Robot-Assisted Laparoscopic Prostatectomy Experience and Pathological Quality: Are They Always Linked?

Objective: We investigated whether pathological outcomes improved with experience and surgeon generation after robot-assisted laparoscopic prostatectomy (RALP). Materials and Methods: The study included 1338 patients who underwent RALP between February 2010 and April 2020. We created learning curves for pelvic lymph node dissection (PLND), number of lymph nodes (LNs) removed, and positive surgical margin (PSM) after adjustment for confounders. We compared the outcomes between the first and second generation of surgeons in regression models. Results: The learning curve regarding PLND indications showed a significant increase with experience for the first generation, whereas the second generation had a learning curve that remained flat at a higher level (92.3%) and significantly better than the first generation (p < 0.001). Similarly, the number of LN removed showed a significant increase with experience in both generations, but the overall median number of LN removed was significantly higher in the second generation compared with the first generation (12 vs 10, p < 0.001). However, the learning curve for PSM remained flat at ∼20% after adjustment and did not show improvement with experience in both generations of surgeons (p = 0.794). Conclusions: Surgeons showed improvement with experience and education with RALP with respect to the indications for PLND and number of LNs removed. However, there was no improvement over time and generations for PSM. Experience based solely on the number of patients operated on is not an intrinsic factor in the pathological quality of RALP. Factors other than experience may also play a role in oncologic improvement.

Independent validation of a pre-specified four-kallikrein marker model for prediction of adverse pathology and biochemical recurrence

BACKGROUND

Accurate markers for prostate cancer (PC) risk stratification could aid decision-making for initial management strategies. The 4Kscore has an undefined role in predicting outcomes after radical prostatectomy (RP).

METHODS

We included 1476 patients with 4Kscore measured prior to RP at two institutions. The 4Kscore was assessed for prediction of adverse pathology at RP and biochemical recurrence (BCR) relative to a clinical model. We pre-specified that all analyses would be assessed in biopsy Grade Group 1 (GG1) or 2 (GG2) PC patients, separately.

RESULTS

The 4Kscore increased discrimination for adverse pathology in all patients (delta area under the receiver operative curve (AUC) 0.009, 95% confidence interval (CI) 0.002, 0.016; clinical model AUC 0.767), driven by GG1 (delta AUC 0.040, 95% CI 0.006, 0.073) rather than GG2 patients (delta AUC 0.005, 95% CI -0.012, 0.021). Adding 4Kscore improved prediction of BCR in all patients (delta C-index 0.014, 95% CI 0.007, 0.021; preop-BCR nomogram C-index 0.738), again with larger changes in GG1 than in GG2.

CONCLUSIONS

This study validates prior investigations on the use of 4Kscore in men with biopsy-confirmed PC. Men with GG1 PC and a high 4Kscore may benefit from additional testing to guide treatment selection. Further research is warranted regarding the value of the 4Kscore in men with biopsy GG2 PC.

Cancer de la prostate et chirurgie robot-assistée

Objectif: Interroger l’impact de l’utilisation d’une assistance robotisée dans le cadre d’une prostatectomie radicale chez des patients opérés d’un cancer de la prostate et sur la relation médecin–patient, en se focalisant particulièrement sur le vécu des patients.

Méthode: Dans le cadre d’une recherche doctorale en cours, des entretiens semi-directifs de recherche en psychologie clinique explorant entre autres cette thématique sont proposés aux patients sur trois temps : en préopératoire, six semaines puis six mois après l’intervention, et s’accompagnent d’observations de consultations urologiques.

Résultats: Le recours à une assistance robotisée est pour de nombreux patients assimilé à un geste anodin, à un simple outil qui vient prolonger le geste du chirurgien et apporter un meilleur confort. Néanmoins, pour certains, cela est source d’angoisse, notamment du fait des fantasmes construits autour du robot. En outre, certains patients associent l’utilisation de l’assistance robotisée à la gravité de leur maladie ou au fait de bénéficier ou non du meilleur traitement possible.

