Abstract Context Despite the wide diffusion of laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP), only few studies comparing the results of these ...techniques with the retropubic radical prostatectomy (RRP) are currently available. Objective To evaluate the perioperative, functional, and oncologic results in the comparative studies evaluating RRP, LRP, and RALP. Evidence acquisition A systematic review of the literature was performed in January 2008, searching Medline, Embase, and Web of Science databases. A “free-text” protocol using the term radical prostatectomy was applied. Some 4000 records were retrieved from the Medline database; 2265 records were retrieved from the Embase database;, and 4219 records were retrieved from the Web of Science database. Three of the authors reviewed the records to identify comparative studies. A cumulative analysis was conducted using Review Manager software v.4.2 (Cochrane Collaboration, Oxford, UK). Evidence synthesis Thirty-seven comparative studies were identified in the literature search, including a single, randomised, controlled trial. With regard to the perioperative outcome, LRP and RALP were more time consuming than RRP, especially in the initial steps of the learning curve, but blood loss, transfusion rates, catheterisation time, hospitalisation duration, and complication rates all favoured LRP. With regard to the functional results, LRP and RRP showed similar continence and potency rates. Similarly, no significant differences were identified between LRP and RALP, while a single, nonrandomised, prospective study suggested advantages in terms of both continence and potency recovery after RALP, compared with RRP. With regard to the oncologic outcome, LRP and RALP were associated with positive surgical margin rates similar to those of RRP. Conclusions The quality of the available comparative studies was not excellent. LRP and RALP are followed by significantly lower blood loss and transfusion rates, but the available data were not sufficient to prove the superiority of any surgical approach in terms of functional and oncologic outcomes. Further high-quality, prospective, multicentre, comparative studies are needed.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Warm ischemia time (WIT) and complication rates are two important parameters for evaluating the perioperative results of robot-assisted partial nephrectomy (RAPN). Few data are ...available about the clinical predictors of WIT and overall complications. Objective To identify clinical predictors of WIT and perioperative complications. Design, setting, and participants This is a retrospective study including 347 patients who underwent RAPN for suspicious renal cell carcinoma (RCC) at four referral centers from September 2008 to September 2010. Intervention All patients underwent RAPN using the da Vinci S Surgical System with hilar clamping. Measurements WIT >20 min and overall complication rates were the main outcomes. Postoperative complications were classified according to the Clavien/Dindo system. Moreover, the following perioperative variables were considered: clinical tumor size, anatomical tumor characteristics according to Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification score, surgeon experience, console time, blood loss, and upper collecting system (UCS) repair. Results and limitations WIT >20 min was reported in 125 (36%) cases. Intraoperative and postoperative complications were observed in 10 (2.9%) and 41 (11.8%) cases, respectively. Surgeon experience (odds ratio OR: 6.381; 95% confidence interval CI, 3.687–11.042; p < 0.001), clinical tumor size (OR: 1.022; 95% CI, 1.002–1.044; p = 0.03), the other anatomic characteristics determined by the PADUA classification score (OR: 1.294; 95% CI, 1.080–1.549; p = 0.005), and the UCS repair (OR: 2.987; 95% CI, 1.728–5.165; p < 0.001) turned out to be independent predictors of WIT >20 min. Similarly, surgeon experience (OR: 3.937; 95% CI, 2.011–7.705; p < 0.001), clinical tumor size (OR: 1.033; 95% CI, 1.009–1.058; p = 0.007), and the other anatomical characteristics determined by the PADUA classification score (OR: 1.427; 95% CI, 1.149–1.773; p < 0.001) turned out to be independent predictors of overall complication rates. The retrospective design is the main limitation of this multicenter, international study. Therefore, some patient characteristics and comorbidities were not recorded. Conclusions Anatomic tumor characteristics as determined by the PADUA classification score were independent predictors of WIT and overall complications, once adjusted for the effects of surgeon experience and clinical tumor size.