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Mulhall JP, Klein EA, Slawin K, Henning AK, Scardino PT. A Randomized, Double-Blind, Placebo-Controlled Trial to Assess the Utility of Tacrolimus (FK506) for the Prevention of Erectile Dysfunction Following Bilateral Nerve-Sparing Radical Prostatectomy. J Sex Med 2019; 15:1293-1299. [PMID: 30224019 DOI: 10.1016/j.jsxm.2018.07.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/25/2018] [Accepted: 07/03/2018] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Radical prostatectomy (RP) is associated with erectile dysfunction, largely mediated through cavernous nerve injury. There are robust pre-clinical data supporting a potential role for neuromodulatory agents in this patient population. This study assessed tacrolimus in improving erectile function recovery rates after RP (ClinicalTrials.gov number, NCT00106392). AIM To define the utility of oral tacrolimus in improving erectile function recovery after nerve sparing radical prostatectomy. METHODS A randomized, double-blind trial compared tacrolimus 2-3 mg daily and placebo in men undergoing RP. Patients had localized prostate cancer and excellent baseline erectile function, underwent bilateral nerve-sparing RP, and were followed up for at least 18 months after RP. Patients received study drug for 27 weeks and completed the International Index of Erectile Function erectile function domain (EFD) questionnaire at baseline and serially after surgery. MAIN OUTCOME MEASURES International Index of Erectile Function erectile function domain score. RESULTS Data were available for 124 patients (59 tacrolimus, 65 placebo); mean age was 54.6 ± 6.2 years. No patient experienced permanent creatinine or potassium elevation. At baseline, mean EFD scores were 28.6 ± 2.1 (tacrolimus group) and 29 ± 1.5 (placebo group). By week 5, mean EFD scores had dropped to 8 ± 9.4 (tacrolimus) and 9 ± 10.7 (placebo). At 18 months, mean EFD scores were 16.0 ± 11.3 (tacrolimus) and 20.2 ± 9.0 (placebo) (P = .09). Tacrolimus failed to meet significance (hazard ratio = 0.83; P = .50), with no difference in: (i) percentage of patients achieving normal spontaneous erectile function (EFD score ≥24), (ii) time to normalization of EFD score (≥24), (iii) percentage of patients capable of intercourse in response to phosphieserase type 5 inhibitor (PDE5i), and (iv) time to achieve response to PDE5i. CLINICAL IMPLICATIONS Despite positive animal data, oral tacrolimus as used in this trial failed to improve erectile function after nerve sparing radical prostatectomy. STRENGTHS & LIMITATIONS The study is limited by a high attrition rate. The strengths include a randomized, placebo controlled design, extensive patient monitoring, use of medication diaries and a validated instrument as the primary outcome measure. CONCLUSION Despite supportive animal data, tacrolimus used in this fashion in the RP population failed to demonstrate any superiority over placebo. Mulhall JP, Klein EA, Slawin K, et al. A Randomized, Double-Blind, Placebo-Controlled Trial to Assess the Utility of Tacrolimus (FK506) for the Prevention of Erectile Dysfunction Following Bilateral Nerve-Sparing Radical Prostatectomy. J Sex Med 2018;15:1293-1299.
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Affiliation(s)
- John P Mulhall
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Eric A Klein
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Peter T Scardino
- Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Suh YS, Jang HJ, Song W, Lee HW, Kim HS, Jeon HG, Jeong BC, Seo SI, Jeon SS, Choi HY, Lee HM. Location of positive surgical margin and its association with biochemical recurrence rate do not differ significantly in four different types of radical prostatectomy. Korean J Urol 2014; 55:802-7. [PMID: 25512814 PMCID: PMC4265714 DOI: 10.4111/kju.2014.55.12.802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/20/2014] [Indexed: 11/18/2022] Open
Abstract
Purpose To analyze the location of the positive surgical margin (PSM) and its association with the biochemical recurrence (BCR) rate in cases of radical prostatectomy (RP) according to the type of surgery. Materials and Methods We retrospectively analyzed 1,880 cases of RP. Baseline characteristics were analyzed. Locations of the PSM were recorded in the four surgery groups as apex, anterior, posterolateral, and base and were analyzed by using chi-square test. The association of the location of the PSM with the BCR rate was analyzed by using Kaplan-Meier survival analysis according to the type of surgery, which included radical perineal prostatectomy (RPP, n=633), radical retroperitoneal prostatectomy (RRP, n=309), laparoscopic radical prostatectomy (LRP, n=164), and robot-assisted laparoscopic radical prostatectomy (RALRP, n=774). Results A PSM was found in a total of 336 cases (18%): 122 cases of RPP (18%), 67 cases of RRP (17%), 29 cases of LRP (17%), and 119 cases of RALRP (15%). The PSM rate did not differ significantly by surgical type (p=0.142). The location of the PSM was the apex in 136 cases (7.2%), anterior in 67 cases (3.5%), posterolateral in 139 cases (7.3%), and base in 95 cases (5.0%), and showed no significant difference according to surgical type (p=0.536, p=0.557, p=0.062, and p=0.109, respectively). The BCR rate according to the location of the PSM did not differ significantly for the four types of surgery (p=0.694, p=0.301, p=0.445, and p=0.309 for RPP, RRP, LRP, and RALRP, respectively). Conclusions The location of the PSM seemed to be unrelated to type of RP. There was no significant correlation between the BCR rate and the location of the PSM for any of the RP types.