Conclusion: Compte tenu du nombre croissant de prostatectomies radicales robot-assistées, il est essentiel de s’intéresser aux effets de cet outil non seulement sur le corps des patients, mais aussi sur les fantasmes et angoisses que son utilisation peut susciter, ainsi que sur la relation médecin–patient.

Intracorporeal urinary diversion during robot-assisted radical cystectomy using indocyanine green

INTRODUCTION To describe the feasibility of total intracorporeal urinary diversion during robotic assisted radical cystectomy using indocyanine green (ICG) and the Firefly system of the da Vinci Xi robot and to evaluate the digestive and urinary outcomes of this technique.

MATERIALS AND METHODS

After approval by the Institutional Review Board, we studied all consecutive patients who underwent robotic assisted radical cystectomy (RARC) and intracorporeal urinary derivation (ICUD) with the da Vinci Xi robot using ICG and the Firefly system, in our institution from January 1st 2018 to September 15th 2018. Pre, intra and postoperative data were analyzed with a follow up of at least 1 month.

RESULTS

We included 25 patients. Preoperative data were the following: 92 % were men, median age was 74 years (IQR 69-76), 64% of patients had an ASA score ≥ 3. Median operative time was 390 min (IQR 360-460). Median return to bowel function was 3 days for gas (IQR 2-5) and 5 days for stool (IQR 3-6). Median length of hospital stay was 8 days (IQR 7-10). After a median follow up of 9.6 months (IQR 8.3-12.5), only one patient (4%) presented with postoperative obstructive syndrome. There were 2 (8%) urinary leaks and 1 (4%) uretrero-enteric stricture. There were no digestive fistulas recorded. Eleven patients (44%) were readmitted within 90 days for complications.

CONCLUSIONS

Total intracorporeal urinary diversion during robotic assisted radical cystectomy using ICG is a feasible technique that might reduce return of bowel function and with low urinary and digestive complications.

Sleep related painful erection: an algorithm for evaluation and management

Background

Sleep related painful erection (SRPE) is a rare parasomnia consisting of nocturnal penile tumescence accompanied by pain that awakens the individual. Normal non-painful erections are experienced when awake. No penile anatomic abnormalities are present. No conclusive randomized clinical trial is present in the literature about the management of this rare condition. The aim of this article is to review the current knowledge about the management of SRPE and to suggest an algorithm to help physicians evaluate and manage SRPE.

Material and methods

A literature review was conducted through PubMed database using the terms: sleep, pain, painful, penile, and erection. The reference lists of the articles were also reviewed. The search returned 23 references that were published between 1987 and 2019. Results were presented in a descriptive manner.

Results

Treatment decision for now is based on reports of the treatment success, the sustainability of remission, the tolerability by the patients and the potential side effects of each medication. From data available in literature, Baclofen is the mostly used medication with a tolerable profile of adverse effects. Phosphodiesterase type 5 inhibitors are considered potential treatments and are already widely used and tolerated for other indications, but so far only 2 successful trials have been reported for SRPE. Cinitapride is very promising, but only one case was studied and no side effects were reported. Clozapine can be very dangerous although highly effective.

Conclusion

Based on the limited number of treatment trials and reported cases, the low level of evidence and the lack of randomized clinical trials, no treatment consensus for SRPE can be reached. We suggested a useful tool for clinicians: an algorithm for the management of SRPE to facilitate their access to the literature without exhaustive return to case reports and series upon each case faced.

Development of Nomograms to Predict the Recovery of Erectile Function Following Radical Prostatectomy

INTRODUCTION

Given the number of confounders in predicting erectile function recovery after radical prostatectomy (RP), a nomogram predicting the chance to be functional after RP would be useful to patients' and clinicians' discussions.

AIM

To develop preoperative and postoperative nomograms to aid in the prediction of erectile function recovery after RP.

MAIN OUTCOME MEASURES

International Index of Erectile Function (IIEF) erectile function domain score-based erectile function.

