Does post prostatectomy decipher score predict biochemical recurrence and impact care?

PURPOSE

To examine the ability of the Decipher test to predict early biochemical recurrence after radical prostatectomy and to impact clinical decisions in advance of metastasis and death.

METHODS

We identified Decipher tests ordered after radical prostatectomy for adverse pathology in men treated for prostate cancer between 1/1/14 and 8/31/18. Biochemical recurrence was defined as prostate-specific antigen > 0.02 ng/mL. Decipher score is reported as lower risk (< 0.6) and higher risk ≥ 0.60). Kaplan-Meier analysis was used to examine the relationship between Decipher score and time to biochemical recurrence (months). Cox regression was used to analyze the relationship between Decipher score and time to biochemical recurrence while controlling for a number of clinical characteristics. Secondary analyses focused on a subset of men with prostate-specific antigen > 0.02 and < 0.20 ng/mL to determine if high-risk Decipher scores were associated with receipt of salvage treatment.

RESULTS

A total of 203 cases were analyzed: 37.9% and 62.1% had lower and higher risk Decipher scores respectively, and 56.2% had a biochemical recurrence. Median (inter-quartile range) follow-up was 20 (13.5, 25.3) months. Decipher score was significantly associated with time to biochemical recurrence (p = 0.027) while in the secondary analyses, high-risk Decipher scores (≥ 0.60) were associated with salvage treatment (p = 0.018). Stage category and Decipher score were significant predictors of time from elevated PSA to salvage treatment in the secondary analyses.

CONCLUSION

While it might not contribute statistically, Decipher score can be clinically useful in helping patients reach treatment decisions.

Use of the Urethral Sling to Treat Symptoms of Climacturia in Men After Radical Prostatectomy

BACKGROUND

Climacturia affects up to 45% of men after radical prostatectomy (RP). Although urethral slings decrease the severity and frequency of stress incontinence after RP, their efficacy as a treatment for climacturia after RP has not been well studied.

AIM

The aim of this study was to assess patient-reported changes in climacturia symptoms after implantation of a urethral sling as a treatment for stress incontinence after RP.

METHODS

After Institutional Review Board approval, a retrospective chart review identified males aged 18-80 years who received urethral slings for stress incontinence after RP at our institution from 2012 to 2017. These patients were mailed an 11-item questionnaire asking them about climacturia symptoms before and after implantation of a urethral sling. Written informed consent was obtained from patients participating in the mailed questionnaire.

OUTCOMES

Respondents were asked to report on climacturia frequency and severity, bother, partner bother, and incontinence before and after implantation of urethral slings.

RESULTS

A total of 42 questionnaires were mailed; 17 were available for analysis. The median age (and interquartile range, IQR) of the sample at RP was 64 (59.5, 68.0). Almost all (94.1%) of the men were sexually active at the time of the study and 64.7% reported experiencing urinary leakage during sexual arousal. Most (58.8%) underwent the urethral sling procedure to treat general incontinence; 35.3% underwent the procedure to treat both general incontinence and incontinence during sexual activity and 1 (5.9%) underwent it for other reasons. A median of 28.1 months elapsed between RP and sling procedure (IQR: 18.36, 53.88; minimum: 8.00; maximum: 108.36). Statistically significant shifts toward improvement from presling to postsling were noted for frequency of leakage during sexual arousal or orgasm (P = .041) and for the degree to which leakage of urine during sexual arousal or orgasm was a "bother" (P = .027). While almost all (94%) of the men were incontinent before sling, this percentage dropped to 53% after sling (P = .031).

CLINICAL IMPLICATIONS

Urethral slings should be discussed as a treatment strategy for climacturia during clinical consultations with patients.

STRENGTHS & LIMITATIONS

Strengths include consistent surgical technique. Limitations include retrospective design, lack of a nonsling comparison group, subjective nature of outcome measures, possible response bias, and variability in time interval between RP and sling procedure.

CONCLUSION

Use of urethral slings after RP is associated with improvements in climacturia symptoms, bother, and incontinence. Nolan J, Kershen R, Staff I, et al. Use of the Urethral Sling to Treat Symptoms of Climacturia in Men After Radical Prostatectomy. J Sex Med 2020;17:1203-1206.

Impact of Urology Resident Involvement on intraoperative, Long-Term Oncologic and Functional Outcomes of Robotic Assisted Laparoscopic Radical Prostatectomy

OBJECTIVE

To evaluate the impact of resident involvement in robot assisted laparoscopic prostatectomy on oncologic, functional, and intraoperative outcomes, both short and long term.

