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Fonseca J, Moraes-Fontes MF, Rebola J, Lúcio R, Almeida M, Muresan C, Palmas A, Gaivão A, Matos C, Santos T, Dias D, Sousa I, Oliveira F, Ribeiro R, Lopez-Beltran A, Fraga A. Retzius-sparing robot-assisted radical prostatectomy in a medium size oncological center holds adequate oncological and functional outcomes. J Robot Surg 2023; 17:1133-1142. [PMID: 36633734 DOI: 10.1007/s11701-022-01517-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 12/31/2022] [Indexed: 01/13/2023]
Abstract
Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has emerged as a surgical option for patients with prostatic cancer in high-volume centers. The objective is to assess oncological and functional outcomes when implementing RS-RARP in a medium-volume center without previous experience of robotic surgery. This is a prospective observational single-center study. Patients operated between July 2017 and April 2020 were divided into two consecutive groups, A and B, each with 104 patients. The surgeons had prior experience in laparoscopic surgery and underwent robotic training. Positive surgical margin (PSM) status, urinary continence, and erectile function projected by Kaplan-Meier curves, together with patient reported quality of life outcomes at 12 months post-surgery were documented. Median patient age was 63 years (IQR = 59-67), overall PSM rate were 33%, 28% for pT2 disease. Pre-operative values showed no significant difference between both groups. The rate of urinary continence dropped from 81 to 78% (SE = 5.7) (Group A) and from 90 to 72% (SE = 6.3) (Group B) using the International Consultation on Incontinence Questionnaire-Short Form. Baseline sexual function was regained in 41% (Group A) and 47% (Group B) of patients. The median Expanded Prostate Index Composite-26 total score decreased from 86 to 82. These outcomes relate favorably to prior reports. There was a clinically significant decrease in median operative time in the successive groups with post-operative complications occurring in less than 2% of surgical procedures overall. A 12-month follow-up suggests that RS-RARP may be safely introduced in a medium-volume center without previous experience of robotic surgery.
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Affiliation(s)
- Jorge Fonseca
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal. .,Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal.
| | | | - Jorge Rebola
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Rui Lúcio
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Miguel Almeida
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Ciprian Muresan
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Artur Palmas
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Ana Gaivão
- Centro Clínico Champalimaud, Serviço de Imagiologia, Champalimaud Foundation, Lisbon, Portugal
| | - Celso Matos
- Centro Clínico Champalimaud, Serviço de Imagiologia, Champalimaud Foundation, Lisbon, Portugal
| | - Tiago Santos
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Daniela Dias
- Centro Clínico Champalimaud, Unidade de Próstata, Champalimaud Foundation, Av. Brasília, 1400-038, Lisbon, Portugal
| | - Inês Sousa
- Centro Clínico Champalimaud, Unidade de Investigação Clínica, Champalimaud Foundation, Lisbon, Portugal
| | - Francisco Oliveira
- Centro Clínico Champalimaud, Serviço de Medicina Nuclear, Champalimaud Foundation, Lisbon, Portugal
| | - Ricardo Ribeiro
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal
| | - Antonio Lopez-Beltran
- Centro Clínico Champalimaud, Unidade de Anatomia Patológica, Champalimaud Foundation, Lisbon, Portugal
| | - Avelino Fraga
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Oporto, Portugal
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Tsumura H, Tanaka N, Oguchi T, Owari T, Nakai Y, Asakawa I, Iijima K, Kato H, Hashida I, Tabata KI, Satoh T, Ishiyama H. Direct comparison of low-dose-rate brachytherapy versus radical prostatectomy using the surgical definition of biochemical recurrence for patients with intermediate-risk prostate cancer. Radiat Oncol 2022; 17:71. [PMID: 35410307 PMCID: PMC8996640 DOI: 10.1186/s13014-022-02046-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/02/2022] [Indexed: 11/10/2022] Open
Abstract
Background We compared the oncological outcomes of patients who received seed brachytherapy (SEED-BT) with those who received radical prostatectomy (RP) for intermediate-risk prostate cancer. Methods Candidates were patients treated with either SEED-BT (n = 933) or RP (n = 334). One-to-one propensity score matching was performed to adjust the patients’ backgrounds. We compared the biochemical recurrence (BCR)-free rate using the Phoenix definition (prostate-specific antigen [PSA] nadir plus 2 ng/mL) for SEED-BT and the surgical definition (PSA cut-off value of 0.2 ng/mL) for RP. We also directly compared the BCR-free rates using the same PSA cut-off value of 0.2 ng/mL for both SEED-BT and RP. Results In the propensity score-matched analysis with 214 pairs, the median follow-up treatment was 96 months (range 1–158 months). Fifty-three patients (24.7%) were treated with combined SEED-BT and external-beam radiotherapy. Forty-three patients (20.0%) received salvage radiotherapy after RP. Comparing the BCR-free rate using the above definitions for SEED-BT and RP showed that SEED-BT yielded a significantly better 8-year BCR-free rate than did RP (87.4% vs. 74.3%, hazard ratio [HR] 0.420, 95% confidence interval [CI] 0.273–0.647). Comparing the 8-year BCR-free rate using the surgical definition for both treatments showed no significant difference between the two treatments (76.7% vs. 74.3%, HR 0.913, 95% CI 0.621–1.341). SEED-BT had a significantly better 8-year salvage hormonal therapy-free rate than did RP (92.0% vs. 85.6%, HR 0.528, 95% CI 0.296–0.942, P = 0.030). The 8-year metastasis-free survival rates (98.5% vs. 99.0%, HR 1.382, 95% CI 0.313–6.083, P = 0.668) and overall survival rates (91.9% vs. 94.6%, HR 1.353, 95% CI 0.690–2.650) did not significantly differ between the treatments. Conclusions The BCR-free rates did not significantly differ between patients treated with SEED-BT and those treated with RP for intermediate-risk prostate cancer even when they were directly compared using the surgical definition for BCR. SEED-BT and RP can be adequately compared for oncological outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s13014-022-02046-x.