METHODS

A prospective quality-of-life database was used to develop a series of nomograms using multivariable ordinal logistic regression models. Standard preoperative and postoperative factors were included.

MAIN OUTCOME MEASURES

The nomograms predicted the probability of recovering functional erections (erectile function domain scores ≥24) and severe erectile dysfunction (≤10) 2 years after RP.

RESULTS

3 nomograms have been developed, including a preoperative, an early postoperative, and a 12-month postoperative version. The concordance indexes for all 3 exceeded 0.78, and the calibration was good.

CLINICAL IMPLICATIONS

These nomograms may aid clinicians in discussing erectile function recovery with patients undergoing RP.

STRENGTHS & LIMITATIONS

Strengths of this study included a large population, validated instrument, nerve-sparing grading, and nomograms that are well calibrated with excellent discrimination ability. Limitations include current absence of external validation and an overall low comorbidity index.

CONCLUSIONS

It is hoped that these nomograms will allow for a more accurate discussion between patients and clinicians regarding erectile function recovery after RP. Mulhall JP, Kattan MW, Bennett NE, et al. Development of Nomograms to Predict the Recovery of Erectile Function Following Radical Prostatectomy J Sex Med 2019;16:1796-1802.

Cancer de la prostate : souffrir de sa guérison

Le diagnostic précoce du cancer de la prostate permet à des patients de choisir de vivre avec un cancer peu menaçant, via une surveillance active (SA) qui mène souvent à une chirurgie, dont les effets secondaires s’inscrivent dans une forme de chronicité, impactant vie quotidienne, image de soi et sexualité. Qu’implique sur le plan psychique de vivre avec un cancer non traité, mais surveillé ? Comment vivre après une intervention chirurgicale aux conséquences mutilantes, handicapantes, portant atteinte au narcissisme ?

Objectif: Interroger les remaniements psychiques à l’œuvre chez des patients diagnostiqués d’un cancer de la prostate, opérés soit après plus d’un an de SA, soit sans délai.

Méthode: Dans le cadre d’une recherche doctorale en cours, des entretiens semi-directifs sont proposés en préopératoire, six semaines après, puis six mois. Ces entretiens sont appuyés par des autoquestionnaires ainsi que des tests projectifs : le Rorschach et le TAT (Thematic Apperception Test).

Résultats: Les patients opérés après avoir vécu une SA ont bénéficié d’une temporalité particulière au cours de laquelle la plupart d’entre eux ont pu accepter l’inacceptable et tolérer l’idée d’avoir un cancer et vivre avec. Si cette période permet à certains de se préparer à l’évolution de leur cancer et à son traitement par ablation, souvent synonyme de guérison, les effets secondaires de la chirurgie restent parfois très difficiles à vivre, surtout lorsqu’ils s’installent dans la durée et impactent le quotidien, constituant alors une nouvelle forme de chronicité. Vivre avec un « corps cancéreux » en SA n’est pas ici une épreuve physique où le corps est le siège de douleurs physiques et de fatigue, mais essentiellement une épreuve psychique. De façon paradoxale, le « corps guéri » subit des transformations en période postopératoire, des bouleversements qui touchent et atteignent l’image que l’homme a de lui-même.

Conclusion: Compte tenu des progrès de la médecine dans le dépistage et le traitement curatif du cancer de la prostate, quels sont les enjeux actuels du dépistage précoce ? Peut-on réellement parler de guérison lorsque le vécu subjectif des patients va à l’encontre de la définition habituelle de ce terme ? La « guérison chronique » succéderait-elle à la « maladie chronique » ?

Vasa nervorum angiogenesis in prostate cancer with perineural invasion

BACKGROUND

Perineural invasion (PNI) is generally accepted as a major route of cancer dissemination in malignancies associated with highly enervated organs. However, the effect of cancer cells on vasa nervorum remains unknown. We studied this effect in locally advanced prostate cancer, a high-risk feature associated with approximately 20% of prostate cancer specific mortality.

