Radical prostatectomy for locally advanced and metastatic prostate cancer

Efficacy of cytoreductive radical cystectomy in metastatic urothelial bladder cancer based on site and number of metastases

BACKGROUND

Recent studies have highlighted the overall survival (OS) benefit of cytoreductive radical cystectomy (CRC) in metastatic bladder cancer (mBCa). Cytoreductive surgery has been established in other urologic cancers. However, the efficacy of CRC and optimal criteria for patient selection in mBCa is unclear. This study investigated the oncologic efficacy of CRC, particularly emphasizing the location and number of metastasis sites as a predictor of survival and treatment response.

METHODS

A retrospective analysis of cT2-4N0-3M1 mBCa patients treated with multiagent chemotherapy between 2004 and 2019 was conducted using the National Cancer Database. Patients were classified by additional treatment with CRC or conservative local treatment (CLT), consisting of transurethral resection of bladder tumor, radiation, or no local treatment and propensity score (PS) matched. Kaplan-Meier analysis and multivariate Cox Proportional Hazards model assessed the effect of CRC or CLT on OS within the matched cohort and in four subgroups (1) patients with only distant lymph node (LN) metastasis vs. any organ metastasis, (2) patients with single metastasis vs. multiple metastases. Sensitivity analysis estimated the influence of unmeasured confounders on CRC OS benefit.

RESULTS

Propensity matching yielded 247 and 251 patients treated with CRC and CLT, respectively. Median OS in patients who received CRC was greater than that of patients treated with CLT (20.4 months vs. 12.0 months, P < 0.001). CRC was associated with reduced mortality risk in patients with only distant LN metastases (HR = 0.545, P = 0.039), any organ metastasis (HR = 0.421, P < 0.001), and single visceral metastasis (HR = 0.483, P = 0.002). However, CRC did not significantly improve OS in patients with multiple metastases (HR = 0.501, P = 0.064).

CONCLUSION

These findings demonstrate an OS benefit of CRC with multiagent chemotherapy and pinpoint multiple visceral metastases as a potential contraindication for CRC. Although limited by the influence of unmeasured confounders, these findings may inform future prospective investigations into CRC.

Develop prediction model to help forecast advanced prostate cancer patients' prognosis after surgery using neural network

Background

The effect of surgery on advanced prostate cancer (PC) is unclear and predictive model for postoperative survival is lacking yet.

Methods

We investigate the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database, to collect clinical features of advanced PC patients. According to clinical experience, age, race, grade, pathology, T, N, M, stage, size, regional nodes positive, regional nodes examined, surgery, radiotherapy, chemotherapy, history of malignancy, clinical Gleason score (composed of needle core biopsy or transurethral resection of the prostate specimens), pathological Gleason score (composed of prostatectomy specimens) and prostate-specific antigen (PSA) are the potential predictive variables. All samples are divided into train cohort (70% of total, for model training) and test cohort (30% of total, for model validation) by random sampling. We then develop neural network to predict advanced PC patients' overall. Area under receiver operating characteristic curve (AUC) is used to evaluate model's performance.

Results

6380 patients, diagnosed with advanced (stage III-IV) prostate cancer and receiving surgery, have been included. The model using all collected clinical features as predictors and based on neural network algorithm performs best, which scores 0.7058 AUC (95% CIs, 0.7021-0.7068) in train cohort and 0.6925 AUC (95% CIs, 0.6906-0.6956) in test cohort. We then package it into a Windows 64-bit software.

Conclusion

Patients with advanced prostate cancer may benefit from surgery. In order to forecast their overall survival, we first build a clinical features-based prognostic model. This model is accuracy and may offer some reference on clinical decision making.

Current treatment patterns within 1 year after prostate cancer diagnosis in Korean patients over 75 years old: a retrospective multicenter study

Background

We aimed to evaluate the current status of first-line treatment options for prostate cancer in patients aged ≥75 years in Korea.

Materials and methods

The study included 873 patients diagnosed with biopsy-proven prostate cancer at 5 institutions in Korea from January 2009 to December 2018. Inclusion criteria were aged ≥75 years at diagnosis, prostate biopsy with ≥12 cores, and follow-up period ≥1 year. Clinical data were retrospectively collected from electronic medical records.

