CD complications from 2.8 to 19.3% (OR = 8283; p < 0.0001). Performing ePLND increased the risk of major complications from 2.4 to 7.4% (OR = 3090; p < 0.0001). Assessing intraoperative blood loss, the risk of major postoperative complications was increased by BL above the third quartile when compared to subjects with intraoperative blood loss up to the third quartile (10.2% vs. 4.6%; OR = 2239; 95%CI: 1233-4064). In the present cohort, radical prostatectomy showed major postoperative complications that were independently predicted by the open approach, extended lymph-node dissection, and excessive intraoperative blood loss.

A ‘real-world’ standard for radical prostatectomy: Analysis of the British Association of Urological Surgeons Complex Operations Reports, 2016–2018

Objective:

To produce comprehensive and detailed benchmarking data allowing surgeons and patients to compare practice against, by using all recorded radical prostatectomies across a 3-year period in England.

Patients and methods:

The British Association of Urological Surgeons (BAUS) manages the radical prostatectomy (RP) Complex Operations Database. Surgical departments upload data which they can review and amend before lockdown and data cleansing. Analysis of 2016–2018 data held on the BAUS Complex Operations Database was performed for 21,973 patients undergoing RP in England, producing procedure-specific benchmarking data. General linear models were used to assess differences in patient selection between different operative modalities. Analysis involved assessment of case selection, operative decisions and outcomes, case volume and pathological outcomes.

Results:

Using national Hospital Episode Statistics, the BAUS RP dataset was estimated 91% complete. Median age was 65 and 96% were American Society of Anesthesiologists (ASA) Grades 1–2. Over 80% had RP performed in a high-volume centre (>100 annual RPs) and 88% had Gleason grade group (GGG) ⩾2 disease on biopsy. Robotic-assisted RP (RARP), laparoscopic RP (LRP) and open RP (ORP) were performed in 85%, 7.2% and 7.7% of cases, respectively. Patient and disease characteristics differed across surgical modalities. Transfusion rates were 0.14% in RARP, 0.38% in LRP and 1.8% in ORP. Increased positive surgical margin (PSM) rates were observed with increasing prostate-specific antigen (PSA), GGG and T-stage, with comparable PSM rates across surgical modalities. Lymph node dissection was performed more commonly in high-risk cases (cT3, PSA > 20, GGG ⩾ 4). Pathological upstaging was common. Median length of stay was 1, 2 and 3 days for RARP, LRP and ORP, respectively. ORP had Clavien–Dindo complications ⩾3 and unplanned hospital readmissions.

Conclusion:

This analysis has enabled the first set of UK national RP standards to be produced allowing procedure, patient and disease-specific national, centre and individual comparisons. The present degree of service centralisation, operative modalities, and specific aspects of surgical practice can be observed.

Level of evidence:

2b

Analysis of Complications Development Predictors after Radical Prostatectomy

Introduction: The standard treatment for prostate cancer is radical prostatectomy (RP). This surgical technique results in typical complications such as intraoperative blood loss, urethral strictures (vesicourethral anastomosis), urinary incontinence, erectile dysfunction, lymphocele, and the ureter or rectum injury. The study aims to analyze the development of complications after radical prostatectomy. Materials and methods: The article presents a retrospective analysis of clinical cases with an established diagnosis of prostate cancer from 2012 to 2018 in Irkutsk, Russian Federation. During this period, 52 patients met the study criteria. A multivariate analysis established Non-Nerve-sparing RRP (OR-0.9; 95% CI-1.9; -0.07; p=0.035) as a significant incontinence predictor after 2 years. Results: Multivariate analysis also established previous transurethral operations as a significant predictor of the vesicourethral anastomosis stricture (OR 6.09; 95% CI 0.71; 11.4; p=0.026), which indicates a six times risk of developing a vesicourethral anastomosis stricture if the patient already had one or more transurethral surgery. Obesity (OR 0.12; 95% CI 0.03; 0.21; p = 0.008), diabetes (OR 2.3; 95% CI 0.45; 4.2; p = 0.015) and coagulopathy (OR 3.1; 95% CI 0.5; 5.7; p = 0.019) became independent predictors of lymphocele development. Conclusions: The study revealed some new information on the possible predictors of such complications as urinary incontinence in the late period, the lymphocele, and stricture of the vesicourethral anastomosis. Some of the results require further study and confirmation.

