Comparison of Functional Outcome after Extended versus Super-Extended Pelvic Lymph Node Dissection during Radical Prostatectomy in High-Risk Localized Prostate Cancer

Baseline factors and surgical procedures affecting changes in lower urinary tract symptoms after robot-assisted radical prostatectomy: the impact of nerve-sparing

PURPOSE

To determine baseline factors and surgical procedures associated with clinically meaningful improvement or deterioration of lower urinary tract symptoms (LUTS) after robot-assisted radical prostatectomy (RARP).

METHODS

We retrospectively reviewed our RARP database and analyzed the changes in the International Prostate Symptom Score (IPSS) at baseline and 1, 3, 6, and 12 months postoperatively. Multivariable ordinal logistic regression analysis was performed to determine variables that predicted clinically meaningful improvement (∆IPSS ≤ -5) or deterioration (∆IPSS ≥ 5) in LUTS after RARP.

RESULTS

A total of 172 patients were eligible for analysis. Patients aged ≥ 70 reported a higher IPSS before and after RARP (all p < 0.05). Patients with a prostate volume of > 30 mL or body mass index of < 24 kg/m2 had worse preoperative LUTS; however, the difference disappeared after RARP. While patients with or without nerve-sparing (NS) had a similar preoperative LUTS burden, the NS group reported significantly lower IPSS than the non-NS group at all postoperative time points (p < 0.05). Twelve months after RARP, LUTS improved in 27% and worsened in 6% of patients in the NS group, compared with 20% and 24% of those in the non-NS group, respectively (p = 0.018). Preoperative IPSS (OR, 0.84; 95% CI, 0.79-0.89) and NS (OR, 0.39; 95% CI, 0.18-0.83) were independently associated with clinically meaningful changes of LUTS at 12 months after RARP.

CONCLUSION

Other than baseline LUTS severity, NS was the only independent factor associated with clinically meaningful changes in LUTS after RARP.

Correlation between extended pelvic lymph node dissection and urinary incontinence at early phase after robot‐assisted radical prostatectomy

OBJECTIVES

To investigate the impact of extended pelvic lymph node dissection (ePLND) on urinary incontinence (UI) at early post-surgery robot-assisted radical prostatectomy (RARP).

METHODS

Patients who underwent RARP without cavernous nerve sparing were included between 2014 and 2019. Patient data were obtained prospectively. The associations between ePLND and postoperative urinary continence were defined as a maximum of one daily pad use. International prostate symptom score (IPSS) was examined. Expression of synaptophysin and tyrosine hydroxylase (TH) in perilymph node adipose tissue (PLA) was evaluated by immunohistochemistry.

RESULTS

In total, 186 and 163 patients underwent RARP with and without ePLND. Urinary continence rate at 1 month postoperatively among patients with ePLND was lower than those without ePLND (24.1% vs. 35.1%, p < 0.05), however, not significantly different at 3, 6, and 12 months after RARP (57.4 vs. 62.6%, 73.1 vs. 74.2%, and 83.0 vs. 81.2%, respectively). Total and voiding plus postvoiding IPSS scores at 1 month were higher in patients with ePLND than in those without ePLND (14.5 ± 0.5 vs. 13.6 ± 0.6, 7.0 ± 0.3 vs. 6.2 ± 0.4, respectively, p < 0.05). In univariate and multivariate analyses, larger prostate volume and ePLND were factors associated with an increased UI rate. Among patients who underwent ePLND, synaptophysin and TH-positive nerve fibers were detected in PLA.

CONCLUSIONS

Detection of synaptophysin and TH-immunopositive nerves suggested denervation of sympathetic and peripheral nerves caused by ePLND might be associated with a higher UI rate and poor urinary symptoms at an early stage after RARP.

Pelvic lymph node dissection in prostate and bladder cancers

Prostate cancer and bladder cancer accounts for approximately 13.5% and 3% of all male cancers and all newly diagnosed cancers (regardless sex), respectively. Thus, these cancers represent a major health and economic burden globally. The knowledge of lymph node status is an integral part of the management of any solid tumor. In the urological field, pelvic lymph node dissection (PLND) is of paramount importance in the diagnosis, management, and prognosis of prostate and bladder cancers. However, PLND may be associated with several comorbidities. In this narrative review, the most recent updates concerning the patterns and incidence of lymph node metastasis, the role of different imaging studies and nomograms in determining patients' eligibility for PLND, and the anatomical templates of PLND in urologic patients with bladder or prostate cancer will be discussed.