Results

Primary treatment for prostate cancer in patients aged ≥75 years included androgen deprivation therapy (ADT) (n = 614), radical prostatectomy (RP) (n = 114), and radiation therapy (n = 62). Among patients with RP, nine patients received ADT before RP. The RP group was younger with better Eastern Cooperative Oncology Group Performance Status (ECOG PS), lower initial prostate-specific antigen (PSA), Gleason score (GS), max percent positive cores, less positive cores, and less advanced clinical Tumor Node Metastasis (TNM) stage compared with the ADT group. Multivariate analysis showed that age, ECOG PS, and PSA were independent prognostic factors for RP. When the ADT group was classified by therapeutic regimens, the most common therapeutic regimen was maximal androgen blockade (MAB) (n = 571), and leuprolide + bicalutamide (n = 330) was the most common MAB regimen. Multivariate analysis for secondary treatment showed that age, ECOG PS, GS, and clinical N1 or M1 stage were independent predictive factors. Enzalutamide was the most preferred treatment for tertiary treatment.

Conclusion

In patients with prostate cancer aged ≥75 years, the most common treatment option was MAB, and the leuprolide + bicalutamide was the most common MAB regimen. Age, ECOG PS, and PSA are the useful indicators of surgical treatment, which increased during the study period. Younger patients with high GS and advanced clinical stage were more likely to undergo secondary treatment.

A retrospective study to evaluate the effect of preoperative hormonal therapy on continence recovery

Objective

To evaluate whether different preoperative hormonal therapy options affect postoperative continence and to identify risk/protective factors for continence recovery.

Methods

This is a retrospective analysis of several clinical trials (NCT04356430, NCT04869371, NCT04992026 and NCT05406999). Data from patients treated with hormonal therapy followed by RARP were collected and analyzed. Continence was defined as 0 pad/day or one safety pad.

Results

The study included 230 patients with adequate information. The median time to continence recovery is 8 weeks. A total of 216 (93.9%) participants recovered to urinary continence within 12 months after surgery. 21 (9.1%) participants achieved immediate continence. 69, 85, 27 and 14 participants restored continence at 1 month, 1-3 month, 3-6 month, 6-12 month, accounting for 30.0%, 40.0%, 11.7% and 6.1% accordingly. No difference in continence recovery was found among different preoperative hormonal treatment options (p=0.821). Cox regression showed that membranous urethral length (MUL) was the only independent factor influencing urinary continence recovery either in the univariate analysis (OR=1.13, 95%CI: 1.04-1.22, p=0.002) or in the multivariate analysis (OR=1.12, 95%CI: 1.04-1.20, p=0.002). Different preoperative treatment options were not associated with urinary recovery. More advanced preoperative T stage (OR=0.46, 95%CI: 0.24-0.85, p=0.014) delayed the recovery of immediate continence. MUL was associated with continence restoring at 1 month (OR=1.20, 95%CI: 1.03-1.39, p=0.017), 3 month (OR=1.27, 95%CI: 1.07-1.51, p=0.006), 6 month (OR=1.34, 95%CI: 1.07-1.67, p=0.011) and 12 month (OR=1.36, 95%CI: 1.01-1.84, p=0.044).

Conclusion

There is no difference in postoperative continence recovery among ADT, ADT+Docetaxel and ADT+Abiraterone preoperative treatment options. More advanced T stage indicated poor immediate continence recovery. Longer membranous urethral length was a promotional factor for both short-time and long-time continence recovery.

Trends and variation in the use of radiotherapy in non-metastatic prostate cancer: A 12-year nationwide overview from the Netherlands

PURPOSE

This population-based study describes nationwide trends and variation in the use of primary radiotherapy for non-metastatic prostate cancer in The Netherlands in 2008-2019.

METHODS

Prostate cancer patients were selected from the Netherlands Cancer Registry (N = 103,059). Treatment trends were studied over time by prognostic risk groups. Multilevel analyses were applied to identify variables associated with external beam radiotherapy (EBRT) and brachy-monotherapy versus no active treatment in low-risk disease, and EBRT versus radical prostatectomy in intermediate and high-risk disease.

