Community-based Outcomes of Open versus Robot-assisted Radical Prostatectomy

Information Behaviour and Knowledge of Patients Before Radical Prostatectomy

BACKGROUND/OBJECTIVES

Robot-assisted and open radical prostatectomy (RARP and ORP) are established procedures for localized prostate cancer, with comparable oncological and functional outcomes. Little is known about patients' knowledge of both procedures. This study aimed to examine comparatively the informational behaviour and knowledge of patients undergoing ORP vs. RARP.

METHODS

This prospective, multicentre study included patients who underwent RARP or ORP prior to presurgery counselling. The questionnaires gathered information about patients' information-seeking behaviours and their assessment of outcomes for RARP vs. ORP. We investigated risk factors for the misperception of procedure outcomes.

RESULTS

A total of 508 patients were included (307 RARP (60%); 201 ORP (40%)). The most common sources of information were outpatient urologists (84%), urologic departments (67%) and the internet (57%). Compared with ORP, RARP patients more often received the same amount of information about both procedures (60% vs. 40%, p < 0.001). Compared with ORP, RARP patients wrongfully considered their procedure to be superior in terms of oncological and functional outcomes. In the multivariable analysis, age > 66 years (OR 2.1, p = 0.02), no high school degree (OR 1.9, p = 0.04), unbalanced information search (OR 2.4, p = 0.02), RARP patient status (OR 8.9, p < 0.001), and treatment at a centre offering only one procedure (OR 3.5, p < 0.001) were independent predictors of misperception.

CONCLUSIONS

RARP patients wrongfully considered their intervention to be oncologically and functionally more beneficial than ORP patients perceived it to be. This may be due to unbalanced sources of information. Urologists and surgical centres must address this misperception to enable patients to make informed decisions.

Imaging of prostate micro-architecture using three-dimensional wide-field optical coherence tomography

Prostate cancer is a global health issue that requires new diagnostic methods to provide accurate and precise visualization of prostate tissue on the micro-scale. Such methods have the potential to improve nerve-sparing surgery and to provide image guidance during prostate biopsy. In this feasibility study, we assess the potential of en face three-dimensional wide-field optical coherence tomography (OCT), covering a volumetric imaging field-of-view up to 46 × 46 × 1 mm3, to visualize micro-architecture in 18 freshly excised human prostate specimens. In each case, validation of contrast in OCT images is provided by co-registered wide-field histology images. Using this co-registration, we demonstrate that OCT can distinguish between healthy and cancerous glands at different stages, as well as visualize micro-architecture in the prostate, such as epineurium and perineurium in nerves and the tunica intima and tunica media in blood vessels.

Economic evaluations of robot-assisted radical prostatectomy and the factors affecting its cost-effectiveness: a systematic review

This systematic review aims to summarize the progress made in the study of the cost-effectiveness of robot-assisted radical prostatectomy (RARP) worldwide and to analyze the economic factors influencing this, in an attempt to provide methodological guidance for conducting economic evaluation studies in a domestic context, and to put forward suggestions for improving the cost-effectiveness of RARP in emerging markets. We conducted a systematic literature review and analysis of studies published worldwide from January 2000 to July 2024 concerning the economic evaluation of RARP compared with laparoscopic radical prostatectomy (LRP) or open radical prostatectomy (ORP). A total of 16 papers were included. The literature was generally of good quality. Methodological approaches. varied among studies, leading to inconsistent economic findings. The choice of research settings, including the perspective of the study and time horizon, as well as differences in parameters such as surgical volumes and cost of equipment purchases, were the main factors that affected the cost-effectiveness of RARP. Based on the methodology used in the included studies, we suggest that short-term, localized economic evaluations should be carried out first, based on follow-up studies in emerging markets, whereas long-term economic evaluations can be performed when sufficient data are available. Referring to the analysis of the economic factors influencing cost-effectiveness in the included studies, we suggest that different research settings should be chosen according to the purpose for which policymakers allocate public funds, and that the cost-effectiveness of RARP can be enhanced through technical improvements and resource optimization.

The Association between Urine N-Glycome and Prognosis after Initial Therapy for Primary Prostate Cancer

Next to prostate-specific antigen, no biochemical biomarkers have been implemented to guide patient follow-up after primary therapy for localized prostate cancer (PCa). We evaluated the prognostic potential of urine N-glycome in terms of event-free survival (EFS) in patients undergoing primary therapy for PCa. The prognostic features of the urine N-glycosylation profile at diagnosis, assessed in 77 PCa patients, were determined in terms of EFS next to standard clinical parameters. The majority of patients were diagnosed with International Society of Urological Pathology grade ≤ 3 (82%) T1-2 tumors (79%) and without pelvic lymph node invasion (96%). The patients underwent active surveillance (14%), robot-assisted laparoscopic prostatectomy (48%), or external beam radiotherapy (37%). Decreased ratios of biantennary core-fucosylation were noted in patients who developed an event, which was linked to a shorter EFS in both the intention-to-treat cohort and all subcohort analyses. Combining the urine N-glycan biomarker with the D'Amico Risk Classification for PCa resulted in an improved nomogram for patient classification after primary therapy. The rate of urine N-glycan biantennary core-fucosylation, typically linked to more aggressive disease status, is lower in patients who eventually developed an event following primary therapy and subsequently in patients with a worse EFS. The combination of urine N-glycan biomarkers together with clinical parameters could, therefore, improve the post-therapy follow-up of patients with PCa.

Anxiety, depression, urinary continence, and sexuality in patients undergoing radical prostatectomy: preliminary findings

OBJECTIVES

Evaluate the relationship between psychological distress, namely anxiety and depression, with urinary continence and recovery of erectile function in patients undergoing radical prostatectomy (RP).

METHODS

We retrospectively analyzed data from 33 consecutive patients who underwent RP in a single tertiary-referral academy between 01/2018 to 01/2019. We used the International Index of Erectile Function (IIEF-15), the Sexual Complaints Screener for Men (SCS-M), and the Hospital Anxiety and Depression Scale (HADS), validated questionnaires for the assessment of sexual function, anxiety, and depression experiences, respectively. These questionnaires were administered at the pre-surgical visit, after surgery, and at intermediate follow-ups (three, six, and twelve months).

RESULTS

The analysis of the questionnaires completed during follow-up shows that erectile function is the most affected, with 90% erectile dysfunction (ED) at three months after surgery. In terms of emotional states, anxiety prevails in the first months following surgery and is statistically significantly associated with incontinence (p = 0.02). Depressive symptoms, on the other hand, appear later and prevail over anxiety at six months after surgery, although not statistically significant.

CONCLUSIONS

In the early post-surgical phase anxiety and ED are the most frequently detected components, while depressive experiences and decreased desire, typical of later stages, have not yet fully emerged.

Imaging classification of prostate cancer with extracapsular extension and its impact on positive surgical margins after laparoscopic radical prostatectomy

Abstract

To explore the impact of different imaging classifications of prostate cancer (PCa) with extracapsular extension (EPE) on positive surgical margins (PSM) after laparoscopic radical prostatectomy.

