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McKay RR, Xie W, Yang X, Acosta A, Rathkopf D, Laudone VP, Bubley GJ, Einstein DJ, Chang P, Wagner AA, Kane CJ, Preston MA, Kilbridge K, Chang SL, Choudhury AD, Pomerantz MM, Trinh QD, Kibel AS, Taplin ME. Postradical prostatectomy prostate-specific antigen outcomes after 6 versus 18 months of perioperative androgen-deprivation therapy in men with localized, unfavorable intermediate-risk or high-risk prostate cancer: Results of part 2 of a randomized phase 2 trial. Cancer 2024; 130:1629-1641. [PMID: 38161319 DOI: 10.1002/cncr.35170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Patients with localized, unfavorable intermediate-risk and high-risk prostate cancer have an increased risk of relapse after radical prostatectomy (RP). The authors previously reported on part 1 of this phase 2 trial testing neoadjuvant apalutamide, abiraterone, prednisone, plus leuprolide (AAPL) or abiraterone, prednisone, and leuprolide (APL) for 6 months followed by RP. The results demonstrated favorable pathologic responses (tumor <5 mm) in 20.3% of patients (n = 24 of 118). Herein, the authors report the results of part 2. METHODS For part 2, patients were randomized 1:1 to receive either AAPL for 12 months (arm 2A) or observation (arm 2B), stratified by neoadjuvant therapy and pathologic tumor classification. The primary end point was 3-year biochemical progression-free survival. Secondary end points included safety and testosterone recovery (>200 ng/dL). RESULTS Overall, 82 of 118 patients (69%) enrolled in part 1 were randomized to part 2. A higher proportion of patients who were not randomized to adjuvant therapy had a favorable prostatectomy pathologic response (32.3% in nonrandomized patients compared with 17.1% in randomized patients). In the intent-to-treat analysis, the 3-year biochemical progression-free survival rate was 81% for arm 2A and 72% for arm 2B (hazard ratio, 0.81; 90% confidence interval, 0.43-1.49). Of the randomized patients, 81% had testosterone recovery in the AAPL group compared with 95% in the observation group, with a median time to recovery of <12 months in both arms. CONCLUSIONS In this study, because 30% of patients declined adjuvant treatment, part B was underpowered to detect differences between arms. Future perioperative studies should be biomarker-directed and include strategies for investigator and patient engagement to ensure compliance with protocol procedures.
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Affiliation(s)
- Rana R McKay
- Department of Medicine, University of California San Diego, La Jolla, California, USA
- Department of Urology, University of California San Diego, La Jolla, California, USA
| | - Wanling Xie
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Xiaoyu Yang
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Andres Acosta
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dana Rathkopf
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vincent P Laudone
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Glenn J Bubley
- Department of Data Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - David J Einstein
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Peter Chang
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew A Wagner
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher J Kane
- Department of Urology, University of California San Diego, La Jolla, California, USA
| | - Mark A Preston
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kerry Kilbridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Steven L Chang
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Atish D Choudhury
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Mark M Pomerantz
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Quoc-Dien Trinh
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Adam S Kibel
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mary-Ellen Taplin
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
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2
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Wilcox Vanden Berg RN, Vertosick EA, Sjoberg DD, Cha EK, Coleman JA, Donahue TF, Eastham JA, Ehdaie B, Laudone VP, Pietzak EJ, Smith RC, Goh AC. Implementation and Validation of an Automated, Longitudinal Robotic Surgical Evaluation and Feedback Program at a High-volume Center and Impact on Training. EUR UROL SUPPL 2024; 62:81-90. [PMID: 38468865 PMCID: PMC10926308 DOI: 10.1016/j.euros.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2024] [Indexed: 03/13/2024] Open
Abstract
Background Surgical education lacks a standardized, proficiency-based approach to evaluation and feedback. Objective To assess the implementation and reception (ie, feasibility) of an automated, standardized, longitudinal surgical skill assessment and feedback system, and identify baseline trainee (resident and fellow) characteristics associated with achieving proficiency in robotic surgery while learning robotic-assisted laparoscopic prostatectomy. Design setting and participants A quality improvement study assessing a pilot of a surgical experience tracking program was conducted over 1 yr. Participants were six fellows, eight residents, and nine attending surgeons at a tertiary cancer center. Intervention Trainees underwent baseline self-assessment. After each surgery, an evaluation was completed independently by the trainee and attending surgeons. Performance was rated on a five-point anchored Likert scale (trainees were considered "proficient" when attending surgeons' rating was ≥4). Technical skills were assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) and Prostatectomy Assessment and Competency Evaluation (PACE). Outcome measurements and statistical analysis Program success and utility were assessed by evaluating completion rates, evaluation completion times, and concordance rates between attending and trainee surgeons, and exit surveys. Baseline characteristics were assessed to determine associations with achieving proficiency. Results and limitations Completion rates for trainees and attending surgeons were 72% and 77%, respectively. Fellows performed more steps/cases than residents (median [interquartile range]: 5 [3-7] and 3 [2-4], respectively; p < 0.01). Prior completion of robotics or laparoscopic skill courses and surgical experience measures were associated with achieving proficiency in multiple surgical steps and GEARS domains. Interclass correlation coefficients on individual components were 0.27-0.47 on GEARS domains. Conclusions An automated surgical experience tracker with structured, longitudinal evaluation and feedback can be implemented with good participation and minimal participant time commitment, and can guide curricular development in a proficiency-based education program by identifying modifiable factors associated with proficiency, individualizing education, and identifying improvement areas within the education program. Patient summary An automated, standardized, longitudinal surgical skill assessment and feedback system can be implemented successfully in surgical education settings and used to inform education plans and predict trainee proficiency.
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Affiliation(s)
| | - Emily A. Vertosick
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D. Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eugene K. Cha
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan A. Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Timothy F. Donahue
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James A. Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent P. Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eugene J. Pietzak
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robert C. Smith
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alvin C. Goh
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Flores JM, Vertosick E, Jenkins LC, Cooper J, Benfante N, Sjoberg D, Vickers AJ, Eastham JA, Laudone VP, Scardino PT, Nelson CJ, Mulhall JP. Do Phosphodiesterase Type 5 Inhibitors Increase the Risk of Biochemical Recurrence After Radical Prostatectomy? J Urol 2024; 211:400-406. [PMID: 38194487 DOI: 10.1097/ju.0000000000003823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 12/08/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE There have been conflicting studies on the association between phosphodiesterase type 5 inhibitor (PDE5i) use and biochemical recurrence (BCR) following radical prostatectomy (RP). Our aim was to determine whether PDE5i drug exposure after RP increases the risk of BCR in patients undergoing RP. MATERIALS AND METHODS An institutional database of prostate cancer patients treated between January 2009 and December 2020 was reviewed. BCR was defined as 2 PSA measurements greater than 0.1 ng/mL. PDE5i exposure was defined using a 0 to 3 scale, with 0 representing never use, 1 sometimes use, 2 regularly use, and 3 routinely use. The risk of BCR with any PDE5i exposure, the quantity of exposure, and the duration of PDE5i exposure were assessed by multivariable Cox proportional hazards models. RESULTS The sample size included 4630 patients to be analyzed, with 776 patients having BCR. The median follow-up for patients without BCR was 27 (IQR 12, 49) months. Eighty-nine percent reported taking a PDE5i at any time during the first 12 months after RP, and 60% reported doing so for 6 or more months during the year after RP. There was no evidence of an increase in the risk of BCR associated with any PDE5i use (HR 1.05, 95% CI 0.84, 1.31, P = .7) or duration of PDE5i use in the first year (HR 0.98 per 1 month duration, 95% CI 0.96, 1.00, P = .055). Baseline oncologic risk was lower in patients using PDE5i, but differences between groups were small, suggesting that residual confounding is unlikely to obscure any causal association with BCR. CONCLUSIONS Prescription of PDE5i to men after RP can be based exclusively on quality of life considerations. Patients receiving PDE5is can be reassured that their use does not increase the risk of BCR.
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Affiliation(s)
- Jose M Flores
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily Vertosick
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lawrence C Jenkins
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John Cooper
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicole Benfante
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Sjoberg
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew J Vickers
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James A Eastham
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent P Laudone
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter T Scardino
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christian J Nelson
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John P Mulhall
- Sexual & Reproductive Medicine Program, Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Fearon NJ, Kurtzman J, Benfante N, Assel M, Vickers A, Carlsson S, Laudone VP, Levine M, Simon BA, Mehrara BJ, Nelson JA. Reducing opioid prescribing after ambulatory breast reconstruction surgery. J Surg Oncol 2023; 128:1235-1242. [PMID: 37653689 PMCID: PMC10841230 DOI: 10.1002/jso.27427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 08/03/2023] [Accepted: 08/15/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND The lack of evidence-based guidelines for postoperative opioid prescriptions following breast reconstruction contributes to a wide variation in prescribing practices and increases potential for misuse and abuse. METHODS Between August and December 2019, women who underwent outpatient breast reconstruction were surveyed 7-10 days before (n = 97) and after (n = 101) implementing a standardized opioid prescription reduction initiative. We compared postoperative opioid use, pain control, and refills in both groups. Patient reported outcomes were compared using the BREAST-Q physical wellbeing of the chest domain and a novel symptom Recovery Tracker. RESULTS Before changes in prescriptions, patients were prescribed a median of 30 pills and consumed three pills (interquartile range [IQR: 1,9]). After standardization, patients were prescribed eight pills and consumed three pills (IQR: 1,6). There was no evidence of a difference in the proportion of patients experiencing moderate to very severe pain on the Recovery Tracker or in the early BREAST-Q physical wellbeing of the chest scores (p = 0.8 and 0.3, respectively). CONCLUSION Standardizing and reducing opioid prescriptions for patients undergoing reconstructive breast surgery is feasible and can significantly decrease the number of excess pills prescribed. The was no adverse impact on early physical wellbeing, although larger studies are needed to obtain further data.
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Affiliation(s)
- Nkechi J. Fearon
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joey Kurtzman
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nicole Benfante
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Melissa Assel
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew Vickers
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Sigrid Carlsson
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Sweden
| | - Vincent P. Laudone
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Marcia Levine
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Brett A. Simon
- Josie Robertson Surgical Center, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Babak J. Mehrara
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Clements MB, Beech BB, Atkinson TM, Dalbagni GM, Li Y, Vickers AJ, Herr HW, Donat SM, Sjoberg DD, Tin AL, Coleman JA, Rapkin BD, Laudone VP, Bochner BH. Health-related Quality of Life After Robotic-assisted vs Open Radical Cystectomy: Analysis of a Randomized Trial. Reply. J Urol 2023; 210:408. [PMID: 37317778 DOI: 10.1097/ju.0000000000003571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Matthew B Clements
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Benjamin B Beech
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Thomas M Atkinson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Guido M Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yuelin Li
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Harry W Herr
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - S Machele Donat
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bruce D Rapkin
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Pellegrino F, Tin AL, Sjoberg DD, Benfante NE, Weber RC, Porwal SP, Briganti A, Montorsi F, Eastham JA, Laudone VP, Vickers AJ. The effect of the da Vinci ® Vessel Sealer on robot-assisted laparoscopic prostatectomy complications. J Robot Surg 2023; 17:1763-1768. [PMID: 37043122 PMCID: PMC10852274 DOI: 10.1007/s11701-023-01595-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/09/2023] [Indexed: 04/13/2023]
Abstract
The da Vinci® Vessel Sealer is a major contributor to the total cost of robot-assisted laparoscopic prostatectomy (RALP). We aimed to assess whether the use of the Vessel Sealer is associated with better surgical outcomes in a population of patients that underwent RALP with lymphadenectomy. We tested whether the use of the Vessel Sealer is associated with the development of lymphocele and/or other surgical outcomes. Most surgeons used the Vessel Sealer in almost all or almost no patients. Thus, to avoid the potential confounding variable of surgeon skill, we performed the initial analyses using data from a single surgeon who changed practice over time, and then using the entire population. Overall, the Vessel Sealer was used in 500 (36%) RALPs. Surgeon 1 performed 492 surgeries, and used the Vessel Sealer in 191 (39%). The Vessel Sealer was not associated with better surgical outcomes in patients operated on by Surgeon 1. The odds ratio for development of lymphocele was 1.95 (95% confidence interval [CI] 0.57-6.75). In the entire population, use of the sealer was significantly associated with a very small reduction of blood loss (22 cc, CI 13-30) but with a 32-min increase in the operating room time (CI 26-37). Use of the Vessel Sealer will have, at best, a very small effect on RALP outcomes that is of highly questionable relevance given its cost. In light of these results, the Vessel Sealer will only be used at our institution in the context of clinical trials.