Transition from open to robotically assisted approach on radical prostatectomies in Iceland. A nationwide, population-based study

OBJECTIVES

In January 2015, radical prostatectomies (RPs) in Iceland changed almost entirely from being performed as open (ORP) to robotically assisted (RARP). This study assesses early surgical and short-term oncological outcome after ORP and RARP and evaluates the safety of transition between the two surgical techniques.

METHODS

The study population involved 160/163 (98%) of all radical prostatectomies performed in Iceland between January 2013 and April 2016. Data on patients was collected retrospectively from medical records. Early surgical and short-term oncological outcomes were compared between the two surgical techniques.

RESULTS

The ORP and RARP cohorts were comparable with respect to all clinical and pathological variables, except for median prostate volume, which was 45 mL in the ORP cohort and 37 mL in the RARP cohort (p = 0.03). Intraoperative blood loss was higher, hospital stay longer, catheterization time longer, and risk of complications within 30 days of surgery higher after ORP than RARP (p < 0.01). The operative time, positive surgical margin rate and recurrence free survival, within two years, was comparable between the two surgical techniques.

CONCLUSIONS

The transition from ORP to RARP in Iceland was safe and resulted in improved early surgical outcome. However, no conclusion can be drawn from this study regarding oncological outcome, due to short follow up and a small sample size.

MRI grading for the prediction of prostate cancer aggressiveness

OBJECTIVES

T o evaluate the value of multiparametric MRI (mpMRI) for the prediction of prostate cancer (PCA) aggressiveness.

METHODS

In this single center cohort study, consecutive patients with histologically confirmed PCA were retrospectively enrolled. Four different ISUP grade groups (1, 2, 3, 4-5) were defined and fifty patients per group were included. Several clinical (age, PSA, PSAD, percentage of PCA infiltration) and mpMRI parameters (ADC value, signal increase on high b-value images, diameter, extraprostatic extension [EPE], cross-zonal growth) were evaluated and correlated within the four groups. Based on combined descriptors, MRI grading groups (mG1-mG3) were defined to predict PCA aggressiveness.

RESULTS

In total, 200 patients (mean age 68 years, median PSA value 8.1 ng/ml) were analyzed. Between the four groups, statistically significant differences could be shown for age, PSA, PSAD, and for MRI parameters cross-zonal growth, high b-value signal increase, EPE, and ADC (p < 0.01). All examined parameters revealed a significant correlation with the histopathologic biopsy ISUP grade groups (p < 0.01), except PCA diameter (p = 0.09). A mixed linear model demonstrated the strongest prediction of the respective ISUP grade group for the MRI grading system (p < 0.01) compared to single parameters.

CONCLUSIONS

MpMRI yields relevant pre-biopsy information about PCA aggressiveness. A combination of quantitative and qualitative parameters (MRI grading groups) provided the best prediction of the biopsy ISUP grade group and may improve clinical pathway and treatment planning, adding useful information beyond PI-RADS assessment category. Due to the high prevalence of higher grade PCA in patients within mG3, an early re-biopsy seems indicated in cases of negative or post-biopsy low-grade PCA.

KEY POINTS

• MpMRI yields relevant pre-biopsy information about prostate cancer aggressiveness. • MRI grading in addition to PI-RADS classification seems to be helpful for a size independent early prediction of clinically significant PCA. • MRI grading groups may help urologists in clinical pathway and treatment planning, especially when to consider an early re-biopsy.

Increased body mass index is associated with operative difficulty during robot‐assisted radical prostatectomy

Objective

This study aimed to identify factors associated with surgeon perception of robot‐assisted radical prostatectomy (RARP) difficulty.

Patients and Methods

This study surveyed surgeons performing RARP between 2017 and 2018 and asked them to rate operative conditions and difficulty as optimal, good, acceptable, or poor. These answers were stratified as optimal or suboptimal for this study. Associations between surgeon responses and variables hypothesized to affect surgical difficulty, including anatomic factors such as pelvic diameter and prostate volume:pelvic diameter ratio, were assessed.

Results

Between November 2017 and September 2018, a total of 100 patients were prospectively enrolled in the study of which 58 cases were rated as optimal and 42 were rated as suboptimal. Of the evaluated variables, only increasing clinical T stage (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.03–2.15, p = 0.03) and increasing body mass index (BMI) (OR 1.14, 95% CI 1.03–1.26, p = 0.01) were associated with increased difficulty; 90‐day complication rates were similar between the optimal and suboptimal cohorts (17.3% vs. 23.8%, respectively; p = 0.5). The number of patients with previous surgery, pelvic diameter, and prostate size:pelvic diameter ratio were not significantly different between cohorts (p > 0.05 for all). Operative time (ρ = 0.23, p = 0.02) and estimated blood loss (EBL) (ρ = 0.38, p = 0.0001) were correlated with suboptimal difficulty.

