Impact of Prostate Size on the Functional and Oncological Outcomes of Robot-assisted Radical Prostatectomy

Functional and Oncological Outcomes of Very Large Prostate Sizes Post Robotic Radical Prostatectomy: A Propensity Score-Matched Analysis

BACKGROUND

Robotic-assisted radical prostatectomy (RARP) is widely used as the main surgical approach to treat prostate cancer in the United States. Prostate size is often described as a factor affecting the outcomes of RARP as shown by many studies. However, these studies are limited to a small number of patients.

OBJECTIVE

To evaluate the functional and oncologic outcomes of RARP in very large prostate sizes.

METHODS

Three hundred and seventy-five RARP patients were divided into two groups according to prostate size: Group 1 had prostates larger than 150 g and Group 2 smaller than 50 g. Perioperative variables were matched with propensity score matching 1:3 and postoperative variables were analyzed for significant differences in outcomes between groups. Variables analyzed included estimated blood loss (EBL), operative time, catheter time, hospitalization time, postoperative complications, pathological staging, positive surgical margins (PSM) rates, biochemical recurrence (BCR), potency, and continence rates.

RESULTS

The two groups exhibited similar preoperative characteristics. Patients with larger prostates (Group 1) were more likely to have higher blood loss (EBL), longer console time, and more days with catheter. However, we could not find significant difference in the overall postoperative complications (Clavien-Dindo). Pathological outcomes were also statistically different as patients with larger prostates had (69.7%) more pT2 disease and (12.1%) lower rates of PSM. Finally, we could not find significant difference in the functional outcomes between the groups.

CONCLUSION

The results demonstrate that prostate size impacts multiple outcomes. Larger prostates had lower-grade disease, reduced EPE and PSM rates, with no significant differences in BCR or functional outcomes. Perioperative differences, such as increased blood loss and console time, were also observed.

Anatomic Factors Associated with Complications After Radical Prostatectomy: A Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVE

The role of anatomical factors in predicting outcomes after radical prostatectomy (RP) remains unclear. This review aims to evaluate the impact of various anatomical factors on the perioperative outcomes of patients undergoing RP for localized prostate cancer (PCa).

METHODS

A comprehensive literature search was conducted through January 2024 using the PubMed/Medline, Embase, and Web of Science databases. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed to identify eligible studies. Data were extracted and pooled for a meta-analysis, with outcomes including operative time, blood loss, transfusion rates, overall complications, and positive surgical margins (PSMs). Heterogeneity was assessed using Cochrane Q test, and subgroup analyses were conducted to explore the influence of surgical approach.

KEY FINDINGS AND LIMITATIONS

A total of 91 studies met our inclusion criteria. Among the anatomical factors, prostate volume (PV), prostate weight, and median lobe (ML) were suitable for the meta-analysis. Larger prostates were associated with increased operative time, blood loss, and complication rates, but with fewer PSMs (all p < 0.05). ML presence was not associated with a higher risk of complications. Heterogeneity was high across studies (Cochrane Q tests <0.05), reflecting inconsistent definitions and methods. In subgroup analyses, the open approach was associated with a longer operative time than robotic surgery for large prostates (p = 0.03) and a lower PSM rate (p < 0.001).

CONCLUSIONS AND CLINICAL IMPLICATIONS

Anatomical factors, particularly PV, play a significant role in RP outcomes. Larger prostates are associated with higher complication rates but fewer PSMs. Further research with standardized outcome measures is necessary to clarify these relationships and guide clinical decision-making.

PATIENT SUMMARY

In this study, we examined how a patient's individual anatomy might affect the results of prostate surgery for cancer. We found that larger prostates tend to lead to longer surgeries and increased blood loss, but these also have a lower risk of leaving cancer cells behind. These findings could help doctors in better planning surgeries and improving patient outcomes.

The impact of prostate volume on Retzius-sparing robot-assisted laparoscopic radical prostatectomy with retrograde release of the neurovascular bundle

OBJECTIVE

Robot-assisted radical prostatectomy (RARP) has emerged as a primary treatment modality for localized prostate cancer. In this context, we report a novel surgical technique termed Retzius-sparing robot-assisted laparoscopic radical prostatectomy with retrograde release of the neurovascular bundle (RNRS-RARP). This study aims to assess the perioperative, oncological, and functional outcomes of RNRS-RARP across varying prostate volumes.

METHODS

A retrospective analysis was conducted on clinical data retrieved from 298 patients who underwent RNRS-RARP from October 2021 to September 2023. Patients were stratified into three groups based on pathological prostate weight: ≤ 30 g, 30-50 g, and ≥ 50 g. Comparative analyses were performed on perioperative and postoperative oncological and functional outcomes among the three groups to discern variations. Separate analyses were performed for patients who received neoadjuvant therapy and those who did not. Additionally, independent predictors of immediate continence following RNRS-RARP were investigated.