A novel tool to predict functional outcomes after robot-assisted radical prostatectomy and the value of additional surgery for incontinence

OBJECTIVES

To develop and validate a model to predict 12-month continence status after robot-assisted radical prostatectomy (RARP) from preoperative and 3-month postoperative data; this model could help in informing patients on their individualised risk of urinary incontinence (UI) after RP in order to choose the best treatment option.

PATIENTS AND METHODS

Data on 9421 patients in 25 Belgian centres were prospectively collected (2009-2016) in a compulsory regional database. The primary outcome was the prediction of continence status, using the International Consultation on Incontinence Urinary Incontinence Short Form (ICIQ-UI-SF) at 12-months after RARP. Linear regression shrinkage was used to assess the association between preoperative 3-month postoperative characteristics and 12-month continence status. This association was visualised using nomograms and an online tool.

RESULTS

At 12 months, the mean (sd) score of the ICIQ-UI-SF questionnaire was 4.3 (4.7), threefold higher than the mean preoperative score of 1.4. For the preoperative model, high European Association of Urology risk classification for biochemical recurrence (estimate [Est.] 0.606, se 0.165), postoperative radiotherapy (Est. 1.563, se 0.641), lower preoperative European Organisation for Research and Treatment of Cancer quality of life questionnaire 30-item core (EORCT QLQ-C30)/quality of life (QoL) score (Est. -0.011, se 0.003), higher preoperative ICIQ-UI-SF score (Est 0.214, se 0.018), and older age (Est. 0.058, se 0.009), were associated with a higher 12-month ICIQ-UI-SF score. For the 3-month model, higher preoperative ICIQ-UI-SF score (Est. 0.083, se 0.014), older age (Est. 0.024, se 0.007), lower 3-month EORCT QLQ-C30/QoL score (Est. -0.010, se 0.002) and higher 3-month ICIQ-UI-SF score (Est. 0.562, se 0.009) were associated with a higher 12-month ICIQ-UI-SF score.

CONCLUSIONS

Our models set the stage for a more accurate counselling of patients. In particular, our preoperative model assesses the risk of UI according to preoperative and early postoperative variables. Our postoperative model can identify patients who most likely would not benefit from conservative treatment and should be counselled on continence surgery.

Standardized and Simplified Robot-assisted Superextended Pelvic Lymph Node Dissection for Prostate Cancer: The Monoblock Technique

BACKGROUND

Extended pelvic lymph node dissection (ePLND) remains the most accurate procedure for lymph node staging in intermediate- and high-risk prostate cancer (PCa) patients undergoing radical prostatectomy (RP). A superextended pelvic lymph node dissection (sePLND) can be considered in selected very-high-risk PCa patients.

OBJECTIVE

To demonstrate a reproducible robot-assisted technique for sePLND at the time of RP for PCa.

DESIGN, SETTING, AND PARTICIPANTS

From June 2016 to August 2019, 41 consecutive patients with localized PCa and very high risk for lymph node invasion (LNI) received a robot-assisted RP and a standardized 10-step monoblock ePLND, followed by a 5-step monoblock sePLND. Very high risk for LNI was defined as ≥30% risk for LNI, as calculated by the Briganti 2017 nomogram.

SURGICAL PROCEDURE

After performing the ePLND template resection (harvesting lymph nodes from the obturator region, external and internal iliac vessels, and common iliac vessels up to the ureter crossing), the 5-step monoblock sePLND approach was performed. The sePLND template was tailored to the common iliac vessels up to the aortic and caval bifurcation as well as the presacral region.

MEASUREMENTS

Lymph node yield, perioperative complications.

RESULTS AND LIMITATIONS

Overall, 41 patients received sePLND, reporting a median (interquartile range [IQR]) number of nodes removed of 23 (19-29). Median operative time (including RP, ePLND, and sePLND) was 256 min. Median preoperative prostate-specific antigen was 12 ng/mL (IQR 6.45-17.6). Disease stage pT <3 was found in 10 (24.4%) patients, pT3a in nine (22%) patients, pT3b in 21 (51.2%) patients, and pT4 in one (2.4%) patient. Of the treated patients, 54% revealed LNI: five (4.9%) in a solitary node, five (4.9%) in two to five nodes, and 12 (29.3%) in more than five nodes. Considering perioperative complications, three (7.3%) patients experienced Clavien I-II and four (9.7%) experienced Clavien ≥ III complications. Median hospital stay was 6 d. No patient underwent postoperative blood transfusion.

CONCLUSIONS

The 5-step sePLND approach is a reproducible and feasible technique for PCa patients at a very high risk of LNI.

PATIENT SUMMARY

In our study, we aimed to provide surgeons with a step-by-step technique for lymph node dissection, which aims to collect possibly metastatic lymph nodes of prostate cancer in an even more extended version ("superextended") than a standard ("extended") lymph node dissection.