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Affiliation(s)
- Francesco Pellegrino
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Division of Oncology/Unit of Urology, IRCCS San Raffaele Hospital, Urological Research Institute, Milan, Italy.
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole E Benfante
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ryan C Weber
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Shaun P Porwal
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, IRCCS San Raffaele Hospital, Urological Research Institute, Milan, Italy
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, IRCCS San Raffaele Hospital, Urological Research Institute, Milan, Italy
| | - James A Eastham
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent P Laudone
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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7
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Pellegrino F, Sjoberg DD, Tin AL, Benfante NE, Briganti A, Montorsi F, Scardino PT, Eastham JA, Vickers AJ, Lilja H, Laudone VP. Predictive value of kallikrein forms and β-microseminoprotein in blood from patients with evidence of detectable levels of PSA after radical prostatectomy. World J Urol 2023; 41:1489-1495. [PMID: 37209144 PMCID: PMC10547122 DOI: 10.1007/s00345-023-04420-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/05/2023] [Indexed: 05/22/2023] Open
Abstract
PURPOSE To determine whether β-microseminoprotein or any of the kallikrein forms in blood-free, total or intact PSA or total hK2-predict metastasis in patients with evidence of detectable levels of PSA in blood after radical prostatectomy. METHOD We determined marker concentrations in blood from 173 men treated with radical prostatectomy and evidence of detectable levels of PSA in the blood (PSA ≥ 0.05) after surgery between 2014 and 2015 and at least 1 year after any adjuvant therapy. We used Cox regression to determine whether any marker was associated with metastasis using both univariate and multivariable models that included standard clinical predictors. RESULTS Overall, 42 patients had metastasis, with a median follow-up of 67 months among patients without an event. The levels of intact and free PSA and free-to-total PSA ratio were significantly associated with metastasis. Discrimination was highest for free PSA (c-index: 0.645) and free-to-total PSA ratio (0.625). Only free-to-total PSA ratio remained associated with overall metastasis (either regional or distant) after including standard clinical predictors (p = 0.025) and increased discrimination from 0.686 to 0.697. Similar results were found using distant metastasis as an outcome (p = 0.011; c-index increased from 0.658 to 0.723). CONCLUSION Our results provide evidence that free-to-total PSA ratio can risk stratifying patients with evidence of detectable levels of PSA in blood after RP. Further research is warranted on the biology of prostate cancer markers in patients with evidence of detectable levels of PSA in blood after radical prostatectomy. Our findings on the free-to-total ratio for predicting adverse oncologic outcomes need to be validated in other cohorts.
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Affiliation(s)
- Francesco Pellegrino
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Division of Oncology/Unit of Urology, IRCCS San Raffaele Hospital, Urological Research Institute, Milan, Italy.
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole E Benfante
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, IRCCS San Raffaele Hospital, Urological Research Institute, Milan, Italy
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, IRCCS San Raffaele Hospital, Urological Research Institute, Milan, Italy
| | - Peter T Scardino
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James A Eastham
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hans Lilja
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Medicine (GU-Oncology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Translational Medicine, Lund University, Malmö, Sweden
| | - Vincent P Laudone
- Department of Surgery (Urology Service), Memorial Sloan Kettering Cancer Center, New York, NY, USA
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8
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Clements MB, Beech BB, Atkinson TM, Dalbagni GM, Li Y, Vickers AJ, Herr HW, Donat SM, Sjoberg DD, Tin AL, Coleman JA, Rapkin BD, Laudone VP, Bochner BH. Health-related Quality of Life After Robotic-assisted vs Open Radical Cystectomy: Analysis of a Randomized Trial. J Urol 2023; 209:901-910. [PMID: 36724053 PMCID: PMC10150857 DOI: 10.1097/ju.0000000000003201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 01/23/2023] [Indexed: 02/02/2023]
Abstract
PURPOSE We compare health-related quality of life using a broad range of validated measures in patients randomized to robotic-assisted radical cystectomy vs open radical cystectomy. METHODS We retrospectively analyzed patients that had enrolled in both a randomized controlled trial comparing robotic-assisted laparoscopic radical cystectomy vs open radical cystectomy and a separate prospective study of health-related quality of life. The prospective health-related quality of life study collected 14 patient-reported outcomes measures preoperatively and at 3, 6, 12, 18, and 24 months postoperatively. Linear mixed-effects models with an interaction term (study arm×time) were used to test for differences in mean domain scores and differing effects of approach over time, adjusting for baseline scores. RESULTS A total of 72 patients were analyzed (n=32 robotic-assisted radical cystectomy, n=40 open radical cystectomy). From 3-24 months post-radical cystectomy, no significant differences in mean scores were detected. Mean differences were small in the following European Organization for Research and Treatment of Cancer QLQ-C30 (Core Quality of Life Questionnaire) domains: Global Quality of Life (-1.1; 95% CI -8.4, 6.2), Physical Functioning (-0.4; 95% CI -5.8, 5.0), Role Functioning (0.7; 95% CI -8.6, 10.0). Mean differences were also small in bladder cancer-specific domains (European Organization for Research and Treatment of Cancer QLQ-BLM30 [Muscle Invasive Bladder Cancer Quality of Life Questionnaire]): Body Image (2.9; 95% CI -7.2, 13.1), Urinary Symptoms (8.0; 95% CI -3.0, 19.0). In Urostomy Symptoms, there was a significant interaction term (P < .001) due to lower open radical cystectomy scores at 3 and 24 months. Other domains evaluating urinary, bowel, sexual, and psychosocial health-related quality of life were similar. CONCLUSIONS Over a broad range of health-related quality of life domains comparing robotic-assisted radical cystectomy and open radical cystectomy, there are unlikely to be clinically relevant differences in the medium to long term, and therefore health-related quality of life over this time period should not be a consideration in choosing between approaches.
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Affiliation(s)
- Matthew B. Clements
- Department of Urology, Lahey Hospital & Medical Center, Burlington, Massachusetts
| | - Benjamin B. Beech
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Thomas M. Atkinson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Guido M. Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yuelin Li
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew J. Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Harry W. Herr
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - S. Machele Donat
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel D. Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy L. Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan A. Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bruce D. Rapkin
- Department of Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, New York
| | - Vincent P. Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Bernard H. Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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9
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Perera M, Lebdai S, Tin AL, Sjoberg DD, Benfante N, Beech BB, Alvim RG, Touijer AS, Jenjitranant P, Ehdaie B, Laudone VP, Eastham JA, Scardino PT, Touijer KA. Oncologic outcomes of patients with lymph node invasion at prostatectomy and post-prostatectomy biochemical persistence. Urol Oncol 2023; 41:105.e19-105.e23. [PMID: 36435708 PMCID: PMC10391319 DOI: 10.1016/j.urolonc.2022.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 08/30/2022] [Accepted: 10/20/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pathologic nodal invasion at prostatectomy is frequently associated with persistently elevated prostate-specific antigen (PSA) and with increased risk of disease recurrence. Management strategies for these patients are poorly defined. We aimed to explore the long-term oncologic outcomes and patterns of disease progression. METHODS We included men treated between 2000 and 2017 who had lymph node invasion at radical prostatectomy and persistently detectable prostate-specific antigen post-prostatectomy. Postoperative imaging and management strategies were collated. Patterns of recurrence and probability of metastasis-free survival, prostate cancer-specific survival, and overall survival (OS) were assessed. RESULTS Among our cohort of 253 patients, 126 developed metastasis. Twenty-five had a positive scan within 6 months of surgery; of these, 15 (60%) had a nodal metastasis, 10 (40%) had a bone metastasis, and 4 (16%) had local recurrence. For metastasis-free survival, 5- and 10-year probabilities were 52% (95% CI 45%, 58%) and 37% (95% CI 28%, 46%), respectively. For prostate cancer-specific survival, 5- and 10-year probabilities were 89% (95% CI 84%, 93%) and 67% (95% CI 57%, 76%), respectively. A total of 221 patients proceeded to hormonal deprivation treatment alone. Ten patients received postoperative radiotherapy. CONCLUSIONS Biochemical persistence in patients with lymph node invasion is associated with high risk of disease progression and reduced prostate cancer-specific survival. Management was hindered by the limitation of imaging modalities utilized during the study period in accurately detecting residual disease. Novel molecular imaging may improve staging and help design a therapeutic strategy adapted to patients' specific needs.
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Affiliation(s)
- Marlon Perera
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Souhil Lebdai
- Urology Service, Department of Surgery, University of Angers, France
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nicole Benfante
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Benjamin B Beech
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Ricardo G Alvim
- Urology Service, Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Adam S Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Pocharapong Jenjitranant
- Urology Service, Department of Surgery, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Peter T Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Karim A Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
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10
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Truong H, Breen K, Nandakumar S, Sjoberg DD, Kemel Y, Mehta N, Lenis AT, Reisz PA, Carruthers J, Benfante N, Joseph V, Khurram A, Gopalan A, Fine SW, Reuter VE, Vickers AJ, Birsoy O, Liu Y, Walsh M, Latham A, Mandelker D, Stadler ZK, Pietzak E, Ehdaie B, Touijer KA, Laudone VP, Slovin SF, Autio KA, Danila DC, Rathkopf DE, Eastham JA, Chen Y, Morris MJ, Offit K, Solit DB, Scher HI, Abida W, Robson ME, Carlo MI. Gene-based Confirmatory Germline Testing Following Tumor-only Sequencing of Prostate Cancer. Eur Urol 2023; 83:29-38. [PMID: 36115772 PMCID: PMC10208030 DOI: 10.1016/j.eururo.2022.08.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/17/2022] [Accepted: 08/24/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Tumor-only genomic profiling is an important tool in therapeutic management of men with prostate cancer. Since clinically actionable germline variants may be reflected in tumor profiling, it is critical to identify which variants have a higher risk of being germline in origin to better counsel patients and prioritize genetic testing. OBJECTIVE To determine when variants found on tumor-only sequencing of prostate cancers should prompt confirmatory germline testing. DESIGN, SETTING, AND PARTICIPANTS Men with prostate cancer who underwent both tumor and germline sequencing at Memorial Sloan Kettering Cancer Center from January 1, 2015 to January 31, 2020 were evaluated. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Tumor and germline profiles were analyzed for pathogenic and likely pathogenic ("pathogenic") variants in 60 moderate- or high-penetrance genes associated with cancer predisposition. The germline probability (germline/germline + somatic) of a variant was calculated for each gene. Clinical and pathologic factors were analyzed as potential modifiers of germline probability. RESULTS AND LIMITATIONS Of the 1883 patients identified, 1084 (58%) had a somatic or germline pathogenic variant in one of 60 cancer susceptibility genes, and of them, 240 (22%) had at least one germline variant. Overall, the most frequent variants were in TP53, PTEN, APC, BRCA2, RB1, ATM, and CHEK2. Variants in TP53, PTEN, or RB1 were identified in 746 (40%) patients and were exclusively somatic. Variants with the highest germline probabilities were in PALB2 (69%), MITF (62%), HOXB13 (60%), CHEK2 (55%), BRCA1 (55%), and BRCA2 (47%), and the overall germline probability of a variant in any DNA damage repair gene was 40%. Limitations were that most of the men included in the cohort had metastatic disease, and different thresholds for pathogenicity exist for somatic and germline variants. CONCLUSIONS Of patients with pathogenic variants found on prostate tumor sequencing, 22% had clinically actionable germline variants, for which the germline probabilities varied widely by gene. Our results provide an evidenced-based clinical framework to prioritize referral to genetic counseling following tumor-only sequencing. PATIENT SUMMARY Patients with advanced prostate cancer are recommended to have germline genetic testing. Genetic sequencing of a patient's prostate tumor may also identify certain gene variants that are inherited. We found that patients who had variants in certain genes, such as ones that function in DNA damage repair, identified in their prostate tumor sequencing, had a high risk for having an inherited cancer syndrome.