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Affiliation(s)
- Yoon Seok Suh
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyeon Jun Jang
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wan Song
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Won Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Seung Kim
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hwang Gyun Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byong Chang Jeong
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Il Seo
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Soo Jeon
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Han Yong Choi
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyun Moo Lee
- Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Hsu M, Chang SL, Ferrari M, Nolley R, Presti JC, Brooks JD. Length of site-specific positive surgical margins as a risk factor for biochemical recurrence following radical prostatectomy. Int J Urol 2011; 18:272-9. [PMID: 21342296 DOI: 10.1111/j.1442-2042.2011.02729.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Positive surgical margins (PSM) have been associated with biochemical recurrence (BCR) after radical prostatectomy, but the significance of PSM length and location are debated. We assessed the impact of PSM lengths at specific locations for BCR in an open radical prostatectomy series. METHODS Detailed clinical and pathological data were collected from 117 post-prostatectomy patients with PSM from 1984 to 2004 at our institution. PSM locations were classified as apex, mid-gland, base, bladder neck, and anterior fibromuscular region with lengths measured at each site. Aggregate PSM length was obtained by summing lengths of all PSM areas in contact with the inked surface. BCR was defined as serum prostate specific antigen level 0.2 ng/mL or greater. Cox proportional hazards regression analyses of PSM lengths were conducted either as a continuous or categorical variable relative to location as a predictor of BCR. RESULTS Multivariate analyses demonstrated that as a continuous variable, PSM length at the anterior fibromuscular region (Hazard ratio [HR] = 1.17; P = 0.027) and bladder neck (HR = 1.29; P = 0.046) were significant predictors for BCR. As a categorical variable, PSM length ≥ 2 mm at the anterior fibromuscular area was significant for BCR (HR = 3.02; P = 0.036). Increasing Gleason grade and positive lymph node status were also found to be significant independent predictors for BCR. CONCLUSION PSM length at the anterior fibromuscular region (continuous and categorical) and the bladder neck (continuous) was significantly associated with BCR. Site-specific PSM length, along with Gleason grade and lymph node status, can be predictive of BCR and assist in risk stratification of patients with PSM following radical prostatectomy.
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Affiliation(s)
- Mark Hsu
- Department of Urology, Stanford University Medical Center, Stanford, California, USA
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Development of “extended radical retropubic prostatectomy”: A surgical technique for improving margin positive rates in prostate cancer. Eur J Surg Oncol 2010; 36:281-6. [DOI: 10.1016/j.ejso.2009.10.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Revised: 10/17/2009] [Accepted: 10/19/2009] [Indexed: 11/30/2022] Open
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Montironi R, Cheng L, Mazzucchelli R, Lopez-Beltran A. PATHOLOGICAL DEFINITION AND DIFFICULTIES IN ASSESSING POSITIVE MARGINS IN RADICAL PROSTATECTOMY SPECIMENS. BJU Int 2009; 103:286-8. [DOI: 10.1111/j.1464-410x.2008.08006.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Adverse prognostic impact of capsular incision at radical prostatectomy for Japanese men with clinically localized prostate cancer. Int Urol Nephrol 2008; 41:581-6. [PMID: 18784981 DOI: 10.1007/s11255-008-9467-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Accepted: 08/21/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the significance of capsular incision (CI) at radical prostatectomy (RP) for men with prostate cancer. MATERIALS AND METHODS This study included 267 men who underwent RP without neoadjuvant therapy and were pathologically diagnosed as having organ-confined disease. CI was defined as exposing benign or malignant glands at the inked margin without documented extraprostatic extension. RESULTS Pathological examinations identified CI in 53 RP specimens (19.9%), while CI was not detected in the remaining 214 specimens (80.1%). The locations of CIs in RP specimens from these 53 patients were as follows: 39 (73.6%) at the apex, 11 (20.0%) at the anterior site, 4 (7.5%) at the posterior site and 12 (22.6%) at the bladder neck. The incidence of CI was significantly affected by surgical procedure, preoperative serum PSA and microvenous invasion in RP specimen. During the observation period of this study, biochemical recurrence occurred in 10 (18.9%) of the 53 with CI and 20 (9.3%) of the 214 without CI, and the biochemical recurrence-free survival in patients with CI was significantly poorer than those without CI. Furthermore, of several factors examined, biochemical recurrence was significantly associated with preoperative serum PSA, Gleason score, perineural invasion and capsular incision, among which only preoperative serum PSA appeared to be an independent predictor of biochemical recurrence. CONCLUSIONS Despite the lack of independent significance, the presence of CI has an adverse impact on biochemical outcome in patients undergoing RP for clinically localized prostate cancer.