Methods

Clinical data were collected for 114 patients with stage PT3a PCa admitted to Ningbo Yinzhou No. 2 Hospital from September 2019 to August 2023. Radiologists classified the EPE imaging of PCa into Type I, Type II, and Type III. A chi-square test or t-test was employed to analyze the factors related to PSM. Multivariate regression analysis was conducted to determine the factors associated with PSM. Receiver operating characteristic curve analysis was used to calculate the area under the curve and evaluate the diagnostic performance of our model. Clinical decision curve analysis was performed to assess the clinical net benefit of EPE imaging classification, biopsy grade group (GG), and combined model.

Results

Among the 114 patients, 58 had PSM, and 56 had negative surgical margins. Multivariate analysis showed that EPE imaging classification and biopsy GG were risk factors for PSM after laparoscopic radical prostatectomy. The areas under the curve for EPE imaging classification and biopsy GG were 0.677 and 0.712, respectively. The difference in predicting PSM between EPE imaging classification and biopsy GG was not statistically significant (P>0.05). However, when used in combination, the diagnostic efficiency significantly improved, with an increase in the area under the curve to 0.795 (P<0.05). The clinical decision curve analysis revealed that the clinical net benefit of the combined model was significantly higher than that of EPE imaging classification and biopsy GG.

Conclusions

EPE imaging classification and biopsy GG were associated with PSM after laparoscopic radical prostatectomy, and their combination can significantly improve the accuracy of predicting PSM.

Prostate Cancer Local Staging with Magnetic Resonance Imaging

Accurate determination of the local stage of prostate cancer is crucial for treatment planning and prognosis. The primary objective of local staging is to distinguish between organ-confined and locally advanced disease, with the latter carrying a worse clinical prognosis. The presence of locally advanced disease features of prostate cancer, such as extra-prostatic extension, seminal vesicle invasion, and positive surgical margin, can impact the choice of treatment. Over the past decade, multiparametric MRI (mpMRI) has become the preferred imaging modality for the local staging of prostate cancer and has been shown to provide accurate information on the location and extent of disease. It has demonstrated superior performance compared to staging based on traditional clinical nomograms. Despite being a relatively new technique, mpMRI has garnered considerable attention and ongoing investigations. Therefore, in this review, we will discuss the current use of mpMRI on prostate cancer local staging.

[Urinary incontinence after radical prostatectomy: risk factors and utilisation of care]

Stress urinary incontinence is a relevant risk of radical prostatectomy (RP), which significantly affects patients' quality of life. The risk of developing stress urinary incontinence depends on pre-, intra- and postoperative factors. In particular, intraoperative factors regarding different surgical techniques are often focused on in order to improve continence rates. If stress urinary incontinence develops after RPE, patients affected should be treated adequately. In this respect, there are indications of healthcare insufficiencies in Germany. On the one hand, these include deficits in the use of incontinence materials. On the other hand, surgical treatment of stress urinary incontinence after RPE is insufficient.

Radical prostatectomy trends between 2010 and 2020 in Ehime, Japan, identified using data from the Medical Investigation Cancer Network (MICAN) study

OBJECTIVES

The use of radical prostatectomy is increasing with the rising incidence of prostate cancer. We assessed the surgical trends related to radical prostatectomy using data from a multi-center, retrospective cohort study, the MICAN (Medical Investigation Cancer Network) study, which was conducted in all the urology-related medical facilities in Ehime Prefecture, Japan.

METHODS

We compared data from the MICAN study with prostate biopsy registry data collected in Ehime between 2010 and 2020 and recorded the surgical trends.

RESULTS

There was a significant increase in the mean age of patients with positive biopsies, and the positivity rate increased from 46.3% in 2010 to 60.5% in 2020, while the number of biopsies obtained decreased. The number of radical prostatectomies performed increased over the years, with robot-assisted radical prostatectomy becoming the predominant procedure. In 2020, robot-assisted radical prostatectomies accounted for 96.0% of the surgeries performed. The age at surgery also gradually increased. Of the registered patients aged ≤75 years, 40.5% underwent surgery in 2010, compared with 83.1% in 2020. The prevalence of surgery also increased from 4.6% to 29.8% in patients aged >75 years. There was a gradual increase in the proportion of high-risk cases, from 29.3% to 44.0%, but a decrease in that of low-risk cases, from 23.8% in 2010 to 11.4% in 2020.

CONCLUSIONS

We have shown that the number of radical prostatectomies performed in Ehime is increasing in patients aged both ≤75 and >75 years. The proportion of low-risk cases has decreased, while that of high-risk cases has increased.

Quality of life after robotic-assisted and laparoscopic radical prostatectomy: Results of a multicenter randomized controlled trial (LAP-01)

BACKGROUND

To explore cross-sectional and longitudinal differences in general health-related and prostate cancer-specific quality of life (QoL) after robotic-assisted (RARP) and laparoscopic (LRP) radical prostatectomy and to analyze predictive variables for QoL outcomes.

METHODS

In this multicenter, randomized controlled trial, prostate cancer patients were randomly assigned 3:1 to undergo either RARP or LRP. Patient-reported outcomes were prospectively collected before and 1, 3, 6, 12 months after radical prostatectomy and included QoL as a secondary outcome. Validated questionnaires were used to assess general health-related (EORTC QLQ-C30) and prostate cancer-specific (QLQ-PR25) QoL. Cross-sectional and longitudinal contrasts were analyzed through linear mixed models. Predictive variables for QoL outcomes were identified by general linear modeling.

RESULTS

Of 782 randomized patients, QoL was evaluable in 681 patients. In terms of general QoL, the cross-sectional analysis showed only small differences between study arms, whereas longitudinal comparison indicated an advantage of RARP on recovery: RARP patients reported an earlier return to baseline in global health status (3 vs. 6 months) and social functioning (6 vs. 12 months). In role functioning, only the RARP arm regained baseline scores. Regarding prostate-specific QoL, LRP patients experienced more urinary symptoms and reported 3.2 points (95% confidence interval 0.4-6, p = 0.024) higher mean scores at 1-month follow-up and in mean 2.9 points (0.1-5, p = 0.042) higher urinary symptoms scores at 3-month follow-up than RARP patients. There were no other significant differences between treatment groups. Urinary symptoms, sexual activity, and sexual function remained significantly worse compared with baseline at all time points in both arms.

CONCLUSIONS

Compared with LRP, the robotic approach led to an earlier return to baseline in several domains of general health-related QoL and better short-term recovery of urinary symptoms. Predictive variables such as the scale-specific baseline status and bilateral nerve-sparing were confirmed.

Comparison of surgical approaches to radical prostatectomy in our series beyond oncological and functional outcomes

OBJECTIVES

To evaluate the outcomes of robot-assisted radical prostatectomy (RARP) compared to those of open (ORP) and laparoscopic (LRP) surgery. The interest lies fundamentally in the quality-of-life (QoL) evaluation, postoperative recovery, and personal satisfaction of patients with the intervention (PS) beyond oncological and functional outcomes.

METHODS

Six hundred eighty-five RPs were performed in our center between 2011-2018 (17,8% ORP, 22,2% LRP and 60% RARP). Patients were prospectively assessed through follow-up until April 2020 and a multiple questionnaire at 12-months post-RP that included ICIQ-SF, SHIM, IPSS, IQL and questions about pain, postoperative recovery and PS. Also baseline and postoperative patient- and treatment-related data were collected, and binomial logistic regressions were performed for the 1 vs.1 comparisons (ORP vs. RARP and LRP vs. RARP).

