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Ajami T, Blachman-Braun R, Porto JG, Ritch CR, Gonzalgo ML, Punnen S, Shah HN, Parekh DJ, Nahar B. Combined holmium laser enucleation of the prostate with high-intensity focused ultrasound in treating patients with localized prostate cancer in a prostate with volume > 60 g: Oncological and functional outcomes from single-institution study. Urol Oncol 2024; 42:289.e1-289.e6. [PMID: 38789378 DOI: 10.1016/j.urolonc.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/31/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVE To assess the efficacy and safety of combined High-Intensity Focused Ultrasound (HIFU) and Holmium Laser Enucleation of the Prostate (HoLEP) in treating patients with both localized prostate cancer (PCa) and prostate > 60 g. METHODS All patients who underwent HIFU for treatment of localized PCa were prospectively enrolled in our study. We reviewed records of patients undergoing procedures from January 2016 to January 2023. For patients with prostate sizes > 60 g, HoLEP was offered before HIFU to prevent worsened urinary symptoms post-treatment. Oncological outcomes-prostatic-specific (PSA) kinetics, recurrence rates, treatment failure - and functional results-Sexual Health Inventory for Men (SHIM), International Prostate Symptoms Score (IPSS), and urinary complications were compared between patients undergoing combined HoLEP and HIFU with those underwent HIFU-monotherapy. RESULTS Among 100 patients, 74 underwent HIFU-monotherapy and 26 underwent the combined HoLEP and HIFU. The majority had intermediate-risk PCa (67%). Pathologic assessment of HoLEP specimens showed no tumor evidence in 57% of cases. In comparison to the HIFU-only group, the combined group exhibited significantly lower PSA metrics across various intervals, however, no differences were found regarding overall and infield recurrences and treatment failure rates. While the combined treatment initially resulted in higher incontinence rates and shorter catheterization durations (P < 0.001), no significant difference in IPSS was observed during subsequent follow-ups. CONCLUSION HoLEP and HIFU can be safely combined for the treatment of PCa in patients with >60 g prostate volume without compromising early oncological outcomes thereby expanding the therapeutic scope of HIFU in treating patients with localized PCa and large adenomas.
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Affiliation(s)
- Tarek Ajami
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Ruben Blachman-Braun
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Joao G Porto
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Chad R Ritch
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Mark L Gonzalgo
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Sanoj Punnen
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Hemendra N Shah
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Dipen J Parekh
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL
| | - Bruno Nahar
- Desai Sethi Urology Institute, University of Miami, Miller School of Medicine, Miami, FL.
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Jaber AR, Moschovas MC, Saikali S, Gamal A, Perera R, Rogers T, Patel E, Sandri M, Tilki D, Patel V. Impact of Prostate Size on the Functional and Oncological Outcomes of Robot-assisted Radical Prostatectomy. Eur Urol Focus 2024; 10:263-270. [PMID: 38290859 DOI: 10.1016/j.euf.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/15/2023] [Accepted: 01/15/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND AND OBJECTIVE Robot-assisted radical prostatectomy (RARP) is the main surgical approach for treatment of prostate cancer in the USA. Prostate size is always depicted as a factor affecting the outcomes of RARP as shown by many studies, but these studies are limited to a small number of patients. Our aim was to evaluate functional and oncologic outcomes of RARP across varying prostate size measured as prostate specimen weight. METHODS A cohort of 14 481 patients who underwent RARP in a single center was divided into four groups according to prostate specimen weight: group 1, <50 g; group 2, 50-100 g; group 3, 100-150 g; and group 4, >150 g. Perioperative and postoperative variables and pathological and functional outcomes were compared among the four groups. Cumulative incidence functions were plotted to visualize the distribution of event-time variables among the groups, and differences were evaluated using the log-rank test. KEY FINDINGS AND LIMITATIONS Patients with larger prostates (groups 3 and 4) were more likely to have higher prostate-specific antigen (PSA), lower biopsy grade group, and worse baseline urinary and sexual characteristics. Group 4 had lower rates of full nerve-sparing surgery (13.7% vs 38.3%) and lymph node dissection (51.3% vs 71.4%), more pT2 disease (69.8% vs 60.3%), less pT3 disease (30.2% vs 39.7%), and lower rates of positive surgical margins (12.8% vs 19.3%) and biochemical recurrence (5.9% vs 7.5%) than group 1. Finally, we observed differences in functional outcomes among the groups for greater prostate size, and patients in group 4 had worse rates of urinary continence (77.8% vs 89.5%) and recovery of sexual function (70.0% vs 84.1%) than group 1. Our study is limited by its retrospective design. CONCLUSIONS AND CLINICAL IMPLICATIONS The results demonstrate that in this large cohort of patients, greater prostate size affects multiple outcomes, including the rate of nerve-sparing surgery, potency and continence recovery, and oncological and pathological outcomes. These data will be valuable when counseling patients regarding possible RARP outcomes and the timeline for recovery. PATIENT SUMMARY Our study shows that prostate size can affect the outcomes of robot-assisted removal of the prostate for patients with prostate cancer. Larger prostate size can be associated with worse functional outcomes after surgery.
