Robotic-assisted prostatectomy and open radical retropubic prostatectomy for locally-advanced prostate cancer: multi-institution comparison of oncologic outcomes

Differences in Quality of Life between German and Dutch Patients with Prostate Cancer Treated with Robot-assisted Radical Prostatectomy: Implications for International Multicenter Randomized Controlled Trials

BACKGROUND

As a local treatment for prostate cancer (PCa), robot-assisted radical prostatectomy (RARP) may have a quality of life (QoL) benefit over open surgery. Recent analyses revealed substantial between-country differences in the function and symptom scale scores for the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), which is typically used to assess patient-reported QoL. Such differences could have implications for multinational studies in PCa.

OBJECTIVE

To examine whether nationality is significantly associated with patient-reported QoL.

DESIGN, SETTING, AND PARTICIPANTS

The study cohort comprised Dutch and German patients with PCa treated with RARP in a single high-volume prostate center from 2006 to 2018. Analyses were restricted to patients who were preoperatively continent with at least one follow-up time point.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

QoL was measured in terms of the global Quality of Life (QL) scale score and the overall summary score for the EORTC QLQ-C30. Linear mixed models for repeated-measures multivariable analyses (MVAs) were used to examine the association between nationality and both the global QL score and the summary score. MVAs were further adjusted for QLQ-C30 baseline values, age, Charlson comorbidity index, preoperative prostate-specific antigen, surgical expertise, pathological tumor and nodal stage, Gleason grade, degree of nerve-sparing, surgical margin status, 30-d Clavien-Dindo grade complications, urinary continence recovery, and biochemical recurrence/postoperative radiotherapy.

RESULTS AND LIMITATIONS

For Dutch (n = 1938) versus German (n = 6410) men, the mean baseline scores were 82.8 versus 71.9 for the global QL scale score and 93.4 versus 89.7 for the QLQ-C30 summary score. Urinary continence recovery (QL: +8.9, 95% confidence interval [CI] 8.1-9.8; p < 0001) and Dutch nationality (QL: +6.9, 95% CI 6.1-7.6; p < 0001) were the strongest positive contributors to the global QL and summary scores, respectively. The main limitation is the retrospective study design. In addition, our Dutch cohort may not be representative of the general Dutch population and reporting bias cannot be ruled out.

CONCLUSIONS

Our findings provide observational evidence under specific conditions involving the same setting for patients of two different nationalities suggesting that cross-national patient-reported QoL differences appear to be real and may need to be taken into consideration in multinational studies.

PATIENT SUMMARY

We observed differences in the quality-of-life scores reported by Dutch and German patients with prostate cancer after they underwent robot-assisted removal of the prostate. These findings should be taken into consideration in cross-national studies.

Extended robot-assisted laparoscopic prostatectomy and extended pelvic lymph node dissection as a monotherapy in patients with very high-risk prostate cancer Patients

Background

Patients with very‐high‐risk prostate cancer (VHRPCa) have earlier biochemical recurrences (BCRs) and higher mortality rates. It remains unknown whether extended robot‐assisted laparoscopic prostatectomy (eRALP) without neoadjuvant or adjuvant therapy can improve the outcomes of VHRPCa patients. We aimed to determine the feasibility and efficacy of eRALP as a form of monotherapy for VHRPCa.

Methods

Data from 76 men who were treated with eRALP without neoadjuvant/adjuvant therapy were analyzed. eRALP was performed using an extrafascial approach. Extended pelvic lymph node (LN) dissection (ePLND) included nodes above the external iliac axis, in the obturator fossa, and around the internal iliac artery up to the ureter. The outcome measures were BCR, treatment failure (defined as when the prostate‐specific antigen level did not decrease to <0.1 ng/ml postoperatively), and urinary continence (UC). Kaplan–Meier, logistic regression, and Cox proportional‐hazards model were used to analyze the data.

Results

The median operative time was 246 min, and median blood loss was 50 ml. Twenty‐one patients experienced postoperative complications. Median follow‐up was 25.2 months; 19.7% of patients had treatment failure. Three‐year, BCR‐free survival rate was 62.0%. Castration‐resistant prostate cancer‐free survival rate was 86.1%. Overall survival was 100%. In 55 patients who had complete postoperative UC data, 47 patients (85.5%) recovered from their UC within 12 months. Clinical stage cT3b was an independent preoperative treatment failure predictor (p = 0.035), and node positivity was an independent BCR predictor (p = 0.037). The small sample size and retrospective nature limited the study.