RESULTS

Patients with larger prostate volumes were significantly older and have higher body mass index and prostate-specific antigen (PSA) (all p < 0.05). Larger prostate volumes exhibited prolonged median console time (65 vs. 70 vs. 90 min, p < 0.01) and increased median estimated blood loss (95 vs. 90 vs. 100 ml). There were no significant differences in duration of catheterization, length of stay, postoperative complications, positive surgical margin, PSA recurrence after 6 months, 1 month and 3 months continence. Immediate continence worsened with increasing prostate volume (80.0% vs. 77.5% vs. 64.2%, p = 0.04). Prostate volume (OR = 0.98; 95% Cl: 0.97-0.99; p = 0.03), age (OR = 0.90; 95% Cl: 0.86-0.95; p < 0.01), and clinical T stage (OR = 0.31; 95% Cl: 0.13-0.74; p = 0.01) were independent risk factors for immediate continence, with an area under the curve of 0.75 in the predictive model.

CONCLUSION

RNRS-RARP can be safely performed regardless of prostate volume. As prostate volume increases, both console time and estimated blood loss tend to rise. However, the oncological outcomes and complication rates remained similar. Immediate continence was significantly lower with larger prostate volume, which also emerged as an independent predictor.

CLINICAL TRIAL REGISTRATION

The clinical trial registration number is ChiCTR2200066350 (December1, 2022).

The impact of preoperative 5-alpha reductase inhibitors on functional outcomes and health-related quality of life following radical prostatectomy - A propensity score matched longitudinal study

OBJECTIVES

While the impact of treatment with 5-alpha Reductase Inhibitors (5-ARI) on the risk of cancer-related mortality in men with prostate cancer (PC) has been extensively studied, little is known about the impact of preoperative 5-ARI use on patient-reported outcomes (PROs) following radical prostatectomy (RP).

METHODS

Within our prospectively maintained institutional database of 5899 patients treated with RP for PC (2008- 2021), 99 patients with preoperative 5-ARI therapy were identified. A 1:4 propensity-score matched analysis of 442 men (n = 90 5-ARI, n = 352 no 5-ARI) was conducted. Primary endpoint was continence recovery using daily pad usage and ICIQ-SF. Health-related quality of life (HRQOL) was assessed using the validated EORTC QLQ-C30 and PR25 questionnaires. Multivariable Cox-regression-models tested the effect of preoperative 5-ARI treatment on continence-recovery (p < 0.05).

RESULTS

Patients were followed up perioperatively, followed by annual assessments up to 60mo postoperatively. Preoperative mean ICIQ-SF score (2.2 vs. 0.9) was significantly higher in the 5-ARI cohort (p = 0.006). 24mo postoperatively, 68.6% (no 5-ARI) vs. 55.7% (5-ARI) had full continence recovery (p = 0.002). Multivariable Cox regression analysis, revealed preoperative 5-ARI treatment as an independent predictor for impaired continence recovery (HR 0.50, 95% CI 0.27-0.94, p = 0.03) In line, general HRQOL was significantly higher for patients without 5-ARI only up to 24mo postoperatively (70.6 vs. 61.2, p = 0.045). There was no significant impact of preoperative 5-ARI treatment on erectile function, biochemical recurrence-free survival and metastasis-free survival.

CONCLUSIONS

Pre-RP 5-ARI treatment was associated with impaired continence outcomes starting 24mo postoperatively, suggesting that preoperative 5-ARI treatment can impair the long-term urinary function recovery following RP.

The Association between Patient Characteristics and Biochemical Recurrence after Radical Prostatectomy

Background: Biochemical recurrence (BCR) represents the rise of prostate-specific antigen (PSA) levels after treatment with curative radical prostatectomy (RP) or radiation for prostate cancer. The objective of the current study was to test for the association between patient characteristics, namely age, body mass index (BMI), as well as prostate volume at surgery, and BCR after RP. Material and Methods: Within a tertiary care database, patients with prostate cancer treated with RP between January 2014 and June 2023 were included. Kaplan-Meier survival analyses and Cox regression models addressed BCR after RP according to patient characteristics. Results: Of 821 patients, the median age was 66 years (interquartile range [IQR] 61-71 years), BMI was 26.2 kg/m2 (IQR 24.3-28.8 kg/m2), and prostate volume was 40 cm3 (IQR 30-55 cm3). Median follow-up was 20 months. In survival analyses, the three-year BCR-free survival rates were 81 vs. 84 vs. 81% in patients aged ≤60 vs. 61-69 vs. 70 years (p = 0.1). In patients with BMI < 25.0 vs. 25.0-29.9 vs. ≥30.0 kg/m2, the three-year BCR-free survival rates were 84 vs. 81 vs. 84% (p = 0.7). In patients with prostate volume ≤40 vs. >40 cm3, the three-year BCR-free survival rates were 85 vs. 80% (p = 0.004). In multivariable Cox regression models accounting for patient and pathologic tumor characteristics and adjuvant radiation therapy, a higher prostate volume independently predicted BCR as continuous (hazard ratio 1.012, 95% confidence interval 1.005-1.019; p < 0.001), as well as categorized the variable based on the median (hazard ratio 1.66, 95% confidence interval 1.17-2.36; p = 0.005). Conversely, neither age nor BMI were significantly associated with BCR after RP. Conclusions: The higher prostate volume independently predicted BCR after RP, but not age or BMI at surgery. Consequently, patients with an elevated prostate volume should be considered for closer postoperative follow-up.