METHODS

We used immunohistochemistry for CD34, fibroblast growth factor-2 (FGF-2), FSHR, podoplanin, vascular endothelial growth factor (VEGF), and VEGFR-2 as well as histochemical methods to examine the vasa nervorum of nerves invaded by cancer cells in tissue samples from 85 patients.

RESULTS

The percentage of the nerve area occupied by CD34-positive vasa nervorum endothelial cells in nerves with PNI was much higher than in nerves without PNI (7.3 ± 1.2 vs 1.9 ± 0.4; P < 0.001 and 5.8 ± 0.6 vs 1.23 ± 0.8; P < 0.001 in pT3a and pT3b prostate cancer specimens, respectively). In 19/85 of the patients the CD34-positive vasa nervorum microvessels have a thick basement membrane, similar to the vessels in diabetic microangiopathy. This subendothelial layer contains collagen fibers. Vasa nervorum endothelia and Schwann cells express FGF-2 (nuclear localization) and FSHR (plasma membrane and cytoplasmic staining). Prostate cancer cells invading nerves express VEGF, a critical cytokine in tumor angiogenesis. The vasa nervorum of prostatic nerves with PNI did not express detectable levels of VEGFR-2. No podoplanin-positive lymphatic vessels were seen in nerves.

CONCLUSION

In locally advanced prostate cancer, PNI of cancer cells is associated with formation of new endoneurial capillaries and changes of vasa nervorum morphology.

Atlas of Ex Vivo Prostate Tissue and Cancer Images Using Confocal Laser Endomicroscopy: A Project for Intraoperative Positive Surgical Margin Detection During Radical Prostatectomy

BACKGROUND

Confocal laser endomicroscopy (CLE) is an optical device that aims to image histological architecture and may be used to reduce positive surgical margins. The ability of CLE to describe prostatic and periprostatic tissues, and prostate cancer (PCa) is still an object of investigation.

OBJECTIVE

To create an atlas of ex vivo CLE images of prostatic and periprostatic tissues, and PCa in order to recognise different prostatic structures.

DESIGN, SETTING, AND PARTICIPANTS

From November 2017 to February 2018, 15 patients underwent radical prostatectomy for biopsy-proven PCa.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Based on preoperative data and macroscopic examination, tumour location was assessed and confirmed on frozen sections. Prior to ex vivo CLE analysis, prostates were stained with fluorescein 10%. We used a GastroFlex probe to collect images of periprostatic tissue (adipose tissue, fibrous and connective tissues, vessels, nerve sheets, seminal vesicles, and urethra). Normal prostatic glands and tumour tissue according to the Gleason grade were analysed. Each PCa Gleason score was represented.

RESULTS AND LIMITATIONS

A total of 139 video clips and 237 pictures of prostatic and periprostatic tissues were collected. Among them, we selected 16 highly representative images. Adipose tissue, fibrous tissue, and connective tissue were supposable in all 15 specimens. PCa glands captured fluorescein in their cytoplasm, normal prostatic glands did not capture fluorescein, and glandular structures were easily recognisable. The principal limitation of this study is its ex vivo nature of the study.

CONCLUSIONS

Each CLE image was correlated with the corresponding haematoxylin/eosin/saffron definitive pathology image, allowing building of an atlas as a necessary tool to assess the diagnostic performance of CLE during radical prostatectomy in achieving negative surgical margins.

PATIENT SUMMARY

In this study, we aim to provide an atlas of images illustrating prostatic, periprostatic, and PCa tissues obtained using Cellvizio confocal laser endomicroscopy as a tool for further interpretation of intraoperative surgical margins during radical prostatectomy.

Splenorenal fusion mimicking renal cancer: One case report and literature review

Splenorenal fusion is an extremely rare benign entity. This abnormality is presented in a case of a 29-year-old-male patient. We discuss the distinction between this condition and renal splenosis and their embryology. The course of this condition and modalities of investigation including radiological imaging, management, and pitfalls are reviewed.