RESULTS

RARP patients have overall fewer comorbidities, less tumor aggressiveness, more operative time requirements and more positive surgical margins than ORP and LRP patients. Nevertheless, RARP outperforms ORP in: hospital stay (days) (OR 0,86; 95% CI: 0,80-0,94), hemoglobin loss (OR 0,38; 95% CI: 0,30-0,47), transfusion rate (OR 0,18; 95% CI: 0,09-0,34), early complications (p = 0,001), IQL (OR 0,82; 95% CI: 0,69-0,98), erectile function (OR 0,41; 95% CI: 0,21-0,79), pain control (OR 0,82; 95% CI: 0,75-0,89), postoperative recovery (p < 0,001) and choice of a different approach (OR 5,55; 95% CI: 3,14-9,80). RARP is superior to LRP in: urinary continence (OR 0,55; 95% CI: 0,37-0,82), IPSS (OR 0,96; 95% CI: 0,93-0,98), IQL (OR 0,76; 95% CI: 0,66-0,88), erectile function (OR 0,52; 95% CI: 0,29-0,93), postoperative recovery (p = 0,02 and 0,004), PS (p = 0,005; 0,002; and 0,03) and choice of a different approach (OR 7,79; 95% CI: 4,63-13,13).

CONCLUSIONS

The findings of our study globally endorse a positive effectiveness of RARP over ORP and/or LRP, both on functional issues, postoperative recovery, QoL and PS. Oncologic results should still be improved.

Cost-utility analysis on robot-assisted and laparoscopic prostatectomy based on long-term functional outcomes

Robot-Assisted Radical Prostatectomy (RARP) is one of the standard treatment options for prostate cancer. However, controversy still exists on its added value. Based on a recent large-sample retrospective cluster study from the Netherlands showing significantly improved long-term urinary functioning after RARP compared to Laparoscopic RP (LRP), we evaluated the cost-effectiveness of RARP compared to LRP. A decision tree was constructed to measure the costs and effects from a Dutch societal perspective over a ~ 7 year time-horizon. The input was based on the aforementioned study, including patient-reported consumption of addition care and consumed care for ergonomic issues reported by surgeons. Intervention costs were calculated using a bottom-up costing analysis in 5 hospitals. Finally, a probabilistic-, one-way sensitivity- and scenario analyses were performed to show possible decision uncertainty. The intervention costs were €9964 for RARP and €7253 for LRP. Total trajectory costs were €12,078 for RARP and €10,049 for LRP. RARP showed higher QALYs compared to LRP (6.17 vs 6.11). The incremental cost-utility ratio (ICUR) was €34,206 per QALY gained, in favour of RARP. As a best-case scenario, when RARP is being centralized (> 150 cases/year), total trajectory costs decreased to €10,377 having a higher utilization, and a shorter procedure time and length of stay resulting in an ICUR of €3495 per QALY gained. RARP showed to be cost-effective compared to LRP based on data from a population-based, large scale study with 7 years of follow-up. This is a clear incentive to fully reimburse RARP, especially when hospitals provide RARP centralized.

Prediction of surgical margin status and location after radical prostatectomy using positive biopsy sites on 12-core standard prostate biopsy

We evaluated the surgical margin status after radical prostatectomy according to sites positive for prostate cancer on standard 12-core transrectal ultrasound-guided prostate biopsy. Among patients who underwent radical prostatectomy at Boramae Medical Center, 520 patients with preoperative prostate-specific antigen (PSA) level < 20 ng/mL and locally confined prostate cancer on preoperative magnetic resonance imaging, treated with nerve-sparing radical prostatectomy, were included in the analysis. The surgical margin was positive for cancer in 166 (31.9% of the total) patients. The preoperative PSA level (9.3 vs. 8.0, ng/mL p = 0.001) and number of positive cores on 12-core prostate biopsy (4.1 vs. 3.4, p = 0.003) were significantly higher in patients with positive surgical margins. Moreover, the biopsy Gleason grade was higher in patients with positive surgical margins (p = 0.001). However, the pathologic Gleason grade and tumor volume were equivalent between the 2 groups. On multivariate analysis, the detection of prostate cancer on anterior lateral biopsy was associated with an increased rate of positive surgical margins (hazard ratio [HR]: 1.781, p = 0.008) after adjusting for other variables. Anterior lateral (HR: 1.919, p = 0.020), basal lateral (HR: 9.176, p < 0.001), basal medial (HR: 3.302, p = 0.031), and mid lateral (HR: 2.501, p = 0.044) biopsies were associated with positive apical, posterior, basal, and lateral surgical margins, respectively, after adjusting for other variables. The sites of prostate cancer on standard 12-core prostate biopsy could be useful for predicting surgical margin positivity after radical prostatectomy. In other words, clinicians should consider the sites of prostate cancer on prostate biopsy to reduce margin positivity after radical prostatectomy.

Comparison of urinary and sexual patient-reported outcomes between open radical prostatectomy and robot-assisted radical prostatectomy: a propensity score matched, population-based study in Victoria

Background

Robot-assisted radical prostatectomy (RARP) rates have been increasing worldwide despite a lack of evidence of superior patient-reported outcomes (PROs) compared to open radical prostatectomy (ORP).

Methods

This retrospective study included men who contributed data to the Prostate Cancer Outcomes Registry-Victoria (PCOR-Vic), underwent ORP or RARP between January 2014 and May 2018, and completed the EPIC-26 questionnaire 12 months post-surgery. Urinary and sexual bother items, the urinary incontinence domain score, the urinary irritative/obstructive domain score, the sexual domain score and the pad usage item from the EPIC-26 questionnaire were compared between the two cohorts. Unmatched and propensity score matched cohorts were used to determine if there were differences in urinary and sexual PROs between ORP and RARP after accounting for the patient case-mix and surgeon characteristics.

Results

Of 3826 patients undergoing radical prostatectomy (RP), 1047 received ORP and 2779 received RARP. Propensity score matching reduced the magnitude of the observed differences in four out of six outcomes (urinary bother, urinary incontinence domain, pad usage and sexual domain). Using a propensity score matched cohort, there were no statistically significant differences for RARP patients, compared to ORP patients, in terms of urinary bother (Rd = 0.47%, P = 0.707), urinary incontinence domain scores (Coeff = − 0.84, P = 0.506), urinary irritative/obstructive domain scores (Coeff = 1.03, P = 0.105), pad usage (Rd = − 0.75%, P = 0.771) and sexual bother (Rd = − 0.89%, P = 0.731). RARP patients had slightly higher sexual domain scores (Coeff = 3.65, P = 0.005).

Conclusion

There were no differences in urinary PROs between ORP and RARP when assessed 12 months post-surgery. The sexual domain slightly favoured RARP, however this was not deemed clinically significant.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12894-022-00966-0.

Prognostic Features of Near-Infrared Spectroscopy Following Primary Radical Prostatectomy

BACKGROUND

Only a few biomarkers have been evaluated for their prognostic value with regard to biochemical recurrence (BCR) following primary radical prostatectomy. We explored the possibilities of using near-infrared (NIR) spectroscopy as a prognostic biomarker for BCR-free survival (BCR-FS).