METHODS

We queried our prospectively maintained database of prostate cancer patients who underwent robotic-assisted laparoscopic prostatectomy from November 20, 2007 to December 27, 2016. We analyzed cases performed by 1 surgeon on a specific day of the week when the morning case involved at least 1 resident (R) and the afternoon case involved the attending physician only (nonresident [NR]). We compared R versus NR on a number of clinical, perioperative, and oncological outcomes.

RESULTS

A total of 230 NR and 230 R cases met inclusion criteria and were included in the analysis. Over one third (36.7%) of the NR group was Gleason 4+3 (Grade Group 3) or higher, relative to 25.9% of the R group, P = .015. Median operative time (OT) was significantly longer for R versus NR (200 minutes versus 156 minutes, P<.001) as was robotic time (161 minutes versus119 minutes, P<.001). No significant differences were noted for any other measure. Median follow-up for oncological outcomes was 30 and 33.5 months for NR and R, respectively (P= .3). Median OT and median estimated blood loss were both significantly greater in later years relative to the earlier years for R (2012-2016 versus 2007-2011; P< .001 for OT; P= .041 for median estimated blood loss) but not for NR.

CONCLUSION

Neither safety nor quality is diminished by R involvement in robot assisted laparoscopic prostatectomy.

Return to work after robot-assisted laparoscopic prostatectomy versus radical retro-pubic prostatectomy

INTRODUCTION

We compared the return-to-work interval (RTWI) after radical retro-pubic prostatectomy (RRP) and robot-assisted laparoscopic prostatectomy (RALP) in men being treated for early-stage prostate cancer.

MATERIALS AND METHODS

We mailed a 28-item questionnaire to a random sample of 2,696 patients who either had RRP from 1995 to 2004 or RALP from 2004 to 2011.

RESULTS

We received analyzable questionnaires from 315 patients; 178 had RALP and 137 had RPP. The median RTWI was shorter in the RALP group than in the RRP group (3 versus 4 weeks, p = .016). The percent of subjects who had not returned to work 4 weeks after surgery was 23.6% for RALP and 38.2% for RRP (p = .010). In multivariate regression analysis, surgical approach was a significant predictor of RTWI independent of other social/clinical variables that were associated with either surgical approach or RTWI (p = .014).

CONCLUSION

Our data support a shortening of RTWI by RALP.

A Double-Blind, Randomized Trial on the Efficacy and Safety of Hyperbaric Oxygenation Therapy in the Preservation of Erectile Function after Radical Prostatectomy

PURPOSE

We evaluated the efficacy and safety of hyperbaric oxygenation therapy to preserve erectile function as part of penile rehabilitation after robot assisted bilateral nerve sparing radical prostatectomy for prostate cancer.

MATERIALS AND METHODS

We performed a prospective, randomized, double-blind study from January 2009 to April 2013. Men 40 to 65 years old who underwent robot assisted bilateral nerve sparing radical prostatectomy were randomized 1:1 to the control or the treatment group. Participants were exposed to air as the control or to 100% oxygen as the treatment in hyperbaric conditions. The primary outcome was erectile function at 18 months as measured by IIEF (International Index of Erectile Function). Secondary outcomes were 12-month urinary symptoms, and 18-month sexual, urinary, bowel and hormonal related symptoms as measured by EPIC-26 (Expanded Prostate Index Composite-26). Adverse events and long-term cancer outcomes were monitored. Primary and secondary outcomes in the 2 groups were compared by the independent group t-test, the Wilcoxon rank sum test and the chi-square test of proportion.

RESULTS

A total of 109 potent men were randomized to hyperbaric oxygenation therapy or the control group. A total of 43 men in the air group and 40 in the hyperbaric oxygenation therapy group completed the 18-month followup. No statistically significant differences were observed between the 2 groups on any outcome measure.

CONCLUSIONS

This study revealed no difference in erectile recovery in men treated with hyperbaric oxygenation therapy vs placebo. Larger studies involving more diverse comorbidities and different hyperbaric oxygenation therapy regimens are needed to better evaluate the usefulness of hyperbaric oxygenation therapy for penile rehabilitation after radical prostatectomy.