Comparison of Short-Term Functional, Oncological, and Perioperative Outcomes Between Laparoscopic and Robotic Partial Nephrectomy Beyond the Learning Curve

PURPOSE

To compare the short-term outcomes of robot-assisted partial nephrectomy (RPN) and laparoscopic partial nephrectomy (LPN) when performed by highly experienced surgeons.

METHODS

A prospective multicenter study was conducted, including the 50 last patients having undergone LPN and RPN for T1-T2 renal tumors in two institutions between 2013 and 2016, performed by two different surgeons with an experience of over 200 procedures each in LPN and RPN, respectively, at the beginning of the study. Perioperative parameters and functional and oncological outcomes were collected and compared between the LPN and RPN groups.

RESULTS

The laparoscopic approach was associated with a longer warm ischemia time (15.7 versus 23 minutes; P < .001) and hospital stay (3.6 versus 4.6 days; P = .01). Conversely, estimated blood loss was significantly higher in the RPN group (381 mL versus 215 mL; P < .001), but transfusion rates were similar between the two groups (8% versus 6%; P = .33). In the RPN group, three patients (6%) required conversion to open partial nephrectomy and three patients (6%) required a conversion to radical nephrectomy (RN), while no conversion was needed in the LPN group. There were no differences in terms of perioperative complications, and change in renal function was comparable in the two groups postoperatively. Positive surgical margin rates were similar in the RPN and LPN groups (2% versus 6%; P = .36). After a median follow-up of 19 and 14 months in the RPN and LPN groups, respectively (P = .38), recurrence-free survivals did not differ significantly (P = .94).

CONCLUSION

In this series, perioperative and short-term oncological and functional outcomes appeared broadly comparable between RPN and LPN when performed by highly experienced surgeons.

Pudendal schwannoma: A case report and literature review

Schwannomas are benign nerve sheath tumours most often associated with the cranial nerves and the peripheral nerve system of the neck and extremities. Pelvic schwannomas are rare, with only about 25 cases reported. We report the case of a 34-year-old man referred for worsening pain of 10 years duration involving the right testicle and right penile shaft. Magnetic resonance imaging discovered a well-circumscribed pelvic tumour of 3.2 × 2.8 × 3.2 cm. Considering the possible complications involved in exposing the pudendal nerve during surgical resection, we performed an extensive literature search to aid preoperative planning. The most commonly described surgical approach for pelvic schwannomas has been open median laparotomy with transperitoneal dissection. To our knowledge, pudendal schwannomas have never been described in the literature. However, after considering the location and characteristics of the tumour, we chose laparoscopy because it offers the advantages of better visualization of anatomical structures with minimal invasiveness and faster recovery. At the 3-week follow-up, the patient described a significant decrease in pain and normal neurological and urological examinations.

Does increasing the nodal yield improve outcomes in contemporary patients without nodal metastasis undergoing radical prostatectomy?

OBJECTIVES

To determine if the number of lymph nodes (LNs) removed is an independent predictor of biochemical recurrence (BCR) in patients without LN metastases undergoing radical prostatectomy (RP).

MATERIAL AND METHODS

Retrospective analysis of 7,310 patients treated at 7 centers with RP and pelvic LN dissection for clinically localized prostate cancer between 2000 and 2011. Patients with LN metastases (n = 398) and other reasons (stated later in the article) (n = 372) were excluded, which left 6,540 patients for the final analyses.

RESULTS

Overall, median biopsy and RP Gleason score were both 7; median prostate specific antigen level was 6 ng/ml (interquartile range [IQR]: 5); and median number of LNs removed was 6 (IQR: 8). A total of 3,698 (57%), 2,064 (32%), and 508 (8%) patients had ≥ 6, ≥ 10, and ≥ 20 LNs removed, respectively. Patients with more LNs removed were older, had a higher prostate specific antigen level, had higher clinical and pathologic T stage, and had higher RP Gleason score (all P<0.002). Within a median follow-up of 21 (IQR: 16) months, more LNs removed was associated with an increased risk of BCR (continuous: P = 0.021; categorical: P = 0.014). In multivariable analyses that adjusted for the effects of standard clinicopathologic factors, none of the nodal stratifications predicted BCR.