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Affiliation(s)
- Hong Truong
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kelsey Breen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Subhiksha Nandakumar
- Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yelena Kemel
- Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nikita Mehta
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew T Lenis
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter A Reisz
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jessica Carruthers
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole Benfante
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vijai Joseph
- Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Aliya Khurram
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anuradha Gopalan
- Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Samson W Fine
- Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Victor E Reuter
- Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ozge Birsoy
- Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ying Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael Walsh
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Pediatrics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alicia Latham
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Diana Mandelker
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Medicine, Gastrointestinal Oncology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eugene Pietzak
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Behfar Ehdaie
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karim A Touijer
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent P Laudone
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Susan F Slovin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karen A Autio
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel C Danila
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dana E Rathkopf
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James A Eastham
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yu Chen
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael J Morris
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kenneth Offit
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David B Solit
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Howard I Scher
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Wassim Abida
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mark E Robson
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria I Carlo
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Niehaus Center for Inherited Cancer Genomics, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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11
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Huang C, Assel M, Beech BB, Benfante NE, Sjoberg DD, Touijer A, Coleman JA, Dalbagni G, Herr HW, Donat SM, Laudone VP, Vickers AJ, Bochner BH, Goh AC. Uretero-enteric stricture outcomes: secondary analysis of a randomised controlled trial comparing open versus robot-assisted radical cystectomy. BJU Int 2022; 130:809-814. [PMID: 35694836 PMCID: PMC10454986 DOI: 10.1111/bju.15825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To analyse the risk of uretero-enteric anastomotic stricture in patients randomised to open (ORC) or robot-assisted radical cystectomy (RARC) with extracorporeal urinary diversion. PATIENTS AND METHODS We included 118 patients randomised to RARC (n = 60) or ORC (n = 58) at a single, high-volume institution from March 2010 to April 2013. Urinary diversion was performed by experienced open surgeons. Stricture was defined as non-malignant obstruction on imaging, corroborated by clinical status, and requiring procedural intervention. The risk of stricture within 1 year was compared between groups using Fisher's exact test. RESULTS In all, 58 and 60 patients were randomised to RARC and ORC, respectively. We identified five strictures, all in the ORC group. In patients with ≥1 year of follow-up, the increase in risk of stricture from open surgery was 9.3% (95% confidence interval 1.5%, 17%). Of the five strictures, three were managed endoscopically while two required open revision. There was no evidence that perioperative Grade 3-5 complications were associated with development of a stricture (P = 1) and no evidence of a difference in 24-month estimated glomerular filtration rate between arms (P = 0.15). CONCLUSIONS In this study at a high-volume centre, RARC with extracorporeal urinary diversion achieved excellent ureteric anastomotic outcomes. Purported increased risk of stricture is not a reason to avoid RARC. Future research should examine the impact of different surgical techniques and operator experience on the risk of stricture, especially as more intracorporeal diversions are performed.
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Affiliation(s)
- Chun Huang
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Division of Urology, Department of Surgery, University of Saskatchewan, Moose Jaw, SK, Canada
| | - Melissa Assel
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Benjamin B Beech
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole E Benfante
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Adam Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Harry W Herr
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sherri Machele Donat
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew J Vickers
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alvin C Goh
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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12
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Fainberg J, Vanden Berg RNW, Chesnut G, Coleman JA, Donahue T, Ehdaie B, Goh AC, Laudone VP, Lee T, Pyon J, Scardino PT, Smith RC. A Novel Expert Coaching Model in Urology, Aimed at Accelerating the Learning Curve in Robotic Prostatectomy. J Surg Educ 2022; 79:1480-1488. [PMID: 35872029 PMCID: PMC10353766 DOI: 10.1016/j.jsurg.2022.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 06/09/2022] [Accepted: 06/10/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION/BACKGROUND The surgical residency model assumes that upon completion, a surgeon is ready to practice and grow independently. However, many surgeons fail to improve after reaching proficiency, which in certain instances has correlated with worse clinical outcomes. Coaching addresses this problem and furthers surgeons' education post-residency. Currently, surgical coaching programs focus on medical students and residents, and have been shown to improve residents' and medical students' technical and non-technical abilities. Coaching programs also increase the accuracy of residents, fellows, and attendings in self-assessing their surgical ability. Despite the potential benefits, coaching remains underutilized and poorly studied. We developed an expert-led, face-to-face, video-based surgical coaching program at a tertiary medical center among specialized attending surgeons. Our goal was to evaluate the feasibility of such a program, measure surgeons' attitudes towards internal peer coaching, determine whether surgeons found the sessions valuable and educational, and to subjectively self-assess changes in operative technique. METHODS/MATERIALS Surgeons who perform robot-assisted laparoscopic prostatectomies were chosen and grouped by number of cases completed: junior (<100 cases), intermediate (100-500 cases), and senior (>500 cases). Surgeons were scheduled for 3 1-hour coaching sessions 1-2 months apart (February-October 2019), meeting individually with the coach (PS), an expert Urologic Oncologist with thousands of cases of experience performing radical prostatectomy. He received training on coaching methodology prior to beginning the coaching program. Before each session, surgeons selected 1 of their recent intraoperative videos to review. During sessions, the coach led discussion on topics chosen by the surgeon (i.e. neurovascular bundle dissection, apical dissection, bladder neck); together, they developed goals to achieve before the next session. Subsequent sessions included presentation and discussion of a case occurring subsequent to the prior session. Sessions were coded by discussion topics and analyzed based on level of experience. Surgeons completed a survey evaluating the experience. RESULTS All 6 surgeons completed 3 sessions. Five surgeons completed the survey; most respondents evaluated themselves as having improved in desired areas and feeling more confident performing the discussed steps of the operation. Discussed surgical principles varied by experience group; when subjectively quantifying the difficulty of surgical steps, the more difficult steps were discussed by the higher experience groups compared to the junior surgeons. The senior surgeons also focused more on oncologic potency, continence outcomes, and more theory-driven questions while the junior surgeons tended to focus more on anatomic and technique-based questions such as tissue handling and the use of cautery and clips. Overall, the surgeons thought this program provoked critical discussion and subsequently modified their technique, and "agreed" or "strongly agreed" that they would seek further sessions. CONCLUSIONS Surgical coaching at a large medical center is not only feasible but was rated positively by surgeons across all levels of experience. Coaching led to subjective self-improvement and increased self-confidence among most surgeons. Surgeons also felt that this program offered a safe space to acquire new skills and think critically after finishing residency/fellowship. Themes discussed and takeaways from the sessions varied based on surgeon experience level. While further research is needed to more objectively quantify the impact coaching has on surgeon metrics and patient outcomes, the results of this study supports the initial "proof-of-concept" of peer-based surgical coaching and its potential benefits in accelerating the learning curve for surgeons' post-residency.
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Affiliation(s)
- Jonathan Fainberg
- Department of Urology, New York Presbyterian Hospital/Weill Cornell Medicine, New York, New York.
| | | | - Gregory Chesnut
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan A Coleman
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Timothy Donahue
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Behfar Ehdaie
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Alvin C Goh
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent P Laudone
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Taehyoung Lee
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jin Pyon
- Weill Cornell Medicine, New York, New York
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13
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Clements MB, Gmelich CC, Vertosick EA, Hu JC, Sandhu JS, Scardino PT, Eastham JA, Laudone VP, Touijer KA, Coleman JA, Vickers AJ, Ehdaie B. Have urinary function outcomes after radical prostatectomy improved over the past decade? Cancer 2022; 128:1066-1073. [PMID: 34724196 PMCID: PMC8837675 DOI: 10.1002/cncr.33994] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/29/2021] [Accepted: 09/20/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Changes in surgical technique and postoperative care that target improvements in functional outcomes are widespread in the literature. Radical prostatectomy (RP) is one such procedure that has seen multiple advances over the past decade. The objective of this study was to leverage RP as an index case to determine whether practice changes over time produced observable improvements in patient-reported outcomes. METHODS This study analyzed patients undergoing RP by experienced surgeons at a tertiary care center with prospectively maintained patient-reported outcome data from 2008 to 2019. Four patient-reported urinary function outcomes at 6 and 12 months after RP were defined with a validated instrument: good urinary function (domain score ≥ 17), no incontinence (0 pads per day), social continence (≤1 pad per day), and severe incontinence (≥3 pads per day). Multivariable logistic regressions evaluated changes in outcomes based on the surgical date. RESULTS Among 3945 patients meeting the inclusion criteria, excellent urinary outcomes were reported throughout the decade but without consistent observable improvements over time. Specifically, there were no improvements in good urinary function at 12 months (P = .087) based on the surgical date, and there were countervailing effects on no incontinence (worsening; P = .005) versus severe incontinence (improving; P = .003). Neither approach (open, laparoscopic, or robotic), nor nerve sparing, nor membranous urethral length mediated changes in outcomes. CONCLUSIONS In a decade with multiple advances in surgical and postoperative care, there was evidence of improvements in severe incontinence, but no measurable improvements across 3 other urinary outcomes. Although worsening disease factors could contribute to the stable observed outcomes, a more systematic approach to evaluating techniques and implementing patient selection and postoperative care advances is needed. LAY SUMMARY Although there have been advances in radical prostatectomy over the past decade, consistent observable improvements in postoperative incontinence were not reported by patients. To improve urinary function outcomes beyond the current high standard, the approach to studying innovations in surgical technique needs to be changed, and further development of other aspects of prostatectomy care is needed.
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Affiliation(s)
- Matthew B. Clements
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Caroline C. Gmelich
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Emily A. Vertosick
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jim C. Hu
- Department of Urology, Weill Cornell Medicine, New York, NY
| | - Jaspreet S. Sandhu
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Peter T. Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James A. Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vincent P. Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Karim A. Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan A. Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrew J. Vickers
- Department of Epidemiology & Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY,Corresponding author: Behfar Ehdaie, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, T: 646-422-4406, F: 212-988-0759,
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14
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Moussa AM, Camacho JC, Maybody M, Gonzalez-Aguirre AJ, Ridouani F, Kim D, Laudone VP, Santos E. Percutaneous Lymphatic Embolization as Primary Management of Pelvic and Retroperitoneal Iatrogenic Lymphoceles. J Vasc Interv Radiol 2021; 32:1529-1535. [PMID: 34363941 PMCID: PMC9150443 DOI: 10.1016/j.jvir.2021.07.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To evaluate the efficacy of lymphatic embolization (LE) in decreasing catheter output and dwell time in iatrogenic lymphoceles after percutaneous catheter drainage. MATERIALS AND METHODS Retrospective review of patients who underwent intranodal lymphangiography (INL) with or without LE for management of iatrogenic lymphoceles between January 2017 and November 2020 was performed. Twenty consecutive patients (16 men and 4 women; median age, 60.5 years) underwent a total of 22 INLs and 18 LEs for 15 pelvic and 5 retroperitoneal lymphoceles. Lymphatic leaks were identified in 19/22 (86.4%) of the INLs. Three patients underwent INL only because a leak was not identified or was identified into an asymptomatic lymphocele. One patient underwent repeat INL and LE after persistent high catheter output, and 1 patient underwent repeat INL with LE after the initial INL did not identify a leak. Catheter output was assessed until catheter removal, and changes in output before and after the procedure were reported. The patients were followed up for 2-30 months, and procedural complications were reported. RESULTS The median catheter output before the procedure was 210 mL/day (50-1,200 mL/day), which decreased to a median of 20 mL/day (0-520 mL/day) 3 days after the procedure, with a median output decrease of 160 mL (0-900 mL). The median time between INL with LE and catheter removal was 6 days, with no recurrence requiring redrainage. Four patients experienced minor complications of low-grade fever (n = 2) and lower limb edema (n = 2). CONCLUSIONS Lymphangiogram and LE are safe and effective methods for the management of lymphoceles.
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Affiliation(s)
- Amgad M Moussa
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Juan C Camacho
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Majid Maybody
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Adrian J Gonzalez-Aguirre
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Fourat Ridouani
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - DaeHee Kim
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent P Laudone
- Department of Surgery, Division of Urology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ernesto Santos
- Department of Radiology, Division of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
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15
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McKay RR, Xie W, Ye H, Fennessy FM, Zhang Z, Lis R, Calagua C, Rathkopf D, Laudone VP, Bubley GJ, Einstein DJ, Chang PK, Wagner AA, Parsons JK, Preston MA, Kilbridge K, Chang SL, Choudhury AD, Pomerantz MM, Trinh QD, Kibel AS, Taplin ME. Results of a Randomized Phase II Trial of Intense Androgen Deprivation Therapy prior to Radical Prostatectomy in Men with High-Risk Localized Prostate Cancer. J Urol 2021; 206:80-87. [PMID: 33683939 PMCID: PMC9807004 DOI: 10.1097/ju.0000000000001702] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE This multicenter randomized phase 2 trial investigates the impact of intense androgen deprivation on radical prostatectomy pathologic response and radiographic and tissue biomarkers in localized prostate cancer (NCT02903368). MATERIALS AND METHODS Eligible patients had a Gleason score ≥4+3=7, prostate specific antigen >20 ng/mL or T3 disease and lymph nodes <20 mm. In Part 1, patients were randomized 1:1 to apalutamide, abiraterone acetate, prednisone and leuprolide (AAPL) or abiraterone, prednisone, leuprolide (APL) for 6 cycles (1 cycle=28 days) followed by radical prostatectomy. Surgical specimens underwent central review. The primary end point was the rate of pathologic complete response or minimum residual disease (minimum residual disease, tumor ≤5 mm). Secondary end points included prostate specific antigen response, positive margin rate and safety. Magnetic resonance imaging and tissue biomarkers of pathologic outcomes were explored. RESULTS The study enrolled 118 patients at 4 sites. Median age was 61 years and 94% of patients had high-risk disease. The combined pathologic complete response or minimum residual disease rate was 22% in the AAPL arm and 20% in the APL arm (difference: 1.5%; 1-sided 95% CI -11%, 14%; 1-sided p=0.4). No new safety signals were observed. There was low concordance and correlation between posttherapy magnetic resonance imaging assessed and pathologically assessed tumor volume. PTEN-loss, ERG positivity and presence of intraductal carcinoma were associated with extensive residual tumor. CONCLUSIONS Intense neoadjuvant hormone therapy in high-risk prostate cancer resulted in favorable pathologic responses (tumor <5 mm) in 21% of patients. Pathologic responses were similar between treatment arms. Part 2 of this study will investigate the impact of adjuvant hormone therapy on biochemical recurrence.