METHODS

Tissue specimens from 82 prostate cancer patients were obtained. Formalin-fixed paraffin-embedded slides (hematoxylin-eosin-stained) were analyzed using NIR spectroscopy. Prognostic features for BCR-FS were determined following normalization of the spectra.

RESULTS

Several differences were found throughout the NIR spectrum for the patients with or without BCR, for both the first derivative and second derivative of the NIR spectrum. Following categorization and Cox regression analysis, spectral regions at 5236 cm^-1 (first derivative; median BCR-FS not reached versus 3.2 years; HR_high = 0.18 [0.08-0.39]; and p < 0.0001) and at 5956 cm^-1 (second derivative; median BCR-FS not reached versus 3.8 years; HR_low = 0.22 [0.10-0.48]; and p = 0.0002) showed prognostic properties for BCR-FS. The combination of both parameters further increased the prognostic value of NIR (p < 0.0001).

CONCLUSIONS

We demonstrated NIR spectral variations between patients with or without BCR, which have been shown to have prognostic value. This easy-to-use technique could possibly further improve post-primary radical prostatectomy monitoring and swift referral to adjuvant local therapies. Further elaboration is highly recommended to fully elucidate these variations and to gain a deeper insight into the changing chemical and physical compositions of the prostate tumor architecture.

Functional and Oncological Outcomes After Open Versus Robot-assisted Laparoscopic Radical Prostatectomy for Localised Prostate Cancer: 8-Year Follow-up

BACKGROUND

Radical prostatectomy reduces mortality among patients with localised prostate cancer. Evidence on whether different surgical techniques can affect mortality rates is lacking.

OBJECTIVE

To evaluate functional and oncological outcomes 8 yr after robot-assisted laparoscopic prostatectomy (RALP) and open retropubic radical prostatectomy (RRP).

DESIGN, SETTING, AND PARTICIPANTS

We enrolled 4003 patients in a prospective, controlled, nonrandomised trial comparing RALP and RRP in 14 Swedish centres between 2008 and 2011. Data for functional outcomes were assessed via validated patient questionnaires administered preoperatively and at 12 and 24 mo and 8 yr after surgery.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was urinary incontinence. Functional outcomes at 8 yr were analysed using the modified Poisson regression approach.

RESULTS AND LIMITATIONS

Urinary incontinence was not significantly different at 8 yr after surgery between RALP and RRP (27% vs 29%; adjusted risk ratio [aRR] 1.05, 95% confidence interval [CI] 0.90-1.23). Erectile dysfunction was significantly lower in the RALP group (66% vs 70%; aRR 0.93, 95% CI 0.87-0.99). Prostate cancer-specific mortality (PCSM) was significantly lower in the RALP group at 8 yr after surgery (40/2699 vs 25/885; aRR 0.56, 95% CI 0.34-0.93). Differences in oncological outcomes were mainly seen in the group with high D'Amico risk, with a lower risk of positive surgical margins (21% vs 34%), biochemical recurrence (51% vs 69%), and PCSM (14/220 vs 11/77) for RALP versus RRP. The main limitation is the nonrandomised design.

CONCLUSIONS

In this prospective multicentre controlled trial, PCSM at 8 yr after surgery was lower for RALP in comparison to RRP. A causal relationship between surgical technique and mortality cannot be inferred, but the result confirms that RALP is oncologically safe. Taken together with better short-term results reported elsewhere, our findings confirm that implementation of RALP may continue.

PATIENT SUMMARY

Our study comparing two surgical techniques for removal of the prostate for localised prostate cancer shows that a robot-assisted minimally invasive technique is safe in the long term. Together with previous results showing some better short-term effects with this approach, our findings support continued use of robot-assisted surgery.

Long-term functional outcomes after robot-assisted prostatectomy compared to laparoscopic prostatectomy: Results from a national retrospective cluster study

BACKGROUND

Despite multiple studies evaluating the effectiveness of Robot-Assisted Radical Prostatectomy (RARP), there is no definitive conclusion about the added value of RARP. A retrospective cluster study was conducted to evaluate long-term sexual and urinary functioning after RARP and Laparoscopic Radical Prostatectomy (LRP) based on real-world data from 12 Dutch hospitals.

METHODS

Data was collected from patients who underwent surgery between 2010 and 2012. A mixed effect model was used to evaluate differences between groups on urinary and sexual functioning (EPIC-26). Additionally, a regression analysis was conducted to evaluate the relationship between these functional outcomes and, among others, hospital volume.

RESULTS

1370 (65.1%) patients participated, 907 underwent RARP and 463 LRP, with a median follow-up time of 7.08 years (SD = 0.98). The RARP group showed a statistically and clinically significant better urinary functioning compared to the LRP group (p = 0.002). RARP showed also a shorter procedure time (p=<0.001), reduced blood loss (p=<0.001), and a higher chance of neurovascular bundle preservation (39.8% vs 29.1%; p=<0.01).

CONCLUSION

RARP resulted in better long-term urinary function compared to LRP. Based on the results from this study, guidelines concerning the preferred surgery type and the position on reimbursement may change, especially when RARP proves to be cost-effective.

Robotic assisted radical cystectomy versus open radical cystectomy: a review of what we do and don't know

Radical cystectomy (RC) is the gold standard treatment for muscle-invasive and high-risk, noninvasive bladder cancer. Since 2003, robot-assisted radical cystectomy (RARC) has been gaining popularity. Metanalyses show that the primary advantage of RARC is less blood loss and the primary advantage of open radical cystectomy (ORC) is shorter operative times. There do not appear to be significant differences in complications, cancer-related outcomes or survival between the two approaches. Cost analyses comparing RARC and ORC are complicated by the often-ill-defined distinction between the cost to the hospital versus the cost to payors. However, it is likely that for both hospitals and payors, RARC is cost effective at high-volume centers. It is feasible that in the future, increased experience with RARC will lead to improved outcomes and justify the use of RARC over ORC.

Surgeon heterogeneity significantly affects functional and oncological outcomes after radical prostatectomy in the Swedish LAPPRO trial

Objectives

To evaluate how surgeon heterogeneity – the variation in outcomes between individual surgeons – influences functional and oncological outcomes after robot‐assisted laparoscopic prostatectomy (RALP) and retropubic radical prostatectomy (RRP), and to assess whether surgeon heterogeneity affects the comparison between RALP and RRP.

Patients and Methods

Laparoscopic Prostatectomy Robot Open (LAPPRO) is a prospective, controlled, non‐randomized trial performed at 14 Swedish centres with 68 operating surgeons. A total of 4003 men with localized prostate cancer were enrolled between 2008 and 2011. The endpoints were urinary incontinence, erectile dysfunction (ED) and recurrence at 24 months after surgery. Logistic regression models were built to evaluate surgeon heterogeneity and, secondarily, surgeon‐specific factors were added to the models to investigate their influence on heterogeneity and the comparison between RALP and RRP.

Results

Among surgeons who performed at least 20 surgeries during the study period (n=25), we observed statistically significant heterogeneity for incontinence (P = 0.001), ED (P < 0.001) and rate of recurrent disease (P < 0.001). The significant heterogeneity remained when analysing only experienced surgeons with a stated experience of at least 250 radical prostatectomies (n=12). Among all participating surgeons (n=68), differences in surgeon volume explained 42% of the observed heterogeneity for incontinence (P = 0.003), 11% for ED (P = 0.03) and 19% for recurrence (P = 0.01). Taking surgeon volume into account when comparing RALP and RRP had a significant impact on the results. The effect was greatest for functional outcomes, and the additional adjustments for the surgeons' previous experience changed whether the difference between techniques was statistically significant or not. The surgeons’ annual volume had the greatest effect on the recurrence rate.

