Contemporary Trends and Survival Outcomes After Aborted Radical Prostatectomy in Lymph Node Metastatic Prostate Cancer Patients

Potential benefit of lymph node dissection during radical nephrectomy for kidney cancer: A review and critical analysis of current literature

Objective

The role of lymph node dissection (LND) is still controversial in patients with renal cell carcinoma undergoing surgery. We aimed to provide a comprehensive review of the literature about the effect of LND on survival, prognosis, surgical outcomes, as well as patient selection and available LND templates.

Methods

Recent literature (from January 2011 to December 2021) was assessed through PubMed and MEDLINE databases. A narrative review of most relevant articles was provided.

Results

The frequencies in which LNDs are being carried out are decreasing due to an increase in minimally invasive and nephron sparing surgery. Moreover, randomized clinical trials and meta-analyses failed to show any survival advantage of LND versus no LND. However, retrospective studies suggest a survival benefit of LND in high-risk patients (bulky tumors, T3-4 stage, and cN1 patients). Moreover, extended LND might provide important staging information, which could be of interest for adjuvant treatment planning.

Conclusion

No level 1 evidence of any survival advantage deriving from LND is currently available in literature. Thus, the role of LND is limited to staging purposes. However, low grade evidence suggests a possible role of LND in high-risk patients. Randomized clinical trials are warranted to corroborate these findings.

Temporal Trends and Predictors in Diagnosing Pathologic Node-Positive Prostate Cancer in Clinically Node-Negative Patients

INTRODUCTION

Managing pathologically node positive (pN+) prostate cancer (PCa) is controversial. We describe temporal patterns and predictors of pN+ PCa in men with initially surgically managed clinically node negative (cN-) PCa.

MATERIALS AND METHODS

This observational retrospective analysis of nonmetastatic, cN- PCa uses the National Cancer Database. Multivariable logistic regression was used to identify covariates associated with pN+ disease. Cox proportional hazards modeling and Kaplan-Meier analysis were used to evaluate survival patients undergoing radical prostatectomy with or without pelvic lymph node dissection (PLND).

RESULTS

The rates of radical prostatectomy in men with grade group (GG) 4 and GG5 increased from 47.6% to 53.1% and from 42.5% to 49.5%, respectively. The annual rate increased from 2.02% in 2010 to 5.12% in 2017 (P < .001). The annual rates of PLND increased from 54.3% to 71.7%. The most significant predictor of pN+ PCa was ISUP GG4 (odds ratio [OR] 12.5, P< .001) and GG 5 (OR 26.2, P < .001). Rates of pN+ identification increased from 5.5% to 9.4% in men with GG4 and from 13.4% to 19.5% in men with GG5 (P< .001). In GG4 and GG5, patients undergoing PLND had superior survival to those managed without PLND (P < .01).

CONCLUSION

Among patients with cN- PCa, the diagnosis of pN+ PCa has become more common over time. GG4 and GG5 are the strongest independent predictors of pN+ disease. Because incidental pN+ results in upstaging these data are useful for informing discussions before radical prostatectomy.

A systematic scoping review of multidisciplinary cancer team and decision-making in the management of men with advanced prostate cancer

PURPOSE

The early diagnosis of prostate cancer and subsequent access to the treatment options helps to achieve optimal cancer outcomes. As the treatment options for patients with advanced prostate cancer continues to evolve, patients need to access a multidisciplinary team (MDT) meeting to receive best-practice care.

METHODS

In this paper a MEDLINE review was performed to assess clinical decision making in the context of MDT discussions for patients with advanced prostate cancer.

RESULTS

From 441 returned articles and abstracts, 50 articles were assessed for eligibility and 16 articles included for analysis. Sixteen articles were identified, 9 of the 16 articles used quantitative methodology including three retrospective analysis of clinical registry data, patient medical records and/or MDT meeting notes and three cross-sectional surveys. Other study designs included one observation study and one study using a combination of qualitative and quantitative methodologies and one mini-review. There were also four editorials included in the review and two consensus statements.