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Affiliation(s)
- Rana R. McKay
- University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA 92093-0987
| | - Wanling Xie
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
| | - Huihui Ye
- University of California Los Angeles, Los Angeles, CA 90095
| | - Fiona M. Fennessy
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
| | - Zhenwei Zhang
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
| | - Rosina Lis
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
| | - Carla Calagua
- University of California Los Angeles, Los Angeles, CA 90095
| | - Dana Rathkopf
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065
| | - Vincent P. Laudone
- Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065
| | - Glenn J. Bubley
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215
| | - David J. Einstein
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215
| | - Peter K. Chang
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215
| | - Andrew A. Wagner
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215
| | - J. Kellogg Parsons
- University of California San Diego, 3855 Health Sciences Drive, La Jolla, CA 92093-0987
| | - Mark A. Preston
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
| | - Kerry Kilbridge
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
| | - Steven L. Chang
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
| | | | - Mark M. Pomerantz
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
| | - Quoc-Dien Trinh
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
| | - Adam S. Kibel
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
| | - Mary-Ellen Taplin
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215
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16
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Simon BA, Assel MJ, Tin AL, Desai P, Stabile C, Baron RH, Cracchiolo JR, Twersky RS, Vickers AJ, Laudone VP. Association Between Electronic Patient Symptom Reporting With Alerts and Potentially Avoidable Urgent Care Visits After Ambulatory Cancer Surgery. JAMA Surg 2021; 156:740-746. [PMID: 34076691 DOI: 10.1001/jamasurg.2021.1798] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance Increasingly complex surgical procedures are being performed in the outpatient setting, increasing the burden on patients and caregivers to manage their postoperative symptoms. Electronic patient-reported symptom tracking may reduce this burden and help patients distinguish between expected symptoms and those requiring intervention. Objective To determine whether electronic symptom reporting with clinical alerts for 10 days after ambulatory cancer surgery is associated with a reduction in potentially avoidable urgent care visits, defined as a visit not leading to admission. Design, Setting, and Participants This retrospective cohort study was conducted at the Josie Robertson Surgery Center (JRSC), Memorial Sloan Kettering Cancer Center's ambulatory surgery center with overnight stay capacity from September 20, 2016, to December 31, 2018. Patients undergoing prostatectomy, nephrectomy, mastectomy with or without immediate reconstruction, hysterectomy, or thyroidectomy at the surgery center before (n = 4195) and after (n = 2970) implementation of the Recovery Tracker (RT) electronic postoperative symptom survey were included. Data analyses were conducted from February 1 to November 24, 2020. Exposures A short electronic survey assessing symptoms daily for 10 days after surgery, administered via the patient portal, with alerts to the clinical team and follow-up for concerning responses. Main Outcomes and Measures The main outcome was Memorial Sloan Kettering urgent care center visits with and without readmission and any readmission within 30 days after surgery. Nursing workload was measured by patient phone calls, emails, and secure messages as documented in the electronic medical record. Results A total of 7165 patients were analyzed, including 4195 (median age, 53 [interquartile range (IQR), 44-63] years; 3490 women [83%]) from the pre-RT implementation period and 2970 (median age, 56 [IQR, 46-65] years; 2221 women [75%]) from after full implementation. On multivariable, intent-to-treat analysis by study period, having surgery in the post-RT period was associated with a 22% decrease in the odds of an urgent care center visit without readmission (OR, 0.78; 95% CI, 0.60-1.00; P = .047). Having responded to at least 1 survey was associated with a 42% reduction in the odds of an urgent care center visit without readmission (OR, 0.58; 95% CI, 0.39-0.87; P = .007). There was no change in the risk of admission. Nursing calls increased by a mean of 0.86 (95% CI, 0.75-0.98) calls per patient after RT implementation (P < .001), a 34% increase. Conclusions and Relevance In this cohort study, electronic symptom reporting with nursing follow-up for clinical alerts was associated with a reduction in potentially avoidable urgent care visits. The low risk and high benefit of this intervention suggest that these systems should be more broadly implemented.
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Affiliation(s)
- Brett A Simon
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Melissa J Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Priyanka Desai
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.,Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cara Stabile
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Roberta H Baron
- Department of Nursing, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Rebecca S Twersky
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Andrew J Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent P Laudone
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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17
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Touijer KA, Sjoberg DD, Benfante N, Laudone VP, Ehdaie B, Eastham JA, Scardino PT, Vickers A. Limited versus Extended Pelvic Lymph Node Dissection for Prostate Cancer: A Randomized Clinical Trial. Eur Urol Oncol 2021; 4:532-539. [PMID: 33865797 DOI: 10.1016/j.euo.2021.03.006] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/08/2021] [Accepted: 03/19/2021] [Indexed: 01/23/2023]
Abstract
BACKGROUND Pelvic lymph node dissection (PLND) is the most reliable procedure for lymph node staging. However, the therapeutic benefit remains unproven; although most radical prostatectomies at academic centers are accompanied by PLND, there is no consensus regarding the optimal anatomical extent of PLND. OBJECTIVE To evaluate whether extended PLND results in a lower biochemical recurrence rate. DESIGN, SETTING, AND PARTICIPANTS We conducted a single-center randomized trial. Patients, enrolled between October 2011 and March 2017, were scheduled to undergo radical prostatectomy and PLND. Patients were assigned to limited or extended PLND by cluster randomization. Specifically, surgeons were randomized to perform limited or extended PLND for 3-mo periods. INTERVENTION Randomization to limited (external iliac nodes) or extended (external iliac, obturator fossa and hypogastric nodes) PLND. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary endpoint was the rate of biochemical recurrence. RESULTS AND LIMITATIONS Of 1440 patients included in the final analysis, 700 were randomized to limited PLND and 740 to extended PLND. The median number of nodes retrieved was 12 (interquartile range [IQR] 8-17) for limited PLND and 14 (IQR 10-20) extended PLND; the corresponding rate of positive nodes was 12% and 14% (difference -1.9%, 95% confidence interval [CI] -5.4% to 1.5%; p = 0.3). With median follow-up of 3.1 yr, there was no significant difference in the rate of biochemical recurrence between the groups (hazard ratio 1.04, 95% CI 0.93-1.15; p = 0.5). Rates for grade 2 and 3 complications were similar at 7.3% for limited versus 6.4% for extended PLND; there were no grade 4 or 5 complications. CONCLUSIONS Extended PLND did not improve freedom from biochemical recurrence over limited PLND for men with clinically localized prostate cancer. However, there were smaller than expected differences in nodal count and the rate of positive nodes between the two templates. A randomized trial comparing PLND to no node dissection is warranted. PATIENT SUMMARY In this clinical trial we did not find a difference in the rate of biochemical recurrence of prostate cancer between limited and extended dissection of lymph nodes in the pelvis. This study is registered on ClinicalTrials.gov as NCT01407263.
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Affiliation(s)
- Karim A Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nicole Benfante
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter T Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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18
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Assel MJ, Laudone VP, Twersky RS, Vickers AJ, Simon BA. Assessing Rapidity of Recovery After Cancer Surgeries in a Single Overnight Short-Stay Setting. Anesth Analg 2020; 129:1007-1013. [PMID: 30633048 DOI: 10.1213/ane.0000000000003992] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In the short-stay surgery setting, where patients remain in hospital for a single overnight at most, it is unclear as to whether postoperative length of stay is a good surrogate for assessing rapidity of recovery. We hypothesized that length of stay would be a function of time of surgery and would be a poorer marker of recovery than time of discharge. METHODS A cohort of 891 mastectomy and 538 prostatectomy patients had a planned single overnight stay after surgery at an ambulatory surgical hospital during 2016. The relationship between surgical start time and postoperative length of stay or discharge time was assessed. RESULTS For both mastectomy and prostatectomy patients, 75% of patients were discharged between 10 AM and 12 noon and the median postoperative length of stay was 20 hours. There was a strong association between time of surgery and calculated length of stay. For mastectomies, having a surgery which begins at 6 PM vs 8 AM results in an estimated decrease of 8.8 hours (95% CI, 8.3-9.3) in postoperative length of stay but only 1.2 hours (95% CI, 0.77-1.6) later time of discharge. For prostatectomies, the estimated difference is a decrease of 6.9 hours (95% CI, 6.4-7.4) for postoperative length of stay and 2.5 hours (95% CI, 2.0-3.0) later discharge time. CONCLUSIONS Postoperative length of stay is a poor outcome measure in a short-stay setting. When assessing rapidity of recovery for single overnight stay patients, we advocate the use of discharge time with adjustment for surgery start time. The effect of surgery start time on both postoperative length of stay and discharge time should be investigated to ascertain which is best to assess rapidity of recovery in other ambulatory care settings where recovery involves a single overnight stay.
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Affiliation(s)
| | | | - Rebecca S Twersky
- Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York
| | | | - Brett A Simon
- Surgery.,Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York City, New York
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19
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Abida W, Cheng ML, Armenia J, Middha S, Autio KA, Vargas HA, Rathkopf D, Morris MJ, Danila DC, Slovin SF, Carbone E, Barnett ES, Hullings M, Hechtman JF, Zehir A, Shia J, Jonsson P, Stadler ZK, Srinivasan P, Laudone VP, Reuter V, Wolchok JD, Socci ND, Taylor BS, Berger MF, Kantoff PW, Sawyers CL, Schultz N, Solit DB, Gopalan A, Scher HI. Analysis of the Prevalence of Microsatellite Instability in Prostate Cancer and Response to Immune Checkpoint Blockade. JAMA Oncol 2020; 5:471-478. [PMID: 30589920 DOI: 10.1001/jamaoncol.2018.5801] [Citation(s) in RCA: 382] [Impact Index Per Article: 95.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance The anti-programmed cell death protein 1 (PD-1) antibody pembrolizumab is approved by the US Food and Drug Administration for the treatment of microsatellite instability-high (MSI-H) or mismatch repair-deficient (dMMR) solid tumors, but the prevalence of MSI-H/dMMR prostate cancer and the clinical utility of immune checkpoint blockade in this disease subset are unknown. Objective To define the prevalence of MSI-H/dMMR prostate cancer and the clinical benefit of anti-PD-1/programmed cell death 1 ligand 1 (PD-L1) therapy in this molecularly defined population. Design, Setting, and Participants In this case series, 1551 tumors from 1346 patients with prostate cancer undergoing treatment at Memorial Sloan Kettering Cancer Center were prospectively analyzed using a targeted sequencing assay from January 1, 2015, through January 31, 2018. Patients had a diagnosis of prostate cancer and consented to tumor molecular profiling when a tumor biopsy was planned or archival tissue was available. For each patient, clinical outcomes were reported, with follow-up until May 31, 2018. Main Outcomes and Measures Tumor mutation burden and MSIsensor score, a quantitative measure of MSI, were calculated. Mutational signature analysis and immunohistochemistry for MMR protein expression were performed in select cases. Results Among the 1033 patients who had adequate tumor quality for MSIsensor analysis (mean [SD] age, 65.6 [9.3] years), 32 (3.1%) had MSI-H/dMMR prostate cancer. Twenty-three of 1033 patients (2.2%) had tumors with high MSIsensor scores, and an additional 9 had indeterminate scores with evidence of dMMR. Seven of the 32 MSI-H/dMMR patients (21.9%) had a pathogenic germline mutation in a Lynch syndrome-associated gene. Six patients had more than 1 tumor analyzed, 2 of whom displayed an acquired MSI-H phenotype later in their disease course. Eleven patients with MSI-H/dMMR castration-resistant prostate cancer received anti-PD-1/PD-L1 therapy. Six of these (54.5%) had a greater than 50% decline in prostate-specific antigen levels, 4 of whom had radiographic responses. As of May 2018, 5 of the 6 responders (5 of 11 total [45.5%]) were still on therapy for as long as 89 weeks. Conclusions and Relevance The MSI-H/dMMR molecular phenotype is uncommon yet therapeutically meaningful in prostate cancer and can be somatically acquired during disease evolution. Given the potential for durable responses to anti-PD-1/PD-L1 therapy, these findings support the use of prospective tumor sequencing to screen all patients with advanced prostate cancer for MSI-H/dMMR. Because not all patients with the MSI-H/dMMR phenotype respond, further studies should explore mechanisms of resistance.