Conclusion

The factors associated with surgeon‐reported RARP difficulty were patient BMI and clinical T stage among surgeons with significant RARP experience. These data should be incorporated into surgical decision making and patient counseling prior to performing a RARP.

Onset and burden of lower limb lymphedema after radical prostatectomy: a cross-sectional study

OBJECTIVES

To explore men's onset and burden of lower limb lymphedema (LLL) after radical prostatectomy (RP) with pelvic lymph node dissection (PLND).

PATIENTS AND METHODS

A cross-sectional survey-based study was conducted nation-wide and web-based in Germany. Part 1 included 15 multidisciplinary compiled questions with three questions from the Short Form 12 Health Survey (SF-12) and the WHO activity recommendation and part 2 included the validated German Lymph-ICF-Questionnaire (Lymph-ICF-LL). Subgroup comparisons and simple regression analyses were used to identify factors associated with therapy and burden of LLL, followed by multiple regression analyses to explain variance in impairment in the patients' daily life.

RESULTS

Fifty-four patients completed the survey. Median time of LLL-onset was reported with 2.0 (0.5-9.75) months after RP. Nineteen patients (35.2%) reported bilateral lymphedema, 28 (51.9%) the use of individually fitted compression stockings (CS), 25 (46.3%) of manual lymphatic drainage (LD), and 26 (48.1%) complete regression. The Lymph-ICF-LL revealed a higher total burden for patients with an active LLL compared to complete regression (total score: 25.5 vs. 11.9, p = 0.01) especially for "physical function" (28.3 vs. 12.9, p < 0.01) and "mental function" (26.2 vs. 6.7, p < 0.01). In multiple linear regression analysis, a higher BMI (β = 0.28), lower subjective general health (β = -0.48), and active lymphedema (β = 0.28) were significant predictors of higher reported impairments in the Lymph-ICF-LL, accounting for 45.4% of variance.

CONCLUSION

Men with LLL after RP with PLND report a significant burden in daily life. Basic therapy needs to be offered early. Postoperative onset of LLL is variable, which should be considered when assessing complications after RP.

Feasibility and outcome of radical prostatectomy following inductive neoadjuvant therapy in patients with suspicion of rectal infiltration

OBJECTIVE

To determine the feasibility and outcome of radical prostatectomy (RP) following neoadjuvant therapy (NAT) in patients with initial inoperable, rectum-infiltrating cT4 prostate cancer (PCa).

METHODS

From 01/2018 to 12/2020, 26 patients with clinical (DRE) or radiographical (mpMRI) suspicion of rectum infiltrating PCa at diagnosis and NAT prior to RP were retrospectively identified from our prospective institutional database. Two patients were still inoperable after NAT. Downsizing was administered for at least 20 weeks and RP was performed after excluding ongoing rectal infiltration.

RESULTS

At diagnosis, median PSA was 42.5 ng/ml (IQR: 23.0-66.1). Inductive NAT consisted of androgen deprivation therapy (ADT) in combination with chemotherapy (n = 9) or without chemotherapy (n = 14). Median preoperative PSA was 0.93 ng/ml (IQR: 0.24-0.40). Median time from NAT to RP was 6 months (IQR: 5-7). Two patients were still inoperable after NAT. Of 24 patients undergoing RP, abortion of surgery due to inoperability was observed in 2 patients (8.4%), demonstrating a total failure rate of NAT in 4 out of 26 patients (15.4%). One patient suffered a rectal injury with consecutive colostomy (4.2%). No Clavien-Dindo complication Grade IV or V were observed. Urinary continence was achieved in 16 patients (84.2%). Sufficient erection for sexual intercourse was present in 2 patients (10.5%). All patients received adjuvant ADT with or without radiation therapy. Median PSA at 13 months was 0.08 ng/ml (IQR: 0.01-0.74).

CONCLUSION

RP of initially rectum infiltrating PCa is feasible and safe after inductive NAT, however complications rates tend to be higher compared to standard RP.

The 90-day cause-specific mortality after radical prostatectomy: a nationwide population-based study

OBJECTIVE

To investigate the cause-specific mortality in the postoperative period after radical prostatectomy (RP) for prostate cancer (PCa).