CONCLUSION

This paper highlights the important role the inter-disciplinary MDT has on shared decision making for men with advanced prostate cancer. The application of MDT care is a rapidly growing trend in uro-oncology and an efficient MDT service requires further research to assess its efficiency so that it may expand through all aspect of uro-oncology.

Management of erectile dysfunction following robot-assisted radical prostatectomy: a systematic review

INTRODUCTION

We aimed to summarize evidences about the efficacy of available treatments for erectile disfunction after robotic assisted radical prostatectomy (RARP).

EVIDENCE ACQUISITION

A systematic literature review searching on PubMed (Medline), Scopus, and Web of Science databases was performed in December 2019. PRISMA guidelines were followed. Population consisted of patients with erectile disfunction after RARP (P), conservative and surgical intervention were considered of interest (I). No comparator was considered mandatory (C). Outcomes of interest were the recovery of erectile function after conservative treatments and sexual function after surgical treatments (O).

EVIDENCE SYNTHESIS

Eleven studies were included. Seven studies focused on the use of phosphodiesterase-5 inhibitors (PDE5i) alone (five studies) or associated with other treatments (two studies). All the studies confirmed the efficacy of PDE5i, while the most promising association is with vacuum pump erectile devices. Two studies investigated topical treatments, namely low intensity extracorporeal shock wave therapy and alprostadil. Low intensity extracorporeal shock wave therapy may be a promising option in patients in whom nerve-sparing surgery was performed. The use of alprostadil could be an effective alternative to intracorporeal injection in those who underwent non-nerve-sparing surgery. One study focused and confirmed the efficacy of penile implants. Furthermore, one study reported the efficacy of a multi-modal treatment with preoperative medication, showing the benefits of a multimodal approach.

CONCLUSIONS

Penile rehabilitation with PDE5i is effective after nerve sparing RARP. The association of PDE5i with vacuum devices could led to a faster recovery. A multimodal approach with preoperative specific care seems to be effective to fasten erectile function recovery.

Contemporary Assessment of Long-Term Survival Rates in Patients With Stage I Nonseminoma Germ-Cell Tumor of the Testis: Population-Based Comparison Between Surveillance and Active Treatment After Initial Orchiectomy

BACKGROUND

Historical data demonstrated similar survival outcomes in patients with stage I nonseminoma germ-cell tumor of the testis (NSGCTT) subjected to either surveillance or active treatment (AT) after orchiectomy. However, data with long-term follow-up are unavailable. We tested contemporary treatment rates and their effect on cancer-specific mortality (CSM) and other-cause mortality (OCM) relative to surveillance, as well as after stratification between chemotherapy (CHT) versus retroperitoneal lymph node dissection (RPLND).

PATIENTS AND METHODS

We identified patients with stage I NSGCTT with initial orchiectomy within the Surveillance, Epidemiology, and End Results (SEER) database (1988-2015). Subsequent surveillance versus CHT versus RPLND use rates were reported. Cumulative incidence plots and multivariable competing-risks regression (CRR) models were used after propensity score (PS) matching. These tests first compared surveillance versus AT (CHT vs. RPLND) and subsequently CHT versus RPLND.

RESULTS

Of 5034 patients with stage I NSGCTT, 61.2%, 24.9%, and 13.9%, respectively, underwent surveillance, CHT, and RPLND. Between 1988 and 2015, surveillance (estimated annual percentage change [EAPC]: +1.1%, P < .001) and CHT (EAPC: +2.3%, P < .001) rates increased. RPLND rates decreased (EAPC: -5.7%; P < .001). After PS matching, CRR models failed to identify AT as an independent predictor of lower mortality relative to surveillance. However, after PS matching, CRR models identified RPLND as an independent predictor of lower CSM (hazard ratio, 0.26; P = .002) relative to CHT. No difference in OCM rates was recorded (hazard ratio, 1.25; P = .2).

CONCLUSION

Surveillance and CHT use rates increased while RPLND decreased in the last two decades. Virtually the same outcomes were recorded between surveillance and AT. However, within AT, RPLND was associated with lower CSM than CHT.

Impact of Age on Perioperative Outcomes at Radical Prostatectomy: A Population-Based Study

BACKGROUND

Radical prostatectomy (RP) represents one standard of care for patients with localized prostate cancer and is associated with several established postoperative complications.

