To update the complications of transurethral resection of the prostate (TURP), including management and prevention based on technological evolution.
Based on a MEDLINE search from 1989 to 2005, the ...2003 results of quality management of Baden-Württemberg, and long-term personal experience at three German centers, the incidence of complications after TURP was analyzed for three subsequent periods: early (1979-1994); intermediate (1994-1999); and recent (2000-2005) with recommendations for management and prevention.
Technological improvements such as microprocessor-controlled units, better armamentarium such as video TUR, and training helped to reduce perioperative complications (recent vs. early) such as transfusion rate (0.4% vs. 7.1%), TUR syndrome (0.0% vs. 1.1%), clot retention (2% vs. 5%), and urinary tract infection (1.7% vs. 8.2%). Urinary retention (3% vs. 9%) is generally attributed to primary detrusor failure rather than to incomplete resection. Early urge incontinence occurs in up to 30-40% of patients; however, late iatrogenic stress incontinence is rare (<0.5%). Despite an increasing age (55% of patients are older than 70), the associated morbidity of TURP maintained at a low level (<1%) with a mortality rate of 0-0.25%. The major late complications are urethral strictures (2.2-9.8%) and bladder neck contractures (0.3-9.2%). The retreatment rate range is 3-14.5% after five years.
TURP still represents the gold standard for managing benign prostatic hyperplasia with decreasing complication rates. Technological alternatives such as bipolar and laser treatments may further minimize the risks of this technically difficult procedure.
Background
Motorized articulating laparoscopic instruments (ALI) offer more degrees of freedom than conventional laparoscopic instruments (CLI). However, a difficult learning curve and complex ...instrument handling are still a problem of ALI. We compared the performance of new prototypes of motorized ALI with CLI in a series of standardized laparoscopic tasks performed by laparoscopic novices. Further, usability of the new ALI was assessed.
Methods
A randomized cross-over study with 50 laparoscopic novices who either started with CLI and then changed to ALI (CA) or vice versa (AC) was conducted. All participants performed the European training in basic laparoscopic urological skills (E-BLUS) with each instrument in given order. Time and errors were measured for each exercise. Instrument usability was assessed.
Results
Overall, using CLI was significantly faster (CLI 4:27 min vs. ALI 4:50 min;
p
-value 0.005) and associated with fewer exercise failures in needle guidance (CLI 0 vs. ALI 12;
p
-value 0.0005) than ALI. Median amount of errors was similar for both instruments. Instrument sequence did not matter, as CA and AC showed comparable completion times. Regarding the learning effect, participants were significantly faster in the second attempt of exercises than in the first. In the needle guidance task, participants using CLI last demonstrated a significant speed improvement, whereas ALI were significantly slower in the second run. Regarding usability, CLI were preferred over ALI due to lighter weight and easier handling. Nevertheless, participants valued ALI’s additional degrees of freedom.
Conclusion
Using new motorized ALI in the E-BLUS examination by laparoscopic novices led to a worse performance compared to CLI. An explanation could be that participants felt overwhelmed by ALI and that ALI have an own distinct learning curve. As participants valued ALI’s additional degrees of freedom, however, a future application of ALI could be for training purposes, ideally in combination with CLI.
Introduction
Focal therapy (FT) for localized prostate cancer (PCa) is a promising treatment strategy. Although, according to guidelines, it should be regarded as an experimental option, its ...introduction into clinical practice has occurred at an accelerated speed. It is, thus, crucial for Urologists to understand FT limitations and potential drawbacks that may derive from its use.
Methods
We performed a literature search of peer-reviewed English language articles using Pubmed and the words “focal therapy” AND “prostate cancer” to identify relevant articles. Web search was complemented by manual search.
Results
From a biological perspective, in contrast with the index lesion theory, which still needs to be better supported, PCa is a multifocal and multiclonal entity. Also, the effects of FT on PCa microenvironment are unclear. From a clinical perspective, patient selection is still not precisely defined. Even when all variables potentially decreasing mpMRI and biopsy accuracy are optimized, up to one out of two men may be incorrectly selected for FT, leaving a significant proportion of clinically significant PCa (csPCa) untreated. Underestimation of PCa volume and variant histologies are other additional mpMRI potential limitations. No RCTs have been performed against the standard of care to support FT. There is absence of long-term results and FT series reaching medium-term follow-up have non-optimal oncological control with significant re-treatment needs. When PCa recurs/persists after FT, little is known about the appropriate management strategies and their outcomes. Finally, the optimal follow-up scheme post-FT remains unclear.
Conclusions
Several arguments are present against the use of FT for localized PCa. Studies are needed to overcome current limitations and support FT before it can be included as part of the standard management of prostate cancer.