RESULTS

EBRT use remained stable (5-6%) in low-risk prostate cancer and increased from 21% to 32% in intermediate-risk, 37% to 45% in high-risk localized and 50% to 57% in high-risk locally advanced disease. Brachy-monotherapy decreased from 19% to 6% and from 15% to 10% in low and intermediate-risk disease, respectively, coinciding an increase of no active treatment from 55% to 73% in low-risk disease. Use of EBRT or brachy-monotherapy versus no active treatment in low-risk disease differed by region, T-stage and patient characteristics. Hospital characteristics were not associated with treatment in low-risk disease, except for availability of brachy-monotherapy in 2008-2013. Age, number of comorbidities, travel time for EBRT, prognostic risk group, and hospital characteristics were associated with EBRT versus prostatectomy in intermediate and high-risk disease.

CONCLUSION

Intermediate/high-risk PCa was increasingly managed with EBRT, while brachy-monotherapy in low/intermediate-risk PCa decreased. In low-risk PCa, the no active treatment-approach increased. Variation in treatment suggests treatment decision related to patient/disease characteristics. In intermediate/high-risk disease, variation seems furthermore related to the treatment modalities available in the diagnosing hospitals.

The curative effect of androgen deprivation therapy alone is insufficient in high-risk prostate cancer

To compare the outcomes of patients with high-risk prostate cancer treated by primary radical prostatectomy (RP) and primary androgen deprivation therapy (ADT).The study included patients with high-risk or very high-risk prostate cancer. Patients treated with definitive radiation therapy and those with clinical N1 and M1 disease were excluded. The RP group was divided into sub-cohorts of patients treated with ADT and those who received ADT after biochemical recurrence post-RP. Cancer-specific survival (CSS) and overall survival (OS) were analyzed using the Kaplan-Meier method and the Cox proportional hazards model.The study analyzed 859 patients divided into the RP group (n = 654) and ADT group (n = 205). Castration-resistant prostate cancer was detected in 23 (3.5%) patients in the RP group and 43 (21.0%) patients in the ADT group. Mortality cases included 63 (9.6%) patients in the RP group and 91 (44.4%) patients in the ADT group. CSS (P = .0002) and OS (P < .0001) were significantly higher in the RP group than in the ADT group. In the sub-cohort, CSS did not differ significantly between the RP and ADT groups, whereas OS was significantly higher in the RP group than in the ADT group (P < .0001). In the multivariate analysis, primary ADT increased CSS (hazard ratio, 2.068; P = .0498) and OS (hazard ratio, 3.218; P < .0001) compared with RP.In clinically localized high-risk prostate cancer patients, primary RP was associated with better CSS and OS than primary ADT. Comprehensive counseling in this cohort of patients will help the selection of treatment.

Sustainable functional urethral reconstruction: Maximizing early continence recovery in robotic-assisted radical prostatectomy

Objective

To evaluate the safety profile and short-term functional outcome of sustainable functional urethral reconstruction (SFUR) in robotic-assisted radical prostatectomy (RARP).

Methods

One hundred and sixty-two consecutive prostate cancer patients who underwent RARP were retrospectively analyzed, in which 53 had undergone SFUR while the other 109 had undergone conventional RARP procedures. Immediate, 2-week, 1-month and 3-month continence recovery and other perioperative data were compared to evaluate short-term surgical and functional outcome.

Results

The median age was 68 and 67 years in the experimental group and control group, respectively (p=0.206), with a median prostate-specific antigen (PSA) of 13.6 ng/mL (interquartile range [IQR], 8.46-27.32 ng/mL) in the experimental group and 13.84 ng/mL (IQR, 9.12-26.80 ng/mL) in control group (p=0.846). Immediate, 2-week, 1-month and 3-month continence recovery rates between the groups were 34.0% vs. 3.7%, 50.9% vs. 14.7%, 62.3% vs. 27.5%, and 79.2% vs. 63.3% (all p<0.05). The morphological changes made by the new reconstruction technique were maintained on magnetic resonance imaging (MRI) 3 months postoperatively. Nerve-sparing procedures and adoption of the new reconstruction technique were significantly relevant to continence recovery on logistics regression model (p<0.001).