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John JB, Pascoe J, Fowler S, Walton T, Johnson M, Aning J, Challacombe B, Bufacchi R, Dickinson AJ, McGrath JS. A ‘real-world’ standard for radical prostatectomy: Analysis of the British Association of Urological Surgeons Complex Operations Reports, 2016–2018. JOURNAL OF CLINICAL UROLOGY 2022. [DOI: 10.1177/20514158211063964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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
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Affiliation(s)
| | - John Pascoe
- Royal Devon and Exeter NHS Foundation Trust, UK
| | - Sarah Fowler
- The British Association of Urological Surgeons, UK
| | | | - Mark Johnson
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, UK
| | | | | | - Rory Bufacchi
- Italian Institute of Technology, Italy
- Department of Neuroscience, Physiology and Pharmacology, University College London (UCL), UK
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John JB, Pascoe J, Fowler S, Walton T, Johnson M, Challacombe B, Dickinson AJ, Aning J, McGrath JS. A nationwide trend away from radical prostatectomy for Gleason Grade Group 1 prostate cancer. BJU Int 2021; 129:311-314. [PMID: 34825460 DOI: 10.1111/bju.15656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 11/08/2021] [Accepted: 11/23/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Joseph B John
- The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - John Pascoe
- The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Sarah Fowler
- British Association of Urological Surgeons (BAUS), The Royal College of Surgeons, London, UK
| | - Thomas Walton
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark Johnson
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | | | | | - John S McGrath
- The Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Gray WK, Day J, Briggs TWR, Harrison S. An observational study of volume-outcome effects for robot-assisted radical prostatectomy in England. BJU Int 2021; 129:93-103. [PMID: 34133832 DOI: 10.1111/bju.15516] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To investigate volume-outcome relationships in robot-assisted radical prostatectomy (RARP) for cancer using data from the Hospital Episodes Statistics (HES) database for England. MATERIALS AND METHODS Data for all adult, elective RPs for cancer during the period January 2013-December 2018 (inclusive) were extracted from the HES database. The HES database records data on all National Health Service (NHS) hospital admissions in England. Data were extracted for the NHS trust and surgeon undertaking the procedure, the surgical technique used (laparoscopic, open or robot-assisted), hospital length of stay (LOS), emergency readmissions, and deaths. Multilevel modelling was used to adjust for hierarchy and covariates. RESULTS Data were available for 35 629 RPs (27 945 RARPs). The proportion of procedures conducted as RARPs increased from 53.2% in 2013 to 92.6% in 2018. For RARP, there was a significant relationship between 90-day emergency hospital readmission (primary outcome) and trust volume (odds ratio [OR] for volume decrease of 10 procedures: 0.99, 95% confidence interval [CI] 0.99-1.00; P = 0.037) and surgeon volume (OR for volume decrease of 10 procedures: 0.99, 95% CI 0.99-1.00; P = 0.013) in the previous year. From lowest to highest volume category there was a decline in the adjusted proportion of patients readmitted as an emergency at 90 days from 10.6% (0-49 procedures) to 7.0% (≥300 procedures) for trusts and from 9.4% (0-9 procedures) to 8.3% (≥100 procedures) for surgeons. LOS was also significantly associated with surgeon and trust volume, although 1-year mortality was associated with neither. CONCLUSIONS There is evidence of a volume-outcome relationship for RARP in England and minimising low-volume RARP will improve patient outcomes. Nevertheless, the observed effect size was relatively modest, and stakeholders should be realistic when evaluating the likely impact of further centralisation at a population level.
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Affiliation(s)
- William K Gray
- Getting It Right First Time programme, NHS England and NHS Improvement, London, UK
| | - Jamie Day
- Getting It Right First Time programme, NHS England and NHS Improvement, London, UK
| | - Tim W R Briggs
- Getting It Right First Time programme, NHS England and NHS Improvement, London, UK.,Royal National Orthopaedic Hospital, Stanmore, London, UK
| | - Simon Harrison
- Getting It Right First Time programme, NHS England and NHS Improvement, London, UK.,Pinderfields Hospital, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
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Van den Broeck T, Oprea-Lager D, Moris L, Kailavasan M, Briers E, Cornford P, De Santis M, Gandaglia G, Gillessen Sommer S, Grummet JP, Grivas N, Lam TBL, Lardas M, Liew M, Mason M, O'Hanlon S, Pecanka J, Ploussard G, Rouviere O, Schoots IG, Tilki D, van den Bergh RCN, van der Poel H, Wiegel T, Willemse PP, Yuan CY, Mottet N. A Systematic Review of the Impact of Surgeon and Hospital Caseload Volume on Oncological and Nononcological Outcomes After Radical Prostatectomy for Nonmetastatic Prostate Cancer. Eur Urol 2021; 80:531-545. [PMID: 33962808 DOI: 10.1016/j.eururo.2021.04.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 04/19/2021] [Indexed: 12/13/2022]
Abstract
CONTEXT The impact of surgeon and hospital volume on outcomes after radical prostatectomy (RP) for localised prostate cancer (PCa) remains unknown. OBJECTIVE To perform a systematic review on the association between surgeon or hospital volume and oncological and nononcological outcomes following RP for PCa. EVIDENCE ACQUISITION Medline, Medline In-Process, Embase, and the Cochrane Central Register of Controlled Trials were searched. All comparative studies for nonmetastatic PCa patients treated with RP published between January 1990 and May 2020 were included. For inclusion, studies had to compare hospital or surgeon volume, defined as caseload per unit time. Main outcomes included oncological (including prostate-specific antigen persistence, positive surgical margin [PSM], biochemical recurrence, local and distant recurrence, and cancer-specific and overall survival) and nononcological (perioperative complications including need for blood transfusion, conversion to open procedure and within 90-d death, and continence and erectile function) outcomes. Risk of bias (RoB) and confounding assessments were undertaken. Both a narrative and a quantitative synthesis were planned if the data allowed. EVIDENCE SYNTHESIS Sixty retrospective comparative studies were included. Generally, increasing surgeon and hospital volumes were associated with lower rates of mortality, PSM, adjuvant or salvage therapies, and perioperative complications. Combining group size cut-offs as used in the included studies, the median threshold for hospital volume at which outcomes start to diverge is 86 (interquartile range [IQR] 35-100) cases per year. In addition, above this threshold, the higher the caseload, the better the outcomes, especially for PSM. RoB and confounding were high for most domains. CONCLUSIONS Higher surgeon and hospital volumes for RP are associated with lower rates of PSMs, adjuvant or salvage therapies, and perioperative complications. This association becomes apparent from a caseload of >86 (IQR 35-100) per year and may further improve hereafter. Both high- and low-volume centres should measure their outcomes, make them publicly available, and improve their quality of care if needed. PATIENT SUMMARY We reviewed the literature to determine whether the number of prostate cancer operations (radical prostatectomy) performed in a hospital affects the outcomes of surgery. We found that, overall, hospitals with a higher number of operations per year have better outcomes in terms of cancer recurrence and complications during or after hospitalisation. However, it must be noted that surgeons working in hospitals with lower annual operations can still achieve similar or even better outcomes. Therefore, making hospital's outcome data publicly available should be promoted internationally, so that patients can make an informed decision where they want to be treated.
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Affiliation(s)
| | - Daniela Oprea-Lager
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, VU University, Amsterdam, The Netherlands
| | - Lisa Moris
- Department of Urology, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Philip Cornford
- Department of Urology, Liverpool University Hospitals, Liverpool, UK
| | - Maria De Santis
- Department of Urology, Charité University Hospital, Berlin, Germany; Department of Urology, Medical University of Vienna, Vienna, Austria
| | - Giorgio Gandaglia
- Unit of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Silke Gillessen Sommer
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Università della Svizzera Italiana, Lugano, Switzerland
| | - Jeremy P Grummet
- Department of Surgery, Central Clinical School, Monash University, Australia
| | - Nikos Grivas
- Department of Urology, Hatzikosta General Hospital, Ioannina, Greece
| | - Thomas B L Lam
- Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Michael Lardas
- Department of Urology, Metropolitan General Hospital, Athens, Greece
| | - Matthew Liew
- Department of Urology, Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, Wigan, UK
| | - Malcolm Mason
- Division of Cancer & Genetics, School of Medicine Cardiff University, Velindre Cancer Centre, Cardiff, UK
| | - Shane O'Hanlon
- Medicine for Older People, Saint Vincent's University Hospital, Dublin, Ireland
| | | | | | - Olivier Rouviere
- Hospices Civils de Lyon, Department of Urinary and Vascular Imaging, Hôspital Edouard Herriot, Lyon, France
| | - Ivo G Schoots
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre, Rotterdam, The Netherlands; Department of Radiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Centre, Hamburg, Germany; Department of Urology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | | | - Henk van der Poel
- Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Peter-Paul Willemse
- Department of Oncological Urology, University Medical Centre, Utrecht Cancer Centre, Utrecht, The Netherlands
| | - Cathy Y Yuan
- Department of Medicine, Health Science Centre, McMaster University, Hamilton, Ontario, Canada
| | - Nicolas Mottet
- Department of Urology, University Hospital, St. Etienne, France
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[Does structural and process quality of certified prostate cancer centers result in better medical care?]. Urologe A 2021; 60:59-66. [PMID: 32876699 DOI: 10.1007/s00120-020-01321-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND An improved structural and process quality could be demonstrated 13 years after certification of the first German prostate cancer center. The question of optimization of the functional quality by establishing organ cancer centers arises. OBJECTIVE A critical benefit-risk analysis of organ cancer centers was carried out to evaluate an improved quality of results. MATERIAL AND METHODS Based on published results from individual centers and the individual annual reports of the German Cancer Society (DKG), the data for evaluating the quality of results were checked. For the issuing of certificates, the focus is on quality indicators for oncological surgery. The functional quality of results is assessed exclusively by a questionnaire-based survey. RESULTS An improvement in the quality of functional results after radical prostatectomy has not yet been demonstrated. The functional quality features of urinary continence and erectile function that are essential for the quality of life and patient satisfaction are only insufficiently assessed due to the lack of objective measuring instruments and are not relevant for certification. There is no reliable evidence for improved overall survival, reduction in tumor-specific mortality, and optimization of functional results in certified centers. CONCLUSION The relationship between certification and excellence cannot be proven without individual consideration of a surgeon-specific pentafecta analysis. For this reason, certification-relevant surgeon-related quality assurance is recommended.
