Abstract Context Radical prostatectomy (RP) approaches have rarely been compared adequately with regard to margin and perioperative complication rates. Objective Review the literature from 2002 to ...2010 and compare margin and perioperative complication rates for open retropubic RP (ORP), laparoscopic RP (LRP), and robot-assisted LRP (RALP). Evidence acquisition Summary data were abstracted from 400 original research articles representing 167 184 ORP, 57 303 LRP, and 62 389 RALP patients (total: 286 876). Articles were found through PubMed and Scopus searches and met a priori inclusion criteria (eg, surgery after 1990, reporting margin rates and/or perioperative complications, study size >25 cases). The primary outcomes were positive surgical margin (PSM) rates, as well as total intra- and perioperative complication rates. Secondary outcomes included blood loss, transfusions, conversions, length of hospital stay, and rates for specific individual complications. Weighted averages were compared for each outcome using propensity adjustment. Evidence synthesis After propensity adjustment, the LRP group had higher positive surgical margin rates than the RALP group but similar rates to the ORP group. LRP and RALP showed significantly lower blood loss and transfusions, and a shorter length of hospital stay than the ORP group. Total perioperative complication rates were higher for ORP and LRP than for RALP. Total intraoperative complication rates were low for all modalities but lowest for RALP. Rates for readmission, reoperation, nerve, ureteral, and rectal injury, deep vein thrombosis, pneumonia, hematoma, lymphocele, anastomotic leak, fistula, and wound infection showed significant differences between groups, generally favoring RALP. The lack of randomized controlled trials, use of margin status as an indicator of oncologic control, and inability to perform cost comparisons are limitations of this study. Conclusions This meta-analysis demonstrates that RALP is at least equivalent to ORP or LRP in terms of margin rates and suggests that RALP provides certain advantages, especially regarding decreased adverse events.
Purpose of Review
Since epidemiological studies first demonstrated a potential positive effect of metformin in reducing cancer incidence and mortality, there has been an increased interest in not ...only better understanding metformin’s mechanisms of action but also in exploring its potential anti-cancer effects. In this review, we aim to summarise the current evidence exploring a role for metformin in prostate cancer therapy.
Recent Findings
Preclinical studies have demonstrated a number of antineoplastic biological effects via a range of molecular mechanisms. Data from retrospective epidemiological studies in prostate cancer has been mixed; however, there are several clinical trials currently underway evaluating metformin’s role as an anti-cancer agent. Early studies have shown benefits of metformin to inhibit cancer cell proliferation and improve metabolic syndrome in prostate cancer patients receiving androgen deprivation therapy (ADT).
Summary
While the body of evidence to support a role for metformin in prostate cancer therapy is rapidly growing, there is still insufficient data from randomised trials, which are currently still ongoing. However, evidence so far suggests metformin could be a useful adjuvant agent, particularly in patients on ADT.
Abstract Background Current trials are investigating radical intervention in men with metastatic prostate cancer. However, there is a lack of safety data for radical prostatectomy as therapy in this ...setting. Objective To examine perioperative outcomes and short-term complications after radical prostatectomy for locally resectable, distant metastatic prostate cancer. Design, setting, and participants A retrospective case series from 2007 to 2014 comprising 106 patients with newly diagnosed metastatic (M1) prostate cancer from the USA, Germany, Italy, and Sweden. Intervention Radical prostatectomy and extended pelvic lymphadenectomy. Outcome measurements and statistical analysis Descriptive statistics were used to present margin status, continence, and readmission, reoperation, and overall complication rates at 90 d, as well as for 21 specific complications. Kaplan-Meier plots were used to estimate survival function. Intercenter variability and M1a/ M1b subgroups were examined. Results and limitations Some 79.2% of patients did not suffer any complications; positive-margin (53.8%), lymphocele (8.5%), and wound infection (4.7%) rates were higher in our cohort than in a meta-analysis of open radical prostatectomy performed for standard indications. At a median follow-up of 22.8 mo, 94/106 (88.7%) men were still alive. The study is limited by its retrospective design, differing selection criteria, and short follow-up. Conclusions Radical prostatectomy for men with locally resectable, distant metastatic prostate cancer appears safe in expert hands for meticulously selected patients. Overall and specific complication rates related to the surgical extirpation are not more frequent than when radical prostatectomy is performed for standard indications, and the use of extended pelvic lymphadenectomy in all of this cohort compared to its selective use in localized/locally advanced prostate cancer accounts for any extra morbidity. Patient summary Men presenting with advanced prostate cancer that has spread beyond the prostate are increasingly being considered for treatments directed at the prostate itself. On the basis of results for our international series of 106 men, surgery appears reasonably safe in this setting for certain patients.
Context
Retzius sparing robotic assisted radical prostatectomy appears to have better continence rates when compared to conventional robotic assisted radical prostatectomy, however, concern with high ...positive surgical margin rates exist.