CONCLUSIONS

The number of LNs did not have any prognostic significance in our contemporary cohort of patients with LN-negative prostate cancer. This suggests that the risk of missed clinically significant micrometastasis may be minimal in patients currently treated with RP and having a lower LN yield.

Environmental impact of minimally invasive surgery in the United States: an estimate of the carbon dioxide footprint

PURPOSE

To attempt to quantitate the carbon footprint of minimally invasive surgery (MIS) through approximated scope 1 to 3 CO(2) emissions to identify its potential role in global warming.

PATIENTS AND METHODS

To estimate national usage, we determined the number of inpatient and outpatient MIS procedures using International Classification of Diseases, ninth revision-clinical modification codes for all MIS procedures in a 2009 sample collected in national databases. Need for surgery was considered essential, and therefore traditional open surgery was used as the comparator. Scope 1 (direct) CO(2) emissions resulting from CO(2) gas used for insufflation were based on both escaping procedural CO(2) and metabolic CO(2) eliminated via respiration. Scopes 2 and 3 (indirect) emissions related to capture, compression, and transportation of CO(2) to hospitals and the disposal of single-use equipment not used in open surgery were calculated.

RESULTS

The total CO(2) emissions were calculated to be 355,924 tonnes/year. For perspective, if MIS in the United States was considered a country, it would rank 189 th on the United Nations 2008 list of countries' carbon emissions per year. Limitations include the inability to account for uncertainty using the various models and tools for approximating CO(2) emissions.

CONCLUSION

CO(2) emission of MIS in the United States may have a significant environmental impact. This is the first attempt to quantify CO(2) emissions related to MIS in the United States. Strategies for reduction, while maintaining high quality medical care, should be considered.

Prostate cancer: new treatments for localized tumours-what matters first?

High-intensity focused ultrasound (HIFU) represents a fairly new treatment option for focal therapy of prostate cancer. However, studies evaluating its efficacy have not provided strong data to support the use of HIFU in the majority of patients. Thus, high-profile studies investigating feasibility of the modality in terms of adverse effects seem premature.

A critical analysis of the long-term impact of radical prostatectomy on cancer control and function outcomes

CONTEXT

The optimal management strategy for men with newly diagnosed clinically localized prostate cancer remains a matter of debate. Numerous series have reported cancer control and quality-of-life (QoL) outcomes following treatment with radical prostatectomy (RP).

OBJECTIVE

Critically review published oncologic and functional outcomes after RP, and evaluate factors associated with these outcome measures.

EVIDENCE ACQUISITION

A review of the literature was performed using the Medline and Web of Sciences databases. Relevant reports published between 1980 and 2011 identified using the keywords prostate cancer, radical prostatectomy, prostate-specific antigen, biochemical recurrence, incontinence, and erectile dysfunction were reviewed and summarized.

EVIDENCE SYNTHESIS

Cancer control rates following RP largely depend on the definition of treatment efficacy. While up to 40% of men have been reported to experience postoperative biochemical recurrence on long-term follow-up, death from prostate cancer has been noted in <10% of men at 15 yr after surgery in contemporary series. For men with high-risk disease, surgery affords pathologic staging, thereby facilitating the selective application of secondary therapies, and has been associated with decreased mortality risk versus radiation in retrospective series. Reported functional outcomes after surgery, particularly urinary continence and erectile dysfunction, have varied greatly to date. These assessments have been limited by nonstandardized reporting methodology. The use of robot-assisted radical prostatectomy has increased in recent years, and while follow-up is thus far short, available data do not suggest the superiority of either approach in terms of functional or oncologic outcomes.