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Bullock N, Simpkin A, Fowler S, Varma M, Kynaston H, Narahari K. Pathological upgrading in prostate cancer treated with surgery in the United Kingdom: trends and risk factors from the British Association of Urological Surgeons Radical Prostatectomy Registry. BMC Urol 2019; 19:94. [PMID: 31623595 PMCID: PMC6798468 DOI: 10.1186/s12894-019-0526-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 09/24/2019] [Indexed: 12/11/2022] Open
Abstract
Background Accurate grading at the time of diagnosis if fundamental to risk stratification and treatment decision making in patients with prostate cancer. Whilst previous studies have demonstrated significant pathological upgrading and downgrading following radical prostatectomy (RP), these were based on historical cohorts and do not reflect contemporary patient selection and management practices. The aim of this national, multicentre observational study was to characterise contemporary rates and risk factors for pathological upgrading after RP in the United Kingdom (UK). Methods All RP entries on the British Association of Urological Surgeons (BAUS) Radical Prostatectomy Registry database of prospectively entered cases undertaken between January 2011 and December 2016 were extracted. Those patients with full preoperative PSA, clinical stage, needle biopsy and subsequent RP pathological grade information were included. Upgrade was defined as any increase in Gleason grade from initial needle biopsy to pathological assessment of the entire surgical specimen. Statistical analysis and multivariate logistic regression were undertaken using R version 3.5 (R Foundation for Statistical Computing, Vienna, Austria). Results A total of 17,598 patients met full inclusion criteria. Absolute concordance between initial biopsy and pathological grade was 58.9% (n = 10,364), whilst upgrade and downgrade rates were 25.5% (n = 4489) and 15.6% (n = 2745) respectively. Upgrade rate was highest in those with D’Amico low risk compared with intermediate and high-risk disease (55.7% versus 19.1 and 24.3% respectively, P < 0.001). Although rates varied between year of surgery and geographical regions, these differences were not significant after adjusting for other preoperative diagnostic variables using multivariate logistic regression. Conclusions Pathological upgrading after RP in the UK is lower than expected when compared with other large contemporary series, despite operating on a generally higher risk patient cohort. As new diagnostic techniques that may reduce rates of pathological upgrading become more widely utilised, this study provides an important benchmark against which to measure future performance.
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Affiliation(s)
- Nicholas Bullock
- Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, UK. .,Department of Urology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK.
| | - Andrew Simpkin
- School of Mathematics, Statistics and Applied Mathematics, National University of Ireland, Galway, Ireland
| | - Sarah Fowler
- British Association of Urological Surgeons, London, UK
| | - Murali Varma
- Department of Cellular Pathology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Howard Kynaston
- Division of Cancer and Genetics, Cardiff University School of Medicine, Cardiff, UK.,Department of Urology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - Krishna Narahari
- Department of Urology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
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9
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Nguyen L, Leung LY, Walker R, Nitkunan T, Sharma D, Seth J. The use of urethral bulking injections in post‐prostatectomy stress urinary incontinence: A narrative review of the literature. Neurourol Urodyn 2019; 38:2060-2069. [DOI: 10.1002/nau.24143] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/31/2019] [Indexed: 11/08/2022]
Affiliation(s)
- Linh Nguyen
- St George's University of LondonCranmer Terrace London UK
| | - Lap Yan Leung
- Department of UrologySt George's NHS Foundation Trust London UK
| | - Roger Walker
- Department of UrologyEpsom and St Helier University Hospitals NHS Trust UK
| | - Tharani Nitkunan
- Department of UrologyEpsom and St Helier University Hospitals NHS Trust UK
| | - Davendra Sharma
- Department of UrologySt George's NHS Foundation Trust London UK
| | - Jai Seth
- Department of UrologySt George's NHS Foundation Trust London UK
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10
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Aning JJ, Reilly GS, Fowler S, Challacombe B, McGrath JS, Sooriakumaran P. Perioperative and oncological outcomes of radical prostatectomy for high-risk prostate cancer in the UK: an analysis of surgeon-reported data. BJU Int 2019; 124:441-448. [DOI: 10.1111/bju.14687] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jonathan J. Aning
- Bristol Urological Institute; North Bristol NHS Trust; Southmead Hospital; Westbury-on-Trym, Bristol UK
| | - Gavin S. Reilly
- Centre for Statistics in Medicine; Botnar Research Centre; University of Oxford; Oxford UK
| | - Sarah Fowler
- British Association of Urological Surgeons; London UK
| | - Ben Challacombe
- King's Health Partners; Guys Hospital; King's College London; London UK
| | - John S. McGrath
- Exeter Surgical Health Services Research Unit; Royal Devon and Exeter Hospital; Exeter UK
| | - Prasanna Sooriakumaran
- University College London Hospital NHS Foundation Trust; London UK
- Nuffield Department of Surgical Sciences; University of Oxford; Oxford UK
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Preisser F, Pompe RS, Salomon G, Rosenbaum C, Graefen M, Huland H, Karakiewicz PI, Tilki D. Impact of the estimated blood loss during radical prostatectomy on functional outcomes. Urol Oncol 2019; 37:298.e11-298.e17. [DOI: 10.1016/j.urolonc.2019.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/11/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022]
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Cashman S, Biers S, Greenwell T, Harding C, Morley R, Cooper D, Fowler S, Thiruchelvam N. Results of the British Association of Urological Surgeons female stress urinary incontinence procedures outcomes audit 2014-2017. BJU Int 2018; 123:149-159. [PMID: 30222915 DOI: 10.1111/bju.14541] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To analyse the results of the stress urinary incontinence (SUI) audit conducted by the British Association of Urological Surgeons (BAUS), and to present UK urologists' contemporary management of SUI. PATIENTS AND METHODS The BAUS audit tool is an online resource, to which all UK urologists performing procedures for SUI are invited to submit data. The data entries for procedures performed during 2014-2016 were collated and analysed. RESULTS Over the 3-year period analysed, 2917 procedures were reported by 109 surgeons, with a median of 20 procedures reported per surgeon. A total of 2 366 procedures (81.1%) were recorded as a primary surgery, with 548 procedures (18.8%) performed for recurrent SUI. Within the time period analysed, changes were noted in the frequency of all procedures performed, with a trend towards a reduction in the use of synthetic mid-urethral tapes, and a commensurate increase in the use of urethral bulking agents and autologous fascial slings. A total of 107 (3.9% of patients) peri-operative complications were recorded, with no association identified with patient age, BMI or surgeon volume. Follow-up data were available on 1832 patients (62.8%) at a median of 100 days postoperatively. Reduced pad use was reported in 1311 of patients (84.5%) with follow-up data available and 86.3% reported a pad use of one or less per day. In all, 375 patients (85%) reported being satisfied or very satisfied with the outcome of their procedure at follow-up, although data entry for this domain was poor. De novo overactive bladder (OAB) symptoms were reported by 15.2% of patients (263/1727), and this was the most commonly reported postoperative complication. For those reporting pre-existing OAB prior to their SUI surgery, 28.7% (307/1069) of patients reported they got better after their procedure, whilst 61.9% (662/1069) of patients reported no change and 9.4% of patients (100/1 069) got worse. CONCLUSIONS This review identified that, despite urological surgeons undertaking a relatively low volume of procedures per year, SUI surgery by UK urologists is associated with excellent short-term surgeon- and patient-reported outcomes and low numbers of low grade complications. Complications do not appear to be associated with surgeon volume, nor do they appear higher in those undergoing mesh surgery. Shortfalls in data collection have been identified, and a longer follow-up period is required to comment adequately on long-term complications, such as chronic pain and tape extrusion/erosion rates.