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Terakawa T, Miyake H, Tanaka K, Takenaka A, Inoue TA, Fujisawa M. Surgical margin status of open versus laparoscopic radical prostatectomy specimens. Int J Urol 2008; 15:704-7; discussion 708. [DOI: 10.1111/j.1442-2042.2008.02057.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Van der Kwast TH, Bolla M, Van Poppel H, Van Cangh P, Vekemans K, Da Pozzo L, Bosset JF, Kurth KH, Schröder FH, Collette L. Identification of Patients With Prostate Cancer Who Benefit From Immediate Postoperative Radiotherapy: EORTC 22911. J Clin Oncol 2007; 25:4178-86. [PMID: 17878474 DOI: 10.1200/jco.2006.10.4067] [Citation(s) in RCA: 226] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose The randomized controlled European Organisation for Research and Treatment of Cancer (EORTC) trial 22911 studied the effect of radiotherapy after prostatectomy in patients with adverse risk factors. Review pathology data of specimens from participants in this trial were analyzed to identify which factors predict increased benefit from adjuvant radiotherapy. Patients and Methods After prostatectomy, 1,005 patients with stage pT3 and/or positive surgical margins were randomly assigned to a wait-and-see (n = 503) and an adjuvant radiotherapy (60 Gy conventional irradiation) arm (n = 502). Pathologic review data were available for 552 patients from 11 participating centers. The interaction between the review pathology characteristics and treatment benefit was assessed by log-rank test for heterogeneity (P < .05). Results Margin status assessed by review pathology was the strongest predictor of prolonged biochemical disease-free survival with immediate postoperative radiotherapy (heterogeneity, P < .01): by year 5, immediate postoperative irradiation could prevent 291 events/1,000 patients with positive margins versus 88 events/1,000 patients with negative margins. The hazard ratio for immediate irradiation was 0.38 (95% CI, 0.26 to 0.54) and 0.88 (95% CI, 0.53 to 1.46) in the groups with positive and negative margins, respectively. We could not identify a significant impact of the positive margin localization. Conclusion Provided careful pathology of the prostatectomy is performed, our results suggest that immediate postoperative radiotherapy might not be recommended for prostate cancer patients with negative surgical margins. These findings require validation on an independent data set.
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Affiliation(s)
- Theodorus H Van der Kwast
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital and University Health Network, Toronto, Canada.
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Peyromaure M, Camparo P, Badoual C, Descazeaud A, Dinh-Xuan AT. The expression of vascular endothelial growth factor is associated with the risk of cancer progression after radical prostatectomy. BJU Int 2007; 99:1150-3. [PMID: 17437444 DOI: 10.1111/j.1464-410x.2007.06734.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To analyse the prognostic value of vascular endothelial growth factor (VEGF) in men with clinically localized prostate cancer. PATIENTS AND METHODS Paraffin wax-embedded sections from the radical prostatectomy (RP) specimens of 40 men operated for clinically localized prostate cancer were used to build tissue microarrays. Of these patients, 17 had cancer progression and bone metastases after RP (group 1), and 23 remained free-of-tumour recurrence after RP (group 2). VEGF-A expression was examined in the RP specimens using immunohistochemistry. RESULTS The groups had similar tumour characteristics in terms of prostate-specific antigen level, Gleason score, and pathological stage. VEGF-A expression was significantly higher in group 1 than in group 2 (P=0.046). In logistic regression analysis, VEGF-A expression was the most significant predictive factor of cancer progression after RP. CONCLUSION VEGF-A expression in prostate cancer tissue is associated with the risk of cancer progression after RP. These results suggest that VEGF-A expression has a prognostic impact in clinically localized prostate cancer.