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Affiliation(s)
- Wassim Abida
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael L Cheng
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joshua Armenia
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sumit Middha
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karen A Autio
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Dana Rathkopf
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael J Morris
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel C Danila
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Susan F Slovin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily Carbone
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ethan S Barnett
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melanie Hullings
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jaclyn F Hechtman
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ahmet Zehir
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jinru Shia
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Philip Jonsson
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York.,Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Preethi Srinivasan
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent P Laudone
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Victor Reuter
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jedd D Wolchok
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicholas D Socci
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.,Bioinformatics Core, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Barry S Taylor
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York.,Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael F Berger
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Philip W Kantoff
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Charles L Sawyers
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nikolaus Schultz
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York.,Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - David B Solit
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York.,Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anuradha Gopalan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Howard I Scher
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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20
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Dean LW, Tin AL, Chesnut GT, Assel M, LaDuke E, Fromkin J, Vargas HA, Ehdaie B, Coleman JA, Touijer K, Eastham JA, Laudone VP. Contemporary Management of Hemorrhage After Minimally Invasive Radical Prostatectomy. Urology 2019; 130:120-125. [PMID: 31034916 DOI: 10.1016/j.urology.2019.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/12/2019] [Accepted: 04/17/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe contemporary management and outcomes of patients experiencing postoperative hemorrhage after minimally invasive radical prostatectomy. MATERIALS AND METHODS We retrospectively analyzed data from patients who underwent minimally invasive radical prostatectomy at our institution between January 2010 and January 2017. Clinically significant hemorrhage was defined as a decrease in hemoglobin of ≥30% or 4 g/dL from preoperative to 4 or 14 hours postoperative measurement, receiving a blood transfusion within 30 days, or undergoing a secondary procedure to control bleeding. Patients were analyzed in 3 groups: (1) serially monitored only, (2) received a blood transfusion, and (3) underwent a secondary procedure. Outcomes included imaging studies performed, length of stay, emergency room visits, hospital readmissions, complication rates, and functional outcomes. RESULTS Of 3749 men, 4% (151/3749) had clinically significant hemorrhage, 1.6% (60/3749) received a transfusion; 0.32% (12/3749) underwent a secondary procedure to control bleeding. In a 30-day composite outcome, increased healthcare utilization (emergency room visit, readmission, or Grade ≥3 complications), was seen in 25% of the serial monitoring group, 65% of the transfusion group, and 100% in the secondary procedure group. This rate in 3598 men without hemorrhage was 12.5%. One-year erectile function was poorest in men who underwent a secondary procedure. Urinary functional outcomes were similar in the 3 groups. CONCLUSION Most patients experiencing clinically significant hemorrhage will stabilize without transfusion, and a very small fraction require secondary intervention. Patients experiencing milder bleeding events utilized additional healthcare resources at approximately twice the rate of those who did not, warranting appropriate counseling and postoperative monitoring.
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Affiliation(s)
- Lucas W Dean
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Amy L Tin
- Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gregory T Chesnut
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - Melissa Assel
- Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Emily LaDuke
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jillian Fromkin
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Behfar Ehdaie
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Karim Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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Feuerstein MA, Goldstein L, Reaves B, Sun A, Goltzman M, Morganstern BA, Shabsigh A, Bajorin DF, Rosenberg JE, Donat SM, Herr HW, Laudone VP, Atkinson TM, Li Y, Dalbagni G, Rapkin B, Bochner BH. Propensity-matched analysis of patient-reported outcomes for neoadjuvant chemotherapy prior to radical cystectomy. World J Urol 2019; 37:2401-2407. [PMID: 30798382 DOI: 10.1007/s00345-019-02692-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/18/2019] [Indexed: 01/07/2023] Open
Abstract
PURPOSE To evaluate patient-reported outcomes (PROs) for bladder cancer patients undergoing neoadjuvant chemotherapy (NAC) prior to radical cystectomy (RC) using longitudinal data and propensity-matched scoring analyses. METHODS 155 patients with muscle-invasive bladder cancer scheduled for RC completed the European Organization for Research and Treatment of Cancer questionnaires, EORTC QLQ-C30, EORTC QLQ-BLM30, Fear of Recurrence Scale, Mental Health Inventory and Satisfaction with Life Scale within 4 weeks of surgery. A propensity-matched analysis was performed comparing pre-surgery PROs among 101 patients who completed NAC versus 54 patients who did not receive NAC. We also compared PROs pre- and post-chemotherapy for 16 patients who had data available for both time points. RESULTS In propensity-matched analysis, NAC-treated patients reported better emotional and sexual function, mental health, urinary function and fewer financial concerns compared to those that did not receive NAC. Longitudinal analysis showed increases in fatigue, nausea and appetite loss following chemotherapy. CONCLUSION Propensity-matched analysis did not demonstrate a negative effect of NAC on PRO. Several positive associations of NAC were found in the propensity-matched analysis, possibly due to other confounding differences between the two groups or actual clinical benefit. Longitudinal analysis of a small number of patients found small to modest detrimental effects from NAC similar to toxicities previously reported. Our preliminary findings, along with known survival and toxicity data, should be considered in decision-making for NAC.
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Affiliation(s)
- Michael A Feuerstein
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA.
| | - Leah Goldstein
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Brieyona Reaves
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Arony Sun
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Michael Goltzman
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Bradley A Morganstern
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Ahmad Shabsigh
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Dean F Bajorin
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Jonathan E Rosenberg
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - S Machele Donat
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Harry W Herr
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Vincent P Laudone
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Thomas M Atkinson
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yuelin Li
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Guido Dalbagni
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
| | - Bruce Rapkin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Bernard H Bochner
- Department of Surgery-Urology Service, Memorial Sloan Kettering Cancer Center, 170 E. 77th St, New York, NY, 10075, USA
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22
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Bochner BH, Dalbagni G, Marzouk KH, Sjoberg DD, Lee J, Donat SM, Coleman JA, Vickers A, Herr HW, Laudone VP. Randomized Trial Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: Oncologic Outcomes. Eur Urol 2018; 74:465-471. [PMID: 29784190 DOI: 10.1016/j.eururo.2018.04.030] [Citation(s) in RCA: 151] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 04/30/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Open radical cystectomy (ORC) has proven to be an important component in the treatment of high-risk bladder cancer (BCa). ORC surgical morbidity remains high; therefore, minimally invasive surgical techniques have been introduced in an attempt to improve patient outcomes. OBJECTIVE To compare cancer outcomes in BCa patients managed with ORC or robotic-assisted radical cystectomy (RARC). DESIGN, SETTING, AND PARTICIPANTS A prospective, randomized trial was completed between 2010 and 2013. Patients were randomized to ORC/pelvic lymphadenectomy (PLND) or RARC/PLND, with all undergoing open/extracorporeal urinary diversion. Median follow-up was 4.9 (IQR: 3.9-5.9) yr after surgery among surviving patients. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Secondary outcomes to the trial included recurrence-free, cancer-specific, and overall survival. RESULTS AND LIMITATIONS The trial randomized 118 patients who underwent RC/PLND and urinary diversion. Sixty were randomized to RARC and 58 to ORC. Four RARC-assigned patients refused randomization and received ORC; however, an intention to treat analysis was performed. No differences were observed in recurrence (hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 0.69-2.36; p=0.4) or cancer-specific survival (p=0.4). No difference in overall survival was observed (p=0.8). However, the pattern of first recurrence demonstrated a nonstatistically significant increase in metastatic sites for those undergoing ORC (sub-HR [sHR]: 2.21; 95% CI: 0.96-5.12; p=0.064) and a greater number of local/abdominal sites in the RARC-treated patients (sHR: 0.34; 95% CI: 0.12-0.93; p=0.035). The major limitation to this study is that the trial was not powered to determine differences in cancer recurrences, survival outcomes, or patterns of recurrence. CONCLUSIONS The secondary outcomes from our randomized trial did not definitively demonstrate differences in cancer outcomes in patients treated with ORC or RARC. However, differences in observed patterns of first recurrence highlight the need for future studies. PATIENT SUMMARY Of 118 patients randomly assigned to undergo radical cystectomy/pelvic lymphadenectomy and urinary diversion, half were assigned to open surgery and half to robot-assisted techniques. We found no difference in risk of recurring or dying of bladder cancer between the two groups.
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Affiliation(s)
- Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA.
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Karim H Marzouk
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Justin Lee
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sheri M Donat
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Harry W Herr
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Weill Cornell Medical College, New York, NY, USA
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Recabal P, Alvim RG, Takeda T, Ehdaie B, Coleman J, Laudone VP. MP97-17 A COMPARISON OF INTRAPERITONEAL ONLAY MESH REPAIR VS. MINIMALLY INVASIVE SUTURE REPAIR OF INGUINAL HERNIAS DURING ROBOTIC-ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY. J Urol 2017. [DOI: 10.1016/j.juro.2017.02.3061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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O'Shaughnessy MJ, McBride SM, Vargas HA, Touijer KA, Morris MJ, Danila DC, Laudone VP, Bochner BH, Sheinfeld J, Dayan ES, Bellomo LP, Sjoberg DD, Heller G, Zelefsky MJ, Eastham JA, Scardino PT, Scher HI. A Pilot Study of a Multimodal Treatment Paradigm to Accelerate Drug Evaluations in Early-stage Metastatic Prostate Cancer. Urology 2016; 102:164-172. [PMID: 27888148 DOI: 10.1016/j.urology.2016.10.044] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/03/2016] [Accepted: 10/03/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate a multimodal strategy aimed at treating all sites of disease that provides a rapid readout of success or failure in men presenting with non-castrate metastatic prostate cancers that are incurable with single modality therapy. MATERIALS AND METHODS Twenty selected men with oligometastatic M1a (extrapelvic nodal disease) or M1b (bone disease) at diagnosis were treated using a multimodal approach that included androgen deprivation, radical prostatectomy plus pelvic lymphadenectomy (retroperitoneal lymphadenectomy in the presence of clinically positive retroperitoneal nodes), and stereotactic body radiotherapy to osseous disease or the primary site. Outcomes of each treatment were assessed sequentially. Androgen deprivation was discontinued in responding patients. The primary end point was an undetectable prostate-specific antigen (PSA) after testosterone recovery. The goal was to eliminate all detectable disease. RESULTS Each treatment modality contributed to the outcome: 95% of the cohort achieved an undetectable PSA with multimodal treatment, including 25% of patients after androgen deprivation alone and an additional 50% and 20% after surgery and radiotherapy, respectively. Overall, 20% of patients (95% confidence interval: 3%-38%) achieved the primary end point, which persisted for 5, 6, 27+ , and 46+ months. All patients meeting the primary end point had been classified with M1b disease at presentation. CONCLUSION A sequentially applied multimodal treatment strategy can eliminate detectable disease in selected patients with metastatic spread at diagnosis. The end point of undetectable PSA after testosterone recovery should be considered when evaluating new approaches to rapidly set priorities for large-scale testing in early metastatic disease states and to shift the paradigm from palliation to cure.
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Affiliation(s)
- Matthew J O'Shaughnessy
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Weill Cornell Medical College, New York, NY
| | - Sean M McBride
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Hebert Alberto Vargas
- Body Imaging Service and Molecular Imaging & Therapy Service, Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Radiology, Weill Cornell Medical College, New York, NY
| | - Karim A Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Weill Cornell Medical College, New York, NY
| | - Michael J Morris
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel C Danila
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Weill Cornell Medical College, New York, NY
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Weill Cornell Medical College, New York, NY
| | - Joel Sheinfeld
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Weill Cornell Medical College, New York, NY
| | - Erica S Dayan
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Lawrence P Bellomo
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Daniel D Sjoberg
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Glenn Heller
- Department of Medicine, Weill Cornell Medical College, New York, NY
| | - Michael J Zelefsky
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Weill Cornell Medical College, New York, NY
| | - Peter T Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Urology, Weill Cornell Medical College, New York, NY
| | - Howard I Scher
- Genitourinary Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY; Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.