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Affiliation(s)
- Sophia Cashman
- Luton and Dunstable Hospital NHS Foundation Trust, London, UK
| | - Suzanne Biers
- Cambridge University Hospitals NHS Trust, Cambridge, UK
| | | | - Chris Harding
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - David Cooper
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Bach PV, Patel N, Najari BB, Oromendia C, Flannigan R, Brannigan R, Goldstein M, Hu JC, Kashanian JA. Changes in practice patterns in male infertility cases in the United States: the trend toward subspecialization. Fertil Steril 2018; 110:76-82. [DOI: 10.1016/j.fertnstert.2018.03.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 03/13/2018] [Accepted: 03/14/2018] [Indexed: 11/16/2022]
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Leow JJ, Leong EK, Serrell EC, Chang SL, Gruen RL, Png KS, Beaule LT, Trinh QD, Menon MM, Sammon JD. Systematic Review of the Volume-Outcome Relationship for Radical Prostatectomy. Eur Urol Focus 2017; 4:775-789. [PMID: 28753874 DOI: 10.1016/j.euf.2017.03.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Radical prostatectomy (RP) is one of the most complex urological procedures performed. Higher surgical volume has been found previously to be associated with better patient outcomes and reduced costs to the health care system. This has resulted in some regionalization of care toward high-volume facilities and providers; however, the preponderance of RPs is still performed at low-volume institutions. OBJECTIVE To provide an updated systematic review of the association of hospital and surgeon volume on patient and system outcomes after RP, including robot-assisted RP. EVIDENCE ACQUISITION A systematic review of literature was undertaken, searching PubMed (1959-2016) for original articles. Selection criteria included RP, hospital and/or surgeon volumes as predictor variables, categorization of hospital and/or surgeon volumes, and measurable end points. EVIDENCE SYNTHESIS Overall 49 publications fulfilled the inclusion criteria. Most of the studies demonstrated that higher-volume surgeries are associated with better outcomes including reduced mortality, morbidity, postoperative complications, length of stay, readmission, and cost-associated factors. The volume-outcome relationship is maintained in robotic surgery. Eleven studies assessed hospital and surgeon volume simultaneously, and findings reflect that neither is an independent predictor variable affecting outcomes. The studies varied in how volume cutoffs were categorized as well as how the volume-outcome relationship was methodologically evaluated. CONCLUSIONS Contemporary evidence continues to support the relationship between high-volume surgeries with improved RP outcomes. Recent studies demonstrate that the volume-outcome relationship applies to robot-assisted RP and may be applied for potential cost savings in health care. An increase in the number of international studies suggests reproducibility of the association. Although regionalization of surgical care remains a contentious issue, there is an increasing body of evidence that short-term outcomes are improved at high-volume centers for RP. PATIENT SUMMARY This systematic review of the latest literature found that higher surgical volume was associated with improved outcomes for radical prostatectomy.
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Affiliation(s)
- Jeffrey J Leow
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Eugene K Leong
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore-Imperial College London, Singapore
| | | | - Steven L Chang
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Russell L Gruen
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore-Imperial College London, Singapore
| | - Keng Siang Png
- Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Lisa T Beaule
- Tufts University School of Medicine, Boston, MA, USA; Division of Urology, Maine Medical Center, Portland, ME, USA; Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA
| | - Quoc-Dien Trinh
- Division of Urological Surgery and Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mani M Menon
- VUI Center for Outcomes Research, Analytics and Evaluation, Henry Ford Health System, Detroit, MI, USA
| | - Jesse D Sammon
- Tufts University School of Medicine, Boston, MA, USA; Division of Urology, Maine Medical Center, Portland, ME, USA; Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME, USA.
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Tallman JE, Packiam VT, Wroblewski KE, Paner GP, Eggener SE. Influence of pathologist experience on positive surgical margins following radical prostatectomy. Urol Oncol 2017; 35:461.e1-461.e6. [PMID: 28302349 DOI: 10.1016/j.urolonc.2017.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 01/10/2017] [Accepted: 02/13/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND A positive surgical margin (PSM) following radical prostatectomy (RP) for prostate cancer is associated with increased risk of biochemical recurrence. We sought to examine whether the pathologist is an independent predictor of PSMs. METHODS We performed a retrospective review of 3,557 men who underwent RP for localized prostate cancer at our institution from 2003 to 2015. We evaluated 29 separate pathologists. Univariate and multivariable logistic regression were used to test variables previously shown to influence PSM rates. RESULTS Overall rate of PSM was 18.9%. Compared with patients without PSM, patients with PSM had higher body mass index (mean: 28.8 vs. 28.3), Gleason score≥7 (84% vs. 66%), extracapsular extension (51% vs. 20%), and median prostate-specific antigen (5.9 vs. 5.1ng/ml) (all P<0.05). Univariate logistic regression showed that surgeon experience, pathologist experience, and pathologist genitourinary fellowship training were all predictors of PSMs (all P<0.05). Multivariable regression analysis confirmed that decreased surgeon experience, increased pathologist experience, higher pathologic Gleason score, higher pathologic stage, and higher prostate-specific antigen were significant predictors of PSMs. Increasing surgeon experience was associated with decreased odds of PSM (odds ratio = 0.79 per 1 standard deviation increase, 95% CI [0.70-0.89]). In contrast, increasing pathologist experience was associated with increased odds of PSM (odds ratio = 1.11 per 1 standard deviation increase, 95% CI [1.03-1.19]). The relationship between pathologist experience and PSM appeared to be nonlinear (Fig. 2). CONCLUSIONS Greater pathologist experience appears to be associated with greater odds of PSMs following radical prostatectomy, even after controlling for case mix, pathologist fellowship training, and surgeon experience. Based on these findings, pathologists with less experience reviewing RP specimens may consider requesting rereview by a dedicated genitourinary pathologist.