Objective
To systematically evaluate evidence comparing functional and oncological outcomes of retzius sparing robotic assisted radical prostatectomy and conventional robotic assisted radical prostatectomy.
Evidence acquisition
The systematic review was performed in accordance with the Cochrane guidelines and the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Bibliographic databases searched were PubMed/MEDLINE, Cochrane central register of controlled trials—CENTRAL (in The Cochrane library—issue 1, 2018). We used the GRADE approach to assess the quality of the evidence.
Evidence synthesis
The search retrieved 137 references through electronic searches of various databases. Six were included in the review. RS-RALP was associated with better early continence rates (≤ 1 month) (moderate quality evidence) (RR 1.72, 95% CI 1.27, 2.32,
p
0.0005) and at 3 months (low quality evidence) (RR 1.39, 95% CI 1.03, 1.88,
p
0.03). Time to continence recovery, number of pads used and pad weight are better with RS-RALP. Based on very low quality evidence, RS-RALP did not alter 6 and 12 months continence rates. Based on very low quality evidence, RS-RALP did not alter T2 positive margin rates (RR 1.67, 95% CI 0.91, 3.06,
p
0.10) and T3 positive margin rates (RR 1.08, 95% CI 0.68, 1.70,
p
= 0.75). Short-term biochemical free survival appears to be similar between the two approaches. Based on low-quality evidence, RS-RALP did not alter overall and major complication rates.
Conclusions
RS-RARP appears to have earlier continence recovery when compared to Con-RARP which does not come at a significant oncologic cost. Whilst there was a trend towards higher PSM rates with RS-RALP, this did not achieve statistical significance. Furthermore this trend appeared to be less pronounced with T3 disease, where the PSM rates are almost similar.
Prostate specific antigen (PSA) is one of the best-known biomarkers for screening, diagnosis and follow-up of patients for prostate cancer. Owing to several inherent limitations with PSA, various ...newer blood and urinary based biomarkers have been evaluated in pursuit of better detection and risk stratification of prostate cancer cases. A combination of these different markers, in adjunct with clinical risk factors, and recent advances in imaging promises to offer better diagnostic performance with clearer risk stratification guiding therapeutics. We carried out an extensive literature search for the different biomarkers available for screening and diagnosis of prostate cancer, compared their performance with serum PSA to allow clinicians to draw meaningful conclusions to offer their patients a more personalized medical care.
Purpose To determine the effect of comorbidity on prostate cancer (PCa)-specific mortality across treatment types. Patients and Methods These are the results of a population-based observational study ...in Sweden from 1998 to 2012 of 118,543 men who were diagnosed with PCa with a median follow-up of 8.3 years (interquartile range, 5.2 to 11.5 years) until death from PCa or other causes. Patients were categorized by patient characteristics (marital status, educational level) and tumor characteristics (serum prostate-specific antigen, tumor grade and clinical stage) and by treatment type (radical prostatectomy, radical radiotherapy, androgen deprivation therapy, and watchful waiting). Data were stratified by Charlson comorbidity index (0, 1, 2, or ≥ 3). Mortality from PCa and other causes and after stabilized inverse probability weighting adjustments for clinical patient and tumor characteristics and treatment type was determined. Kaplan-Meier estimates and Cox proportional hazards regression models were used to calculate hazard ratios. Results In the complete unadjusted data set, we observed an effect of increased comorbidity on PCa-specific and other-cause mortality. After adjustments for patient and tumor characteristics, the effect of comorbidity on PCa-specific mortality was lost but maintained for other-cause mortality. After additional adjustment for treatment type, we again failed to observe an effect for comorbidity on PCa-specific mortality, although it was maintained for other-cause mortality. Conclusion This large observational study suggests that comorbidity affects other cause-mortality but not PCa-specific- mortality after accounting for patient and tumor characteristics and treatment type. Regardless of radical treatment type (radical prostatectomy or radical radiotherapy), increasing comorbidity does not seem to significantly affect the risk of dying from PCa. Consequently, differences in oncologic outcomes that were observed in population-based comparative effectiveness studies of PCa treatments may not be a result of the varying distribution of comorbidity among treatment groups.
What's known on the subject? and What does the study add?
During radical prostatectomy, urological surgeons have tried to identify the “cord‐like NVB” at the lateral aspect of the prostate. However, ...little histological or physiological investigation was conducted to verify that the NVB identified at surgery really included the cavernous nerve. Recently, there have been observations that refute the dogma that the cavernous nerve is always within the NVB.
In this study, we have described a hammock‐like distribution of the nerves on which the prostate rests, demonstrating that the NVB is more a network of multiple fine dispersed nerves than a distinct structure. We presented a novel nerve‐sparing approach to complete hammock preservation. This risk‐stratified approach for determining the degree of nerve sparing based on the patient's likelihood of ipsilateral EPE seeks to categorize patients for optimal balance between oncological outcomes and functional outcomes.
