Role of robot-assisted radical prostatectomy in the management of high-risk prostate cancer

The impact of receptor of advanced glycation end-products polymorphisms on prostate cancer progression and clinicopathological characteristics

The receptor for advanced glycation end products (RAGE) overexpression was suggested to be associated with prostate cancer development and poor prognosis. In this study, we focused on the correlations between the clinicopathological characteristics and susceptibility of prostate cancer and RAGE single-nucleotide polymorphisms (SNPs). In 579 prostate cancer patients, the RAGE SNPs rs1800625, rs1800624, rs2070600 and rs184003 in patients with or without grade group upgrade were analysed with real-time polymerase chain reaction. The results demonstrated that the prostate cancer patients who carried the RAGE SNPs rs2070600 'GA' genotypic variants were significantly associated with lower risk to develop grade group upgrade. Moreover, patients with the RAGE rs1800625 'TC + CC' genotypic variants were associated with higher risk of perineural invasion. In 343 prostate cancer patients who carried the RAGE rs1800625 'TC + CC' genotype without grade group upgrade were correlated with higher risk of biochemical recurrence and perineural invasion. In the analysis of TCGA database, significant differences of the RAGE mRNA level were found between the normal controls and prostate cancer patients (p < 0.0001), and the pathologic stage N1 and N0 patients (p = 0.0027). The prostate cancer patients with high RAGE expression were associated with lower overall survival rate (p = 0.025). In conclusion, our results have revealed that the RAGE SNPs rs2070600 and rs1800625 were associated with the grade group upgrade of prostate cancer and clinical status. The RAGE polymorphisms may provide as a pivotal predictor to evaluate prostate cancer disease progression and prognosis.

Pathological outcomes and biochemical recurrence-free survival after radical prostatectomy for high-risk prostate cancer in the Indian population

Introduction:

We analyzed the biochemical recurrence-free survival (BRFS) of patients with high-risk prostate cancer (HRCaP) as per the D’Amico classification undergoing radical prostatectomy (RP) at our center. We aimed to determine whether the number and type of risk factors (cT2c-T3b, prostate-specific antigen >20 ng/ml, Gleason score >7) are associated with biochemical recurrence (BCR) in HRCaP patients undergoing RP in the Indian population.

Methods:

Between 2006 and 2017, 192 patients underwent RP (open RP [ORP], laparoscopic RP [LRP], and robotic RP [RRP]) at our center, of which 109 had D’Amico HR disease. Preoperative, postoperative, and pathological outcome data were analyzed for patients with HR disease as per the D’Amico classification. Subgroups were formed to determine whether an increasing number of risk factors (1, 2, or 3) were associated with poorer oncological results and early BCR. The Kaplan–Meier method with log-rank test was used to test the difference in BRFS between the groups. Univariate and multivariate analyses were done to find significant variable against BCR.

Results:

According to the D’Amico criteria, 109 patients had HR, 63 patients had intermediate-risk, and 19 patients had low-risk disease. These 109 patients with HR disease were analyzed in our study (50 RRP, 33 ORP, and 26 LRP). A total of 59 (54.1%) patients had one HR factor (1HR), 44 (40%) had two HR factors (2HR), and 6 (5.5%) had three HR factors (3HR). The mean follow-up for our patient population was 21.5 ± 19 months (median 18 months; range, 0–108). Overall, the 2-year and 5-year BRFS was 45% and 35%, respectively (mean BRFS 46 ± 6 months). Two-year BRFS was 63%, 23%, and 22%, respectively, for 1HR, 2HR, and 3HR (logrank, P < 0.0001). The prognostic substratification based on the three risk factors was significantly predictive for adverse pathologic features and oncologic outcomes.

Conclusion:

Substratification based on the three well-defined criteria leads to a better identification of the more aggressive cancers and prediction of need for additional treatment modalities. Localized HRCaP includes a heterogeneous population of patients with variable oncological outcomes.

Robot-assisted Radical Prostatectomy and Extended Pelvic Lymph Node Dissection in Patients with Locally-advanced Prostate Cancer

BACKGROUND

Limited data are available on the role of robot-assisted radical prostatectomy (RARP) in patients with locally advanced prostate cancer (PCa).