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Jenkins LC, Krishnan R, Berookhim BM, Coleman J, Eastham JA, Ehdaie B, Laudone VP, Nelson CJ, Mulhall JP. PD50-07 SAFETY OF TESTOSTERONE THERAPY IN PATIENTS ON ACTIVE SURVEILLANCE FOR PROSTATE CANCER. J Urol 2016. [DOI: 10.1016/j.juro.2016.02.2797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Jenkins LC, Eastham JA, Laudone VP, Nelson CJ, Mulhall JP. MP86-13 IMPACT OF TESTOSTERONE DEFICIENCY ON ERECTILE FUNCTION RECOVERY POST-RADICAL PROSTATECTOMY. J Urol 2016. [DOI: 10.1016/j.juro.2016.02.2321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Recabal P, Assel M, Sjoberg DD, Lee D, Laudone VP, Touijer K, Eastham JA, Vargas HA, Coleman J, Ehdaie B. The Efficacy of Multiparametric Magnetic Resonance Imaging and Magnetic Resonance Imaging Targeted Biopsy in Risk Classification for Patients with Prostate Cancer on Active Surveillance. J Urol 2016; 196:374-81. [PMID: 26920465 DOI: 10.1016/j.juro.2016.02.084] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE We determined whether multiparametric magnetic resonance imaging targeted biopsies may replace systematic biopsies to detect higher grade prostate cancer (Gleason score 7 or greater) and whether biopsy may be avoided based on multiparametric magnetic resonance imaging among men with Gleason 3+3 prostate cancer on active surveillance. MATERIALS AND METHODS We identified men with previously diagnosed Gleason score 3+3 prostate cancer on active surveillance who underwent multiparametric magnetic resonance imaging and a followup prostate biopsy. Suspicion for higher grade cancer was scored on a standardized 5-point scale. All patients underwent a systematic biopsy. Patients with multiparametric magnetic resonance imaging regions of interest also underwent magnetic resonance imaging targeted biopsy. The detection rate of higher grade cancer was estimated for different multiparametric magnetic resonance imaging scores with the 3 biopsy strategies of systematic, magnetic resonance imaging targeted and combined. RESULTS Of 206 consecutive men on active surveillance 135 (66%) had a multiparametric magnetic resonance imaging region of interest. Overall, higher grade cancer was detected in 72 (35%) men. A higher multiparametric magnetic resonance imaging score was associated with an increased probability of detecting higher grade cancer (Wilcoxon-type trend test p <0.0001). Magnetic resonance imaging targeted biopsy detected higher grade cancer in 23% of men. Magnetic resonance imaging targeted biopsy alone missed higher grade cancers in 17%, 12% and 10% of patients with multiparametric magnetic resonance imaging scores of 3, 4 and 5, respectively. CONCLUSIONS Magnetic resonance imaging targeted biopsies increased the detection of higher grade cancer among men on active surveillance compared to systematic biopsy alone. However, a clinically relevant proportion of higher grade cancer was detected using only systematic biopsy. Despite the improved detection of disease progression using magnetic resonance imaging targeted biopsy, systematic biopsy cannot be excluded as part of surveillance for men with low risk prostate cancer.
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Affiliation(s)
- Pedro Recabal
- Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York; Urology Service, Fundacion Arturo Lopez Perez, Santiago, Chile
| | - Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel Lee
- Department of Urology, Weill-Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Vincent P Laudone
- Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karim Touijer
- Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James A Eastham
- Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hebert A Vargas
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan Coleman
- Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Behfar Ehdaie
- Urology Service, Sidney Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York.
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Recabal P, Assel M, Musser JE, Caras RJ, Sjoberg DD, Coleman JA, Mulhall JP, Parra RO, Scardino PT, Touijer K, Eastham JA, Laudone VP. Erectile Function Recovery after Radical Prostatectomy in Men with High Risk Features. J Urol 2016; 196:507-13. [PMID: 26905018 DOI: 10.1016/j.juro.2016.02.080] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2016] [Indexed: 11/19/2022]
Abstract
PURPOSE We describe the efficacy of radical prostatectomy to achieve complete primary tumor excision while preserving erectile function in a cohort of patients with high risk features in whom surgical resection was tailored according to clinical staging, biopsy data, preoperative imaging and intraoperative findings. MATERIALS AND METHODS In a retrospective review we identified 584 patients with high risk features (prostate specific antigen 20 ng/ml or greater, clinical stage T3 or greater, preoperative Gleason grade 8-10) who underwent radical prostatectomy between 2006 and 2012. The probability of neurovascular bundle preservation was estimated based on preoperative characteristics. Positive surgical margin rates and erectile function recovery were determined in patients who had some degree of neurovascular bundle preservation. RESULTS The neurovascular bundles were resected bilaterally in 69 (12%) and unilaterally in 91 (16%) patients. The remaining patients had some degree of bilateral neurovascular bundle preservation. Preoperative features associated with a lower probability of neurovascular bundle preservation were primary biopsy Gleason grade 5 and clinical stage T3 disease. Among the patients with some degree of neurovascular bundle preservation 125 of 515 (24%) had a positive surgical margin, and 75 of 160 (47%) men with preoperatively functional erections and available erectile function followup had recovered erectile function within 2 years. CONCLUSIONS High risk features should not be considered an indication for complete bilateral neurovascular bundle resection. Some degree of neurovascular bundle preservation can be done safely by high volume surgeons in the majority of these patients with an acceptable rate of positive surgical margins. Nearly half of high risk patients with functional erections preoperatively recover erectile function after radical prostatectomy.
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Affiliation(s)
- Pedro Recabal
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York; Urology Service, Fundacion Arturo Lopez Perez, Santiago, Chile.
| | - Melissa Assel
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - John P Mulhall
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Raul O Parra
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter T Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karim Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Anderson CB, Rapkin B, Reaves BC, Sun AJ, Morganstern B, Dalbagni G, Donat M, Herr HW, Laudone VP, Bochner BH. Idiographic quality of life assessment before radical cystectomy. Psychooncology 2015; 26:206-213. [PMID: 26620583 DOI: 10.1002/pon.4025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 09/03/2015] [Accepted: 10/16/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND We sought to determine if idiographic, or self-defined, measures added to our understanding of patients with bladder cancer's quality of life (QOL) prior to radical cystectomy (RC). We tested whether idiographic measures increased prediction of global QOL beyond standard (nomothetic) measures of QOL components. METHODS We administered the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (QLQ)-C30 and QLQ-BLM30, and our own idiographic Quality of Life Appraisal Profile prior to RC. Idiographic measures included number of goal statements, distance from goal attainment, and ability to complete goal attainment activities. Multivariate linear regression was used to predict measures of global QOL and related constructs of life satisfaction and mental health. RESULTS Two hundred fiftheen patients reported a median of 8 (interquartile range [IQR] 6, 11) goals and half had an average goal attainment rating above 6.9 out of 10 (IQR 5.5, 8.2). On multivariable analysis, QLQ-C30 role functioning and QLQ-BLM30 future perspective explained 15.7% of the variability in preoperative global QOL. Including goal attainment and activity difficulty explained an additional 12% of global QOL variance. Smaller gains were seen on measures of global health, life satisfaction, mental health, and activity, suggesting that idiographic measures capture aspects of QOL distinct from health and functional status defined by nomothetic scales. CONCLUSIONS Idiographic assessment of QOL added to prediction of global QOL above and beyond health-related components measured using nomothetic instruments. This self-defined information may be valuable in communicating with cancer patients about their QOL. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Christopher B Anderson
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Bruce Rapkin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Brieyona C Reaves
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Arony J Sun
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Bradley Morganstern
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Machele Donat
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Harry W Herr
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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30
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Anderson CB, Tin AL, Sjoberg DD, Mulhall JP, Sandhu J, Touijer K, Laudone VP, Eastham JA, Scardino PT, Ehdaie B. Association between number of prostate biopsies and patient-reported functional outcomes after radical prostatectomy: implications for active surveillance protocols. BJU Int 2015; 117:E46-51. [PMID: 26118438 DOI: 10.1111/bju.13215] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To evaluate whether the number of preoperative prostate biopsies affects functional outcomes after radical prostatectomy (RP). METHODS We identified patients treated with RP at our institution between 2008 and 2011. At 6 and 12 months postoperatively, the patients completed questionnaires assessing erectile and urinary function. Patients with preoperative incontinence or erectile dysfunction or who did not complete the questionnaire were excluded. Primary outcomes were urinary and erectile function at 12 months postoperatively. We used logistic regression to estimate the impact of number of prostate biopsies on functional outcomes after adjusting for demographic and clinical factors. RESULTS We identified 2 712 patients treated with RP between 2008 and 2011. Most of the patients (80%) had one preoperative prostate biopsy, 16% had two, and 4% had at least three. On adjusted analysis, erectile function at 12 months was not significantly different for patients with two (odds ratio [OR] 1.25; 95% confidence interval [CI] 0.90, 1.75) or three or more (OR 1.52; 95% CI 0.84, 2.78) biopsies, compared with those with one biopsy. Similarly, urinary function at 12 months was not significantly different for patients with two (0.84, 95% CI 0.64, 1.10) or three or more (0.99, 95% CI 0.60, 1.61) biopsies compared with those with one. CONCLUSIONS We did not find evidence that a greater number of preoperative prostate biopsies adversely affected erectile or urinary function at 12 months after RP.
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Affiliation(s)
- Christopher B Anderson
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amy L Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - John P Mulhall
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jaspreet Sandhu
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karim Touijer
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent P Laudone
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - James A Eastham
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter T Scardino
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Behfar Ehdaie
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Cotero VE, Kimm SY, Siclovan TM, Zhang R, Kim EM, Matsumoto K, Gondo T, Scardino PT, Yazdanfar S, Laudone VP, Tan Hehir CA. Improved Intraoperative Visualization of Nerves through a Myelin-Binding Fluorophore and Dual-Mode Laparoscopic Imaging. PLoS One 2015; 10:e0130276. [PMID: 26076448 PMCID: PMC4468247 DOI: 10.1371/journal.pone.0130276] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 05/19/2015] [Indexed: 11/18/2022] Open
Abstract
The ability to visualize and spare nerves during surgery is critical for avoiding chronic morbidity, pain, and loss of function. Visualization of such critical anatomic structures is even more challenging during minimal access procedures because the small incisions limit visibility. In this study, we focus on improving imaging of nerves through the use of a new small molecule fluorophore, GE3126, used in conjunction with our dual-mode (color and fluorescence) laparoscopic imaging instrument. GE3126 has higher aqueous solubility, improved pharmacokinetics, and reduced non-specific adipose tissue fluorescence compared to previous myelin-binding fluorophores. Dosing and kinetics were initially optimized in mice. A non-clinical modified Irwin study in rats, performed to assess the potential of GE3126 to induce nervous system injuries, showed the absence of major adverse reactions. Real-time intraoperative imaging was performed in a porcine model. Compared to white light imaging, nerve visibility was enhanced under fluorescence guidance, especially for small diameter nerves obscured by fascia, blood vessels, or adipose tissue. In the porcine model, nerve visualization was observed rapidly, within 5 to 10 minutes post-intravenous injection and the nerve fluorescence signal was maintained for up to 80 minutes. The use of GE3126, coupled with practical implementation of an imaging instrument may be an important step forward in preventing nerve damage in the operating room.