Impact of active surveillance on pathology and nerve sparing status

INTRODUCTION

We assessed whether, in comparison to immediate surgery, a time delay in performing radical prostatectomy (RP) in patients electing to undergo a period of active surveillance (AS) of low grade prostate cancer, is associated with adverse pathologic features, biochemical recurrence and the ability to perform effective nerve sparing surgery.

MATERIALS AND METHODS

From our RP database of 2769 patients, we identified 41 men under AS who subsequently underwent RP. This study group was compared to control group A (164 patients who chose RP rather than AS), matched for prostate-specific antigen (PSA) and initial diagnostic biopsy characteristics. With time, PSA and biopsy characteristics in the AS study group changed, prompting these men to undergo RP. These changes were matched to create a separate control group B (123 patients most of whom did not meet AS criteria). The incidence of nerve sparing surgery, pathologic features, and biochemical recurrence were compared. Outcome variables were compared using Chi-square tests of proportions. Fisher's Exact test was used for recurrence rates due to the low expected frequencies in some cells.

RESULTS

Compared with control group A, the AS patients experienced higher rates of Gleason score upgrading (33/41; 81.1% versus 76/164; 46.3%, p < 0.001), biochemical recurrence (5/41; 11.4% versus 2/164; 1.3%, p = 0.012) and lower rates of bilateral nerve sparing surgery (31/41; 75.6% versus 154/164; 93.9%, p < 0.001). Control group B and active surveillance group were comparable across all indices measured.

CONCLUSIONS

Delaying RP, through undergoing a period of AS, had a significant negative impact on the incidence of bilateral nerve sparing surgery and adverse pathologic features when compared to patients with similar parameters at the time of diagnosis. Close monitoring and surveillance biopsies did not improve pathologic outcomes compared to patients from whom a single diagnostic biopsy was obtained (and were not candidates for AS), and who subsequently underwent immediate surgery.

Prostate biopsy volume predicts final tumor volume

AIM

To assess the ability of prostate biopsy volume to effectively predict actual tumor volume, and whether increasing the number of prostate biopsy cores improves the ability to forecast actual tumor volume.

METHODS

765 patients who underwent robotic radical prostatectomy (2009-2010) were identified. Of these, 663 had complete demographics, biopsy, and final pathology data available. The number ofbiopsy samples, biopsy tumor volume, and actual tumor volume were calculated from pathology reports.

RESULTS

Data from 663 radical prostatectomy specimens indicated a positive linearrelationship between biopsy tumor volume and actual tumor volume (R=0.524, P< 0.0001). The number ofbiopsy samples collected (i.e., < or =6, 7-8, 9-10, 11-12, 13-14, or > or =15) did not affect the ability of biopsy tumor volume to predict final tumor volume.

CONCLUSIONS

The routine collection of biopsy tumor volume may prove useful in predicting actual tumor volume and the construction of more effective preoperative nomograms.

Prostate cancer biochemical recurrence rates after robotic-assisted laparoscopic radical prostatectomy

Negative surgical margins for prostate cancer patients undergoing robotic-assisted laparoscopic radical prostatectomy result in lower biochemical recurrence rates for low and intermediate risk groups.

Background and Objectives:

To determine prostate cancer biochemical recurrence rates with respect to surgical margin (SM) status for patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP).

Methods:

IRB-approved radical prostatectomy database was queried. Patients were stratified as low, intermediate, and high risk according to D’Amico's risk classification. Postoperative prostate-specific antigen (PSA) values were obtained every 3 mo for the first year, then biannually and annually thereafter. Biochemical recurrence was defined as ≥0.2ng/mL. Patients receiving adjuvant or salvage treatment were included. Positive surgical margin was defined as presence of cancer cells at inked resection margin in the final specimen. Margin presence (negative/positive), margin multiplicity (single/multiple), and margin length (≤3mm focal and >3mm extensive) were noted. Kaplan-Meier curves of biochemical recurrence-free survival (BRFS) as a function of SM were generated. Forward stepwise multivariate Cox regression was performed, with preoperative PSA, Gleason score, pathologic stage, prostate gland weight, and SM as covariates.

Results:

At our institution, 1437 patients underwent RALP (2003-2009). Of these, 1159 had sufficient data and were included in our analysis. Mean follow-up was 16 mo. Kaplan-Meier curves demonstrated significant increase in BRFS in low-risk and intermediate-risk groups with negative SM. Overall BRFS at 5 y was 72%. Gleason score, pathologic stage, and SM status were significant prognostic factors in multivariate analysis.