METHODS

In the National Prostate Cancer Register of Sweden (NPCR), we identified all men who died within 90 days after RP performed 1998-2018 and we assessed cause of death in a chart review. We compared the adjudications of death from our medical record review with those in in the Swedish Cause of Death Registry (CDR).

RESULTS

Out of 44 635, 58 (0.13%) men who had undergone RP from 1998 through 2018 died within 90 days after RP. Per medical record review the most common causes of death were cardiac disease (30%) and venous thromboembolic events (VTE; 21%). No men died of metastatic PCa as was first indicated in the CDR. After robot-assisted RP (RARP) or open retropubic RP (RRP), the postoperative mortality was 0.09% (19/21 520) and 0.19% (37/19 635), respectively. The effect off modality was confounded mainly by year of surgery, age at surgery, Charlson Comorbidity Index score and the concomitant pelvic lymph node dissection.

CONCLUSION

The validated absolute 90-day mortality after RP was 1.3/1000 during the 21-year study period. Cardiovascular diseases were the most common causes of death after RP. Our validation of the CDR refuted the occurrence of postoperative deaths from metastatic PCa. There were differences in rates and type of mortality between RRP and RARP, but the RARP cohort was more recent than the RRP cohort, which likely explain the differences.

Options for Curative Treatment of Localized Prostate Cancer

BACKGROUND

Prostate cancer is the most frequently occurring malignancy among men in Germany, with 60 000 new cases each year. Three of every four tumors are detected at an early, localized stage, when various curative treatment strategies are possible.

METHODS

A selective search of the literature in PubMed accompanied by consideration of guidelines from Germany and other countries.

RESULTS

Owing to the usually prolonged natural course of localized prostate cancer, local treatment is recommended for patients with a life expectancy of at least 10 years. The established treatments with curative intent are radical prostatectomy, percutaneous radiotherapy, and brachytherapy, with active surveillance as a further option for patients with low-risk disease. The eventual choice of treatment is determined by tumor stage, risk group, comorbidities, and patient preference. Conversations with the patient must cover not only the oncological outcome but also the potential adverse effects of the different treatment options. Depending on the procedure, urinary incontinence, erectile dysfunction, and inflammation of the bladder and/or rectum may be frequently occurring complications.

CONCLUSION

A number of curative and other treatments are available for patients with localized prostate cancer. The goal is to identify the appropriate option for each individual patient by means of detailed discussion.

Cytoreductive radical prostatectomy after chemohormonal therapy in patients with primary metastatic prostate cancer

Objective

Methods

Results

Conclusion

The TransEnterix European Patient Registry for Robotic-Assisted Laparoscopic Procedures in Urology, Abdominal, Thoracic, and Gynecologic Surgery ("TRUST")

INTRODUCTION

Robotic surgery was first introduced in the mid-1980s, and at the end of the '90s, the da Vinci® System (Intuitive Surgical Inc., Sunnyvale, California) was introduced in Europe and held a monopoly for years afterward. In 2016, Senhance™ digital laparoscopic platform (TransEnterix Inc., Morrisville, North Carolina) came to the market. This new platform is based on laparoscopic movements and is designed for laparoscopic surgeons. This study shows the surgical outcomes of patients after different visceral, colorectal, gynecological, and urological surgical procedures done with the Senhance™ digital laparoscopic platform with a focus on safety.

MATERIALS AND METHODS

The study population consists of 871 patients who underwent robotic surgery with the Senhance™ platform. The most common procedures were hernia repairs (unilateral and bilateral), cholecystectomies, and prostatectomies. The procedures were performed in five centers in Europe between February 2017 and July 2020 by experienced laparoscopic surgeons.

RESULTS

220 (25.3 %) out of 871 patients had a unilateral hernia repair, 70 (8.0%) a bilateral hernia repair, 159 (18.3%) underwent a cholecystectomy, and 168 (19.3%) a prostatectomy. The other procedures included visceral, colorectal, and gynecological surgery procedures. The median docking time was 7.46 minutes for the four most common procedures. The duration of surgery varied from 32 to 313 minutes, the average time was 114.31 minutes. Adverse events were rare overall. There were 48 (5.5 %) adverse events out of 871 patients, 24 of them (2.8 % of all cases) were severe. Out of all 24 severe adverse events, five events (20.8%) were likely related to the robot, 17 events (70.8%) were unlikely related to the robot, and two events (8.3%) could not be categorized. Regarding complications following unilateral hernia repairs, data from 212 patients was available. Thirteen (6.1%) complications occurred, and six of those (2.8%) were serious. Out of 68 patients with a bilateral hernia repair, six patients (8.8%) developed complications, three of which were severe (4.4%). The complication rate was 2.8% in the patients following a cholecystectomy (4/144); two of them serious. After prostatectomy, six out of 141 patients (4.3 %) had complications; one serious (0.7%) No mortality was observed. Data about unplanned conversions to laparoscopic surgery could be collected from 761 patients which is a rate of 3.7%. There were 12 conversions out of 760 procedures to open surgery (1.6%).