Conclusions

There was a large degree of heterogeneity among surgeons regarding both functional and oncological outcomes and this had a significant impact on the results when comparing RALP and RRP. Some of the observed heterogeneity was explained by differences in surgeon volume. Efforts to decrease heterogeneity are warranted and variation among surgeons must be accounted for when conducting comparative analyses between surgical techniques.

How to Prevent and Manage Post-Prostatectomy Incontinence: A Review

PURPOSE

To provide an overview of the currently available evidence relating to the prevention and management strategies of urinary incontinence (UI) after radical prostatectomy (RP).

MATERIALS AND METHODS

A comprehensive research was carried out on MEDLINE/PubMed database to identify pertinent studies concerning post-RP UI. The search strategy included these words: urinary continence; urinary continence recovery; urinary incontinence; radical prostatectomy; and prostate cancer.

RESULTS

Post-RP UI still represents a challenging issue for both urologic patients and clinicians. A complete preoperative assessment of the risk factors associated with post-RP UI aids both in counseling those patients with a higher estimated likelihood of postoperative UI and in identifying those who would probably benefit from preventive strategies in the preoperative and in the intraoperative settings. Over the last decades different surgical strategies based on either the "preservation" or the "reconstruction" of the anatomical elements responsible for urinary continence (UC) led to an overall improvement of postoperative functional outcomes. Finally, several therapeutic strategies should be evaluated for the postoperative UI management. Artificial urinary sphincter implantation represents the gold standard for treatment, notwithstanding its wide adoption is limited due to high costs and significant risk of surgical revision. In this context, male sling positioning seems the most promising strategy, in particular in mild and moderate post-RP UI.

CONCLUSIONS

To enhance the likelihood of obtaining an optimal UC recovery after RP, it is here strongly suggested to intervene throughout the overall clinical management process thus including the pre-, intra- and postoperative settings.

Comparing the effect of positioning on cerebral autoregulation during radical prostatectomy: a prospective observational study

Purpose

Surgery in the prolonged extreme Trendelenburg position may lead to elevated intracranial pressure and compromise cerebral hemodynamic regulation. We hypothesized that robot-assisted radical prostatectomy with head-down tilt causes impairment of cerebral autoregulation compared with open retropubic radical prostatectomy in the supine position.

Methods

Patients scheduled for elective radical prostatectomy were included at a tertiary care prostate cancer clinic. Continuous monitoring of the cerebral autoregulation was performed using the correlation method. Based on measurements of cerebral oxygenation with near-infrared spectroscopy and invasive mean arterial blood pressure (MAP), a moving correlation coefficient was calculated to obtain the cerebral oxygenation index as an indicator of cerebral autoregulation. Cerebral autoregulation was measured continuously from induction until recovery from anesthesia.

Results

There was no significant difference in cerebral autoregulation between robot-assisted and open retropubic radical prostatectomy during induction (p = 0.089), intraoperatively (p = 0.162), and during recovery from anesthesia (p = 0.620). Age (B = 0.311 [95% CI 0.039; 0.583], p = 0.025) and a higher difference between baseline MAP and intraoperative MAP (B = 0.200 [95% CI 0.073; 0.327], p = 0.002) were associated with impaired cerebral autoregulation, whereas surgical technique was not (B = 3.339 [95% CI  1.275; 7.952], p = 0.155).

Conclusion

Compared with open radical prostatectomy in the supine position, robot-assisted surgery in the extreme Trendelenburg position with capnoperitoneum did not lead to an impairment of cerebral autoregulation during the perioperative period in our study population.

Trial registration number: DRKS00010014, date of registration: 21.03.2016, retrospectively registered.

Electronic supplementary material

The online version of this article (10.1007/s10877-020-00549-0) contains supplementary material, which is available to authorized users.

Health-related quality of life after open and robot-assisted radical prostatectomy in low- and intermediate-risk prostate cancer patients: a propensity score-matched analysis

Purpose

Introduction of robot-assisted radical prostatectomy (RARP) has revolutionized the therapeutic landscape of organ-confined prostate cancer (PCa). However, comparative analyses focused on health-related quality of life (HRQOL) after RARP and open retropubic prostatectomy (ORP) are sparse.

Methods

In the current retrospective analysis,inclusion criteria encompassed PSA ≤ 10 ng/ml, ≤ pT2c, ISUP ≤ 3, age ≤ 65 years, and preoperative continence. A propensity score-matched patient cohort [n = 418 (ORP: 209, RARP: 209)] was created and HRQOL was prospectively assessed based on validated questionnaires (EORTC QLQ-C30) preoperatively, 3 months, 12 months, and 24 months postoperatively. Primary endpoint was good general HRQOL based on previously published cut-off values. Erectile function was measured via IIEF-5, urinary continence via ICIQ-SF questionnaire. Multivariable analysis included binary logistic regression models (p < 0.05).

Results

Open retropubic prostatectomy and RARP cohorts were well balanced. General HRQOL was significantly higher for ORP compared to RARP after 3 months (70.1 vs. 61.6, p = 0.001), but not at the remaining follow-up time points. There were no significant differences for the remaining QLQ-C30 functioning and symptom scores. In multivariable analysis stratified for IIEF-5 and ICIQ-SF scores and surgeon experience, RARP could be confirmed as a marginally independent predictor for lower ratios of good general HRQOL after 3 months (OR 0.464, 95% CI 0.215–0.999; p = 0.050) without any differences at the remaining time points.

Conclusions

The current study addresses various HRQOL outcomes over a postoperative period of up to 2 years in a homogenous propensity score-matched contemporary cohort. Marginally better general HRQOL outcomes could be detected for ORP compared to RARP 3 months postoperatively.

Electronic supplementary material

The online version of this article (10.1007/s00345-020-03144-9) contains supplementary material, which is available to authorized users.

Patient-reported outcomes after open radical prostatectomy, laparoscopic radical prostatectomy and permanent prostate brachytherapy

OBJECTIVE

To assess patient-reported outcomes after open radical prostatectomy, laparoscopic radical prostatectomy and permanent prostate brachytherapy.

METHODS

patient-reported outcomes were evaluated using Expanded Prostate Cancer Index Composite scores at baseline and 1, 3, 6, 12 and 36 months after treatment, respectively, using differences from baseline scores.

RESULTS

Urinary function was the same in the three groups at baseline, but worse after surgery than after permanent prostate brachytherapy until 12 months, and similar after open radical prostatectomy and permanent prostate brachytherapy and better than after laparoscopic radical prostatectomy at 36 months. Urinary bother was significantly worse at 1 month after surgery, but better after open radical prostatectomy than after permanent prostate brachytherapy and laparoscopic radical prostatectomy at 3 months, after which symptoms improved gradually in all groups. Obstructive/irritative symptoms were worse after permanent prostate brachytherapy than after open radical prostatectomy at 36 months, and worse after laparoscopic radical prostatectomy until 6 months. Urinary incontinence was worse after surgery, particularly after 1 month. This symptom returned to the baseline level at 12 months after open radical prostatectomy, but recovery after laparoscopic radical prostatectomy was slower. Bowel function after permanent prostate brachytherapy was significantly worse than after surgery at 1 month and this continued until 6 months. Bowel bother was slightly worse at 3 and 6 months after permanent prostate brachytherapy compared to these time points after surgery.