Conclusions:

Negative surgical margins resulted in lower biochemical recurrence rates for low-risk and intermediate-risk groups. Multifocal and longer positive margins were associated with higher biochemical recurrence rates compared with unifocal and shorter positive margins. Documenting biochemical recurrence rates for RALP is important, because this treatment for localized prostate cancer is validated.

The impact of mid-urethral slings for the treatment of urodynamic stress incontinence on female sexual function: a multicenter prospective study

INTRODUCTION

Urinary incontinence is a common condition that negatively impacts on female sexuality (FS).

AIM

To evaluate FS before and after a mid-urethral sling (MUS) procedure using the Female Sexual Function Index (FSFI). We included women that were both sexually and nonsexually active at baseline.

METHODS

One hundred fifty-seven women complaining of urodynamic stress incontinence underwent a MUS procedure and were enrolled in the study. All patients answered the Italian translation of FSFI, before and 12 months after surgery. To understand the real impact of the MUS on female sexual function, for the first time in the literature, we also monitored and included in the final analysis all the women who are nonsexually active at baseline. We evaluated the prevalence of female sexual dysfunction according to the FSFI cutoff point (26.55).

MAIN OUTCOME MEASURES

FSFI total score, pads use, and stress test presurgery and postsurgery.

RESULTS

One hundred thirty-three patients completed the study protocol: 105 out of 133 underwent to a trans-obturator procedure, while 28 out of 133 had a retropubic procedure. After the 12-month follow up, 115 out of 133 patients (86%) were dry, 10 improved their symptoms, and the remaining 8 were unchanged. Seventy-nine out of 133 (59%) patients reported an active sexual life before surgery. Fifty-four (41%) reported they were not sexually active before surgery. Twelve months after surgery, 22 out of 54 nonsexually active women (40%) reestablished sexual activity, whereas only 6 out of 79 (7.5%) patients, sexually active at baseline, were not sexually active 1 year after surgery (P < 0.05). After adjusting for multiple testing, only age, menopause, and storage symptoms remained significantly correlated with the FSFI total score postsurgery as independent variables. Conclusions.  Our data showed that after a MUS procedure, female sexual function improves. We also found that a very relevant percentage of nonsexually active women reported renewed sexual activity after MUS.

New determination of the astrophysical S factor SE1 of the 12C(alpha,gamma)16O reaction

A new measurement of the beta-delayed alpha decay of 16N has been performed using a set of high efficiency ionization chambers. Sources were made by implantation of a 16N beam, yielding very clean alpha spectra down to energies as low as 400 keV. Our data are in good agreement with earlier results. For the S factor S(E1), we obtain a value of 74 +/- 21 keV b. In spite of improvements in the measurement, the error in S(E1) remains relatively large because of the correlations among the fit parameters and the uncertainties inherent to the extrapolation.

[Management of lymphedema: experience of the Cognacq-Jay Hospital]

Treatment of lymphedema includes practical advices, manual lymph drainage, bandaging, self-bandaging, elastic compression garment, skin care and physical exercises. Weight loss may be useful if obesity. Surgery is indicated in genital lymphedema more than in limb lymphedema. In 2001, in Lymphology Unit, 248 women were treated for secondary upper limb lymphedema after breast cancer. Excess of volume of lymphedema was reduced by 31.3% after a mean time of 2.1 weeks. For lower limb lymphedema (primary or secondary), 136 patients were treated with a mean reduction of excess of lymphedema by 29.8% after a mean time of 2.2 weeks. After this treatment, long term follow-up is necessary to maintain results and the motivation of the patient.

Proteolytic activity of bacteria isolated from the oral cavities of BALB/c mice toward salivary proteins

The proteolytic activities of 350 bacterial isolates from different sites (saliva, tongue, teeth, and mucosa) of the oral cavities of BALB/c mice were tested against different proteins found in saliva (immunoglobulins A, M, G, albumin, lysozyme, mucin, lactoferrin, and lactoperoxidase), some of which are considered to possess antibacterial activity. The results indicate that: (1) lysozyme, lactoferrin, and lactoperoxidase are hydrolyzed by from 46 to 70% of the indigenous flora of the oral cavities of BALB/c mice; (2) IgA and IgM appeared less sensitive to the proteolytic activities of these strains than did the other proteins tested; (3) the colonization of the oral cavity does not seem to be correlated with the proteolytic activity; and (4) the presence of specific Ig proteases is relatively scarce within this population.