CONCLUSIONS

Our series shows these procedures are safe and reproducible. The findings suggest that the surgical results after robotic surgery with the Senhance™ system are promising. Long-term data regarding complication rates should be the subject of future studies.

Perioperative and Functional Outcomes of Robot-Assisted Radical Prostatectomy in Octogenarian Men

Background: The functional and oncologic outcomes of robot-assisted radical prostatectomy (RARP) in octogenarians are not well studied. We sought to study the perioperative, functional, and oncologic outcomes of RARP in octogenarian men. Methods: Between January 2009 and 2019, 46 patients ≥80 years with localized prostate cancer (PCa) underwent RARP in three high-volume robotic urologic practices in the United States. Clinical and pathologic features, and perioperative and postoperative complications were retrospectively evaluated. Functional outcomes for urinary and sexual function were collected via patient-reported questionnaires. Continence was defined as the use of zero or one safety pad per day. Results: The median (interquartile range) age was 81 (80-82), the mean (standard deviation [SD]) operative time was 116.5 (36.4) minutes, and the mean (SD) blood loss was 132 (35.6) mL. All cases were completed robotically, no intraoperative complications were encountered, and the mean length of stay was 1.21 (0.78) days. Regarding 30- and 90-day complication, nine patients had postoperative complications; seven were Clavien-Dindo grade I-II, and two were Clavien-Dindo grade ≥III. Post-RARP continence rates at 3 and 12 months were 68.4% and 84.8%, respectively. Conclusions: RARP represents a feasible option to treat PCa in well-selected octogenarian men. Careful patient selection and counseling are critical before offering surgical treatment for these men.

Comparison of robotic and open radical prostatectomy: Initial experience of a single surgeon

Objective:

In this study, we aimed to make a comprehensive comparison of the first hundred robot-assisted radical prostatectomy (RARP) and open retropubic radical prostatectomy (RRP) cases of a single surgeon in a high-volume center.

Methods:

Preoperative, perioperative and postoperative data were collected retrospectively. Perioperative, oncological data and functional results in the first year were compared between the two groups. There were 204 RARPs between January 1, 2014 and December 31, 2019, and 755 RRPs between April 1, 2007 and December 31, 2019.

Results:

While the operation time was in favor of the open group (117 vs 188 min, p<0.001), the estimated blood loss (328 vs 150 ml, p<0.001), blood transfusion rate (12 vs 2, p=0.021), and re-operation rate (6 vs 0, p=0.001) were in favor of the robotic group. Mean length of hospital stay (5.4 vs 3.1, p<0.001), urine leak rate (11 vs 2, p=0.033), complication rate (37 vs 16, p=0.018), and the 12th month continence rate (67 vs 85, p=0.002) were better in the robotic group.

Conclusions:

RARP may provide better perioperative outcomes and lower complication rates after the surgeon factor is eliminated in the early period. Since our case group includes the initial 100 patients, studies with larger patient groups with longer follow-up are needed to adapt these early results to general outcomes.

Comparison and trend of perioperative outcomes between robot-assisted radical prostatectomy and open radical prostatectomy: nationwide inpatient sample 2009-2014

Purpose:

To make a further evaluation of perioperative outcomes between the robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP), we conducted a comparison and trend analysis by using the Nationwide Inpatient Sample (NIS) from 2009 to 2014.

Materials and Methods:

Adult prostate cancer patients with radical prostatectomy were abstracted from the NIS. RARP and ORP were identified according to the International Classification of Diseases, 9^th Revision, Clinical Modification procedure codes. The perioperative outcomes included blood transfusion, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Propensity score matching method and multivariable logistic regression model were performed to adjust for the pre-defined covariates. The annual percent change (APC) was used to detect the change trend of rates for outcomes.