CONCLUSION

Urinary function and bother were worst after laparoscopic radical prostatectomy, especially in the early postoperative phase, whereas urinary obstructive/irritative symptom, bowel function and bother were worse after permanent prostate brachytherapy. These findings are useful and informative for the treatment of patients with prostate cancer.

Contemporary Comparison of Open to Robotic Prostatectomy at a Veteran's Affairs Hospital

INTRODUCTION

Among veterans, prostate cancer is the most common malignancy and has a higher incidence compared to the rest of the nation. No study has compared the effectiveness of Robotic-assisted-laparoscopic radical prostatectomy (RALP) vs. open radical prostatectomy (ORP) in the Veteran's Affairs (VA) hospital setting during the adoption of RALP.

METHODS

Institutional Review Board approval was obtained. Retrospective review was completed on Veterans with prostate cancer who underwent ORP or RALP from March 2011 to January 2017 during the introduction of RALP at one VA hospital. Perioperative and functional outcomes between ORP and RALP were compared as well as between the initial 50 and final 53 RALPs.

RESULTS

Among 91 ORPs and 153 RALPs, RALP had significant reductions in blood transfusions [2(1.3%) vs. 44(40%), p < 0.001], length of stay [2 days(1-2) vs. 3 days(2-4), p < 0.001], Clavien grade >2 complications [1(0.7%) vs. 20 (22.0%), p < 0.001], urine leak [2(1.3%) vs. 11 (12.1%), p < 0.001], and ICU readmissions [0(0%) vs. 3(3.3%), p < 0.001]. There were no significant differences in positive margin status or functional outcomes. Compared to the first 50 cases, the last 53 RALPs demonstrated a shorter operative time (349 vs. 292 min, p < 0.001), lower EBL (300 vs. 150 mL, p < 0.001), more frequent 1-day length of stay (34% vs. 60%, p = 0.02), and fewer composite adverse events (82% vs. 51%, p = 0.004). Operative time for the final 53 RALPs (292 minutes) was shorter than that of ORP (325 minutes, p = 0.013).

CONCLUSIONS

During the introduction of RALP at one VA hospital, RALP was associated with several improved parameters compared to ORP and similar operative times were noted after the first 100 cases of RALPs. RALP is safe to introduce in a VA setting without compromising outcomes.

Sexual function recovery after robot-assisted radical prostatectomy: Outcomes from an Italian referral centre and predicting nomogram

Aims of this study were to assess sexual recovery after robotic-assisted radical prostatectomy (RARP) and to build a nomogram predicting 1-year sexual function. From May 2015 to July 2016, all patients eligible for RARP at our institution were invited to enter the study. The Expanded Prostate cancer Index Composite (EPIC) questionnaire was administered pre-operatively, then at 45 days, and at 3, 6, 9, and 12 months post-operatively. According to sexual function scores, patients were divided into four classes. Multivariate analysis was used to investigate the influence of patient- and disease-related features on sexual recovery. A total of 643 patients were included. Age was associated with baseline potency (p < .0001). Bioptic Gleason score (GS; p = .0002), American Society of Anesthesiologists (ASA) score ( = .002ASA Physical Status Classification System ) and Charlson Comorbidity Index (CCI; p = .02) were negatively associated with potency. Baseline sexual function was associated with potency recovery. A nomogram resulted from fitting a proportional odds logistic model for ordinal outcomes, with 1-year sexual function as a dependent variable and baseline sexual potency, age, body mass index (BMI), clinical stage, biopsy GS, initial prostate-specific antigen (iPSA), ASA score, and CCI as predictors. After further validation, this nomogram could be a useful tool for the pre-operative counselling.

Extended pelvic lymph node dissection during radical prostatectomy: comparison between initial robotic experience of a high-volume open surgeon and his contemporary open series

BACKGROUND

The aim of this study was to evaluate intra- and perioperative outcomes of a single high volume open radical prostatectomy (ORP) surgeon, during his learning curve period for robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND).

METHODS

The study included 264 intermediate-high risk prostate cancer patients, treated by ORP + ePLND or RARP + ePLND, prospectively collected. Descriptive statistics compared clinical and pathological variables between groups. Bivariate (Pearson) correlation analysis assessed the relationship between the number of lymph node (LN) removed, positive surgical margins (PSM), surgical time and the number of procedures performed per group.

RESULTS

pT stage and Gleason score (GS) were lower in RARP than in ORP group (both P=0.04), while PSM were more frequent in the RARP group (40% vs. 25%; P=0.02). However, PSM decreased with the increase of RARP procedures. The number of LNs removed was 25 and 22, in RARP and ORP group (P=0.03). However, LN+ rate did not differ between groups (11% vs. 16%; P=0.216). In the RARP group, overall surgical time and ePLND time decreased with the increase of surgical procedures (all P<0.001).

CONCLUSIONS

RARP requires significant learning curve to reduce operative room time and obtain PSM comparable to those of an ORP high-volume surgeon. On the contrary, the quality of ePLND during RARP seems to be not related to the number of procedures performed, allowing removal of a number of LNs that is clinically comparable to ORP.

Robotic-Assisted Pelvic Lymphadenectomy for Metastatic Melanoma Results in Durable Oncologic Outcomes

BACKGROUND

Robotic pelvic lymphadenectomy (rPLND) has been demonstrated to be a safe and effective minimally invasive approach for patients with metastatic melanoma to the iliac nodes. However, the long-term oncologic benefit of this procedure remains poorly defined.

METHODS

A single-institutional study comparing perioperative outcomes and survival [recurrence-free (RFS) and overall survival (OS)] between rPLND and open PLND (oPLND) for metastatic melanoma was conducted.

RESULTS

From 2006 to 2018, a total of 63 PLND cases were identified: 22 rPLND and 41 oPLND. Evidence of isolated pelvic metastasis was the most common indication for PLND in both groups (rPLND: 64%, oPLND: 85%). There was no difference in median pelvic lymph node yield (11 vs. 9 nodes, p = 0.65). Neither treatment group experienced a Clavien-Dindo complication ≥ 3. rPLND was associated with a shorter length of stay compared with oPLND (2 vs. 4 days, p < 0.001). With a median follow-up of 37 months, there was no difference in RFS (14.4 vs. 9.6 months, p = 0.47) and OS (43 vs. 50 months, p = 0.58) between rPLND and oPLND, respectively. In basin recurrence was low with 1 (4.5%) and 3 (7.3%) patients in the rPLND and oPLND cohorts, respectively, experiencing an event (p = 0.9).

CONCLUSIONS

rPLND for metastatic melanoma is a safe, minimally invasive treatment strategy that appears to result in similar intermediate term recurrence and survival rates as oPLND but shorter hospital stays.

Outcomes of health-related quality of life after open, laparoscopic, or robot-assisted radical prostatectomy in China

Purpose

To compare the outcomes of health-related quality of life (HRQOL) in patients undergoing open (ORP), laparoscopic (LRP), or robot-assisted (RARP) radical prostatectomy.