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Affiliation(s)
- Victoria E. Cotero
- Diagnostics, Imaging and Biomedical Technologies, GE Global Research, Niskayuna, New York, United States of America
| | - Simon Y. Kimm
- Urology Service, Department of Surgery, Memorial Sloan—Kettering Cancer Center, New York, New York, United States of America
| | - Tiberiu M. Siclovan
- Diagnostics, Imaging and Biomedical Technologies, GE Global Research, Niskayuna, New York, United States of America
| | - Rong Zhang
- Diagnostics, Imaging and Biomedical Technologies, GE Global Research, Niskayuna, New York, United States of America
| | - Evgenia M. Kim
- Diagnostics, Imaging and Biomedical Technologies, GE Global Research, Niskayuna, New York, United States of America
| | - Kazuhiro Matsumoto
- Urology Service, Department of Surgery, Memorial Sloan—Kettering Cancer Center, New York, New York, United States of America
| | - Tatsuo Gondo
- Urology Service, Department of Surgery, Memorial Sloan—Kettering Cancer Center, New York, New York, United States of America
| | - Peter T. Scardino
- Urology Service, Department of Surgery, Memorial Sloan—Kettering Cancer Center, New York, New York, United States of America
| | - Siavash Yazdanfar
- Diagnostics, Imaging and Biomedical Technologies, GE Global Research, Niskayuna, New York, United States of America
| | - Vincent P. Laudone
- Urology Service, Department of Surgery, Memorial Sloan—Kettering Cancer Center, New York, New York, United States of America
| | - Cristina A. Tan Hehir
- Diagnostics, Imaging and Biomedical Technologies, GE Global Research, Niskayuna, New York, United States of America
- * E-mail:
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Bochner BH, Dalbagni G, Sjoberg DD, Silberstein J, Keren Paz GE, Donat SM, Coleman JA, Mathew S, Vickers A, Schnorr GC, Feuerstein MA, Rapkin B, Parra RO, Herr HW, Laudone VP. Comparing Open Radical Cystectomy and Robot-assisted Laparoscopic Radical Cystectomy: A Randomized Clinical Trial. Eur Urol 2015; 67:1042-1050. [PMID: 25496767 PMCID: PMC4424172 DOI: 10.1016/j.eururo.2014.11.043] [Citation(s) in RCA: 396] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 11/21/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Open radical cystectomy (ORC) and urinary diversion in patients with bladder cancer (BCa) are associated with significant perioperative complication risk. OBJECTIVE To compare perioperative complications between robot-assisted radical cystectomy (RARC) and ORC techniques. DESIGN, SETTING, AND PARTICIPANTS A prospective randomized controlled trial was conducted during 2010 and 2013 in BCa patients scheduled for definitive treatment by radical cystectomy (RC), pelvic lymph node dissection (PLND), and urinary diversion. Patients were randomized to ORC/PLND or RARC/PLND, both with open urinary diversion. Patients were followed for 90 d postoperatively. INTERVENTION Standard ORC or RARC with PLND; all urinary diversions were performed via an open approach. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary outcomes were overall 90-d grade 2-5 complications defined by a modified Clavien system. Secondary outcomes included comparison of high-grade complications, estimated blood loss, operative time, pathologic outcomes, 3- and 6-mo patient-reported quality-of-life (QOL) outcomes, and total operative room and inpatient costs. Differences in binary outcomes were assessed with the chi-square test, with differences in continuous outcomes assessed by analysis of covariance with randomization group as covariate and, for QOL end points, baseline score. RESULTS AND LIMITATIONS The trial enrolled 124 patients, of whom 118 were randomized and underwent RC/PLND. Sixty were randomized to RARC and 58 to ORC. At 90 d, grade 2-5 complications were observed in 62% and 66% of RARC and ORC patients, respectively (95% confidence interval for difference, -21% to -13%; p=0.7). The similar rates of grade 2-5 complications at our mandated interim analysis met futility criteria; thus, early closure of the trial occurred. The RARC group had lower mean intraoperative blood loss (p=0.027) but significantly longer operative time than the ORC group (p<0.001). Pathologic variables including positive surgical margins and lymph node yields were similar. Mean hospital stay was 8 d in both arms (standard deviation, 3 and 5 d, respectively; p=0.5). Three- and 6-mo QOL outcomes were similar between arms. Cost analysis demonstrated an advantage to ORC compared with RARC. A limitation is the setting at a single high-volume, referral center; our findings may not be generalizable to all settings. CONCLUSIONS This trial failed to identify a large advantage for robot-assisted techniques over standard open surgery for patients undergoing RC/PLND and urinary diversion. Similar 90-d complication rates, hospital stay, pathologic outcomes, and 3- and 6-mo QOL outcomes were observed regardless of surgical technique. PATIENT SUMMARY Of 118 patients with bladder cancer who underwent radical cystectomy, pelvic lymph node dissection, and urinary diversion, half were randomized to open surgery and half to robot-assisted laparoscopic surgery. We compared the rate of complications within 90 d after surgery for the open group versus the robotic group and found no significant difference between the two groups. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01076387, www.clinicaltrials.gov.
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Affiliation(s)
- Bernard H Bochner
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Guido Dalbagni
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel D Sjoberg
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan Silberstein
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Gal E Keren Paz
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - S Machele Donat
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jonathan A Coleman
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sheila Mathew
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Geoffrey C Schnorr
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael A Feuerstein
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Bruce Rapkin
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Raul O Parra
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Harry W Herr
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Musser JE, Assel MJ, Meeks JJ, Sjoberg DD, Vickers AJ, Coleman JA, Eastham JA, Parra RO, Scardino PT, Touijer KA, Laudone VP. Ambulatory Extended Recovery: Safely Transitioning to Overnight Observation for Minimally Invasive Prostatectomy. Urol Pract 2015; 2:121-125. [PMID: 37559295 DOI: 10.1016/j.urpr.2014.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We evaluated the safety and efficacy of a clinical pathway designed and implemented to transition inpatient minimally invasive radical prostatectomy to a procedure with overnight observation. METHODS In April 2011 ambulatory extended recovery was implemented at our institution. This was a multidisciplinary program of preoperative teaching and postoperative care for patients undergoing minimally invasive radical prostatectomy. We compared the risk of requiring a more than 1-night hospital stay by patients treated with surgery the year before the program vs those treated after the program was initiated, adjusting for age, ASA® status and surgery type. We also examined the rates of readmission and urgent care visits within 48 hours, and 7 and 30 days before and after the program began. RESULTS The proportion of patients who stayed longer than 1 night was 53% in the year before initiating the ambulatory extended recovery program vs 8% during the program, representing an adjusted absolute risk decrease of 45% (95% CI 39-50, p <0.0001). There was no important predictor of a greater than 1-night length of stay among ambulatory extended recovery patients. Rates of readmission and urgent care visits were slightly lower during the ambulatory extended recovery phase with no significant difference between the groups. CONCLUSIONS The ambulatory extended recovery program successfully transitioned most patients to a 1-night hospital stay without resulting in an increased rate of readmission or urgent care visits.
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Affiliation(s)
- John E Musser
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa J Assel
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joshua J Meeks
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Daniel D Sjoberg
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew J Vickers
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jonathan A Coleman
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - James A Eastham
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Raul O Parra
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Peter T Scardino
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Karim A Touijer
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent P Laudone
- Urology Service, Department of Surgery and Department of Epidemiology and Biostatistics (MJA, DDS, AJV), Memorial Sloan Kettering Cancer Center, New York, New York
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Gao D, Vela I, Sboner A, Iaquinta PJ, Karthaus WR, Gopalan A, Dowling C, Wanjala JN, Undvall EA, Arora VK, Wongvipat J, Kossai M, Ramazanoglu S, Barboza LP, Di W, Cao Z, Zhang QF, Sirota I, Ran L, MacDonald TY, Beltran H, Mosquera JM, Touijer KA, Scardino PT, Laudone VP, Curtis KR, Rathkopf DE, Morris MJ, Danila DC, Slovin SF, Solomon SB, Eastham JA, Chi P, Carver B, Rubin MA, Scher HI, Clevers H, Sawyers CL, Chen Y. Organoid cultures derived from patients with advanced prostate cancer. Cell 2014; 159:176-187. [PMID: 25201530 DOI: 10.1016/j.cell.2014.08.016] [Citation(s) in RCA: 1011] [Impact Index Per Article: 101.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 07/22/2014] [Accepted: 08/12/2014] [Indexed: 12/11/2022]
Abstract
The lack of in vitro prostate cancer models that recapitulate the diversity of human prostate cancer has hampered progress in understanding disease pathogenesis and therapy response. Using a 3D organoid system, we report success in long-term culture of prostate cancer from biopsy specimens and circulating tumor cells. The first seven fully characterized organoid lines recapitulate the molecular diversity of prostate cancer subtypes, including TMPRSS2-ERG fusion, SPOP mutation, SPINK1 overexpression, and CHD1 loss. Whole-exome sequencing shows a low mutational burden, consistent with genomics studies, but with mutations in FOXA1 and PIK3R1, as well as in DNA repair and chromatin modifier pathways that have been reported in advanced disease. Loss of p53 and RB tumor suppressor pathway function are the most common feature shared across the organoid lines. The methodology described here should enable the generation of a large repertoire of patient-derived prostate cancer lines amenable to genetic and pharmacologic studies.
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Affiliation(s)
- Dong Gao
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Ian Vela
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andrea Sboner
- Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY 10065, USA; Institute for Precision Medicine of Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Pathology and Laboratory Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA
| | - Phillip J Iaquinta
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Wouter R Karthaus
- Hubrecht Institute, Royal Netherlands Academy of Arts and Sciences and University Medical Center Utrecht, 3584 CT, Utrecht, The Netherlands
| | - Anuradha Gopalan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Catherine Dowling
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Jackline N Wanjala
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Eva A Undvall
- Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Vivek K Arora
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - John Wongvipat
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Myriam Kossai
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA
| | - Sinan Ramazanoglu
- Institute for Computational Biomedicine, Weill Cornell Medical College, New York, NY 10065, USA; Department of Pathology and Laboratory Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA
| | - Luendreo P Barboza
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Wei Di
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Zhen Cao
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Qi Fan Zhang
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Inna Sirota
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Leili Ran
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Theresa Y MacDonald
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA
| | - Himisha Beltran
- Institute for Precision Medicine of Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA
| | - Juan-Miguel Mosquera
- Institute for Precision Medicine of Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Pathology and Laboratory Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA
| | - Karim A Touijer
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Peter T Scardino
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Vincent P Laudone
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Kristen R Curtis
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Dana E Rathkopf
- Department of Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Michael J Morris
- Department of Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Daniel C Danila
- Department of Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Susan F Slovin
- Department of Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Stephen B Solomon
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - James A Eastham
- Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Ping Chi
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Brett Carver
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Mark A Rubin
- Institute for Precision Medicine of Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Pathology and Laboratory Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA
| | - Howard I Scher
- Department of Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Hans Clevers
- Hubrecht Institute, Royal Netherlands Academy of Arts and Sciences and University Medical Center Utrecht, 3584 CT, Utrecht, The Netherlands
| | - Charles L Sawyers
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Howard Hughes Medical Institute, Chevy Chase, MD 20815, USA.
| | - Yu Chen
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Medicine, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, NY 10065, USA; Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA.
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Musser JE, Assel M, Guglielmetti GB, Pathak P, Silberstein JL, Sjoberg DD, Bernstein M, Laudone VP. Impact of routine use of surgical drains on incidence of complications with robot-assisted radical prostatectomy. J Endourol 2014; 28:1333-7. [PMID: 24934167 DOI: 10.1089/end.2014.0268] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To assess the impact of eliminating routine drain placement in patients undergoing robot-assisted laparoscopic prostatectomy (RALP) and pelvic lymph node dissection (PLND) on the risk of postoperative complications. PATIENTS AND METHODS An experienced single surgeon performed RALP on 651 consecutive patients at our institution from 2008 to 2012. Before August 2011, RALP with or without PLND included a routine peritoneal drain placed during surgery. Thereafter, routine intraoperative placement of drains was omitted, except for intraoperatively noted anastomotic leakage. We used multivariable logistic regression to compare complication rates between study periods and the actual drain placement status after adjusting for standard prespecified covariates. RESULTS Most patients (92%) did not have ≥grade 2 complications after surgery and only two patients (0.3%) experienced a grade 4 complication. The absolute adjusted risk of a grade 2-5 complication was 0.9% greater among those treated before August 2011 (95% confidence interval [CI] -3.3%-5.1%; p=0.7), while absolute adjusted risk of a grade 3-5 complication was 2.8% less (-2.8%; 95% CI-5.3%-0.1%; p=0.061). RESULTS based on drain status were similar. CONCLUSIONS Routine peritoneal drain placement following RALP with PLND did not confer a significant advantage in terms of postoperative complications. Further data are necessary to confirm that it is safe to omit drains in most patients.
