Surgery for high-risk localized prostate cancer

Lower urinary tract symptoms (LUTS) before and after robotic-assisted laparoscopic prostatectomy: does improvement of LUTS mitigate worsened incontinence after robotic prostatectomy?

Background

Urinary incontinence is a major concern for patients scheduled for radical prostatectomy. However, after prostatectomy lower urinary tract symptoms (LUTS) may improve and thus mitigate this concern. We assessed LUTS and its interference with the quality of life (QoL) using the short form of the international continence society male questionnaire (ICSMALESF-Q) in patients before and after robot-assisted radical prostatectomy (RARP). Furthermore, we aimed to identify risk factors for postoperative urinary incontinence.

Methods

Data of all patients who underwent RARP from 2009 to 2014 were prospectively collected in our customized database. We identified 453 eligible patients for whom a preoperative and at least two postoperative datasets including ICSMALESF-Q were available.

Results

Both the ICSMALESF-Q at 6 months (P<0.001) and the related QoL at 12 months (P<0.01) have significantly improved after RARP (P<0.001). Two years after RARP ICSMALESF-Q and thus LUTS have improved in 64%, remained unchanged in 18% and worsened in 18% of patients. The daily pad use was 0 in 79% and 0 or 1 pad in 95.6%, respectively. Increased patient age (P<0.05) was significantly associated with an increased average number of pads used per day (multiplicative effect: +2.1% pads for each year). Being in the D'Amico low-risk group reduced the average number of pads used by 22% (P<0.05, multiplicative effect 0.780). The prostate volume, planned nerve sparing, adjuvant or salvage radiotherapy, body mass index (BMI), or a history of transurethral resection of the prostate (TUR-P) before radical prostatectomy were not associated with the postoperative pad use or changes in LUTS.

Conclusions

The ICSMALESF-Q and thus LUTS have significantly improved in a majority of patients after RARP and hence the associated QoL improved as well. Preoperative D'Amico low-risk group significantly reduced pad use after RARP, whereas increased age significantly increased postoperative pad use. These results will help providers counsel their patients more appropriately before prostatectomy by focusing not only on pad use and incontinence after RARP, but also on changes of the bothersomeness of LUTS and risk factors in general.

Oncologic and Functional Outcomes after Radical Prostatectomy for High or Very High Risk Prostate Cancer: European Validation of the Current NCCN® Guideline

PURPOSE

We validated the current NCCN (National Comprehensive Cancer Network®) classification of very high risk patients, and compared the pathological, functional and oncologic outcomes between surgically treated high risk and very high risk patients.

MATERIALS AND METHODS

We retrospectively analyzed 4,041 patients stratified into high risk or very high risk groups who underwent radical prostatectomy between 1992 and 2016. Kaplan-Meier as well as multivariable logistic and Cox regression analyses were used to compare outcomes between the groups.

RESULTS

After radical prostatectomy the rate of adverse pathological features was higher in 1,369 very high risk vs 2,672 high risk cases. Functional outcomes were similar between the groups, with 1-year continence and potency rates of 81.0% and 43.6% in the very high risk compared to 81.9% and 45.2% in the high risk group, respectively (p = 0.7 and p = 0.9). In a subset of 1,835 patients who underwent radical prostatectomy between 1992 and 2011 (median followup 58.8 months, IQR 36.5-84.6), those with very high risk disease had significantly worse 5 and 8-year biochemical recurrence-free survival, metastatic progression-free survival, prostate cancer specific mortality-free survival and overall survival rates compared to those with high risk disease.

CONCLUSIONS

Despite the relatively poor prognosis of patients with high risk prostate cancer, radical prostatectomy results in favorable 5 and 8-year metastatic progression-free survival, prostate cancer specific mortality-free survival and overall survival rates. Relative to high risk cases, their very high risk counterparts have significantly worse pathological and oncologic outcomes, and more frequently require additional therapies. These observations validate the stratification between high risk and very high risk in European patients with prostate cancer. Interestingly, very high risk patients treated with radical prostatectomy did not have a worse functional outcome than their high risk counterparts.