Patients and methods

We retrospectively analyzed 347 men with clinically localized prostate cancer treated with ORP (n=97), LRP (n=71), or RARP (n=179) by high-volume surgeons in our institution between January 2014 and December 2016. The primary endpoint was HRQOL including urinary incontinence and erectile dysfunction.

Results

One year after surgery, 15.9% of men reported moderate to severe urinary incontinence (ORP 16.5%, LRP 15.4%, and RARP 15.7%), with only 4.6% using pads. There were no statistically significant differences in the ratios of no pad usage and urinary incontinence bother after 12 months postoperatively among the three groups. However, 67.7% of the men reported moderate to severe erectile dysfunction (ORP 66%, LRP 66.1%, and RARP 69.3%) 12 months after surgery. There was no statistically significant difference in the international index of erectile function-5 (IIEF-5) postoperatively among the different surgical groups. In the univariate and multivariate analyses, age at surgery, preoperative IIEF-5, and neurovascular bundle preservation were the risk factors for moderate to severe sexual bother. Interestingly, 16.1% of men with an erection hardness score of grade 3-4 were hesitant to become sexually active postoperatively.

Conclusion

ORP, LRP, and RARP have similar early HRQOL outcomes with respect to urinary incontinence and erectile dysfunction. In contrast to urinary continence, erectile dysfunction is still a serious concern for patients who undergo radical prostatectomy.

Robotic-assisted vs. open radical prostatectomy: A machine learning framework for intelligent analysis of patient-reported outcomes from online cancer support groups

BACKGROUND

The advantages of Robot-assisted laparoscopic prostatectomy (RARP) over open radical prostatectomy (ORP) in Prostate cancer perioperatively are well-established, but quality of life is more contentious. Increasingly, patients are utilising online cancer support groups (OCSG) to express themselves. Currently there is no method of analysis of these sophisticated data sources. We have used the PRIME-2 (Patient Reported Information Multidimensional Exploration version 2) framework for automated identification and intelligent analysis of decision-making, functional and emotional outcomes in men undergoing ORP vs. RARP from OCSG discussions.

METHODS

The PRIME-2 framework was developed to retrospectively analyse individualised patient-reported information from 5,157 patients undergoing RARP and 579 ORP. The decision factors, side effects, and emotions in 2 groups were analysed and compared using Chi-squared, t tests, and Pearson correlation.

RESULTS

There were no differences in Gleason score, Prostate Specific Antigen (PSA), and age between the groups. Surgeon experience and preservation of erectile function (P < 0.01) were important factors in the decision making process. There were no significant differences in urinary, sexual, or bowel symptoms between ORP and RARP on a monthly basis during the initial 12 months. Emotions expressed by patients undergoing RARP were more consistent and positive while ORP expressed more negative emotions at the time of surgery and 3 months postsurgery (P < 0.05), due to pain and discomfort, and during ninth month due to fear and anxiety of pending PSA tests.

CONCLUSIONS

ORP and RARP demonstrated similar side effect profiles for 12 months, but PRIME-2 enables identification of important quality of life features and emotions over time. It is timely for clinicians to accept OCSG as an adjunct to Prostate cancer care.

Robot-assisted radical cystectomy with intracorporeal urinary diversion versus open radical cystectomy (iROC): protocol for a randomised controlled trial with internal feasibility study

INTRODUCTION

Bladder cancer (BC) is a common malignancy and one of the most expensive to manage. Radical cystectomy (RC) with pelvic lymphadenectomy is a gold standard treatment for high-risk BC. Reductions in morbidity and mortality from RC may be achieved through robot-assisted RC (RARC). Prospective comparisons between open RC (ORC) and RARC have been limited by sample size, use of extracorporeal reconstruction and use of outcomes important for ORC. Conversely, while RARC is gaining in popularity, there is little evidence to suggest it is superior to ORC. We are undertaking a prospective randomised controlled trial (RCT) to compare RARC with intracorporeal reconstruction (iRARC) and ORC using multimodal outcomes to explore qualitative and quantitative recovery after surgery. METHODS AND ANALYSIS: iROC is a multicentre prospective RCT in English National Health Service (NHS) cancer centres. We will randomise 320 patients undergoing RC to either iRARC or ORC. Treatment allocation will occur after trial entry and consent. The primary outcome is days alive and out of hospital within the first 90 days from surgery. Secondary outcomes will measure functional recovery (activity trackers, chair-to-stand tests and health related quality of life (HRQOL) questionnaires), morbidity (complications and readmissions), cost-effectiveness (using EuroQol-5 Domain-5 levels (EQ-5D-5L) and unit costs) and surgeon fatigue. Patients will be analysed according to intention to treat. The primary outcome will be transformed and analysed using regression. All statistical assumptions will be investigated. Secondary outcomes will be analysed using appropriate regression methods. An internal feasibility study of the first 30 patients will evaluate recruitment rates, acceptance of randomised treatment choice, compliance outcome collection and to revise our sample size.

ETHICS AND DISSEMINATION

The study has ethical approval (REC reference 16/NE/0418). Findings will be made available to patients, clinicians, funders and the NHS through peer-reviewed publications, social media and patient support groups.

TRIAL REGISTRATION NUMBERS

ISRCTN13680280 and NCT03049410.

Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: 24-month outcomes from a randomised controlled study

BACKGROUND

Previous trials have found similar early outcomes after robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy. We report functional and oncological postoperative outcomes up to 24 months after surgery for these two surgical techniques.

METHODS

In this randomised controlled phase 3 study, men who had newly diagnosed clinically localised prostate cancer and who had chosen surgery as their treatment approach, and were aged between 35 years and 70 years were eligible and recruited from the Royal Brisbane and Women's Hospital (Brisbane, QLD, Australia). Participants were randomly assigned (1:1) to have either robot-assisted laparoscopic prostatectomy or open radical retropubic prostatectomy. Randomisation was computer generated and occurred in blocks of ten. This was an open trial; however, study investigators involved in data analysis were masked to each patient's surgical treatment. Primary outcomes were urinary function (urinary domain of Expanded Prostate Cancer Index Composite [EPIC]) and sexual function (sexual domain of EPIC and International Index of Erectile Function Questionnaire [IIEF]) at 6 months, 12 months, and 24 months and oncological outcome (biochemical recurrence and imaging evidence of progression). The trial was powered to assess health-related and domain-specific quality-of-life outcomes over 24 months. All analyses were done on a per-protocol basis. The trial was registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000661976.