Efficacy of modified radical prostatectomy technique for recovery of urinary incontinence in high-grade prostate cancer

BACKGROUND

This study was conducted to evaluate predictive factors of urinary continence recovery after radical prostatectomy (RP) for high-grade prostate cancer (PCa).

METHODS

A total of 241 patients with high-grade (Gleason Score 8 or 9) PCa who underwent RP in a single Korean center between January 2011 and May 2018 were retrospectively reviewed. Urinary continence was defined as no pads use. Urinary continence was evaluated at 1, 3, 6, and 12 months after RP. Univariate and multivariate analyses were performed to determine the predictive factors of urinary continence recovery after RP.

RESULTS

The mean age was 67.6±6.4 years, and the mean PSA was 18.7±21.1 ng/dL. A total of 197 (81.7%) patients underwent nerve-sparing RP, and 198 patients (82.2%) were continent 1 year after RP. Multivariate analysis showed that the age (odds ratio [OR]=1.091 [1.015-1.172], P=0.018), Body Mass Index (BMI) (OR=1.227 [1.057-1.424], P=0.007), and modified surgical technique (OR=0.109 [0.044-0.267], P<0.001) were independent factors for predicting urinary continence recovery after RP.

CONCLUSIONS

Younger age, low BMI, and modified surgery were independent predictors of urinary continence recovery after RP in patients with high-grade PCa. These findings may help surgeons to give pre- and postoperative advice to patients with high-grade PCa about urinary continence recovery after RP.

Retzius-sparing robot-assisted laparoscopic radical prostatectomy: functional and early oncologic results in aggressive and locally advanced prostate cancer

Background

Retzius-sparing robot-assisted laparoscopic radical prostatectomy (rsRARP) allows entire prostatectomy procedure via the pouch of Douglas. In low- and intermediate-risk prostate cancer (PCa) there is level 1 evidence that the Retzius-sparing approach impacts early continence recovery. Since specific data on aggressive and locally advanced cancer is lacking and avoiding rsRARP is presently suggested, we investigated urinary and sexual recovery, perioperative complications and early oncologic outcomes after rsRARP in this particular cohort.

Methods

Prospectively collected data of 50 consecutive men (median age 66 years) with high-risk PCa who underwent rsRARP in a single institution was analysed retrospectively. The follow-up for all patients was 12 months after surgery.

Results

3 vs. 12 months after surgery, 82% vs. 98% of men used no pad or one safety pad and 50% vs. 72% used no pad. 89% of patients did not observe a decline of continence if postoperative radiotherapy was carried out.

Considering the 17 preoperatively potent patients who underwent bi- or unilateral nerve-sparing surgery, 41% reported their first sexual intercourse within 1 year after rsRARP.

84% of patients had ≥pT3a disease and 42% positive surgical margins. A lymphadenectomy was done in 94% of patients with a median lymph node removal of 15 and lymph node metastasis in 13%.

34% underwent adjuvant radiotherapy and 22% adjuvant androgen deprivation therapy (ADT). 1-year recurrence-free survival was 96%, including 25% of patients on adjuvant or salvage ADT.

Conclusions

RsRARP in high-risk PCa is feasible and results in excellent continence rates, even after postoperative radiotherapy. The potency rates are promising but need further clarification in larger cohorts. Reliable oncologic outcomes require longterm follow-up and are awaited.

Robot-assisted extended lymphadenectomy in prostate cancer

INTRODUCTION

The extent of lymph node dissection (LND) and its potential survival benefit are still a matter of debate. Aim of our review was to summarize the latest literature data regarding the surgical templates, the potential oncological benefits, the functional outcomes and the complications of extended lymph node dissection (eLND) during robot-assisted radical prostatectomy (RARP).

EVIDENCE ACQUISITION

We systematically reviewed all relevant studies using PubMed, MEDLINE, Embase, American Urological Association (AUA), European Society of Medical Oncology (ESMO) and European Association of Urology (EAU) guidelines.

EVIDENCE SYNTHESIS

A narrative synthesis of all relevant publications on surgical templates, complications, oncological and functional outcomes of robot assisted eLND was undertaken.

CONCLUSIONS

A great deal of evidence supports that an extended template of LND is not only technically feasible but also safe in the context of RARP. It is really promising that in the era of minimally invasive surgery, parameters like the lymph node yield and the detection rates of positive lymph nodes during LND have become highly comparable with open series. The extended approach has already proved its benefits in terms of proper patient staging but more studies are needed with regard to functional outcomes and oncological benefits of this procedure.