Results:

A total of 77.054 patients were included in our study. According to the results of propensity score matching analyses, RARP outperformed ORP in blood transfusion (1.96% vs. 9.40%), intraoperative complication (0.73% vs. 1.25%), overall postoperative complications (8.87% vs. 11.97%), and pLOS (13.39% vs. 36.70%). We also found that there was a significant decreasing tendency of incidence in blood transfusion (APC=-9.81), intraoperative complication (APC=-12.84), and miscellaneous surgical complications (APC=-14.09) for the RARP group. The results of multivariable analyses were almost consistent with those of propensity score matching analyses.

Conclusions:

The RARP approach has lower incidence rates of perioperative complications than the ORP approach, and there is a potential decreasing tendency of complication incidence rates for the RARP.

Prostatic artery embolization in patients with benign prostatic hyperplasia: perfusion cone-beam CT to evaluate planning and treatment response

This proof of concept is to evaluate the utility of perfusion cone-beam computed tomography (CT) in patients undergoing prostatic artery (PA) embolization (PAE) for benign prostatic hyperplasia (BPH) with moderate or severe-grade lower urinary tract symptoms (LUTS). PAE is a novel minimally invasive therapy and is both safe and effective procedure with low risks and high technical successes, making this procedure as the best alternative to surgery. A lot of technical changes would compromise clinical outcomes after procedure, including a variable prostate vascular anatomy, thin PA, and extensive atherosclerotic disease. The purpose of our study is to exploit the advantages of Perfusion Cone Beam Computed Tomography (CBCT) that could impact treatment and help interventional radiologists for treatment planning, diagnosis and for assessing the technical feasibility during PAE, mitigating the risk of nontarget embolization and suggesting clinical outcomes. Qualitative and quantitative clinical pre- and post-treatment values will be compared, to reach the best possible results.

Single-night stay for open radical prostatectomy

INTRODUCTION

The aim of this study was to assess the effect of an enhanced care pathway on length of stay (LOS) for open radical prostatectomy (RP) given that robotic-assisted laparoscopic prostatectomy (RALP) is not available to all patients in Canada.

METHODS

A retrospective review was conducted of all RPs performed. An enhanced care pathway was established for RPs in 2011. Patients were compared in the period before (2005-2010) and after (2011-2019) the introduction of the pathway.

RESULTS

During the study period, 581 RPs were performed by a single surgeon with a median followup of 66.9 months (range 3-176). A total of 211 (36.3%) RPs were performed from 2005-2010, while 370 (63.9%) were performed from 2011-2019. The median age at RP was 65 years (range 44-81). Following the introduction of an enhanced care pathway, there were significant decreases in intraoperative blood loss (350 ml vs. 200 ml; p=0.0001) and the use of surgical drains (90% vs. 9.5%; p=0.0001). The median LOS over the whole study period was one day (range 1-7), which significantly decreased with the enhanced care pathway (3 vs. 1 day; p=0.0001). Since introducing the enhanced care pathway in 2011, 344 (93%) patients were discharged day 1 following surgery. There were no differences in post-discharge presentations to the emergency department (5.7% vs. 9%; p=0.15) or 30-day readmission rates (3.8% vs. 3.8%; p=1.00).

CONCLUSIONS

A single-night stay for open RP is safe and achievable for most patients. A dedicated, multifaceted pathway is required to attain targets for a safe and timely discharge.

Management of erectile dysfunction following robot-assisted radical prostatectomy: a systematic review

INTRODUCTION

We aimed to summarize evidences about the efficacy of available treatments for erectile disfunction after robotic assisted radical prostatectomy (RARP).

EVIDENCE ACQUISITION

A systematic literature review searching on PubMed (Medline), Scopus, and Web of Science databases was performed in December 2019. PRISMA guidelines were followed. Population consisted of patients with erectile disfunction after RARP (P), conservative and surgical intervention were considered of interest (I). No comparator was considered mandatory (C). Outcomes of interest were the recovery of erectile function after conservative treatments and sexual function after surgical treatments (O).

EVIDENCE SYNTHESIS

Eleven studies were included. Seven studies focused on the use of phosphodiesterase-5 inhibitors (PDE5i) alone (five studies) or associated with other treatments (two studies). All the studies confirmed the efficacy of PDE5i, while the most promising association is with vacuum pump erectile devices. Two studies investigated topical treatments, namely low intensity extracorporeal shock wave therapy and alprostadil. Low intensity extracorporeal shock wave therapy may be a promising option in patients in whom nerve-sparing surgery was performed. The use of alprostadil could be an effective alternative to intracorporeal injection in those who underwent non-nerve-sparing surgery. One study focused and confirmed the efficacy of penile implants. Furthermore, one study reported the efficacy of a multi-modal treatment with preoperative medication, showing the benefits of a multimodal approach.