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

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

Racial disparities in operative outcomes after major cancer surgery in the United States

BACKGROUND

Numerous studies have recorded racial disparities in access to care for major cancers. We investigate contemporary national disparities in the quality of perioperative surgical oncological care using a nationally representative sample of American patients and hypothesize that disparities in the quality of surgical oncological care also exists.

METHODS

A retrospective, serial, and cross-sectional analysis of a nationally representative cohort of 3,024,927 patients, undergoing major surgical oncological procedures (colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, pneumonectomy, pancreatectomy, and prostatectomy), between 1999 and 2009.

RESULTS

After controlling for multiple factors (including socioeconomic status), Black patients undergoing major surgical oncological procedures were more likely to experience postoperative complications (OR: 1.24; p < 0.001), in-hospital mortality (OR: 1.24; p < 0.001), homologous blood transfusions (OR: 1.52; p < 0.001), and prolonged hospital stay (OR: 1.53; p < 0.001). Specifically, Black patients have higher rates of vascular (OR: 1.24; p < 0.001), wound (OR: 1.10; p = 0.004), gastrointestinal (OR: 1.38; p < 0.001), and infectious complications (OR: 1.29; p < 0.001). Disparities in operative outcomes were particularly remarkable for Black patients undergoing colectomy, prostatectomy, and hysterectomy. Importantly, substantial attenuation of racial disparities was noted for radical cystectomy, lung resection, and pancreatectomy relative to earlier reports. Finally, Hispanic patients experienced no disparities relative to White patients in terms of in-hospital mortality or overall postoperative complications for any of the eight procedures studied.

CONCLUSIONS

Considerable racial disparities in operative outcomes exist in the United States for Black patients undergoing major surgical oncological procedures. These findings should direct future health policy efforts in the allocation of resources for the amelioration of persistent disparities in specific procedures.

Novel epigenetic target therapy for prostate cancer: a preclinical study

Epigenetic events are critical contributors to the pathogenesis of cancer, and targeting epigenetic mechanisms represents a novel strategy in anticancer therapy. Classic demethylating agents, such as 5-Aza-2′-deoxycytidine (Decitabine), hold the potential for reprograming somatic cancer cells demonstrating high therapeutic efficacy in haematological malignancies. On the other hand, epigenetic treatment of solid tumours often gives rise to undesired cytotoxic side effects. Appropriate delivery systems able to enrich Decitabine at the site of action and improve its bioavailability would reduce the incidence of toxicity on healthy tissues. In this work we provide preclinical evidences of a safe, versatile and efficient targeted epigenetic therapy to treat hormone sensitive (LNCap) and hormone refractory (DU145) prostate cancers. A novel Decitabine formulation, based on the use of engineered erythrocyte (Erythro-Magneto-Hemagglutinin Virosomes, EMHVs) drug delivery system (DDS) carrying this drug, has been refined. Inside the EMHVs, the drug was shielded from the environment and phosphorylated in its active form. The novel magnetic EMHV DDS, endowed with fusogenic protein, improved the stability of the carried drug and exhibited a high efficiency in confining its delivery at the site of action in vivo by applying an external static magnetic field. Here we show that Decitabine loaded into EMHVs induces a significant tumour mass reduction in prostate cancer xenograft models at a concentration, which is seven hundred times lower than the therapeutic dose, suggesting an improved pharmacokinetics/pharmacodynamics of drug. These results are relevant for and discussed in light of developing personalised autologous therapies and innovative clinical approach for the treatment of solid tumours.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

High resolution ultrasound features of prostatic rib metastasis: a prospective feasibility study with implication in the high-risk prostate cancer patient

OBJECTIVE

In a prior study, high resolution ultrasound (US) was shown to be accurate for evaluating rib metastasis detected on bone scan. However, that study did not address the specific US appearance typical of osteoblastic rib metastasis. Our objective was to determine the specific US imaging appearance of osteoblastic prostate carcinoma rib metastasis using osteolytic renal cell carcinoma rib metastasis as a comparison group.