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van der Kwast TH, Collette L, Van Poppel H, Van Cangh P, Vekemans K, DaPozzo L, Bosset JF, Kurth KH, Schröder FH, Bolla M. Impact of pathology review of stage and margin status of radical prostatectomy specimens (EORTC trial 22911). Virchows Arch 2006; 449:428-34. [PMID: 16941153 DOI: 10.1007/s00428-006-0254-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2006] [Accepted: 06/13/2006] [Indexed: 11/29/2022]
Abstract
Pathological staging and surgical margin status of radical prostatectomy specimens are next to grading the most important prognosticators for recurrence. A central review of pathological stage and surgical margin status was performed on a series of 552 radical prostatectomy specimens of patients, participating in the European Organisation for Research and Treatment of Cancer trial 22911. Inclusion criteria of the trial were pathological stage pT3 and/or positive surgical margin at local pathology. All specimens were totally embedded. Data of the central review were compared with those of local pathologists and related to clinical follow-up. Although a high concordance between review pathology and local pathologists existed for seminal vesicle invasion (94%, kappa=0.83), agreement was much less for extraprostatic extension (57.5%, kappa=0.33) and for surgical margin status (69.4%, kappa=0.45). Review pathology of surgical margin status was a stronger predictor of biochemical progression-free survival in univariate analysis [hazard ratio (HR)=2.16 and p=0.0002] than local pathology (HR=1.08 and p>0.1). The review pathology demonstrated a significant difference between those with and without extraprostatic extension (HR=1.83 and p=0.0017), while local pathology failed to do so (HR=1.05 and p>0.8). The observations suggest that review of pathological stage and surgical margin of radical prostatectomy strongly improves their prognostic impact in multi-institutional studies or trials.
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Affiliation(s)
- Theodorus H van der Kwast
- Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Canada, and Department of Urology, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium.
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Schostak M, Krause H, Miller K, Schrader M, Weikert S, Christoph F, Kempkensteffen C, Kollermann J. Quantitative real-time RT-PCR of CD24 mRNA in the detection of prostate cancer. BMC Urol 2006; 6:7. [PMID: 16539730 PMCID: PMC1435920 DOI: 10.1186/1471-2490-6-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2005] [Accepted: 03/15/2006] [Indexed: 11/23/2022] Open
Abstract
Background Gene expression profiling has recently shown that the mRNA for CD24 is overexpressed in prostate carcinomas (Pca) compared to benign or normal prostate epithelial tissues. Immunohistochemical studies have reported the usefulness of anti-CD24 for detecting prostate cancer over the full range of prostate specimens encountered in surgical pathology, e.g. needle biopsies, transurethral resection of prostate chips, or prostatectomies. It is a small mucin-like cell surface protein and thus promises to become at least a standard adjunctive stain for atypical prostate biopsies. We tested the usefulness of real-time RT-PCR for specific and sensitive detection of CD24 transcripts as a supplementary measure for discriminating between malignant and benign lesions in prostatic tissues. Methods Total RNA was isolated from snap-frozen chips in 55 cases of benign prostatic hyperplasia (BPH) and from frozen sections in 59 prostatectomy cases. The latter contain at least 50% malignant epithelia. Relative quantification of CD24 transcripts was performed on the LightCycler instrument using hybridization probes for detection and porphobilinogen deaminase transcripts (PBGD) for normalization. Results Normalized CD24 transcript levels showed an average 2.69-fold increase in 59 Pca-cases (mean 0.21) when compared to 55 cases of BPH (mean 0.08). This difference was highly significant (p < 0.0001). The method has a moderate specificity (47.3%) but a high sensitivity (86.4%) if the cutoff is set at 0.0498. CD24 expression levels among Pca cases were not statistically associated with the tumor and lymph-node stage, the grading (WHO), the surgical margins, or the Gleason score. Conclusion The present study demonstrates the feasibility of quantitative CD24 RNA transcript detection in prostatic tissues even without previous laser microdissection.
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Affiliation(s)
- M Schostak
- Department of Urology, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
| | - H Krause
- Department of Urology, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
| | - K Miller
- Department of Urology, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
| | - M Schrader
- Department of Urology, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
| | - S Weikert
- Department of Urology, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
| | - F Christoph
- Department of Urology, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
| | - C Kempkensteffen
- Department of Urology, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Germany
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Smith JA, Herrell SD. Robotic-assisted laparoscopic prostatectomy: do minimally invasive approaches offer significant advantages? J Clin Oncol 2005; 23:8170-5. [PMID: 16278469 DOI: 10.1200/jco.2005.03.1963] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Radical prostatectomy has maintained a cardinal role in the treatment of localized prostate cancer. Robotic-assisted laparoscopic prostatectomy (RALP) has been introduced as a less invasive surgical approach. Available data on RALP versus open approaches were reviewed for surgical and cancer related outcomes. RALP is consistently associated with decreased blood loss and limited postoperative pain and hospital stay. Surgical margins seem similar between most reported series of RALP or open radical prostatectomy. Most intrainstitutional comparisons demonstrate better postoperative continence and potency with RALP, but there is still debate about whether results are superior to radical retropubic prostatectomy in the hands of a highly experienced surgeon. RALP provides outcomes at least comparable, and, in some measures, superior to open surgery. Refinements of instrumentation may provide even better results in the future.
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Affiliation(s)
- Joseph A Smith
- Vanderbilt University Medical Center, Department of Urologic Surgery, A 1302 Medical Center N, Nashville, TN 37232-2765, USA.
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