Conclusions

SFUR is a safe and easy-to-handle modification that may contribute to early continence return for RARP. Long-term follow-up and prospective studies are required to further evaluate its value in postoperative quality-of-life improvement.

A Surveillance, Epidemiology and End Results database analysis of the prognostic value of organ-specific metastases in patients with advanced prostatic adenocarcinoma

Prostate cancer (PCa) survival markedly decreases with the occurrence of distant metastasis, and treatment decisions can be influenced by metastasis site, and affect patient survival outcomes. The aim of the present study was to evaluate the potential prognostic value of metastasis to specific sites and the prognostic value of prostatectomy in patients with only bone metastasis, and to determine potential risk factors for bone metastasis in prostatic adenocarcinoma using large scale clinical data. The Surveillance, Epidemiology and End Results (SEER) database (2010–2013) was queried via the SEER*Stat (version 8.3.4) program. A total of 210,730 prostatic adenocarcinoma patients were identified from the SEER database between January 2010 and December 2013. Univariate and multivariate Cox regression analysis and Kaplan-Meier curves were used for survival comparisons with corresponding 95% confidence intervals. Patients with PCa with only liver metastatic lesions had worse overall and cancer-specific survival rates compared with those patients with only bone or lung metastasis. Multivariate Cox regression analysis revealed that age <50 years, married status, T1 and T3 tumor stage according to Tumor-Node-Metastasis (TNM) staging system from the 7th AJCC cancer staging manual, and prostatectomy were associated with better overall survival and cancer-specific survival in patients with only bone metastasis. Binary logistic regression analysis revealed that unmarried status, African descent and undifferentiated histological grade were risk factors for PCa bone metastasis. Prostatic adenocarcinoma patients with only liver metastasis had worse prognostic outcomes compared with patients with other distant organ metastases. Prostatectomy improved the 3-year survival rate in stage IV PCa patients and stage IV PCa patients with only bone metastasis. These findings were based on large-scale clinical data and can provide novel perspectives for the treatment of patients with advanced prostate adenocarcinoma.

Impact of cancer service centralisation on the radical treatment of men with high-risk and locally advanced prostate cancer: A national cross-sectional analysis in England

In many countries, specialist cancer services are centralised to improve outcomes. We explored how centralisation affects the radical treatment of high‐risk and locally advanced prostate cancer in the English NHS. 79,085 patients diagnosed with high‐risk and locally advanced prostate cancer in England (April 2014 to March 2016) were identified in the National Prostate Cancer Audit database. Poisson models were used to estimate risk ratios (RR) for undergoing radical treatment by whether men were diagnosed at a regional co‐ordinating centre (‘hub’), for having surgery by the presence of surgical services on‐site, and for receiving high dose‐rate brachytherapy (HDR‐BT) in addition to external beam radiotherapy by its regional availability. Men were equally likely to receive radical treatment, irrespective of whether they were diagnosed in a hub (RR 0.99, 95% CI 0.91–1.08). Men were more likely to have surgery if they were diagnosed at a hospital with surgical services on site (RR 1.24, 1.10–1.40), and more likely to receive additional HDR‐BT if they were diagnosed at a hospital with direct regional access to this service (RR 6.16, 2.94–12.92). Centralisation of specialist cancer services does not affect whether men receive radical treatment, but it does affect treatment modality. Centralisation may have a negative impact on access to specific treatment modalities.

What's new?

More than one‐quarter of men with high‐risk or locally advanced prostate cancer in England do not receive radical treatment with radiotherapy or surgery, potentially owing to differences in treatment access. Here, prostate cancer service centralisation in England was investigated for potential impacts on treatment access. Among English patients in the National Prostate Cancer Audit database, centralisation had no impact on decisions to use radical treatment. It did, however, affect treatment option availability, with potential consequences for patient outcome. Patients were more likely to undergo surgery or high dose‐rate brachytherapy when diagnosed at hospitals with direct links to these services.