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Affiliation(s)
- Jacob E Tallman
- Pritzker School of Medicine, The University of Chicago, Chicago, IL.
| | - Vignesh T Packiam
- Department of Surgery, The University of Chicago Medicine, Chicago, IL
| | | | - Gladell P Paner
- Department of Pathology, The University of Chicago Medicine, Chicago, IL
| | - Scott E Eggener
- Department of Surgery, The University of Chicago Medicine, Chicago, IL
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Jallad S, Hounsome L, Verne J, Mayer E. Where are we with improving outcome guidance? An update on pelvic urological services in the NHS. JOURNAL OF CLINICAL UROLOGY 2017. [DOI: 10.1177/2051415816664272] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background: The volume–outcome relationship in surgery has been a focus of interest for over a decade. The National Institute for Health and Care Excellence (NICE) published their improving outcome guidance in 2002, which encouraged a regionalised multidisciplinary approach in managing urological cancer cases and recommended centralisation of urological pelvic surgery. The current study offers an updated view on the urological pelvic services in England with regard to radical cystectomy (RC) and radical prostatectomy (RP) and adherence to improving outcome guidance guidelines and patterns of services provision since its introduction in 2002. Methods: The data for inpatient elective RC and RP were taken from hospital episodes statistics for 2003–2013. The RC and RP cases were calculated separately per year for every trust to calculate the annual rates and then combined for every trust. The catchment areas for RC and RP were calculated using the proportionate-flow method. Results: The number of trusts performing RC and RP reduced significantly over the 10 years, while in the same period, the numbers of RC and RP performed increased significantly ( P<0.05). There has been a steady increase in the cases referred to another trust for their RC or RP surgery ( P<0.05). Overall, there has been a significant increase in the number of trusts achieving the improving outcome guidance recommended minimal case volume of 50 or more (RC + RP combined) over the 10-year analysis ( P=0.0006). Conclusion: There has been a shift in urological pelvic surgery provision in England since the publication of improving outcome guidance by NICE in 2002, with over 95% of cases being performed in improving outcome guidance compliant centres achieving 50 cases or more per year. Simultaneously, a significant reduction in postoperative mortality and the hospital length of stay has been seen over this period.
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Affiliation(s)
- Samer Jallad
- Department of Urology, London North West Healthcare NHS Trust, UK
| | - Luke Hounsome
- Public Health England Knowledge and Intelligence Team (South West) Bristol, UK
| | - Julia Verne
- Public Health England Knowledge and Intelligence Team (South West) Bristol, UK
| | - Erik Mayer
- Department of Surgery & Cancer, Imperial College London, UK
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Leapman MS, Carroll PR. What is the best way not to treat prostate cancer? Urol Oncol 2016; 35:42-50. [PMID: 27746147 DOI: 10.1016/j.urolonc.2016.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 09/08/2016] [Accepted: 09/08/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Selective treatment approaches for prostate cancer (PCa) are warranted given the highly varied nature of the disease and the consequences associated with definitive therapy. MATERIALS AND METHODS We present a stepwise overview of strategies optimized to not treat PCa, ranging from improved screening practices that seek to maximize the yield at initial diagnosis, as well as refinements to clinical risk prediction and the performance of active surveillance. RESULTS Improved adherence to screening guidelines offering simplistic, rational practice recommendations are poised to improve the performance of early detection strategies. In addition, measures to improve the quality of PCa screening would include greater integration of novel markers with higher specificity for clinically significant disease, in an effort to stem the tide of over-diagnosis and consequential overtreatment of low-grade tumors. For men diagnosed with PCa, the use of validated, multi-variable risk stratification stands to offer greater certainty in initial management choices: consideration of active surveillance for those with low-risk status, and definitive therapy for men with intermediate and high-risk features. We review the efficacy and nature of active surveillance protocols, and offer a context for refinements that may be anticipated with future study. CONCLUSIONS The question of how best to not treat prostate cancer is often more complex than policies of universal treatment, yet is integral to minimize morbidity of over-treatment in patients with low-risk tumors. An array of refined risk stratification instruments, biomarkers, and genomic assays seek to improve the confidence both prior to, and following diagnosis.
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Affiliation(s)
- Michael S Leapman
- Department of Urology, Yale University School of Medicine, New Haven, CT.
| | - Peter R Carroll
- Department of Urology, University of California San Francisco, San Francisco, CA
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Aggarwal A, Nossiter J, Cathcart P, van der Meulen J, Rashbass J, Clarke N, Payne H. Organisation of Prostate Cancer Services in the English National Health Service. Clin Oncol (R Coll Radiol) 2016; 28:482-489. [DOI: 10.1016/j.clon.2016.02.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 11/28/2022]
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Bang SL, Almallah YZ. The Impact of Post-radical Prostatectomy Urinary Incontinence on Sexual and Orgasmic Well-being of Patients. Urology 2016; 89:1-5. [DOI: 10.1016/j.urology.2015.11.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/11/2015] [Accepted: 11/18/2015] [Indexed: 10/22/2022]
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20
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[Positive surgical margin status after minimally invasive radical prostatectomy: a multicenter study]. Urologia 2015; 82:229-37. [PMID: 26429390 DOI: 10.5301/uro.5000125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2015] [Indexed: 11/20/2022]
Abstract
UNLABELLED UNLABELLED: The aim of our study is to evaluate the status of positive margins (PSMs) comparing their incidence between aparoscopic radical prostatectomy (LRP) and robot assisted radical prostatectomy (RARP) in centers with medium case-load (50-150 cases/year). We also analyzed the correlations between surgical technique, nerve-sparing approach (NS), and incidence of PSMs, stratifying our results by pathological stage. MATERIALS AND METHODS We analyzed 1992 patients who underwent RP in various urologic centers. We evaluated the incidence of PSMs, and then we compared the stage-related incidence of PSMs, for both the techniques. RESULTS We did not find a statistically significant difference between the two surgical modalities in the study regarding the overall incidence of PSMs. CONCLUSIONS In our retrospective study, we did not find any difference in terms of PSMs in RARP versus LRP. Our PSMs were not negligible, particularly in pT3 stages, compared with high-volume centers; surgical experience and patients' selection can be a possible explanation.
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Abstract
PURPOSE OF REVIEW The purpose of this study is to review advances in both the pathogenesis and clinical management of biliary atresia. RECENT FINDINGS Immunologic studies have further characterized roles of helper T-cells, B-cells, and natural killer cells in the immune dysregulation following viral replication within and damage of biliary epithelium. Prominin-1-expressing portal fibroblasts may play an integral role in the biliary fibrosis associated with biliary atresia. A number of genetic polymorphisms have been characterized as leading to susceptibility for biliary atresia. Postoperative corticosteroid therapy is not associated with greater transplant-free survival. Newborn screening may improve outcomes of infants with biliary atresia and may also provide a long-term cost benefit. SUMMARY Although recent advances have enhanced our understanding of pathogenesis and clinical management, biliary atresia remains a significant challenge requiring further investigation.