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Affiliation(s)
| | - Marcio Covas Moschovas
- AdventHealth Global Robotics Institute, Celebration, FL, USA; University of Central Florida, Orlando, FL, USA
| | - Shady Saikali
- AdventHealth Global Robotics Institute, Celebration, FL, USA
| | - Ahmed Gamal
- AdventHealth Global Robotics Institute, Celebration, FL, USA
| | - Roshane Perera
- AdventHealth Global Robotics Institute, Celebration, FL, USA
| | - Travis Rogers
- AdventHealth Global Robotics Institute, Celebration, FL, USA
| | - Ela Patel
- AdventHealth Global Robotics Institute, Celebration, FL, USA
| | - Marco Sandri
- Big and Open Data Innovation Laboratory, University of Brescia, Brescia, Italy
| | - Derya Tilki
- Martini-Klinik Prostate Cancer Center, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Vipul Patel
- AdventHealth Global Robotics Institute, Celebration, FL, USA; University of Central Florida, Orlando, FL, USA
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Gold SA, Goueli R, Mostardeiro TR, Carpinito GP, El-Eishy A, Mauck R, Woldu SL, Strand DW, Lotan Y, Roehrborn CG, Costa DN, Gahan JC. Optimal Prostate Cancer Diagnostic Pathways for Men With Prostatomegaly in the MRI Era. Urology 2023; 179:95-100. [PMID: 37182648 DOI: 10.1016/j.urology.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/17/2023] [Accepted: 05/03/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To evaluate utilities of multiparametric MRI and targeted biopsy to detect clinically significant prostate cancer in men with prostatomegaly. MATERIALS AND METHODS We conducted a retrospective review of multiparametric MRI obtained for elevated PSA between 2017 and 2020. We selected patients with prostates ≥80 g who had undergone biopsy. Clinically significant prostate cancer was defined as grade group ≥2. Predictive and logistic regression analyses quantified impacts of diagnostic components. RESULTS A total of 338 patients met inclusion criteria: 89 (26.3%) had clinically significant prostate cancer. On MRI, positive predictive value for clinically significant prostate cancer was 26.5% for PIRADS 4% and 73.5% for PIRADS 5; negative predictive value for MRI without suspicious lesions was 98.8%. Applying PSA density to MRI yielded a negative predictive value of 78.9% for PIRADS 4 lesions at PSA density <0.05 and a positive predictive value of 90.5% for PIRADS 5 lesions at PSA density ≥0.15. Targeted (versus standard) biopsy reduced likelihood of missing clinically significant prostate cancer by >50% (12.2% vs 28.3%). MRI in-bore biopsies trended towards better accuracy versus MRI-transrectal ultrasound fusion biopsies (75% versus 52%). On logistic regression analyses, MRI improved predictive accuracy (area under the curve 0.91), and PIRADS score demonstrated the strongest association with clinically significant prostate cancer (odds ratio 6.42, P < .001). CONCLUSION For large prostates, MRI is less predictive of clinically significant prostate cancer but effectively rules out malignancy. PSA density better informs biopsy decisions for PIRADS 4 and 5 lesions. There may be a pronounced role for targeted biopsy, specifically in-bore, in prostatomegaly.