FINDINGS

Between Aug 23, 2010, and Nov 25, 2014, 326 men were enrolled, of whom 163 were randomly assigned to robot-assisted laparoscopic prostatectomy and 163 to open radical retropubic prostatectomy. 18 withdrew (12 assigned to radical retropubic prostatectomy and six assigned to robot-assisted laparoscopic prostatectomy); thus, 151 in the radical retropubic prostatectomy group and 157 in the robot-assisted laparoscopic prostatectomy group proceeded to surgery. At the 24-month follow-up time point, 150 men remained in the robot-assisted laparoscopic prostatectomy group and 146 remained in the open radical retropubic prostatectomy group. Urinary function scores did not differ significantly between robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy at 6 months post-surgery (88·68 [95% CI 86·79-90·58] vs 88·45 [86·54-90·36]; p1<0·0001, p2<0·0001), 12 months post-surgery (90·76 [88·89-92·62] vs 91·53 [90·07-92·98]; p1<0·0001, p2<0·0001), or 24 months post-surgery (91·33 [89·64-93·03] vs 90·86 [89·01-92·70]; p1<0·0001, p2<0·0001). Sexual function scores were not significantly different between robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy at 6 months post-surgery (EPIC: 37·40 [33·60-41·19] vs 38·63 [34·76-42·49], p1=0·0001, p2<0·0001; IIEF: 29·75 [26·66-32·84] vs 29·78 [26·41-33·16], p1<0·0001, p2<0·0001), 12 months post-surgery (EPIC: 42·28 [38·05-46·51] vs 42·51 [38·29-46·72], p1<0·0001, p2<0·0001; IIEF: 33·10 [29·59-36·61] vs 33·50 [29·87-37·13], p1=0·0002, p2<0·0001), or 24 months post-surgery (EPIC: 45·70 [41·17-50·23] vs 46·90 [42·20-51·60], p1=0·0003, p2<0·0001; IIEF: 33·95 [30·11-37·78] vs 33·89 [29·82-37·96], p1=0·0003, p2=0·0004). Equivalence testing on the difference between the proportion of biochemical recurrences between the two groups (13 [9%] in the open radical retropubic prostatectomy group vs four [3%] in the robot-assisted laparoscopic prostatectomy group) showed that equality between the two techniques could not be established based on a 90% CI with a prespecified margin of 10%. However, a superiority test showed that the two proportions were significantly different (p=0·0199). Equivalence testing on the proportion of patients who had imaging evidence of progression revealed that the two groups were not significantly different (p=0·2956).

INTERPRETATION

Robot-assisted laparoscopic prostatectomy and open radical retropubic prostatectomy yielded similar functional outcomes at 24 months. We advise caution in interpreting the oncological outcomes of our study because of the absence of standardisation in postoperative management between the two trial groups and the use of additional cancer treatments. Clinicians and patients should view the benefits of a robotic approach as being largely related to its minimally invasive nature.

FUNDING

Cancer Council Queensland.

Long-term functional outcome analysis in a large cohort of patients after radical prostatectomy

INTRODUCTION

Goal of the study was an analysis of functional outcomes after radical prostatectomy (RP) in a large cohort of patients.

METHODS

Functional outcomes were assessed with the ICIQ-SF questionnaire and daily pad-usage for the evaluation of stress urinary incontinence (SUI) as well as with the IIEF-5 score for the evaluation of erectile dysfunction (ED). Statistical analysis included log-rank test, Mann-Whitney-Test, ANOVA test and logistic regression (P < 0.05).

RESULTS

In total 4003 patients were included in the study. Median follow-up was 42 months (min. 2-max. 147 mo.). Regarding ED, an IIEF-5 score of ≥20 was reached by 39% of patients. Regarding SUI, 55% stated that they needed no pads, 21% of patients needed one pad per day. 33% of patients reported of no incontinence (0 p. in ICIQ), 26% of patients reported of a mild incontinence (1-5 p. in ICIQ). Patientś global impression of their overall health respectively patientś subjective quality of life were assessed with the EORTC QLC-C30 and were both high with a median of six points (on a scale of 1-7). In multivariate analysis time since surgery could be identified as independent risk factors on QOL (P = 0.0028), IIEF-5 (P = 0.0149), ICIQ (P < 0.001), and pads per day (P < 0.001).

CONCLUSIONS

Our data show a good continence status, a clearly impaired erectile function but overall a good quality of life after surgery. In summary older patients-with an advanced tumor and adjuvant radiation therapy-were at highest risk for an impaired functional outcome.

Robot-assisted radical prostatectomy vs laparoscopic and open retropubic radical prostatectomy: functional outcomes 18 months after diagnosis from a national cohort study in England

BACKGROUND

Robot-assisted radical prostatectomy (RARP) has been rapidly adopted without robust evidence comparing its functional outcomes against laparoscopic radical prostatectomy (LRP) or open retropubic radical prostatectomy (ORP) approaches. This study compared patient-reported functional outcomes following RARP, LRP or ORP.

METHODS

All men diagnosed with prostate cancer in England during April - October 2014 who underwent radical prostatectomy were identified from the National Prostate Cancer Audit and mailed a questionnaire 18 months after diagnosis. Group differences in patient-reported sexual, urinary, bowel and hormonal function (EPIC-26 domain scores) and generic health-related quality of life (HRQoL; EQ-5D-5L scores), with adjustment for patient and tumour characteristics, were estimated using linear regression.

RESULTS

In all, 2219 men (77.0%) responded; 1310 (59.0%) had RARP, 487 (21.9%) LRP and 422 (19.0%) ORP. RARP was associated with slightly higher adjusted mean EPIC-26 sexual function scores compared with LRP (3·5 point difference; 95% CI: 1.1-5.9, P=0.004) or ORP (4.0 point difference; 95% CI: 1.5-6.5, P=0.002), which did not meet the threshold for a minimal clinically important difference (10-12 points). There were no significant differences in other EPIC-26 domain scores or HRQoL.

CONCLUSIONS

It is unlikely that the rapid adoption of RARP in the English NHS has produced substantial improvements in functional outcomes for patients.

Urinary Incontinence-85: An Expanded Prostate Cancer Composite (EPIC) Score Cutoff Value for Urinary Incontinence Determined Using Long-term Functional Data by Repeated Prospective EPIC-Score Self-assessment After Radical Prostatectomy

Purpose

To determine an objective cutoff value (COV) for urinary incontinence (UI) using the Expanded Prostate Cancer Composite (EPIC) score after radical prostatectomy (RP).

Methods

From 2004–2013, all RP patients at our institution completed the EPIC urinary domain (EPIC-UD) questionnaire preoperatively and 6 weeks; 3, 6, 9, 12, and 18 months postoperatively; and yearly thereafter. The EPIC-UD is composed of several questions, 4 of which address UI qualitatively (EPIC-UI). Furthermore, patients were asked to complete a global quality of life (QoL) questionnaire regarding continence. The EPIC COV was calculated using receiver operating characteristic (ROC) analysis. Correlations between the EPIC-UI and quantitative QoL were evaluated using the Kendall-Tau test.

Results

We analyzed 239 patients with a median age of 63 years (interquartile range [IQR], 59–66 years), a median follow-up of 48 months (IQR, 30–78 months) and a median preoperative EPIC-UI score of 100 (IQR, 91.75–100). The ROC analysis for the distinction between EPIC-UI and the use of ≤1 pad/day yielded an EPIC-UI COV of >85, which we termed the UI-85, with an area under the curve of 0.857 (P<0.0001). A stronger correlation was seen between QoL scores and the UI-85 (1 year postoperatively: correlation coefficient [CC], 0.592; P<0.0001) than between QoL and not using a pad (CC, 0.512; P<0.0001).

Conclusions

The calculated COV of the EPIC-UI for continence was 85. UI is a multidimensional condition that cannot be adequately characterized by a single piece of information, such as pad usage only. Hence, the UI-85 represents a nuanced and straightforward tool for monitoring and comparing continence between different time points and cohorts in a multidimensional and objective manner.