CONCLUSIONS

RP is associated with excellent long-term cancer control. Continued efforts to conduct prospective assessments of postoperative functional outcomes are necessary using validated QoL instruments. The importance of surgical approach will also require further study, incorporating comparative oncologic, functional, and economic data.

Role of prostate specific antigen and immediate confirmatory biopsy in predicting progression during active surveillance for low risk prostate cancer

PURPOSE

We evaluated predictors of progression after starting active surveillance, especially the role of prostate specific antigen and immediate confirmatory prostate biopsy.

MATERIALS AND METHODS

A total of 238 men with prostate cancer met active surveillance eligibility criteria and were analyzed for progression with time. Cox proportional hazards regression was used to evaluate predictors of progression. Progression was evaluated using 2 definitions, including no longer meeting 1) full and 2) modified criteria, excluding prostate specific antigen greater than 10 ng/ml as a criterion.

RESULTS

Using full criteria 61 patients progressed during followup. The 2 and 5-year progression-free probability was 80% and 60%, respectively. With prostate specific antigen included in progression criteria prostate specific antigen at confirmatory biopsy (HR 1.29, 95% CI 1.14-1.46, p <0.0005) and positive confirmatory biopsy (HR 1.75, 95% CI 1.01-3.04, p = 0.047) were independent predictors of progression. Of the 61 cases 34 failed due to increased prostate specific antigen, including only 5 with subsequent progression by biopsy criteria. When prostate specific antigen was excluded from progression criteria, only 32 cases progressed, and 2 and 5-year progression-free probability was 91% and 76%, respectively. Using modified criteria as an end point positive confirmatory biopsy was the only independent predictor of progression (HR 3.16, 95% CI 1.41-7.09, p = 0.005).

CONCLUSIONS

Active surveillance is feasible in patients with low risk prostate cancer and most patients show little evidence of progression within 5 years. There is no clear justification for treating patients in whom prostate specific antigen increases above 10 ng/ml in the absence of other indications of tumor progression. Patients considering active surveillance should undergo confirmatory biopsy to better assess the risk of progression.

The depth of the prostatic apex is an independent predictor of positive apical margins at radical prostatectomy

OBJECTIVE

To determine the effect of a deep and narrow pelvis on apical positive surgical margins (PSM) at radical prostatectomy (RP), controlling for other clinical and pathological variables and surgical approach, i.e. open retropubic (RRP) vs laparoscopic (LRP), as apical dissection is expected to be more challenging at RP with a prostate situated deep in a narrow pelvis.

PATIENTS AND METHODS

From July 2003 to January 2005, 512 consecutive patients with preoperative prostate magnetic resonance imaging (MRI) underwent RRP or LRP with no previous radio- or hormonal therapy. An additional 74 patients with preoperative MRI undergoing RP from December 2001 to June 2007 who had an apical PSM were also included, with 586 patients comprising the study population. Bony and soft-tissue pelvic dimensions, including interspinous distance (ISD), bony (BFW) and soft tissue (SW) pelvic width, apical prostate depth (AD) and symphysis pubis angle, were measured on preoperative MRI. The pelvic dimension index (PDI), bony width index (BWI) and soft-tissue width index (SWI) were defined as ISD/AD, BFW/AD and SW/AD, respectively. Multivariate logistic regression was used to assess the effect of pelvic dimensions on apical PSM, controlling for surgical approach and clinical and pathological variables.

RESULTS

There was no significant difference in ISD, BFW, SW or symphysis angle between patients with and without apical PSM. The AD was significantly greater in men with an apical PSM and consequently PDI, BWI and SWI were significantly lower in men with an apical PSM. Each of PDI, AD, BWI and SWI was a significant independent predictor of apical PSM, independent of surgical approach, and other clinicopathological variables. The main limitations of the study were that it was retrospective, and the relatively few patients with apical PSM.

CONCLUSIONS

Apical prostate depth is an independent risk factor for apical PSM at RP. MRI pelvimetry might allow for preoperative planning of the approach to RP.