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Affiliation(s)
- John E Musser
- 1 Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center , New York, New York
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Affiliation(s)
- Vincent P Laudone
- Department of Surgery, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY
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Garg T, Bazzi WM, Silberstein JL, Abu-Rustum N, Leitao MM, Laudone VP. Improving safety in robotic surgery: intraoperative crisis checklist. J Surg Oncol 2013; 108:139-40. [PMID: 23775871 DOI: 10.1002/jso.23363] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 05/28/2013] [Indexed: 11/05/2022]
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Silberstein JL, Su D, Glickman L, Kent M, Keren-Paz G, Vickers AJ, Coleman JA, Eastham JA, Scardino PT, Laudone VP. A case-mix-adjusted comparison of early oncological outcomes of open and robotic prostatectomy performed by experienced high volume surgeons. BJU Int 2013; 111:206-12. [PMID: 23356747 DOI: 10.1111/j.1464-410x.2012.11638.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare early oncological outcomes of robot assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) performed by high volume surgeons in a contemporary cohort. METHODS We reviewed patients who underwent radical prostatectomy for prostate cancer by high volume surgeons performing RALP or ORP. Biochemical recurrence (BCR) was defined as PSA ≥ 0.1 ng/mL or PSA ≥ 0.05 ng/mL with receipt of additional therapy. A Cox regression model was used to evaluate the association between surgical approach and BCR using a predictive model (nomogram) based on preoperative stage, grade, volume of disease and PSA. To explore the impact of differences between surgeons, multivariable analyses were repeated using surgeon in place of approach. RESULTS Of 1454 patients included, 961 (66%) underwent ORP and 493 (34%) RALP and there were no important differences in cancer characteristics by group. Overall, 68% of patients met National Comprehensive Cancer Network (NCCN) criteria for intermediate or high risk disease and 9% had lymph node involvement. Positive margin rates were 15% for both open and robotic groups. In a multivariate model adjusting for preoperative risk there was no significant difference in BCR rates for RALP compared with ORP (hazard ratio 0.88; 95% CI 0.56-1.39; P = 0.6). The interaction term between nomogram risk and procedure type was not statistically significant. Using NCCN risk group as the covariate in a Cox model gave similar results (hazard ratio 0.74; 95% CI 0.47-1.17; P = 0.2). The interaction term between NCCN risk and procedure type was also non-significant. Differences in BCR rates between techniques (4.1% vs 3.3% adjusted risk at 2 years) were smaller than those between surgeons (2.5% to 4.8% adjusted risk at 2 years). CONCLUSIONS In this relatively high risk cohort of patients undergoing radical prostatectomy we found no evidence to suggest that ORP resulted in better early oncological outcomes then RALP. Oncological outcome after radical prostatectomy may be driven more by surgeon factors than surgical approach.
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Ginzburg S, Nevers T, Staff I, Tortora J, Champagne A, Kesler SS, Laudone VP, Wagner JR. Prostate cancer biochemical recurrence rates after robotic-assisted laparoscopic radical prostatectomy. JSLS 2013; 16:443-50. [PMID: 23318071 PMCID: PMC3535788 DOI: 10.4293/108680812x13462882736538] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Serge Ginzburg
- University of Connecticut Health Center, Farmington, CT, USA
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Laudone VP, Silberstein JL. Editorial comment from Dr Laudone and Dr Silberstein to pelvic lymph node dissection for prostate cancer: adherence and accuracy of the recent guidelines. Int J Urol 2012; 20:411. [PMID: 23039361 DOI: 10.1111/j.1442-2042.2012.03190.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Godoy G, von Bodman C, Chade DC, Dillioglugil O, Eastham JA, Fine SW, Scardino PT, Laudone VP. Pelvic lymph node dissection for prostate cancer: frequency and distribution of nodal metastases in a contemporary radical prostatectomy series. J Urol 2012; 187:2082-6. [PMID: 22498221 DOI: 10.1016/j.juro.2012.01.079] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Indexed: 10/28/2022]
Abstract
PURPOSE We determined the frequency and distribution of metastases to pelvic lymph nodes in a contemporary American radical prostatectomy series. MATERIALS AND METHODS In 642 consecutive patients with clinically localized prostate cancer treated by a single surgeon between 2002 and 2009 pelvic lymph nodes were removed and submitted to the pathologist in separate packets (external iliac, obturator and hypogastric). We assessed the total number of nodes and the number with metastases in each packet. RESULTS Complete pathological information was available for 427 patients, who had a median of 16 lymph nodes removed. Of the patients 35 (8.2%) had lymph node metastases, including 1.7% with low, 8.6% with intermediate and 23.9% with high risk cancer. Of those with nodal metastases 24 (69%) had positive lymph nodes in only 1 of the 3 areas, including the external iliac in 4 (11%), the obturator in 9 (26%) and the hypogastric in 11 (31%). Only 37% of the patients had positive nodes only in the external iliac area above the obturator nerve while 60% and 49% had at least 1 positive node in the obturator and the hypogastric area, respectively. Of the patients 80% had only 1 (49%) or 2 (31%) positive nodes. CONCLUSIONS In contemporary American patients with clinically localized prostate cancer lymph node metastases were found more often and frequently exclusively in the obturator and hypogastric areas than in the external iliac area. Pelvic lymph node dissection limited to the external iliac area above the obturator nerve would identify and remove lymph node metastases in only a third of the patients with positive nodes found at full pelvic lymph node dissection.
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Affiliation(s)
- Guilherme Godoy
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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Bochner BH, Laudone VP. Bladder cancer treatment: optimize, don't compromise. Oncology (Williston Park) 2011; 25:1412-1413. [PMID: 22329193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Bernard H Bochner
- Kimmel Center for Prostate and Urologic Cancers, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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Silberstein JL, Vickers AJ, Power NE, Parra RO, Coleman JA, Pinochet R, Touijer KA, Scardino PT, Eastham JA, Laudone VP. Pelvic lymph node dissection for patients with elevated risk of lymph node invasion during radical prostatectomy: comparison of open, laparoscopic and robot-assisted procedures. J Endourol 2011; 26:748-53. [PMID: 22050490 DOI: 10.1089/end.2011.0266] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Published outcomes of pelvic lymph node dissection (PLND) during robot-assisted laparoscopic prostatectomy (RALP) demonstrate significant variability. The purpose of the study was to compare PLND outcomes in patients at risk for lymph node involvement (LNI) who were undergoing radical prostatectomy (RP) by different surgeons and surgical approaches. PATIENTS AND METHODS Institutional policy initiated on January 1, 2010, mandated that all patients undergoing RP receive a standardized PLND with inclusion of the hypogastric region when predicted risk of LNI was ≥ 2%. We analyzed the outcomes of consecutive patients meeting these criteria from January 1 to September 1, 2010 by surgeons and surgical approach. All patients underwent RP; surgical approach (open radical retropubic [ORP], laparoscopic [LRP], RALP) was selected by the consulting surgeon. Differences in lymph node yield (LNY) between surgeons and surgical approaches were compared using multivariable linear regression with adjustment for clinical stage, biopsy Gleason grade, prostate-specific antigen (PSA) level, and age. RESULTS Of 330 patients (126 ORP, 78 LRP, 126 RALP), 323 (98%) underwent PLND. There were no significant differences in characteristics between approaches, but the nomogram probability of LNI was slightly greater for ORP than RALP (P=0.04). LNY was high (18 nodes) by all approaches; more nodes were removed by ORP and LRP (median 20, 19, respectively) than RALP (16) after adjusting for stage, grade, PSA level, and age (P=0.015). Rates of LNI were high (14%) with no difference between approaches when adjusted for nomogram probability of LNI (P=0.15). Variation in median LNY among individual surgeons was considerable for all three approaches (11-28) (P=0.005) and was much greater than the variability by approach. CONCLUSIONS PLND, including hypogastric nodal packet, can be performed by any surgical approach, with slightly different yields but similar pathologic outcomes. Individual surgeon commitment to PLND may be more important than approach.
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Affiliation(s)
- Jonathan L Silberstein
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10065, USA
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Lowrance WT, Eastham JA, Yee DS, Laudone VP, Denton B, Scardino PT, Elkin EB. Costs of medical care after open or minimally invasive prostate cancer surgery: a population-based analysis. Cancer 2011; 118:3079-86. [PMID: 22025192 DOI: 10.1002/cncr.26609] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2011] [Revised: 06/29/2011] [Accepted: 07/18/2011] [Indexed: 11/09/2022]
Abstract
BACKGROUND Evidence suggests that minimally invasive radical prostatectomy (MRP) and open radical prostatectomy (ORP) have similar short-term clinical and functional outcomes. MRP with robotic assistance is generally more expensive than ORP, but it is not clear whether subsequent costs of care vary by approach. METHODS In the Surveillance, Epidemiology, and End Results (SEER) cancer registry linked with Medicare claims, men aged 66 years or older who received MRP or ORP in 2003 through 2006 for prostate cancer were identified. Total cost of care was estimated as the sum of Medicare payments from all claims for hospital care, outpatient care, physician services, home health and hospice care, and durable medical equipment in the first year from the date of surgical admission. The impact of surgical approach on costs was estimated, controlling for patient and disease characteristics. RESULTS Of 5445 surgically treated prostate cancer patients, 4454 (82%) had ORP and 991 (18%) had MRP. Mean total first-year costs were more than $1200 greater for MRP compared with ORP ($16,919 vs $15,692; P = .08). Controlling for patient and disease characteristics, MRP was associated with 2% greater mean total payments, but this difference was not statistically significant. First-year costs were greater for men who were older, black, lived in the Northeast, had lymph node involvement, more advanced tumor stage, or greater comorbidity. CONCLUSIONS In this population-based cohort of older men, MRP and ORP had similar economic outcomes. From a payer's perspective, any benefits associated with MRP may not translate to net savings compared with ORP in the first year after surgery.
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Affiliation(s)
- William T Lowrance
- Division of Urology, Department of Surgery, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah 84112, USA.
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Power NE, Silberstein JL, Kulkarni GS, Laudone VP. The dorsal venous complex (DVC): dorsal venous or dorsal vasculature complex? Santorini's plexus revisited. BJU Int 2011; 108:930-2. [PMID: 21884359 DOI: 10.1111/j.1464-410x.2011.10586.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Nicholas E Power
- Department of Surgery, Urology Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Power NE, Silberstein JL, Kulkarni GS, Laudone VP. The dorsal venous complex (DVC): dorsal venous or dorsal vasculature complex? Santorini's plexus revisited. BJU Int 2011. [PMID: 21884359 DOI: 10.1111/j.1464-410x.2011.10586.x)] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Nicholas E Power
- Department of Surgery, Urology Service, Memorial Sloan-Kettering Cancer Center, New York, NY 10065, USA
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Silberstein JL, Vickers AJ, Power NE, Fine SW, Scardino PT, Eastham JA, Laudone VP. Reverse stage shift at a tertiary care center. Cancer 2011; 117:4855-60. [DOI: 10.1002/cncr.26132] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 02/17/2011] [Accepted: 02/23/2011] [Indexed: 11/11/2022]
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Feifer AH, Elkin EB, Lowrance WT, Denton B, Jacks L, Yee DS, Coleman JA, Laudone VP, Scardino PT, Eastham JA. Temporal trends and predictors of pelvic lymph node dissection in open or minimally invasive radical prostatectomy. Cancer 2011; 117:3933-42. [PMID: 21412757 DOI: 10.1002/cncr.25981] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 12/15/2010] [Accepted: 01/03/2011] [Indexed: 11/06/2022]
Abstract
BACKGROUND Pelvic lymph node dissection (PLND) is an important component of prostate cancer staging and treatment, especially for surgical patients who have high-risk tumor features. It is not clear how the shift from open radical prostatectomy (ORP) to minimally invasive radical prostatectomy (MIRP) has affected the use of PLND. The objectives of this study were to identify predictors of PLND and to assess the impact of surgical technique in a contemporary, population-based cohort. METHODS In Surveillance, Epidemiology, and End Results (SEER) cancer registry data linked with Medicare claims, the authors identified men who underwent ORP or MIRP for prostate cancer during 2003 to 2007. The impact of surgical approach on PLND was evaluated, and interactions were examined between surgical procedure, prostate-specific antigen (PSA), and Gleason score with the analysis controlled for patient and tumor characteristics. RESULTS Of 6608 men who underwent ORP or MIRP, 70% (n = 4600) underwent PLND. The use of PLND declined over time both overall and within subgroups defined by procedure type. PLND was 5 times more likely in men who underwent ORP than in men who underwent MIRP when the analysis was controlled for patient and tumor characteristics. Elevated PSA and biopsy Gleason score, but not clinical stage, were associated with a greater odds of PLND in both the ORP group and the MIRP group. However, the magnitude of the association between these factors and PLND was significantly greater for patients in the ORP group. CONCLUSIONS PLND was less common among men who underwent MIRP, independent of tumor risk factors. A decline in PLND rates was not fully explained by an increase in MIRP. The authors concluded that these trends may signal a surgical approach-dependent disparity in prostate cancer staging and therapy.
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Affiliation(s)
- Andrew H Feifer
- Urology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA.
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