Objective
To evaluate the clinical impact of 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography on the planned management of prostate cancer patients with ...biochemical recurrence after surgery.
Methods
We enrolled 276 prostate cancer patients referred to 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography due to biochemical recurrence after surgery (two consecutive prostate‐specific antigen assays ≥0.2 ng/mL). First, the detection rate of 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography was assessed according to different prostate‐specific antigen levels. Second, the independent predictors of 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography positive results were assessed. Finally, the intended treatment before revision of 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography was assessed by a multidisciplinary team based on the European Association of Urology guidelines, patient clinical condition and clinical parameters. Then, re‐assessment of the treatment plan was prospectively recorded by the same board after revision of 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography. The effective clinical impact of 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography was rated as major (change in therapeutic approach), minor (same treatment, but modified therapeutic strategy) or none.
Results
The overall detection rate of 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography was 47.5%. Prostate‐specific antigen at 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography (odds ratio 3.52) and prostate‐specific antigen doubling time <3 months (odds ratio 3.98) were independent predictors of positive 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography results (all P ≤ 0.03). 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography led to a major treatment change in 177 cases (64.1%), with a minor clinical impact of 2.5%. The overall clinical impact of 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography was 42.4%, 27.7%, 21.2% and 8.7% in men with prostate‐specific antigen at 68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography of 0.2–0.4, 0.5–1, 1.1–2 and >2 ng/mL, respectively.
Conclusions
68Ga‐prostate‐specific membrane antigen positron emission tomography/computed tomography allows clinicians to radically change the intended treatment approach before imaging evaluation, in roughly two out three individuals.
Radical Cystectomy (RC) with ileal urinary diversion is one of the most complex urological surgical procedure, and many Fast Track (FT) protocols have been described to reduce hospitalization, ...without increasing postoperatory complications. We present the one-year results of a dedicated protocol developed at a high volume centre.
The FT protocol was designed after a review of the literature and a multidisciplinary collegiate discussion, and it was applied to patients scheduled to open RC with intestinal urinary diversion. To validate its feasibility, we compared its results with data collected from a 1:1 matched population of patients who had undergone the same surgical procedure, without the implementation of the FT protocol.
We enrolled in the FT group 11 (55%) patients scheduled to RC with ileal conduit diversion, and 9 patients (45%) scheduled to orthotopic neobladder (Studer) substitution, while a numerically equivalent population was enrolled in the control group, matched according to age at surgery, BMI, gender, ASA score, CCI, preoperative stage and type of urinary diversion. No statistically significant difference was found in terms of pre-operatory and intra-operatory domains. Median overall age was 71 years (Inter Quartile Range - IQR: 63-76) and mean operatory time was 276 ± 57 minutes. Hospitalization time was significantly reduced in the FT group, considering oralization and canalization items we found a significant advantage in the FT group. No statistically significant difference was found in the control of the post-operatory pain. We found no difference, in terms of both early and late complications ratio, among the two populations. Complications graded Clavien ≥ 3 were found in 4 patients of the control group (20%), while in only one patient (5%) in the Fast Track group, though this difference was not statistically significant.
The Fast Track protocol developed in this study has proven to be effective in significantly reducing hospitalization time in patients submitted to RC with intestinal urinary diversion, without increasing post-operatory complications ratio.
Abstract Purpose To assess survivals and competing causes of mortality in prostate cancer (PCa) patients referred to radical prostatectomy (RP), through a combination of unfavorable characteristics. ...Patients and Methods We evaluated 615 PCa patients referred to RP and pelvic lymph node dissection (PLND) at single tertiary care center with at least one adverse feature (AF): preoperative PSA ≥ 20 ng/ml, pathological Gleason score 8-10 and no organ-confined at final pathology (seminal vesicles involvement and/or positive surgical margins and/or lymph node invasion). Kaplan-Meier analyses were used to assess cancer specific mortality (CSM) free survival rates, by stratifying patients in three risk categories according to the number of AFs (namely, 1, 2 and 3 AFs). Multivariable competing-risk Cox regression analyses were used to assess CSM and other cause of mortality (OCM). Results Significant differences were found in terms of preoperative and pathologic tumor characteristics, adjuvant therapies and biochemical recurrence (BCR). Men with 1 AF had higher CSM free-survival estimates compared to those with 2 AFs and with 3 AFs (92.8% vs. 84.2% vs. 27.7% at 10-years follow-up, p<0.001). Moreover, the presence of 3 AFs (hazard ratio HR: 2.96), postoperative adjuvant treatment status, (HR: 2.44) and time to BCR (HR: 0.96) were all independent predictors of CSM (p≤0.04). Age at surgery and time to BCR were the only independent predictors of OCM (p≤0.0009). Conclusion The risk group stratification according to the number of AFs could help physician to accurate predict oncologic outcomes and to select PCa patients to the most appropriate postoperative strategies.
The success of Robot Assisted Laparoscopic Prostatectomy (RALP) is mainly due to his relatively short learning curve. Twenty cases are needed to reach a "4 hours-proficiency". However, to achieve ...optimal functional outcomes such as urinary continence and potency recovery may require more experience. We aim to report the perioperative and early functional outcomes of patients undergoing RALP, after a structured modular training program.