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Currently available predictive models fail to assist clinical decision making in prostate cancer (PCa) patients who are possible candidates for radical prostatectomy (RP). New ...biomarkers would be welcome. Objective Test the hypothesis that prostate-specific antigen (PSA) isoform p2PSA and its derivates, percentage of p2PSA to free PSA (%p2PSA) and the Prostate Health Index (PHI), predict PCa characteristics at final pathology after RP. Design, setting, and participants An observational prospective study was performed in 350 consecutive men diagnosed with clinically localised PCa who underwent RP. Measurements We determined the predictive accuracy of serum total PSA (tPSA), free PSA (fPSA), fPSA-to-tPSA ratio (%fPSA), p2PSA, %p2PSA, and PHI. The primary end point was to determine the accuracy of these biomarkers in predicting the presence of pT3 disease, pathologic Gleason sum ≥7, Gleason sum upgrading, and tumour volume <0.5 ml. Intervention Open retropubic and robot-assisted laparoscopic RP was performed. Pelvic lymphadenectomy was performed according to baseline oncologic parameters and the surgeon's judgement. Results and limitations The %p2PSA and PHI levels were significantly higher in patients with pT3 disease, pathologic Gleason sum ≥7, and Gleason sum upgrading (all p values <0.001). Conversely, %p2PSA and PHI levels were significantly lower in patients with tumour volume <0.5 ml ( p < 0.001). By univariate analysis, both %p2PSA and PHI were accurate predictors of pT3 disease, pathologic Gleason sum ≥7, Gleason sum upgrading, and tumour volume <0.5 ml. By multivariate analyses, the inclusion of both %p2PSA and PHI significantly increased the predictive accuracy of a base multivariate model (excluding the tumour volume prediction for both variables, and Gleason sum upgrading for the model including %p2PSA) that included patient age, tPSA, fPSA, f/tPSA, clinical stage, and biopsy Gleason sum. Conclusions We found that p2PSA and its derivatives are predictors of PCa characteristics at final pathology after RP and are more accurate than currently available markers.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Purpose We developed and validated a Prostate Health Index (Beckman Coulter, Brea, California) based nomogram to predict prostate cancer at extended prostate biopsy. Materials and Methods The study ...population consisted of 729 patients who were scheduled for prostate biopsy following suspicious digital rectal examination and/or increased prostate specific antigen. Total and free prostate specific antigen, percent free-to-total prostate specific antigen, –2proPSA and the prostate health index (–2proPSA/free prostate specific antigen) × √total prostate specific antigen) were determined. Logistic regression models were fitted to test prostate cancer predictors. Predictive accuracy estimates of biopsy outcome predictions were quantified. Regression coefficients were used to create a decision making tool to predict prostate cancer. A calibration plot was used to evaluate the extent of overestimating or underestimating the observed prostate cancer rate. Decision curve analysis provided an estimate of the net benefit obtained using the prostate health index based nomogram. Results Overall 280 of 729 patients (38.4%) were diagnosed with prostate cancer at extended prostate biopsy. On accuracy analyses prostate health index emerged as the most informative predictor of prostate cancer (AUC 0.70) compared to established predictors, such as total prostate specific antigen (0.51) and percent free-to-total prostate specific antigen (0.62). Including the prostate health index in a multivariable logistic regression model based on patient age, prostate volume, digital rectal examination and biopsy history significantly increased predictive accuracy by 7% from 0.73 to 0.80 (p <0.001). Nomogram calibration was good. Decision curve analysis showed that using the prostate health index based nomogram resulted in the highest net benefit. Conclusions The prostate health index based nomogram can assist clinicians in the decision to perform biopsy by providing an accurate estimation of an individual risk of prostate cancer.
To study the clinicopathological characteristics of patients with synchronous medullary and papillary thyroid carcinomas.
The clinical data of patients with medullary thyroid carcinoma (MTC) operated ...in our hospital (Department of Thyroid Surgery, China-Japan Union Hospital, Jilin University) from February 2009 to February 2023 were evaluated using an analytical review approach. They were divided into an observation group (patients with synchronous MTC and papillary thyroid carcinoma PTC) and a control group (simple MTC) according to whether the clinical data were associated with MTC, in order to compare the clinical features, pathological types, stage characteristics and molecular biology characteristics of the two groups and to investigate the follow-up of the two groups.