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Affiliation(s)
- Samuel A Gold
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ramy Goueli
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | | | | | - Alfarooq El-Eishy
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ryan Mauck
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Solomon L Woldu
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Douglas W Strand
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Yair Lotan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Claus G Roehrborn
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Daniel N Costa
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jeffrey C Gahan
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX.
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Gyftopoulos K. Radical Prostatectomy and Anatomical Controversies: The Urethral Sphincter and the Elusive Continence Mechanisms. Cancers (Basel) 2023; 15:3410. [PMID: 37444520 DOI: 10.3390/cancers15133410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/02/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
Prostate cancer incidence is rising [...].
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Affiliation(s)
- Kostis Gyftopoulos
- Department of Anatomy, School of Medicine, University of Patras, 26504 Patras, Greece
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Farzat M, Rosenbauer J, Tanislav C, Wagenlehner FM. Prostate Volume Influence on Postoperative Outcomes for Patients Undergoing RARP: A Monocentric Serial Analysis of 500 Cases. J Clin Med 2023; 12:jcm12072491. [PMID: 37048575 PMCID: PMC10095532 DOI: 10.3390/jcm12072491] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/16/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023] Open
Abstract
Elevated prostate volume is considered to negatively influence postoperative outcomes after robot-assisted radical prostatectomy (RARP). We aim to investigate the influence of prostate volume on readmissions and complications after RARP. Methods: A total of 500 consecutive patients who underwent RARP between April 2019 and August 2022 were included. Patients were dichotomized into two groups using a prostate volume cut-off of 50 mL (small and normal prostate (SNP) n = 314, 62.8%; large prostate n = 186, 37.2%). Demographic, baseline, and perioperative data were analyzed. The postoperative complications and readmission rates within 90 days after RARP were compared between groups. A univariate linear analysis was performed to investigate the association between prostate volume and other relevant outcomes. Results: Patients with larger prostates had a higher IPSS score, and therefore, more relevant LUTS at the baseline. They had higher ASA scores (p = 0.015). They also had more catheter days (mean 6.6 days for SNP vs. 7.5 days for LP) (p = 0.041). All oncological outcomes were similar between the groups. Although statistical analysis showed no significant difference between the groups (p = 0.062), a trend for minor complications in patients with larger prostates, n = 37/186 (19.8%) for the LP group vs. n = 37/314 (11.7%) in the SNP group, was observed. Namely, acute urinary retention and secondary anastomosis insufficiency. Major complications with an SNP (4.4%) and LP (3.7%) (p = 0.708) and readmissions with an SNP (6.25%) and LP (4.2%) (p = 0.814) were infrequent and distributed equally between the groups. In univariate analysis, prostate volume could solely predict a longer console time (p = 0.005). Conclusions: A higher prostate volume appears to have minimal influence on the perioperative course after RARP. It can prolong catheter days and increase the incidence of minor complications such as acute urinary retention. However, it might predict minor changes in operating time. Yet, prostate volume has less influence on major complications, readmissions, or oncological results.
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Affiliation(s)
- Mahmoud Farzat
- Department of Urology and Robotic Urology, Diakonie Klinikum Siegen, Academic Teaching Hospital of the University of Bonn, 53127 Bonn, Germany
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University of Giessen, 35390 Giessen, Germany
- Correspondence: ; Tel.: +49-1737506737
| | - Josef Rosenbauer
- Department of Geriatric and Neurology, Diakonie Klinkum Siegen, Academic Teaching Hospital of the University of Bonn, 53127 Bonn, Germany
| | - Christian Tanislav
- Department of Geriatric and Neurology, Diakonie Klinkum Siegen, Academic Teaching Hospital of the University of Bonn, 53127 Bonn, Germany
| | - Florian M. Wagenlehner
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University of Giessen, 35390 Giessen, Germany
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