A surgeon with no previous laparoscopic or robotic experience attained a 3 month modular training including: a) e-learning; b) assistance and training to the operating table; c) dry console training; d) step by step in vivo modular training performing 40 surgical steps in increasing difficulty, under the supervision of an experienced mentor. Demographics, intraoperative and postoperative functional outcomes were recorded after his first 120 procedures, considering four groups of 30 cases.
All procedures were completed successfully without conversion to open approach. Overall 19 (15%) post operative complications were observed and 84% were graded as minor (Clavien I-II). Overall operative time and console time gradually decreased during the learning curve, with statistical significance in favour of Group 4. The overall continence rate at 1 and 3 months was 74% and 87% respectively with a significant improvement in continence rate throughout the four groups (p = 0.04). Considering those patients submitted to nerve-sparing procedure we found a significant increase in potency recovery over the four groups (p = 0.04) with the higher potency recovery rate up to 80% in the last 30 cases.
Optimal perioperative and functional outcomes have been attained since early phase of the learning curve after an intensive structured modular training and less than 100 consecutive procedures seem needed in order to achieve optimal urinary continence and erectile function recovery.
To evaluate the impact of multiparametric magnetic0 resonance imaging (mpMRI) to guide the nerve-sparing (NS) surgical plan in prostate cancer (PCa) patients referred to robot-assisted radical ...prostatectomy (RARP).
One hundred thirty-seven consecutive PCa patients were submitted to RARP between September 2016 and February 2017 at two high-volume European centers. Before RARP, each patient was referred to 1.5T or 3T mpMRI. NS was recorded as Grade 1, Grade 2, Grade 3, and Grade 4 according to Tewari and colleagues classification. A preliminary surgical plan to determinate the extent of NS approach was recorded based on clinical data. The final surgical plan was reassessed after mpMRI revision. The appropriateness of surgical plan change was considered based on the presence of extracapsular extension or positive surgical margins (PSMs) at level of neurovascular bundles area at final pathology. Furthermore, we analyzed a control group during the same period of 166 PCa patients referred to RARP in both institutions without preoperative mpMRI to assess the impact of the use of mpMRI on the surgical margins.
Considering 137 patients with preoperative mpMRI, the mpMRI revision induced the main surgeon to change the NS surgical plan in 46.7% of cases on patient-based and 56.2% on side-based analysis. The surgical plan change results equally assigned between the direction of more radical and less radical approach both on patient-based (54.7% vs 54.3%) and on side-based levels (50% vs 50%), resulting an overall appropriateness of 75%. Moreover, patients staged with mpMRI revealed significant lower overall PSMs compared with control group with no mpMRI (12.4% vs 24.1%; p ≤ 0.01).
mpMRI induces robotic surgeons to change the surgical plan in almost half of individuals, thus tailoring the NS approach, without compromising the oncologic outcomes. Compared to patients treated without mpMRI, the use of preoperative mpMRI can significantly reduce the overall PSMs.
Multiparametric magnetic resonance imaging (mpMRI) can guide the surgical plan during robot-assisted radical prostatectomy (RARP), and intraoperative frozen section (IFS) can facilitate real-time ...surgical margin assessment.
To assess a novel technique of IFS targeted to the index lesion by using augmented reality three-dimensional (AR-3D) models in patients scheduled for nerve-sparing RARP (NS-RARP).
Between March 2019 and July 2019, 20 consecutive prostate cancer patients underwent NS-RARP with IFS directed to the index lesion with the help of AR-3D models (study group). Control group consists of 20 patients matched with 1:1 propensity score for age, clinical stage, Prostate Imaging Reporting and Data System score v2, International Society of Urological Pathology grade, prostate volume, NS approach, and prostate-specific antigen in which RARP was performed by cognitive assessment of mpMRI.
In the study group, an AR-3D model was superimposed to the surgical field to guide the surgical dissection. Tissue sampling for IFS was taken in the area in which the index lesion was projected by AR-3D guidance.
Chi-square test, Student t test, and Mann-Whitney U test were used to compare, respectively, proportions, means, and medians between the two groups.
Patients in the AR-3D group had comparable preoperative characteristics and those undergoing the NS approach were referred to as the control group (all p ≥ 0.06). Overall, positive surgical margin (PSM) rates were comparable between the two groups; PSMs at the level of the index lesion were significantly lower in patients referred to AR-3D guided IFS to the index lesion (5%) than those in the control group (20%; p = 0.01).
The novel technique of AR-3D guidance for IFS analysis may allow for reducing PSMs at the level of the index lesion.
Augmented reality three-dimensional guidance for intraoperative frozen section analysis during robot-assisted radical prostatectomy facilitates the real-time assessment of surgical margins and may reduce positive surgical margins at the index lesion.
We proposed a novel technique of augmented reality three-dimensional (AR-3D) guided intraoperative frozen section (IFS) for real-time assessment of surgical margins during robot-assisted radical prostatectomy. The AR-3D guidance for IFS allows combination of the reduction of positive surgical margins at the level of the index lesion and preservation of neurovascular bundles.
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