The study included 122 MTC, 30 with synchronous MTC/PTC and 92 simple MTC. When the data were compared, the sex ratio, preoperative calcitonin level, preoperative CEA level, presence of calcifications in the MTC lesions, surgical methods, number of MTC lesions, presence of nodular goitre and presence of thyroiditis were higher in the observation group than in the control group. There was a significant difference between the groups when the MTC lesion diameter was ≤1cm in terms of preoperative CEA value (P<0.05); when the MTC lesion diameter was >1cm, there was a statistical difference between the two groups in terms of preoperative Ctn value (P<0.05). Type III was significantly different from the simple group, while type IV was more similar to the simple group. The preoperative serum Ctn value was positively correlated with maximum tumour diameter in both groups, although the correlation was stronger in the easy group. Preoperative CEA was positively correlated with maximum tumour diameter in both groups, with a stronger correlation in the combination group. Preoperative Ctn and CEA were positively correlated with lymph node metastasis in the simple group, whereas there was no apparent correlation with lymph node metastasis in the combination group. The cut-off value of preoperative serum Ctn for cervical lymph node metastases in the simple group was 39.2pg/ml and for lateral cervical lymph node metastases 195.5pg/ml. The cut-off value of preoperative serum Ctn for cervical lymph node metastases in the combination group was 60.79pg/ml and for lateral cervical lymph node metastases 152.6pg/ml. In the simple group, prognosis was significantly worse in the progression group (P<0.001), with no statistical difference between the remission and stable groups. In the combination group, the prognosis of the progression and stable groups was significantly worse than that of the remission group (P<0.001), with no statistical difference between the progression and stable groups.
In patients with synchronous medullary and papillary thyroid carcinomas, preoperative Ctn and CEA levels, calcifications, solitary lesions, combined goitre or thyroiditis differ significantly from simple MTC. Therefore, clinical management should pay attention to the above factors and early risk screening should be performed to improve prognosis as much as possible.
Purpose We tested the hypothesis that serum isoform -2proPSA derivatives %p2PSA and Prostate Health Index are accurate predictors of prostate cancer in men scheduled for repeat biopsy. Materials and ...Methods The study was an observational prospective evaluation of a clinical cohort of men with 1 or 2 previous negative prostate biopsies, with persistent suspicion of prostate cancer. They were enrolled in the study to determine the diagnostic accuracy of %p2PSA using the formula, (p2PSA pg/ml)/(free prostate specific antigen ng/ml × 1,000)× 100, and Beckman-Coulter Prostate Health Index using the formula, (p2PSA/free prostate specific antigen) × √total prostate specific antigen), and to compare it with the accuracy of established prostate cancer serum tests (total prostate specific antigen, free prostate specific antigen and percent free prostate specific antigen). Multivariable logistic regression models were complemented by predictive accuracy analysis and decision curve analysis. Results Prostate cancer was found in 71 of 222 (31.9%) subjects. %p2PSA and Prostate Health Index were the most accurate predictors of disease. %p2PSA significantly outperformed total prostate specific antigen, free prostate specific antigen, percent free prostate specific antigen and p2PSA in the prediction of prostate cancer (p ≤0.01), but not Prostate Health Index (p = 0.094). Prostate Health Index significantly outperformed total prostate specific antigen and p2PSA (p ≤0.001) but not free prostate specific antigen (p = 0.109) and free/total prostate specific antigen (p = 0.136). In multivariable logistic regression models %p2PSA and Prostate Health Index achieved independent predictor status, and significantly increased the accuracy of multivariable models including prostate specific antigen and prostate volume with or without percent free prostate specific antigen and prostate specific antigen density by 8% to 11% (p ≤0.034). At a %p2PSA cutoff of 1.23, 153 (68.9%) biopsies could have been avoided, missing prostate cancer in 6 patients. At a Prostate Health Index cutoff of 28.8, 116 (52.25%) biopsies could have been avoided, missing prostate cancer in 6 patients. Conclusions Serum %p2PSA and Prostate Health Index are more accurate than standard reference tests in predicting repeat prostate biopsy outcome, and could avoid unnecessary repeat biopsies.
Study Type – Therapy (case series) Level of Evidence 4
OBJECTIVE
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To identify clinical and pathological variables that may help clinicians in predicting, preventing and managing lymphorrhoea and ...clinically significant lymphocoeles (CSL), which are reported complications after pelvic lymphadenectomy (PLND) and retropubic radical prostatectomy (RRP).
PATIENTS AND METHODS
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We prospectively analysed 552 consecutive men with prostate cancer who underwent RRP and PLND (2006–2008).
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All patients had detailed clinical and pathological data prospectively recorded in an electronic database. Drains were removed when the amount of lymph was <20 mL in the previous 24 h. A CSL was defined as the presence of a symptomatic lymphocoele requiring treatment. Lymphorrhoea was defined as the total amount of lymph drained by the drains until their removal.
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Univariable and multivariable logistic regression models were used to test the association between all the predictors (age, body mass index, American Society of Anesthesiologists score, prostate volume, clinical stage, number of LNs removed, surgeon, pathological T and N stage) and the presence of CSL.