OBJECTIVE

We tested the relationship between RP early postoperative outcomes and age within a population-based data repository.

DESIGN, SETTING, AND PARTICIPANTS

Within the National Inpatient Sample database (2008-2013), we identified patients who underwent robotically assisted or open RP.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Multivariable logistic regression (MLR), multivariable Poisson regression (MPR), and linear regression models were used. Cubic spline graphically depicted the relationship between age and complications.

RESULTS AND LIMITATIONS

Overall, 68780 patients underwent RP with a median age of 62 yr (interquartile range: 57-67 yr). In MLR models, patient age represented an independent predictor of overall [odds ratio (OR): 1.02, p<0.001], intraoperative (OR: 1.03, p<0.001), cardiac (OR: 1.03, p<0.001), miscellaneous medical (OR: 1.02, p<0.001), miscellaneous surgical (OR: 1.01, p=0.01), pulmonary (OR: 1.02, p<0.001), and vascular complications (OR: 1.05, p<0.001); blood transfusions (OR: 1.02, p<0.001); and bowel obstruction (OR: 1.02, p<0.001). In MPR models, patient age was associated with longer stay (OR: 1.001, p=0.02). Similar results were recorded after adjustment for clustering in stratified analyses (<70 vs ≥70 yr) and in the subgroup of patients that underwent robotically assisted RP. For nine out of twelve examined outcomes, a virtually direct relationship existed with increasing age, in cubic spline analyses.

CONCLUSIONS

Virtually all early postoperative RP complications are directly related to age. In consequence, these observations should be considered from an individual patient perspective as well as from a health management perspective.

PATIENT SUMMARY

RP is provided through a wide patient age spectrum. Virtually all early postoperative RP complications are directly related to age. Individual patient's age needs to be considered in treatment decision-making.

North American population-based validation of the National Comprehensive Cancer Network Practice Guideline Recommendations for locoregional lymph node and bone imaging in prostate cancer patients

BACKGROUND

The National Comprehensive Cancer Network (NCCN) guidelines provide recommendations for staging of prostate cancer patients in the objective regarding presence of locoregional lymph node metastases (LNM) and bone metastases. We tested the performance characteristics of these recommendations in a community setting.

METHODS

Within the Surveillance, Epidemiology, and End Results database (2004-2014), we identified patients with available Gleason, clinical stage and prostatic specific antigen. Performance characteristics endpoints consisted of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NVP), overall accuracy and the number needed to image (NNI).

RESULTS

Totally, 191,308 patients were assessable for the validation of the LNM staging recommendations. Sensitivity ranged from 80.6 to 86.3%, specificity from 74.7 to 79.3%, PPV from 7.8 to 8.0%, overall accuracy from 75.0 to 79.3% and NPV was 99.5%. The respective NNI values were 12.5 and 12.8. 197,408 patients were assessable for the validation of bone scan recommendations. These recommendations resulted in 90.8% sensitivity, 76.3% specificity, PPV of 5.7%, NPV of 99.8% and overall accuracy of 76.5%. The NNI was 17.5.

CONCLUSION

The NCCN recommendations for locoregional LNM miss few patients with clinical LNM (0.3-0.4%) and provide a virtually perfect NPV of 99.5%. Also, the recommendations for bone scan miss a marginal number of patients with established bone metastases (0.14%) and yield a virtually perfect NPV of 99.8%.

Sentinel node evaluation in prostate cancer

Sentinel lymph node (SLN) based pelvic lymph node dissection (PLND) in prostate cancer (PCa) is appealing over the time, cost and morbidity classically attributed to conventional PLND during radical prostatectomy. The initial report of feasibility of the SLN concept in prostate cancer was nearly 20 years ago. However, PLND based on the SLN concept, either SLN biopsy of a single node or targeted SLN dissection of multiple nodes, is still considered investigational in PCa. To better appreciate the challenges, and potential solutions, associated with SLN-based PLND in PCa, this review will discuss the rationale behind PLND in PCa and evaluate current SLN efforts in the most commonly diagnosed malignancy in men in the US.