MATERIALS AND METHODS

The Institutional Review Board approval and informed consent were obtained for this prospective feasibility study. We performed high resolution US of 16 rib metastases in 4 patients with prostate carcinoma metastases and compared them to 8 rib metastases in 3 male patients with renal cell carcinoma. All patients had rib metastases proven by radiographs and computed tomography (CT). High resolution US scanning was performed by a musculoskeletal radiologist using a 12-5 MHz linear-array transducer. Transverse and longitudinal scans were obtained of each rib metastasis.

RESULTS

All 16 prostate carcinoma metastases demonstrated mild cortical irregularity of the superficial surface of the rib without associated soft tissue mass, cortical disruption, or bone destruction. 7 of 8 (88%) renal cell carcinoma rib metastases demonstrated cortical disruption or extensive bone destruction without soft tissue mass. One of 8 (12%) renal cell carcinoma rib metastases demonstrated only minimal superficial cortical irregularity at the site of a healed metastasis.

CONCLUSION

Osteoblastic prostate carcinoma rib metastases have a distinctive appearance on US. Our success in visualizing these lesions suggests that US may be a useful tool to characterize isolated rib abnormalities seen on a bone scan in high-risk prostate cancer patients who are being evaluated for curative surgery or radiation treatment.

The trifecta outcome in 300 consecutive cases of robotic-assisted laparoscopic radical prostatectomy according to D'Amico risk criteria

BACKGROUND

To analyze the trifecta outcome (continence, potency, and cancer control) in 300 cases of robotic-assisted laparoscopic radical prostatectomy (RARP).

METHODS

A prospective assessment of outcomes in 300 consecutive patients that underwent a RARP performed by a single surgeon. Patients were grouped according to D'Amico risk criteria: Group I consisted of 'low-risk' cases (n = 64), Group II consisted of 'intermediate-risk' cases (n = 88), and Group III consisted of 'high-risk' cases (n = 148). Patients were evaluated for perioperative complications and the trifecta outcome.

RESULTS

The operation time, blood loss, post-operative stay, duration of urethral catheterization, and perioperative complication rate were similar among all groups. The incidence of bilateral neurovascular bundle (NVB) preservation was significantly decreased with the increasing risk of cases (P < 0.001). The continence rates at the 1-week, 1-month, 3-month, 6-month, and 12-month follow-ups did not differ significantly between groups. The potency rates at the 12-month follow-up were not significantly different. The positive surgical margin and positive lymph node metastasis rate increased with the increasing risk of cases (P < 0.001). The biochemical recurrence rate (BCR, PSA >0.2 ng/mL) was 3.1, 11.36, and 19.59% in Groups I, II and III, respectively (P = 0.004). The trifecta outcome for RARP with bilateral NVB preservation showed no significant differences among groups.

CONCLUSIONS

Undergoing a RARP is safe and feasible in high-risk prostate cancer patients. Compared to low-risk and intermediate-risk groups, the high-risk group had a significant higher incidence of positive surgical margin, positive lymph node metastasis, and BCR rate.

Is radical prostatectomy a useful therapeutic option for high-risk prostate cancer in older men?

Prostate cancer affects a high proportion of men over 70 years of age, who are likely to have high-risk disease and a substantial risk of prostate-cancer-specific death. With life expectancy increasing worldwide, the burden of prostate cancer is also expected to rise. Thus, effective management of this high-risk senior patient group is increasingly important. Radical prostatectomy can increase survival and decrease the risk of metastatic progression. Postsurgery complications are affected more by comorbidity than by age. In patients without comorbidities, surgery is associated with a low risk of mortality. Advanced age may increase the likelihood of incontinence following radical prostatectomy, but patients with higher risk disease are no more likely to experience this complication compared with lower risk groups. Treatment decisions should be made after considering the health status and life expectancy of the individual patient. If eligible, the patient should be offered radical prostatectomy as a potentially curative treatment, without a rigid restriction to a certain chronological age.