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Univariable and multivariable linear regression models were also used to test the association between the available predictors and lymphorrhoea.
RESULTS
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The median (range) number of LNs removed was 20 (1–63). Both linear and logistic multivariable regression analysis showed that the number of removed LNs and age were the only two statistically significant predictors of total amount of lymphorrhoea and CSL after RRP and PLND (both P < 0.01).
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Specifically, the risk of developing a CSL increased by 5% for every LN removed. Similarly, every year of age increased the risk of having CSL by 5%.
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The most informative thresholds for predicting CSL were 65 years of age and 20 LNs removed.
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External iliac lymphadenectomy resulted in a higher associated risk of lymphorrhoea and CLS relative to obturator LN removal (P= 0.001 vs P= 0.1, respectively).
CONCLUSIONS
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There was a positive association between the number of LNs removed and age at RRP with the amount of lymphorrhoea and the risk of developing a CSL.
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The most informative thresholds in predicting CSL were 65 years of age and 20 LNs removed. External iliac lymphadenectomy resulted in a higher risk of lymphorrhoea and CLS relative to obturator LN removal.
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BFBNIB, DOBA, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UILJ, UKNU, UL, UM, UPUK
Backgrounds
Limited data are available for the use of robot-assisted partial nephrectomy (RAPN) in tumors >4 cm. The objectives of this study were to report the perioperative outcomes of a series of ...patients who underwent RAPN for suspicious >4 cm renal tumors and to compare these results with those observed in a group of patients with ≤4 cm tumors.
Methods
We analyzed retrospectively the clinical records of 49 patients who underwent RAPN for suspicious of renal cell carcinoma (RCC) >4 cm in size at four centers from September 2008 to September 2010. All patients underwent da Vinci RAPN. The results were compared with those observed in a group of patients undergoing RAPN for ≤4 cm renal tumors.
Results
The median warm ischemia time (WIT) was 22 min (Interquartile range IQR 18–28). The median console time was 145 min (median IQR 112–177). The median blood loss was 120 mL (IQR 62–237). In two cases, we observed intraoperative renal vein injury (4 %). Postoperative complications were reported in 13 (26.5 %) patients. Major complications were observed in 4 (8.2 %) cases. Patients with large tumors showed perioperative outcomes worse than those received the RAPN for ≤4 cm tumors. Conversely, no significant difference was observed in positive surgical margin (PSM) rates.
Conclusions
These outcomes support the use of RAPN as possible alternative to open PN for the treatment for patients with suspicious renal masses >4 cm. Positive surgical margin rates demonstrated RAPN is an oncologically safe procedure for tumors >4 cm.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract Background Although the incidence of iatrogenic ureteral strictures is low, the treatment remains challenging. Objective To report our technique of robot-assisted uretero-ureterostomy (RAUU) ...for adults with iatrogenic lumbar and iliac stricture. Design, setting, and participants A descriptive study was performed by our department. Since April 2009, five patients underwent RAUU: Two patients had developed a lumbar or iliac ureteral stricture following a ureterorenoscopy, one had ureteral catheter positioning, one had colon surgery, and one had resection of retroperitoneal cystic lymphangioma. Preoperative evaluation includes history, computed tomography (CT) scan, and mercaptoacetyltriglycine-3 (MAG3) diuretic renal scan. Surgical procedure A flank position was used for all patients with lumbar stenosis. A supine position with the bed turned 30° was required for iliac stricture. The optical port, two 8-mm robotic ports, and one 5-mm assistant port were used. A precise definition of the site and extension of the stricture was done using the flexible ureterorenoscope. After the stricture resection, the anastomosis was performed with two running sutures on a ureteral double-J stent. Measurements Success was defined as no postoperative symptoms and evidence of no obstruction at the CT/urography and at the MAG3 scan at 6-mo follow-up. Results and limitations RAUU was technically feasible in all five patients. Average operating time was 135 min, and median hospital stay was 3 d. No significant complications occurred. Absence of stricture recurrence and no reduction of kidney function were confirmed by CT/urography and MAG3 scans. At a mean follow-up of 8 mo, all patients were asymptomatic. The main limitations were the short follow-up and the small sample size. Conclusions RAUU is feasible and safe for repairing iatrogenic lumbar and iliac ureteral strictures. The flexible ureterorenoscopy is useful to localise the obstruction and to correctly define its site and extension to spare as much ureter as possible.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