Conclusions

This approach was safe and produced acceptable UC‐recovery rates. Preoperative seminal vesicle invasion is associated with treatment failure, and pathological LN metastases are associated with BCR. Therefore, our results may help informed decisions about neoadjuvant or adjuvant therapies in VHRPCa cases.

Precis

Extended robot‐assisted laparoscopic prostatectomy and extended pelvic lymph node dissection without adjuvant therapy is safe and effective for some patients with very‐high‐risk prostate cancer. The clinical stage and node positivity status predicted monotherapy failure, which may indicate good adjuvant therapy candidate.

Is There an Optimal Curative Option in HIV-Positive Men with Localized Prostate Cancer? A Systematic Review

Aims

We aimed to compare the outcome of curative treatment options in localised Prostate Cancer (PCa) amongst HIV positive (HIV+) men.

Methods

A systematic search of the Cochrane Library of Systematic Reviews, the Scopus and PubMed databases was performed (January 1995 to November 2015) using pre-determined search terms. Outcome measures for comparison included the rate of biochemical failure (BCF), survival benefit and complications.

Results

A total of 14 eligible articles were identified for inclusion, representing a total of 202 HIV+ men with PCa. Radical Prostatectomy was performed in 40/153 compared to 109/153 patients undergoing alternative (non-surgical) treatments options. Only 3 studies compared outcomes within their respective study cohort. One study (n = 10) reported BCF results with 1/2 BCF patient in the surgical arm vs. 1/8 BCF positive patients in the non-surgical arm (mean 46 months follow-up), while two other studies reported no occurrences of BCF within both arms of their studies.

Conclusion

Due to paucity in the literature, there is insufficient evidence to support a certain treatment modality arm specifically for HIV+ men with localized PCa. An individualized management algorithm seems feasible within this cohort, until more definitive studies are performed.

Robotic vs. Retropubic radical prostatectomy in prostate cancer: A systematic review and an meta-analysis update

CONTEXT

The safety and feasibility of robotic-assisted radical prostatectomy (RARP) compared with retropubic radical prostatectomy(RRP) is debated. Recently, a number of large-scale and high-quality studies have been conducted.

OBJECTIVE

To obtain a more valid assessment, we update the meta-analysis of RARP compared with RRP to assessed its safety and feasibility in treatment of prostate cancer.

METHODS

A systematic search of Medline, Embase, Pubmed, and the Cochrane Library was performed to identify studies that compared RARP with RRP. Outcomes of interest included perioperative, pathologic variables and complications.

RESULTS

78 studies assessing RARP vs. RRP were included for meta-analysis. Although patients underwent RRP have shorter operative time than RARP (WMD: 39.85 minutes; P < 0.001), patients underwent RARP have less intraoperative blood loss (WMD = -507.67ml; P < 0.001), lower blood transfusion rates (OR = 0.13; P < 0.001), shorter time to remove catheter (WMD = -3.04day; P < 0.001), shorter hospital stay (WMD = -1.62day; P < 0.001), lower PSM rates (OR:0.88; P = 0.04), fewer positive lymph nodes (OR:0.45;P < 0.001), fewer overall complications (OR:0.43; P < 0.001), higher 3- and 12-mo potent recovery rate (OR:3.19;P = 0.02; OR:2.37; P = 0.005, respectively), and lower readmission rate (OR:0.70, P = 0.03). The biochemical recurrence free survival of RARP is better than RRP (OR:1.33, P = 0.04). All the other calculated results are similar between the two groups.

CONCLUSIONS

Our results indicate that RARP appears to be safe and effective to its counterpart RRP in selected patients.

Evaluation of periprostatic neurovascular fibers before and after radical prostatectomy by means of 1.5 T MRI diffusion tensor imaging

OBJECTIVE

To evaluate if diffusion tensor imaging (DTI) is able to detect changes of periprostatic neurovascular fibers (PNFs) before and after radical prostatectomy (RP), and if these changes are related to post-surgical urinary incontinence and erectile dysfunction.