Voiding cystourethrography after prostatectomy: spectrum of appearances

PURPOSE

This article reviews current prostatectomy techniques and then techniques for fluoroscopic voiding cystourethrography (VCUG) evaluation of the prostate and bladder after prostatectomy. Both normal post-prostatectomy appearances and complications will be reviewed.

CONCLUSION

VCUG is a useful evaluation for both common and uncommon post-prostatectomy complications and appropriate interpretation of the VCUG complications is important to aid the urologist's clinical decision making.

Preoperative PROSTATE scoring system: a potential predictive tool for the risk of biochemical recurrence after radical prostatectomy

Purpose

To study the association between the preoperative PROSTATE scoring system and the prediction of biochemical recurrence (BCR) risk, after radical prostatectomy (RP) in prostate cancer patients.

Patients and methods

A total of 340 patients who underwent a laparoscopic radical prostatectomy in Peking University First Hospital between November 2007 and March 2016 were included in the study. The preoperative PROSTATE scoring system was measured and calculated. The performance of the scoring system to predict BCR risk was estimated using the receiver operating characteristic curve (ROC curve). BCR-free survival was analyzed using the Kaplan– Meier method, and the log-rank test was applied to compare the differences in risk among the patient groups. The Cox proportional hazards regression was used to analyze the performance of the grouped PROSTATE scores.

Results

Of the total population, 91 (26.8%) patients had BCR. The PROSTATE score was significantly different between the BCR-developed and BCR-free groups (P<0.001). The ROC curve analysis of the scoring system showed an accuracy of 70.7% (95% CI 0.643–0.771) (P<0.001). The percentage of BCR in the high-risk (10–15), moderate-risk (5–9) and low-risk (0–4) groups was 63.3%, 24.6% and 10.3% respectively (P<0.001). The Cox proportional hazards regression analysis revealed that the grouped score was an independent predictor of BCR after RP (HR=2.002; 95% CI 1.222–3.280) (P=0.006).

Conclusion

The PROSTATE scoring system performed adequately in predicting the risk of BCR after RP. The scoring system can assist in decision-making about the operation and post- operative follow-up for patients with high-risk.

Extrafascial robot-assisted laparoscopic radical prostatectomy in locally advanced prostate cancer

INTRODUCTION

Up to 26.5% of new diagnosed prostate cancers (PCa) are locally advanced (LA). Although traditionally discouraged in this setting, radical prostatectomy (RP) lowers the risk of metastatic progression and cancer-specific death. We report a review of the available evidences and describe our surgical technique of extrafascial robot-assisted RP.

EVIDENCE ACQUISITION

The PubMed/Medline database was searched for "prostate cancer," "high-risk," "locally advanced," "prostatectomy." Duplicates and expert opinion papers were removed.

EVIDENCE SYNTHESIS

RP is an option in selected patients with LA-PCa and >10 years life expectancy. Five, 10 and 15 years after open RP, disease free survival rates were 85%, 73% and 67%. At the same time-points, cancer specific survival and overall survival were 95%, 90%, 79% and 90%, 76%, 53%, respectively. Postoperative potency was achieved by 25% of the patients while 79% were continent. Robotic prostatectomy provides comparable cancer control outcomes, but it is associated with a lower transfusion rate and a shorter hospitalization time. The concept of "extrafascial prostatectomy" was introduced in 2000 by Villers: this surgical approach reduces the incidence of mid- and postero-lateral positive margins (28% vs. 51%, when compared to intrafascial; P=0.08), expecially in pT3 cancers, but markedly affects potency.

CONCLUSIONS

Robot-assisted RP is an option in patients with LA-PCa. Removing the prostate gland and the seminal vesicles still contained inside their aponeurotic covering, minimize the risk of positive surgical margins and clinical recurrence.

Is Retzius-sparing robot-assisted radical prostatectomy associated with better functional and oncological outcomes? Literature review and meta-analysis

Objective

To evaluate the efficiency, safety and clinical outcomes of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) in comparison with the standard RARP.