Abstract Background Use of an augmented reality (AR)–based soft tissue navigation system in urologic laparoscopic surgery is an evolving technique. Objective To evaluate a novel soft tissue ...navigation system developed to enhance the surgeon's perception and to provide decision-making guidance directly before initiation of kidney resection for laparoscopic partial nephrectomy (LPN). Design, setting, and participants Custom-designed navigation aids, a mobile C-arm capable of cone-beam imaging, and a standard personal computer were used. The feasibility and reproducibility of inside-out tracking principles were evaluated in a porcine model with an artificially created intraparenchymal tumor in vitro. The same algorithm was then incorporated into clinical practice during LPN. Interventions Evaluation of a fully automated inside-out tracking system was repeated in exactly the same way for 10 different porcine renal units. Additionally, 10 patients underwent retroperitoneal LPNs under manual AR guidance by one surgeon. Measurements The navigation errors and image-acquisition times were determined in vitro. The mean operative time, time to locate the tumor, and positive surgical margin were assessed in vivo. Results and limitations The system was able to navigate and superpose the virtually created images and real-time images with an error margin of only 0.5 mm, and fully automated initial image acquisition took 40 ms. The mean operative time was 165 min (range: 135–195 min), and mean time to locate the tumor was 20 min (range: 13–27 min). None of the cases required conversion to open surgery. Definitive histology revealed tumor-free margins in all 10 cases. Conclusions This novel AR tracking system proved to be functional with a reasonable margin of error and image-to-image registration time. Mounting the pre- or intraoperative imaging properties on real-time videoendoscopic images in a real-time manner will simplify and increase the precision of laparoscopic procedures.
Objective
Age is known to have an impact on outcomes after radical prostatectomy (RP). However, age differences can be investigated from a cross-sectional as well as from a longitudinal perspective. ...This study combines both perspectives.
Materials and methods
LAP-01 is the first multicenter randomized patient blinded trial comparing outcomes after robotic-assisted and laparoscopic RP. This study stratified the entire population that received nerve-sparing surgery and was potent at baseline by the following ages: ≤ 60 years, 61–65 years, and > 65 years. Potency was assessed using the IIEF-5. The EORTC QLQ-C30 was used for global health perception and the EORTC QLQ-PR25 for urinary symptoms. Continence was assessed by the number of pads used. Longitudinal change was assessed using either validated anchor-based criteria or the 1 or 0.5-standard-deviation criterion. Worsening of continence was measured by increasing numbers of pads.
Results
310 patients were included into this study. Older patients had a significantly higher risk for worsening of continence at 3 and 6 months (OR 2.21, 95% CI 1.22, 4.02,
p
= 0.009 and OR 2.00, 95% CI 1.16, 3.46,
p
= 0.013, respectively); at 12 months, the odds of worsening did not differ significantly between age groups. Potency scores were better in younger patients from a cross-sectional perspective, but longitudinal change did not differ between the age groups. In contrast, global health perception was better in older patients from a cross-sectional perspective and longitudinal decreases were significantly more common among the youngest patients, at 12 months (36.9% vs. 24.4%,
p
= 0.038).
Conclusion
From a cross-sectional perspective, function scores were better in younger patients, but from a longitudinal perspective, age differences were found in continence only. In contrast, global health scores were better in older patients from a cross-sectional and longitudinal perspective.
Trial registration
The LAP-01 trial was registered with the U.S. National Library of Medicine clinical trial registry (clinicaltrials.gov), NCT number: NCT03682146, and with the German Clinical Trial registry (Deutsches Register Klinischer Studien), DRKS ID number: DRKS00007138
.
This trial compared the sequential therapy with the multikinase inhibitor sorafenib (So) followed by pazopanib (Pa) or vice versa in advanced/metastatic renal cell carcinoma (mRCC) patients.
This ...multicenter, randomized phase 3 study assessed the sequential use of So-Pa versus Pa-So in patients with mRCC without prior systemic therapy. Pts were randomized to So 2 × 400 mg/day followed by Pa 1 × 800 mg/day in case of progression or intolerable toxicity or vice versa. Primary endpoint was total PFS (tPFS), defined as time from randomization to progression, or death during second-line therapy. Key secondary endpoints included overall survival (OS), first-line PFS, disease control rate (DCR) and safety.
A total of 377 pts were randomized (So-Pa, n = 189; Pa-So, n = 188). Recruitment of a total 544 pts was calculated, but actual accrual rate turned out to be lower than expected. The primary endpoint median tPFS was 8.6 mo (95% CI 7.7–10.2) for So-Pa and 12.9 mo (95% CI 10.8–15.2) for Pa-So with a hazard ratio (HR) of 1.36 (upper limit of one-sided 95% CI 1.68), which exceeded a predefined HR <1.225 as a one-sided 95% confidence interval. Non-inferiority of So-Pa regarding tPFS was not met. Secondary endpoints displayed marked statistical differences in favor of Pa-So in first-line PFS and DCR but not for OS and 2nd-line PFS. Side effect profiles were consistent with known toxicities of the respective multikinase-inhibitor including diarrhea, fatigue, hand-foot skin reaction and hypertension.