METHODS

22 patients (mean age 62.6 years) with biopsy-proven prostate cancer underwent 1.5 T DTI before and after RP. The number, fractional anisotropy (FA) values and length of PNFs before and after RP were compared using Student's t-test. Each patient filled out two questionnaires before and after RP, one for the evaluation of urinary continence (ICIQ-SF) and one for the evaluation of erectile function (IIEF-5). The ratios of the number, FA values and length of PNFs before and after RP (DTI B-A RATIOs) and the ratios between the scores obtained before and after RP for both ICIQ-SF and IIEF-2 (ICIQ-SF B-A RATIOs and IIEF-2 B-A RATIOs) were calculated to perform the Kendall's τ-test between them.

RESULTS

There was a statistically significant decrease of the number of PNFs after RP at base, midgland, and apex (p < 0.01) and of FA values at midgland (p < 0.05), with positive statistically significant correlation between the DTI B-A RATIOs of the number of PNFs and IIEF-2 B-A RATIOs (p < 0.05, ρ = 0.47).

CONCLUSION

DTI was able to detect that the decrease of the number of the PNFs after RP was statistically related to the post-surgical erectile dysfunction (p < 0.05). Advances in knowledge: This work demonstrates that: (1) 1.5 T MRI DTI is able to detect the decrease of the number and of the FA of PNFs after prostatectomy; (2) the decrease of the number of PNFs after prostatectomy is related with the post-surgical erectile dysfunction; (3) 1.5 T MRI DTI has demonstrated to be a reproducible technique in detecting the changes of the PNFs induced by RP, with high interobserver agreement.

[Imaging of locally advanced prostate cancer : Importance of ultrasound and especially MRI]

Prostate cancer is the most common male malignant tumor in Germany, which thus places growing demands on differentiated imaging and risk-adapted therapeutic approaches. Multiparametric MRI (mpMRI) of the prostate enables reliable detection of clinically significant cancers and is currently the leading imaging modality for the detection, characterization, and local staging of prostate cancer. According to the German S3 guideline, mpMRI of the prostate is currently primarily recommended in patients with previous negative TRUS biopsies and persisting tumor suspicion. The serial use of mpMRI in the pretherapeutic setting can support individual therapy planning of patients with locally advanced prostate cancer in the near future.

Role of robot-assisted radical prostatectomy in locally advanced prostate cancer

Locally advanced prostate cancer is regarded as a very high-risk disease with a poor prognosis. Although there is no definitive consensus on the definition of locally advanced prostate cancer, radical prostatectomy for locally advanced prostate cancer as a primary treatment or part of a multimodal therapy has been reported. Robot-assisted radical prostatectomy is currently carried out even in high-risk prostate cancer because it provides optimal outcomes. However, limited studies have assessed the role of robot-assisted radical prostatectomy in patients with locally advanced prostate cancer. Herein, we summarize and review the current knowledge in terms of the definition and surgical indications of locally advanced prostate cancer, and the surgical procedure and perisurgical/oncological outcomes of robot-assisted radical prostatectomy and extended pelvic lymphadenectomy for locally advanced prostate cancer.

[Multimodal therapy of locally advanced prostate cancer]

Locally advanced prostate cancer (LAPCA) comprises about 5-10 % of all newly diagnosed prostate cancers and is associated with the highest prostate cancer specific mortality (approximately 8-20 %). LAPCA is defined by the presence of extraprostatic extension, seminal vesicle invasion, and bladder neck infiltration of pelvic lymph node metastases. It is evident that prognosis can only be improved by interdisciplinary multimodality treatment strategies. Adequate local staging by multiparametric MRI is one of the cornerstones for an individualized, risk-adapted treatment approach. This might consist of extended radical prostatectomy with an extended pelvic lymphadenectomy or intensity-modulated radiation therapy with androgen deprivation as the primary local therapeutic approach. Both treatment strategies may be combined with neoadjuvant or adjuvant radiation therapy or salvage surgery. Combination with neoadjuvant or adjuvant chemotherapy and new androgen receptor pathway inhibitors might also be possible. This article summarizes the current treatment strategies for LAPCA.

Laparoscopic radical prostatectomy outcome data: how should surgeon's performance be reported? A retrospective learning curve analysis of two surgeons

Objective

To document the learning curve for the laparoscopic radical prostatectomy (LRP) procedure and discuss the optimal usage of prospectively documented outcome data for reporting a surgeon’s performance.