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23
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Surgical learning curve for open radical prostatectomy: Is there an end to the learning curve? World J Urol 2015; 33:1721-7. [DOI: 10.1007/s00345-015-1540-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 03/10/2015] [Indexed: 11/26/2022] Open
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Retèl VP, Bouchardy C, Usel M, Neyroud-Caspar I, Schmidlin F, Wirth G, Iselin C, Miralbell R, Rapiti E. Determinants and effects of positive surgical margins after prostatectomy on prostate cancer mortality: a population-based study. BMC Urol 2014; 14:86. [PMID: 25374000 PMCID: PMC4234867 DOI: 10.1186/1471-2490-14-86] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/24/2014] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND The objective of this population-based study was to assess patient, physician and tumour determinants associated with positive surgical margins after prostatectomy, and to assess the effects of positive surgical margins on prostate cancer-specific survival. METHODS We included 1'254 prostate cancer patients recorded at the Geneva Cancer Registry who had radical prostatectomy during 1990-2008. To assess factors associated with positive margins, we used logistic regression. We assessed the effects of positive margins on prostate cancer-specific survival by Cox proportional hazard models accounting for numerous other prognostics factors including prostate and tumour volume, the total percentage of tumour, radiotherapy, surgical approach and surgeon's caseload. RESULTS Among men undergoing prostatectomy, 479 (38%) had positive margins. In the multivariate logistic regression analysis, period, clinical- and pathological T stage, Prostate Specific Antigen (PSA) level, Gleason score and percentage of tumour in the prostate were significantly associated to positive margins. Ten-year prostate cancer-specific survival was 96.6% for the negative margins group and 92.0% for the positive margins group (log rank p = 0.008). In the Cox survival analysis adjusted for tumour characteristics, surgical margin status per se was not an independent prognostic factor while age, pathological T, PSA level and Gleason score remained associated with prostate cancer-specific survival. CONCLUSIONS More aggressive tumour characteristics were strong determinants for positive margins. Furthermore, surgical margin status per se was not an independent prognostic factor for prostate cancer-specific survival after adjusting by the gravity of the disease in the multivariate analysis.
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Affiliation(s)
- Valesca P Retèl
- />Geneva Cancer Registry, Global Health Institute, University of Geneva, 55 Bd. de la Cluse, Geneva, 1205 Switzerland
| | - Christine Bouchardy
- />Geneva Cancer Registry, Global Health Institute, University of Geneva, 55 Bd. de la Cluse, Geneva, 1205 Switzerland
| | - Massimo Usel
- />Geneva Cancer Registry, Global Health Institute, University of Geneva, 55 Bd. de la Cluse, Geneva, 1205 Switzerland
| | - Isabelle Neyroud-Caspar
- />Geneva Cancer Registry, Global Health Institute, University of Geneva, 55 Bd. de la Cluse, Geneva, 1205 Switzerland
| | - Franz Schmidlin
- />Urological Centre, Clinique des Grangettes, chemin des Grangettes 7, Chêne-Bougeries, 1224 Switzerland
| | - Gregory Wirth
- />Department of Urology, Geneva University Hospitals, rue Gabrielle Perret-Gentil 4, Geneva, 1205 Switzerland
| | - Christophe Iselin
- />Department of Urology, Geneva University Hospitals, rue Gabrielle Perret-Gentil 4, Geneva, 1205 Switzerland
| | - Raymond Miralbell
- />Department of Radiation Oncology, Geneva University Hospitals, rue Willy Donzé 6, Geneva, 1205 Switzerland
| | - Elisabetta Rapiti
- />Geneva Cancer Registry, Global Health Institute, University of Geneva, 55 Bd. de la Cluse, Geneva, 1205 Switzerland
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Nayak JG, Drachenberg DE, Mau E, Suderman D, Bucher O, Lambert P, Quon H. The impact of fellowship training on pathological outcomes following radical prostatectomy: a population based analysis. BMC Urol 2014; 14:82. [PMID: 25339410 PMCID: PMC4216843 DOI: 10.1186/1471-2490-14-82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 10/15/2014] [Indexed: 11/23/2022] Open
Abstract
Background Radical prostatectomy (RP) is a common treatment for prostate cancer (PCa). Morbidity, mortality and pathological outcomes may be superior in academic institutions. One explanation may be the involvement of oncology fellowship trained urologists within academic institutions. The literature examining pathological outcomes often lacks individual surgeon data. The objective of this study was to compare pathological outcomes following RP between fellowship trained and non-fellowship trained urologists. Methods Population-based, retrospective chart review of men diagnosed with PCa between 2003 and 2008, the majority treated with open approach RP (>99%). Pathological outcomes were compared between oncology fellowship trained academic (FTA), non-fellowship trained academic (NFTA) and non-academic (NA) urologists. Relationships with pathological outcomes were examined utilizing multivariable logistic regression. Results 83.1% of eligible patients were included in our analysis resulting in 1075 patients. In multivariable analysis, surgeon group was an independent predictor of positive surgical margin (PSM) (p < 0.0001). NFTA and NA urologists were more likely to have PSM compared to FTA urologists (OR 2.50; 95% CI: 1.44 - 4.35 and OR 2.10; 95% CI: 1.53 - 2.88, respectively). However, the proportion of PSM between NFTA and NA urologists was not significant (p = 0.492). In addition, pathological stage (p = 0.0004), Gleason sum (p < 0.0001), and surgeon volume (p = 0.017) were associated with PSM. Limitations include retrospective design and lack of clinical and functional outcomes. Conclusions Uro-oncology fellowship trained surgeons had significantly lower rates of PSM than non-fellowship trained surgeons in this population based cohort. This study demonstrates the importance of surgeon-related variables on pathological outcomes and highlights the value of additional urologic oncology fellowship training.
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Affiliation(s)
| | | | | | | | | | | | - Harvey Quon
- CancerCare Manitoba, Winnipeg, Manitoba, Canada.
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Laird A, Fowler S, Good DW, Stewart GD, Srinivasan V, Cahill D, Brewster SF, McNeill SA. Contemporary practice and technique-related outcomes for radical prostatectomy in the UK: a report of national outcomes. BJU Int 2014; 115:753-63. [DOI: 10.1111/bju.12866] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Alexander Laird
- Department of Urology; Western General Hospital; Edinburgh UK
| | - Sarah Fowler
- The British Association of Urological Surgeons; London UK
| | - Daniel W. Good
- Department of Urology; Western General Hospital; Edinburgh UK
| | | | | | - Declan Cahill
- Department of Urology; Guy's and St Thomas' NHS Hospital Trust; London UK
| | | | - S. Alan McNeill
- Department of Urology; Western General Hospital; Edinburgh UK
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Sooriakumaran P, Srivastava A, Shariat SF, Stricker PD, Ahlering T, Eden CG, Wiklund PN, Sanchez-Salas R, Mottrie A, Lee D, Neal DE, Ghavamian R, Nyirady P, Nilsson A, Carlsson S, Xylinas E, Loidl W, Seitz C, Schramek P, Roehrborn C, Cathelineau X, Skarecky D, Shaw G, Warren A, Delprado WJ, Haynes AM, Steyerberg E, Roobol MJ, Tewari AK. A Multinational, Multi-institutional Study Comparing Positive Surgical Margin Rates Among 22393 Open, Laparoscopic, and Robot-assisted Radical Prostatectomy Patients. Eur Urol 2014; 66:450-6. [DOI: 10.1016/j.eururo.2013.11.018] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 11/14/2013] [Indexed: 10/26/2022]
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Trinh QD, Bjartell A, Freedland SJ, Hollenbeck BK, Hu JC, Shariat SF, Sun M, Vickers AJ. A systematic review of the volume-outcome relationship for radical prostatectomy. Eur Urol 2013; 64:786-98. [PMID: 23664423 PMCID: PMC4109273 DOI: 10.1016/j.eururo.2013.04.012] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Accepted: 04/09/2013] [Indexed: 01/09/2023]
Abstract
CONTEXT Due to the complexity and challenging nature of radical prostatectomy (RP), it is likely that both short- and long-term outcomes strongly depend on the cumulative number of cases performed by the surgeon as well as by the hospital. OBJECTIVE To review systematically the association between hospital and surgeon volume and perioperative, oncologic, and functional outcomes after RP. EVIDENCE ACQUISITION A systematic review of the literature was performed, searching PubMed, Embase, and Scopus databases for original and review articles between January 1, 1995, and December 31, 2011. Inclusion and exclusion criteria comprised RP, hospital and/or surgeon volume reported as a predictor variable, a measurable end point, and a description of multiple hospitals or surgeons. EVIDENCE SYNTHESIS Overall 45 publications fulfilled the inclusion criteria, where most data originated from retrospective institutional or population-based cohorts. Studies generally focused on hospital or surgeon volume separately. Although most of these analyses corroborated the impact of increasing volume with better outcomes, some failed to find any significant effect. Studies also differed with respect to the proposed volume cut-off for improved outcomes, as well as the statistical means of evaluating the volume-outcome relationship. Five studies simultaneously compared hospital and surgeon volume, where results suggest that the importance of either hospital or surgeon volume largely depends on the end point of interest. CONCLUSIONS Undeniable evidence suggests that increasing volume improves outcomes. Although it would seem reasonable to refer RP patients to high-volume centers, such regionalization may not be entirely practical. As such, the implications of such a shift in practice have yet to be fully determined and warrant further exploration.