Non-inferiority of the primary endpoint tPFS could not be demonstrated for So-Pa. The results for first-line PFS and DCR favored the Pa-So sequence.
NCT01613846, www.clinicaltrials.gov.
•SWITCH II is a phase III study of sequential therapy with Sorafenib (So).•Pazopanib (Pa) vs Pa-So for advanced RCC.•The primary endpoint of non-inferiority of total PFS (tPFS) for So-Pa was not met.•Sequential therapy with Pa-So resulted in longer median tPFS (12.9 vs 8.6 months) and median OS (28.0 vs 22.7 months).
Intratumoural heterogeneity (ITH) is a major cause of cancer-associated lethality. Extensive genomic ITH has previously been reported in clear cell renal cell carcinoma (ccRCC). Here we address the ...question whether ITH increases with malignant progression and can hence be exploited as a prognostic marker. Unexpectedly, precision quantitative image analysis reveals that the degree of functional ITH is virtually identical between primary ccRCCs of the lowest stage and advanced, metastatic tumours. Functional ITH was found to show a stage-independent topological pattern with peak proliferative and signalling activities almost exclusively in the tumour periphery. Exome sequencing of matching peripheral and central primary tumour specimens reveals various region-specific mutations. However, these mutations cannot directly explain the zonal pattern suggesting a role of microenvironmental factors in shaping functional ITH. In conclusion, our results indicate that ITH is an early and general characteristic of malignant growth rather than a consequence of malignant progression.
Purpose
To analyze urinary continence outcome following robot-assisted radical prostatectomy (RARP) for aggressive prostate cancer in men aged ≥ 70 and < 70 years.
Methods
Retrospective analyses of ...prospectively collected long-term data from a monocentric cohort of 350 men with D’Amico high-risk prostate cancer undergone robot-assisted radical prostatectomy at a single institution between 2005 and 2016. The association between time since operation and zero-pad urinary continence recovery was comparatively analyzed by separate pre-operative and post-operative Cox proportional-hazard regression models.
Results
Median age in the age group ≥ 70 years was 73 years compared with 62 years in the < 70 year age group. Distribution of men receiving adjuvant and salvage radiotherapy/hormonal therapy was similar in both age groups. Urinary continence recovery rate at 12, 24, and 36 months after surgery of men aged ≥ 70 years was 66, 79 and 83%, respectively, and statistically similar to that of men < 70 years: 71, 81, and 85% (log-rank test
p
= 0.24). Multivariable analyses demonstrated no significant difference in return to continence between the two age groups (
p
= 0.28 and
p
= 0.17). In addition, clinical stage and type of nerve sparing (unilateral, bilateral or non-nerve sparing) were found to be independently predictive of pad-free continence recovery.
Conclusions
Regardless of age, return to continence in men with aggressive prostate cancer undergoing RARP continues to improve way beyond the first 12 months after surgery. Considering the dire effects of post-operative radiotherapy on continence in this aggressive cancer cohort, advanced age alone should not discourage recommending multimodal therapy involving RARP.
We present an augmented reality (AR) navigation system that conveys virtual organ models generated from transrectal ultrasonography (TRUS) onto a real laparoscopic video during radical prostatectomy. ...By providing this additional information about the actual anatomy, we can support surgeons in their working decisions. This work reports the system's first in-vivo application.
The system uses custom-developed needles with colored heads that are inserted into the prostate as soon as the organ surface is uncovered. These navigation aids are once segmented in three-dimensional (3D) TRUS data that is acquired right after the placement of the needles and then continuously tracked in the laparoscopic video images by the surgical navigation system. The navigation system traces the navigation aids in real time and computes a registration between TRUS image and laparoscopic video based on the two-dimensional-three dimensional (2D-3D) point correspondences. With this registration, the system correctly superimposes TRUS-based 3D information on an additional AR monitor placed next to the normal laparoscopic screen. Surgical navigation guidance took place until the prostate was removed from the rectal wall. Finally, the navigation aids were removed together with the specimen inside the specimen bag.
The initial human in-vivo application of the surgical navigation system was successful. No complications occurred, the prostate was removed together with the navigation aids, and the system supported the surgeons as intended with an AR visualization in real time. In case of tissue deformations, changes in the spatial configuration of the navigation aids are detected, which preserves the system from erroneous navigation visualization.
Feasibility of the navigation system was shown in the first in-vivo application. TRUS information could be superimposed via AR in real time. To show the benefit for the patient, results obtained from a larger number of trials are needed.
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