Materials and methods

Using prospectively collected data from the first series of patients to undergo LRP by two surgeons in the same institution, linear and logistic regression multivariate analyses per 25 patients were carried out to graphically represent the surgical learning curve for operative time, blood loss, complications, length of stay (LOS), and positive margins. Surgeon A carried out 275 operations between 2003–2009; Surgeon B carried out 225 between 2008–2012.

Results

Learning curves showing continuous improvement of each of the above outcomes were demonstrated for both cohorts. For surgeon A, a plateau was observed for LOS and T2 positive margins after 100 and 150 surgeries respectively. No such plateau was observed for surgeon B.

Conclusion

On documenting these learning curves and discussion of the reporting methods used, we concluded that the most informative outcome measure, with the least potential observer bias was T2 positive margins. Whether as a single measure or in combination with others, this has potential for use as an objective outcome representative of improvement in a surgeon’s skill over time.

[Oncological outcomes of prostate cancer surgery]

OBJECTIVE

Review of the oncological results of the radical prostatectomy as initial treatment of prostate cancer, according to the surgical approach and the risk stratification using D'Amico risk groups.

MATERIALS AND METHODS

Review of literature using Medline databases and MedScience based on scientific relevance. Research focused on the oncological results of the radical prostatectomy in series and meta-analysis published since 10 years, taking into consideration the surgical approach if mentioned.

RESULTS

The characteristics of the operated tumor highly impact the local control authenticated by the pathologic stage and the rates of positive surgical margins (PSM), in addition to the survival and the biochemical recurrence. Surgical technique adapted according to the tumor treated, was a constant challenge to the urologist, who counter balance between the oncological control and the conservation of urinary and sexual function by conditioning the type of radical prostatectomy. Results of radical prostatectomy acceptable in terms of PSM and survival are not influenced by the surgical approach but by the degree of surgical experience.

CONCLUSION

Results of radical prostatectomy show the efficient local control of prostate cancer, taking into consideration the oncological rules and indications validated by multidisciplinary meetings, based on the national (CCAFU) and European oncological guidelines. Tendency is going toward considering radical prostatectomy indicated for patients with higher risk of disease progression, so integrating surgery in a multidisciplinary personalized approach.

Urologic robotic surgery in Korea: past and present

Since 2005 when the da Vinci surgical system was approved as a medical device by the Korean Ministry of Health and Welfare, 51 systems have been installed in 40 institutions as of May 2015. Although robotic surgery is not covered by the national health insurance service in Korea, it has been used in several urologic fields as a less invasive surgery. Since the first robotic-assisted laparoscopic radical prostatectomy in 2005, partial nephrectomy, radical cystectomy, pyeloplasty, and other urologic surgeries have been performed. The following should be considered to extend the indications for robotic surgery: training systems including accreditation, operative outcomes from follow-up results, and cost-effectiveness. In this review, the history and current status of robotic surgeries in Korea are presented.

Retropubic, laparoscopic, and robot-assisted radical prostatectomy: surgical, oncological, and functional outcomes: a systematic review

OBJECTIVES

Despite the wide diffusion of minimally invasive approaches, such as laparoscopic (LRP) and robot-assisted radical prostatectomy (RALP), few studies compare the results of these techniques with the retropubic radical prostatectomy (RRP) approach. The aim of this study is to compare the surgical, functional, and oncological outcomes and cost-effectiveness of RRP, LRP, and RALP.

METHODS

A systematic review of the literature was performed in the PubMed and Embase databases in December 2013. A 'free-text' protocol using the term 'radical prostatectomy' was applied. A total of 16,085 records were found. The authors reviewed the records to identify comparative studies to include in the review.

RESULTS

44 comparative studies were identified. With regard to the perioperative outcome, LRP and RALP were more time-consuming than RRP, but blood loss, transfusion rates, catheterisation time, hospitalisation duration, and complication rates were the most optimal in the laparoscopic approaches. With regard to the functional and oncological results, RALP was found to have the best outcomes.

CONCLUSION

Our study confirmed the well-known perioperative advantage of minimally invasive techniques; however, available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. On the contrary, cost comparison clearly supports RRP.