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Affiliation(s)
- Quoc-Dien Trinh
- CRCHUM, Centre Hospitalier de l'Université de Montréal, Montreal, Canada; Cancer Prognostics and Health Outcomes Unit, Centre Hospitalier de l'Université de Montréal, Montreal, Canada; Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA.
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Bartkowiak D, Bottke D, Wiegel T. Radiotherapy in the management of prostate cancer after radical prostatectomy. Future Oncol 2013; 9:669-79. [PMID: 23647296 DOI: 10.2217/fon.13.3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The choice of treatment options for prostate cancer patients who have undergone radical prostatectomy depends on their risk profile, which is determined by the tumor node metastasis (TNM) status, histopathologic findings, and the pre- and post-radical prostatectomy PSA characteristics. The results of large clinical studies with a 10-year follow-up or more are the backbone of predictive models for risk estimates that incorporate these criteria and also for guideline recommendations. For low-to-intermediate-risk prostate cancer patients and older patients, observation with--in case of biochemical recurrence--early salvage radiotherapy can be advised after R0 resection, thus, avoiding overtreatment. After R1 resection, adjuvant radiotherapy should be considered. Patients with two or more positive lymph nodes and/or with distant metastasis may benefit from adjuvant hormone deprivation therapy. Beyond this rough outline, detailed analysis of subgroups is still required (and ongoing) to enable individually optimized treatment.
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Affiliation(s)
- Detlef Bartkowiak
- Radiation Oncology Department, University Hospital Ulm, Ulm, Germany.
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Greenberg DC, Wright KA, Lophathanon A, Muir KR, Gnanapragasam VJ. Changing presentation of prostate cancer in a UK population--10 year trends in prostate cancer risk profiles in the East of England. Br J Cancer 2013; 109:2115-20. [PMID: 24071596 PMCID: PMC3798976 DOI: 10.1038/bjc.2013.589] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 09/03/2013] [Accepted: 09/04/2013] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Prostate cancer incidence is rising in the United Kingdom but there is little data on whether the disease profile is changing. To address this, we interrogated a regional cancer registry for temporal changes in presenting disease characteristics. METHODS Prostate cancers diagnosed from 2000 to 2010 in the Anglian Cancer Network (n=21,044) were analysed. Risk groups (localised disease) were assigned based on NICE criteria. Age standardised incidence rates (IRs) were compared between 2000-2005 and 2006-2010 and plotted for yearly trends. RESULTS Over the decade, overall IR increased significantly (P<0.00001), whereas metastasis rates fell (P<0.0007). For localised disease, IR across all risk groups also increased but at different rates (P<0.00001). The most striking change was a three-fold increase in intermediate-risk cancers. Increased IR was evident across all PSA and stage ranges but with no upward PSA or stage shift. In contrast, IR of histological diagnosis of low-grade cancers fell over the decade, whereas intermediate and high-grade diagnosis increased significantly (P<0.00001). CONCLUSION This study suggests evidence of a significant upward migration in intermediate and high-grade histological diagnosis over the decade. This is most likely to be due to a change in histological reporting of diagnostic prostate biopsies. On the basis of this data, increasing proportions of newly diagnosed cancers will be considered eligible for radical treatment, which will have an impact on health resource planning and provision.
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Affiliation(s)
- D C Greenberg
- Public Health England, National Cancer Registration Service (Eastern Office), Cambridge CB22 3AD, UK
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Loeb S, Zhu X, Schroder FH, Roobol MJ. Long-term radical prostatectomy outcomes among participants from the European Randomized Study of Screening for Prostate Cancer (ERSPC) Rotterdam. BJU Int 2012; 110:1678-83. [PMID: 22998182 DOI: 10.1111/j.1464-410x.2012.11367.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
UNLABELLED Study Type--Therapy (cohort) Level of Evidence 2b. What's known on the subject? and What does the study add? Radical prostatectomy was previously shown to improve long-term outcomes among men with clinically-detected prostate cancer. Our data suggests that radical prostatectomy is also associated with improved outcomes in men with screen-detected prostate cancer. OBJECTIVE • To examine the long-term outcomes of radical prostatectomy (RP) among men diagnosed with prostate cancer from the screening and control arms of the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer (ERSPC). PATIENTS AND METHODS • Among 42,376 men randomised during the period of the first round of the trial (1993-1999), 1151 and 210 in the screening and control arms were diagnosed with prostate cancer, respectively. • Of these men, 420 (36.5%) screen-detected and 54 (25.7%) controls underwent RP with long-term follow-up data (median follow-up 9.9 years). • Progression-free (PFS), metastasis-free (MFS) and cancer-specific survival (CSS) rates were examined, and multivariable Cox proportional hazards models were used to determine whether screen-detected (vs control) was associated with RP outcomes after adjusting for standard predictors. RESULTS • RP cases from the screening and control arms had statistically similar clinical stage and biopsy Gleason score, although screen-detected cases had significantly lower prostate-specific antigen (PSA) levels at diagnosis. • Men from the screening arm had a significantly higher PFS (P = 0.003), MFS (P < 0.001) and CSS (P = 0.048). • In multivariable models adjusting for age, PSA level, clinical stage, and biopsy Gleason score, the screening group had a significantly lower risk of biochemical recurrence (hazard ratio [HR] 0.43, 95% confidence interval [CI] 0.23-0.83, P = 0.011) and metastasis (HR 0.18, 95% CI 0.06-0.59, P = 0.005). • Additionally adjusting for tumour volume and other RP pathology features, there was no longer a significant difference in biochemical recurrence between the screening and control arms. • Limitations of the present study include lead-time bias and non-randomised treatment selection. CONCLUSIONS • After RP, screen-detected cases had significantly improved PFS, MFS and CSS compared with controls within the available follow-up time. • The screening arm remained significantly associated with lower rates of biochemical recurrence and metastasis after adjusting for other preoperative variables. • However, considering also RP pathology, the improved outcomes in the screening group appeared to be mediated by a significantly lower tumour volume.
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Affiliation(s)
- Stacy Loeb
- Department of Urology, New York University, New York, NY, USA.