OBJECTIVES
•
To report the potency and oncological outcomes of patients undergoing robot‐assisted radical prostatectomy (RARP) using a risk‐stratified approach based on layers of periprostatic fascial dissection.
•
We also describe the surgical technique of complete hammock preservation or nerve sparing grade 1.
PATIENTS AND METHODS
•
This is a retrospective study of 2317 patients who had robotic prostatectomy by a single surgeon at a single institution between January 2005 and June 2010.
•
Included patients were those with ≥1 year of follow‐up and who were potent preoperatively, defined as having a sexual health inventory for men (SHIM) questionnaire score of >21; thus, the final number of patients in the study cohort was 1263.
•
Patients were categorized pre‐operatively by a risk‐stratified approach into risk grades 1–4, where risk grade 1 patients received nerve‐sparing grade 1 or complete hammock preservation and so on for risk grades 2–4, as long as intraoperative findings permitted the planned nerve sparing.
•
We considered return to sexual function post‐operatively by two criteria: i) ability to have successful intercourse (score of ≥4 on question 2 of the SHIM) and ii) SHIM >21 or return to baseline sexual function.
RESULTS
•
There was a significant difference across different NS grades in terms of the percentages of patients who had intercourse and returned to baseline sexual function (P < 0.001), with those that underwent NS grade 1 having the highest rates (90.9% and 81.7%) as compared to NS grades 2 (81.4% and74.3%), 3 (73.5% and 66.1%), and 4 (62% and 54.5%).
•
The overall positive surgical margin (PSM) rates for patients with NS grades 1, 2, 3, and 4 were 9.9%, 8.1%, 7.2%, and 8.7%, respectively (P = 0.636).
•
The extraprostatic extension rates were 11.6%, 14.3%, 29.3%, and 36.2%, respectively (P < 0.001).
•
Similarly, in patients younger than 60, intercourse and return to baseline sexual function rates were 94.9% and 84.3% for NS grade 1 as compared to 85.5% and 77.2% for NS grades 2, 76.9% and 69% for NS grades 3, and 64.8% and 57.7% for NS Grade 4 (P < 0.001).
CONCLUSIONS
•
The risk‐stratified approach and anatomical technique of neural‐hammock sparing described in the present manuscript was effective in improving potency outcomes of patients without compromising cancer control.
•
Patients with greater degrees of NS had higher rates of intercourse and return to baseline sexual function without an increase in PSM rates.
Abstract Background The impact of nerve sparing (NS) on urinary continence recovery after robot-assisted laparoscopic radical prostatectomy (RALP) has yet to be defined. Objective To evaluate the ...effect of a risk-stratified grade of NS technique on early return of urinary continence. Design, setting, and participants Data were collected from 1546 patients who underwent RALP by a single surgeon at a tertiary care center from December 2008 to October 2011. Patients were categorized preoperatively by a risk-stratified approach into risk grades 1–4, with risk grade 1 patients more likely to receive NS grade 1 or complete hammock preservation. This categorization was also conducted for risk grades 2–4, with grade 4 patients receiving a non-NS procedure. Intervention Risk-stratified grading of NS RALP. Outcome measurements and statistical analysis Univariate and multivariate analysis identified predictors of early return of urinary continence, defined as no pad use at ≤12 wk postoperatively. Results and limitations Early return of continence was achieved by 791 of 1417 men (55.8%); of those, 199 of 277 (71.8%) were in NS grade 1, 440 of 805 (54.7%) were in NS grade 2, 132 of 289 (45.7%) were in NS grade 3, and 20 of 46 (43.5%) were in NS grade 4 ( p < 0.001). On multivariate analysis, better NS grade was a significant independent predictor of early return of urinary continence when NS grade 1 was the reference variable compared with NS grade 2 ( p < 0.001; odds ratio OR: 0.46), NS grade 3 ( p < 0.001; OR: 0.35), and NS grade 4 ( p = 0.001; OR: 0.29). Lower preoperative International Prostate Symptom Score ( p = 0.001; OR: 0.97) and higher preoperative Sexual Health Inventory for Men score ( p = 0.002; OR: 1.03) were indicative of early return of urinary continence. Positive surgical margin rates were 7.2% (20 of 277) of grade 1 cases, 7.6% (61 of 805) of grade 2 cases, 7.6% (22 of 289) of grade 3 cases, and 17.4% (8 of 46) of grade 4 cases ( p = 0.111). Extraprostatic extension occurred in 6.1% (17 of 277) of NS grade 1 cases, 17.5% (141 of 805) of NS grade 2 cases, 42.5% (123 of 289) of NS grade 3 cases, and 63% (29 of 46) of NS grade 4 cases ( p < 0.001). Some limitations of the study are that the study was not randomized, grading of NS was subjective, and possible selection bias existed. Conclusions Our study reports a correlation between risk-stratified grade of NS technique and early return of urinary continence as patients with a lower grade (higher degree) of NS achieved an early return of urinary continence without compromising oncologic safety.
PDF