CONCLUSIONS

Penile rehabilitation with PDE5i is effective after nerve sparing RARP. The association of PDE5i with vacuum devices could led to a faster recovery. A multimodal approach with preoperative specific care seems to be effective to fasten erectile function recovery.

Comparing the effect of positioning on cerebral autoregulation during radical prostatectomy: a prospective observational study

Purpose

Surgery in the prolonged extreme Trendelenburg position may lead to elevated intracranial pressure and compromise cerebral hemodynamic regulation. We hypothesized that robot-assisted radical prostatectomy with head-down tilt causes impairment of cerebral autoregulation compared with open retropubic radical prostatectomy in the supine position.

Methods

Patients scheduled for elective radical prostatectomy were included at a tertiary care prostate cancer clinic. Continuous monitoring of the cerebral autoregulation was performed using the correlation method. Based on measurements of cerebral oxygenation with near-infrared spectroscopy and invasive mean arterial blood pressure (MAP), a moving correlation coefficient was calculated to obtain the cerebral oxygenation index as an indicator of cerebral autoregulation. Cerebral autoregulation was measured continuously from induction until recovery from anesthesia.

Results

There was no significant difference in cerebral autoregulation between robot-assisted and open retropubic radical prostatectomy during induction (p = 0.089), intraoperatively (p = 0.162), and during recovery from anesthesia (p = 0.620). Age (B = 0.311 [95% CI 0.039; 0.583], p = 0.025) and a higher difference between baseline MAP and intraoperative MAP (B = 0.200 [95% CI 0.073; 0.327], p = 0.002) were associated with impaired cerebral autoregulation, whereas surgical technique was not (B = 3.339 [95% CI  1.275; 7.952], p = 0.155).

Conclusion

Compared with open radical prostatectomy in the supine position, robot-assisted surgery in the extreme Trendelenburg position with capnoperitoneum did not lead to an impairment of cerebral autoregulation during the perioperative period in our study population.

Trial registration number: DRKS00010014, date of registration: 21.03.2016, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1007/s10877-020-00549-0) contains supplementary material, which is available to authorized users.

Conservative management of urinary incontinence following robot-assisted radical prostatectomy

INTRODUCTION

Robotic assisted radical prostatectomy (RARP) is getting more and more popular becoming the most common radical prostatectomy technique. Unfortunately, a not negligible proportion of patients in whom RARP is performed experience urinary incontinence. We aimed to systematically review the current literature evidence on urinary incontinence conservative treatment after RARP.

EDIDENCE AQUISITION

A systematic literature review search using PubMed (Medline), Scopus, and Web of Science databases was performed in December 2019. PRISMA guidelines have been adopted. Population consisted of patients with urinary incontinence after RARP (P), conservative intervention was considered of interest (I). No comparator was considered mandatory (C). Outcomes of interest were the recovery of continence and quality of life (O).

EVIDEDENCE SYNTHESIS

Six studies were included. Four of them investigated the use of pelvic floor muscle training (PFMT). PFMT improved pelvic muscle strength. Continence recovery was faster when guided PFMT was adopted. Moreover, two studies tested the effect of solifenacin on urinary incontinence. One of them, a randomized clinical trial, failed to show shorter time to continence in solifenacin group compared to placebo.

CONCLUSIONS

The use of pads is associated with a detrimental effect on quality of life thus active treatments for UI post-RARP are warranted. PFMT has the main advantage to shorten the time for recovery. The use of solifenacin seems to not offer striking advantages in UI following RARP. Future studies should focus on testing the efficacy of these treatments when used after robotic vs. open radical prostatectomy.

An evaluation of the timing of surgical complications following radical prostatectomy: Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP)

Objective

To perform a time-to-complication analysis for radical prostatectomy (RP) and computing risk factors for these complications, as RP is established as a first-line treatment for localised prostate cancer with excellent oncological outcomes but is not without its complications.

Patients and methods

We used the National Surgical Quality Improvement Program (NSQIP) database to analyse data of patients who underwent RP, between 2008 and 2015, with the primary endpoint of time-to-complications. Categorical variables were analysed using descriptive statistics and continuous variables were recorded as medians and interquartile ranges (IQRs) such as timing of complications. Multivariable regression analyses were used to analyse time-to-complication and its effect on other outcomes. A P < 0.05 was defined as statistically significant.