Methods

A systematic search from Web of Science, PubMed, EMBase, Cochrane Library and Google Scholar was performed using the terms “Retzius-sparing”, “Bocciardi approach” and “robot-assisted radical prostatectomy”. Video articles and abstract papers for academic conferences were excluded. Meta-analysis of interested outcomes such as positive surgical margins (PSMs) and continence recovery was undertaken. A comprehensive literature review of all studies regarding Retzius-sparing (RS) approach was conducted and summarized.

Results

From 2010 to 2017, 11 original articles about RS-RARP approach were retrieved. Of that, only four studies comparing the RS-RARP approach to the conventional RARP were comparable for meta-analysis. Faster overall continence recovery within 1 month after the surgery was noted in the RS group (61% vs. 43%; p = 0.004). PSMs of pT2 and pT3 stages were not significantly different between the groups (10.0% vs. 7.4%; p = 0.39 and 13.1% vs. 9.5%, p = 0.56, respectively). Of all the studies, only one reported sexual recovery outcomes after RS treatment in which 40% of the participants achieved sexual intercourse within the first month.

Conclusion

Though more technically demanding than the conventional RARP, the RS technique is a safe and feasible approach. This meta-analysis and literature review indicates that RS technique, as opposed to the conventional approach, is associated with a faster continence recovery while PSMs were comparable between the two groups. The limitations of observational studies and the small data in our meta-analysis may prevent an ultimate conclusion. Future well-designed RCTs are needed to validate and confirm our findings.

The role of radical prostatectomy for the treatment of metastatic prostate cancer: a systematic review and meta-analysis

The recommended therapy by EAU guidelines for metastatic prostate cancer (mPCa) is androgen deprivation therapy (ADT) with or without chemotherapy. The role of radical prostatectomy (RP) in the treatment of mPCa is still controversial. Hence, a meta-analysis was conducted by comprehensively searching the databases PubMed, EMBASE and Web of Science for the relevant studies published before September 1st, 2017. Our results successfully shed light on the relationship that RP for mPCa was associated with decreased cancer-specific mortality (CSM) (pooled HR = 0.41, 95%CI = 0.36–0.47) and enhanced overall survival (OS) (pooled HR = 0.49, 95%CI = 0.44–0.55). Subsequent stratified analysis demonstrated that no matter how RP compared with no local therapy (NLT) or radiation therapy (RT), it was linked to a lower CSM (pooled HR = 0.36, 95%CI = 0.30–0.43 and pooled HR = 0.56, 95%CI 0.43–0.73, respectively) and a higher OS (pooled HR = 0.49, 95%CI = 0.44–0.56 and pooled HR = 0.46, 95%CI 0.33–0.65, separately). When comparing different levels of Gleason score, M-stage or N-stage, our results indicated that high level of Gleason score, M-stage or N-stage was associated with increased CSM. In summary, the outcomes of the present meta-analysis demonstrated that RP for mPCa was correlated with decreased CSM and enhanced OS in eligible patients of involved studies. In addition, patients with less aggressive tumors and good general health seemed to benefit the most. Moreover, no matter compared with NLT or RT, RP showed significant superiority in OS or CSM. Upcoming prospective randomized controlled trials were warranted to provide more high-quality data.

Role of robot-assisted radical prostatectomy in locally advanced prostate cancer

Locally advanced prostate cancer is regarded as a very high-risk disease with a poor prognosis. Although there is no definitive consensus on the definition of locally advanced prostate cancer, radical prostatectomy for locally advanced prostate cancer as a primary treatment or part of a multimodal therapy has been reported. Robot-assisted radical prostatectomy is currently carried out even in high-risk prostate cancer because it provides optimal outcomes. However, limited studies have assessed the role of robot-assisted radical prostatectomy in patients with locally advanced prostate cancer. Herein, we summarize and review the current knowledge in terms of the definition and surgical indications of locally advanced prostate cancer, and the surgical procedure and perisurgical/oncological outcomes of robot-assisted radical prostatectomy and extended pelvic lymphadenectomy for locally advanced prostate cancer.