OBJECTIVE

To describe our surgical technique of extrafascial RARP and extended pelvic lymph node dissection (ePLND) in locally advanced PCa.

DESIGN, SETTING, AND PARTICIPANTS

Ninety-four patients with clinical stage ≥T3 undergoing RARP with ePLND at three European centers between 2011 and 2015 were retrospectively evaluated.

SURGICAL PROCEDURE

Surgery was performed using the DaVinci Si system. The anatomically defined ePLND included nodes overlying the external iliac axis, those in the obturator fossa, and around the internal iliac artery up to the ureter. RARP was performed using an extrafascial approach where the Denonvillers' fascia was dissected free and left on the posterior surface of the seminal vesicles.

MEASUREMENTS

Perioperative outcomes consisted of operative time, blood loss, length of hospital stay, and complications occurred within 30 d after surgery. Biochemical recurrence (BCR) was defined as two consecutive prostate-specific antigen values ≥0.2ng/ml. Kaplan-Meier analyses assessed time to BCR and clinical recurrence. Multivariable Cox regression analyses assessed predictors of BCR.

RESULTS AND LIMITATIONS

Median operative time, blood loss, and length of hospital stay were 230min, 200ml, and 6 d. Overall, 12 (12.7%) patients experienced complications and five (5.3%), four (4.3%), and three (3.2%) patients had Clavien I, II, and III/IV complications. Overall, 72 (76.6%), 35 (37.2%), and 30 (32.3%) patients had pT3/4, pN1, and positive margins. The median number of nodes removed was 16. Overall, 19 (20.2%) and 21 (22.3%) patients received adjuvant radiotherapy and hormonal therapy. The median follow-up was 23.5 mo. At 3-yr follow-up, the BCR- and clinical recurrence-free survival rates were 63.3% and 95.8%. Pathologic stage, Gleason score, and positive margins represented predictors of BCR (all p≤0.03). Our study is limited by its retrospective nature and by the follow-up duration.

CONCLUSIONS

RARP represents a well-standardized, safe, and oncological effective option in patients with locally advanced PCa. Pathologic stage, Gleason score, and positive margins should be considered to select patients for multimodal approaches.

PATIENT SUMMARY

Robot-assisted surgery represents a well-standardized, safe, and oncological effective option in men with locally advanced prostate cancer. Two out of three patients treated with this approach are free from recurrence at 3-yr follow-up. Pathologic stage, Gleason score, and positive surgical margins represent predictors of BCR and should be considered to select patients for multimodal approaches.

Analysis of outcome following robotic assisted radical prostatectomy for patients with high risk prostate cancer as per D'Amico classification

INTRODUCTION

Prognosis of prostate cancer depends on the risk stratification. D'Amico classification, the most commonly used risk stratification method is based on three factors, i.e., prostate specific antigen (PSA), Gleason grade and clinical stage. The impact of presence of multiple risk factors on prognosis after radical prostatectomy has not been studied in Indian patients. We analyzed the outcome of patients with high-risk disease undergoing robotic-assisted radical prostatectomy (RARP), as per D'Amico classification.

MATERIALS AND METHODS

Our study is a review of the data of all patients with high-risk prostate cancer who underwent RARP between July 2010 and January 2015. Preoperative, perioperative and outcome data were analyzed for patients with high-risk disease as per D'Amico classification.

RESULTS

Of 227 patients who underwent RARP, 90 (39.6%) were in the high-risk group. PSA > 20 ng/ml was the most common risk factor, present in 50 (55.6%) patients. All three risk factors were present in 3 patients, and single risk factor was present in 65 patients. Nine (10%) patients had lymphnode involvement, 18 (20%) had positive margin, and 38 (41.1%) had extraprostatic extension (EPE). Among these adverse outcomes, only EPE showed significant association with multiplicity of risk factors. At 12 months, 27.8% had biochemical recurrence (BCR). 92% of patients were continent at 12 months.

CONCLUSION

About 92% of patients with high-risk disease were continent at 12 months, whereas less than one-third of the patients had BCR. EPE was the only outcome associated with multiplicity of risk factors. Adjuvant treatment is not required in two-thirds of patients.