Results

The overall 30-day complication rate was 7.54% and was equally distributed before and after discharge. Bleeding/transfusion (3.37%), urinary tract infection (1.58%), deep venous thrombosis (DVT; 0.74%), and wound infection (1.08%) were the five most common complications after RP. The median (IQR) time-to-complication unique for each complication was: bleeding/transfusion occurred on the same operative day (1), renal complications occurred at 4 (2–6) days, sepsis at 12 (6.5–17.5) days, DVT at 11 (5.5–16.5) days, pneumonia at 4 (0.5–7.5) days, and cardiac arrest occurred at 5 (1.75–8.25) days. After discharge complications were associated with greater odds of re-admission (odds ratio [OR] 16.40, P < 0.001), but associated with a lesser length of stay (OR – 3.33, P < 0.001) when compared to pre-discharge complications.

Conclusion

Several risk factors predict pre- and post-discharge complication rates. Knowledge regarding the timing of complications and their respective risk factors should improve patient–physician communication and prediction, and thus patient care.

Abbreviations

ACS: American College of Surgeons; BMI: body mass index; DM: diabetes mellitus; DVT: deep venous thrombosis; Hct: haematocrit; IQR: interquartile range; LOS: length of stay; NSQIP: National Surgical Quality Improvement Program; OR: odds ratio; RP: radical prostatectomy

Postanesthesia care unit delirium following robot-assisted vs open retropubic radical prostatectomy: A prospective observational study

BACKGROUND

The aim of this study was to compare the incidence of early postoperative delirium in the postanesthesia care unit (PACU) between robot-assisted radical prostatectomy (RARP) in the extreme Trendelenburg position and open retropubic radical prostatectomy (ORP) in supine position.

METHODS

Patients were screened for delirium signs 15, 30, 45, and 60 minutes following extubation.

RESULTS

PACU delirium was present in 39.3% of RARP (64/163) patients and 41.8% of ORP (77/184) patients. Higher age (OR 1.072, 95%CI: 1.034-1.111, P < .001), total intravenous anesthesia (OR 2.001, 95%CI: 1.243-3.221, P = .004), and anesthesia duration (OR 1.255, 95%CI: 1.067-1.476, P = .006) were associated with PACU delirium, but no association was found between surgical technique and PACU delirium.

CONCLUSION

Compared with inhalational anesthesia, total intravenous anesthesia using propofol-sufentanil, higher age, and longer duration of anesthesia were associated with PACU delirium. Based on these findings, adverse effects on postoperative recovery and delirium signs do not have to be considered in the choice of surgical approach for radical prostatectomy.

TRIAL REGISTRATION

https://www.drks.de/, identifier: DRKS00010014.

Comparison of Cognitive Function After Robot-Assisted Prostatectomy and Open Retropubic Radical Prostatectomy: A Prospective Observational Single-Center Study

OBJECTIVE

To assess the effects of robot-assisted radical prostatectomy in the Trendelenburg position on postoperative neurocognitive outcomes this study compared cognitive function between patients who underwent robot-assisted radical prostatectomy and those who underwent open retropubic radical prostatectomy.

METHODS

Objective evaluations of pre- and postoperative cognitive function were performed upon admission and before hospital discharge, by using a neuropsychological test battery. We collected self-reported data on cognitive failures at 3 months postoperatively. Binary logistic regression analysis was used to assess the effects of surgical technique on postoperative cognitive performance.

RESULTS

The pre- and postoperative neuropsychological assessments were completed by 367 patients with a median age of 64 years (range 44-76). The incidence of postoperative cognitive dysfunction was 23.9% after robot-assisted (39/165) and 22.3% after open radical prostatectomy (45/202). There was no significant difference in postoperative cognitive function during the early postoperative period (P = 0.758) and self-reported cognitive failures at 3 months (P = 0.303) between robot-assisted and open surgery. Surgical technique was not associated with early postoperative cognitive dysfunction in multivariable analysis (OR 1.012, 95%CI: 0.608-1.685, P = 0.962).

CONCLUSION

Compared with open surgery in supine position postoperative neurocognitive disorders do not occur more frequently after robot-assisted radical prostatectomy in the extreme Trendelenburg position. Based on these findings potential adverse effects on cognitive function do not have to be considered in the choice of surgical approach for radical prostatectomy.