Role of short-term antibiotic therapy at the moment of catheter removal after laparoscopic radical prostatectomy

OBJECTIVE

To assess the role of short-term antibiotic therapy (ABT) in preventing urinary tract infection (UTI) after catheter removal following laparoscopic radical prostatectomy (LRP).

METHODS

729 consecutive patients underwent LRP by one of two surgeons. One surgeon systematically prescribed a 3-day course of ABT (ciprofloxacin) starting the day before catheter removal; the other surgeon did not. The groups were compared for the incidence of symptomatic UTI occurring within 6 weeks after catheter removal.

RESULTS

ABT was given to 261 of 713 patients (37%), while the remaining 452 patients (63%) did not receive ABT. After catheter removal, UTI was observed less frequently among patients receiving ABT: 3.1 vs. 7.3% in those not receiving ABT (p = 0.019). A number needed to treat to prevent 1 UTI is 24. Hospital readmission for febrile UTI was observed only in patients who did not receive ABT (n = 5, 1.1 vs. 0%, p = 0.16). One would need to prescribe ABT for 91 LRP patients to prevent 1 case of febrile UTI.

CONCLUSIONS

ABT at the time of catheter removal reduced the risk of postoperative UTI after LRP. One would need to prescribe ABT to 24 patients to prevent 1 case of UTI.

The learning curve for laparoscopic radical prostatectomy: an international multicenter study

PURPOSE

It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy.

MATERIALS AND METHODS

We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation.

RESULTS

Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve.

CONCLUSIONS

The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.

Subjective characterization of nerve sparing predicts recovery of erectile function after radical prostatectomy: defining the utility of a nerve sparing grading system

INTRODUCTION

Radical prostatectomy (RP) is a common technique for managing prostate cancer. Concern regarding functional outcomes in patients prompted the development of nerve sparing to improve recovery of erectile function.

AIM

To assess if a cumulative nerve damage grading system is a more precise predictor of recovery of erectile function as compared to the current "all-or-none" grading system.

METHODS

Baseline demographic, medical history, and International Index of Erectile Function (IIEF)-erectile function domain (EFD) scores were collected. At the time of RP, patients were assigned a nerve sparing score (NSS) by their surgeon for each neurovascular bundle (left and right) to assess the quality of intraoperative nerve sparing (1-complete preservation, 4-complete resection). Patients completed IIEF questionnaires at 24 months after RP.

MAIN OUTCOME MEASURES

Group comparisons and multiple regression analyses were used to test the association between the NSS and IIEF-EFD scores for patients with preoperative EFD scores ≥ 24.

RESULTS

A total of 173 patients were included in this analysis. Mean age for patients was 59, and 62% of patients had at least one comorbidity. Baseline EFD scores were comparable between all NSS assignments. At 24 months, EFD scores were reduced by 7.2, 11.6, 13.9, and 15.4 points for patients with NSS grades of 2, 3, 4, and 5-8, respectively (P < 0.01). Multivariate analysis demonstrated lower NSS predicted recovery of erectile function at 24 months (P = 0.001), as did age (P = 0.001) and baseline EFD score (P = 0.02).

CONCLUSION

Our data support the adoption of a subjectively assigned NSS to more precisely predict erectile function outcomes and suggest that even minor nerve trauma significantly impairs the recovery of erectile function after procedures classically regarded as having achieved bilateral nerve sparing. Further studies are needed to identify the optimal NSS system.

[Neurological and vascular preservation during laparoscopic radical prostatectomy]

The objective of the cavernous nerve preservation is to avoid injury of the unmyelinated nerve fibers and arteries destined to the corpora cavernosa. Dissection anatomical plans could be inter or extra fascial allowing complete or partial neurovascular bundle preservation. The technique is chosen according to the carcinological evaluated risk and anatomical characteristics. Accessory pudendal arteries preservation must be performed when such an artery is identified in order to improve the chance of recovery of spontaneous erections.