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Karavitakis M, Ahmed HU, Abel PD, Hazell S, Winkler MH. Anatomically versus biologically unifocal prostate cancer: a pathological evaluation in the context of focal therapy. Ther Adv Urol 2012; 4:155-60. [PMID: 22852025 DOI: 10.1177/1756287212447092] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Since tumor focality in prostate cancer continues to be considered a major limitation for focal prostate therapy, in this study we attempted to compare the pathological features and the proportion of patients with anatomically unifocal versus biologically unifocal tumors (i.e. multifocal prostate cancer in which the secondary nonindex elements are small, low grade and clinically insignificant) who were suitable for focal therapy. METHODS Ninety-five consecutive whole mount laparoscopic radical prostatectomy samples underwent pathological assessment (from January 2007 to November 2009). Tumor focality, laterality, Gleason score and volume of individual foci, total tumor volume, pathological stage and surgical margin status were assessed. The index lesion was defined as the largest by volume. Patients suitable for focal ablation were defined as having tumors that were unifocal, organ confined, with a Gleason score (GS) up to 7 prostate cancer, or multifocal, organ confined, GS up to 7 prostate cancer, with one large index lesion and the remaining foci demonstrating features of clinically insignificant disease (total tumor volume of all secondary foci ≤0.5 cm(3) with GS ≤ 6). RESULTS Patients with biologically unifocal cancer had significantly lower total tumor volume (3.26 versus 7.28 cm(3); p < 0.001), index lesion volume (2.9 versus 7.16 cm(3); p < 0.001), rates of seminal vesicle invasion (4% versus 34%; p < 0.001), rates of positive surgical margins (22.4% versus 52.1%; p < 0.001) and rates of 4+3 GS tumors (10.2% versus 29.1%; p = 0.018). The proportion of patients suitable for focal therapy was higher in the biologically unifocal versus anatomically unifocal cancer group, although without reaching statistical significance (65.3% versus 45.8%; p = 0.11). CONCLUSIONS Patients with biologically unifocal tumors have better pathological outcome than those with anatomically unifocal disease. At present the assumption that multifocality should a priori exclude patients from any organ-preserving prostate cancer treatment is only theoretical and needs to be validated by future clinical trials since there are a large proportion of patients with multifocal disease apparently suitable for focal prostate therapy.
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Affiliation(s)
- Markos Karavitakis
- Department of Urology, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK and Department of Urology, "St. Panteleimon" General Hospital of Nikaia, Peiraeus, Greece Kinikiou 30, 18450, Nikea, Piraeus, Greece
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Trinh QD, Sammon J, Jhaveri J, Sun M, Ghani KR, Schmitges J, Jeong W, Peabody JO, Karakiewicz PI, Menon M. Variations in the quality of care at radical prostatectomy. Ther Adv Urol 2012; 4:61-75. [PMID: 22496709 DOI: 10.1177/1756287211433187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Postoperative morbidity and mortality is low following radical prostatectomy (RP), though not inconsequential. Due to the natural history of the disease process, the implications of treatment on long-term oncologic control and functional outcomes are of increased significance. Structures, processes and outcomes are the three main determinants of quality of RP care and provide the framework for this review. Structures affecting quality of care include hospital and surgeon volume, hospital teaching status and patient insurance type. Process determinants of RP care have been poorly studied, by and large, but there is a developing trend toward the performance of randomized trials to assess the merits of evolving RP techniques. Finally, the direct study of RP outcomes has been particularly controversial and includes the development of quality of life measurement tools, combined outcomes measures, and the use of utilities to measure operative success based on individual patient priority.
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Steinsvik EAS, Axcrona K, Angelsen A, Beisland C, Dahl A, Eri LM, Haug ES, Svindland A, Fosså S. Does a surgeon's annual radical prostatectomy volume predict the risk of positive surgical margins and urinary incontinence at one-year follow-up? Findings from a prospective national study. Scand J Urol 2012; 47:92-100. [PMID: 22860630 DOI: 10.3109/00365599.2012.707684] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study aimed to assess the prevalence of positive surgical margins (PSM) and urinary incontinence (UI) in relation to surgeons' annual radical prostatectomy (RP) volume. MATERIAL AND METHODS This national study prospectively assessed 521 preoperatively continent patients with prostate cancer (PCa), scheduled for RP by surgeons with high (>50), medium (20-50) or low annual volume (<20) at 14 urological departments in Norway. Patients responded to UI questions from the Expanded Composite prostate cancer index (EPIC-50) before and 1 year after RP. UI was defined as "use of pad(s)" and/or "a moderate or severe urinary leakage problem (ULP)". Preoperative prediction of PSMs and UI was explored in multivariate regression analyses with the following independent variables: surgeons' annual RP volume, type of hospital (university versus community), patient's health, sociodemographic features and PCa characteristics. RESULTS Based on histopathological reports, the overall PSM rate was 26%, with differences between the high- (18%), medium- (28%) and low-volume (44%) groups. Increasing PSM rates were predicted by surgeons belonging to the low- and medium-volume categories, prostate-specific antigen> 10 µg/l, Gleason score >7, patient age >65 years and <12 years of education. At 1-year follow-up 40% reported UI, without significant differences between the volume groups. Only 46% of those who used pad(s) experienced ULP. UI was predicted by clinical category ≥T2 and community type of hospital, but not by surgeons' annual RP volume. CONCLUSIONS. Preoperative counselling should take into account the relationship between surgeon's annual RP volume and PSM rate and the current knowledge about UI and ULP.
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Affiliation(s)
- Eivind Andreas Svaboe Steinsvik
- National Resource Center for Late Effects after Cancer Treatment, The Norwegian Radium Hospital, Oslo University Hospital, Norway.
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Wehrberger C, Berger I, Willinger M, Madersbacher S. Radical prostatectomy in Austria from 1992 to 2009: an updated nationwide analysis of 33,580 cases. J Urol 2012; 187:1626-31. [PMID: 22425090 DOI: 10.1016/j.juro.2011.12.080] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE We analyzed the demographics and outcome of radical prostatectomy in Austria in a nationwide series. MATERIALS AND METHODS We analyzed the records of all 33,580 patients who underwent radical prostatectomy at a public hospital, including 95% of all surgical procedures, in Austria between 1992 and 2009. Patient demographics, perioperative mortality, interventions for anastomotic strictures and urinary incontinence, and overall survival were determined. Data were provided by the Austrian Health Institute. RESULTS The annual number of radical prostatectomies increased 688% from 396 in 1992 to 3,123 in 2007 and gradually decreased to 2,612 in 2009. Mean ± SD patient age at surgery decreased slightly from 64.4 ± 6.3 years in 1992 to 62.0 ± 6.7 years in 2003. Age has remained at that level since then. Endourological intervention for anastomotic stricture and urinary incontinence was done in 7.5% and 2.8% of cases, respectively. The risk of each intervention increased with patient age and decreased in patients treated within the last 10 years compared to those treated before 2000. The 30-day mortality rate was 0.1%, which increased threefold from the youngest to the oldest age group. Ten-year overall survival decreased from 93% in patients 45 to 49 years old to 63% in those 70 years old or older at surgery. CONCLUSIONS This nationwide analysis of a country that has had a public, equal access health care system for decades describes some current radical prostatectomy trends. Since 2007, the absolute number of radical prostatectomies has decreased. Data on morbidity, perioperative mortality and overall survival raise caution about performing radical prostatectomy in elderly men, eg those 70 years old or older.
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Affiliation(s)
- Clemens Wehrberger
- Department of Urology and Andrology, Donauspital and Austrian Health Institute (MW), Vienna, Austria
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