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Current Oncology (Toronto, Ont.) Dec 2022(Background) Radiation failure for localized prostate cancer is seen in 20-60% of patients who do not undergo extirpative surgery. Though potentially curative, salvage... (Review)
Review
(Background) Radiation failure for localized prostate cancer is seen in 20-60% of patients who do not undergo extirpative surgery. Though potentially curative, salvage prostatectomy (SS) has not been frequently performed historically due to high rates of complications and postoperative incontinence. With the advent of robotic-assisted radical prostatectomy, these rates appear to be improved. Retzius-sparing approaches have additionally been shown to improve continence outcomes in the index setting, and may further improve continence outcomes in salvage cases while maintaining oncologic integrity. (Methods) We performed a literature review and qualitative analysis of published papers on salvage Retzius-sparing robotic-assisted radical prostatectomy (SRS). Three studies met criteria and were included in analysis. (Results) There were more patients with Gleason Grade Group 1 disease after initial treatment in the SRS group vs. SS (22% vs. 8%). Patients most frequently underwent external beam radiation therapy in both groups (52% vs. 49%). 30-day complication rates were 10% and 26% for SRS and SS, respectively. Continence outcomes were significantly improved in SRS with 59% of continence (based on study criteria) compared to 38% in SS. Time to continence was similarly improved for SRS. Positive surgical margins and biochemical recurrence were not significantly different between SRS and SS in any study. (Conclusions) SRS is a safe and feasible option for salvage treatment of localized prostate cancer and may improve postoperative continence outcomes. Positive surgical margin and biochemical recurrence rates are similar to those reported in SS.
Topics: Male; Humans; Treatment Outcome; Prostate; Prostatectomy; Prostatic Neoplasms; Urinary Incontinence
PubMed: 36547178
DOI: 10.3390/curroncol29120764 -
Journal of Immunology Research 2021Erectile dysfunction (ED) is an important cause of reduced quality of life for men and their partners. Recent studies have found that cavernous nerve injury (CNI) during... (Review)
Review
Erectile dysfunction (ED) is an important cause of reduced quality of life for men and their partners. Recent studies have found that cavernous nerve injury (CNI) during prostate cancer surgery and other pelvic surgery results in medically induced CNIED in more than 80% of patients. The efficacy of first- and second-line treatment options for ED is poor. A great deal of research has been devoted to exploring new methods of neuroprotection and nerve regeneration to save erectile function in patients with CNIED, especially in patients with cavernous nerve injury after prostate cancer surgery. In addition, such as neuromodulatory proteins, proimmune ligands, gene therapy, stem cell therapy, and the current cutting-edge low-energy shock wave therapy have shown advantages in basic research and limited clinical studies. In the context of today's modern medicine, these new therapeutic techniques are expected to be new tools in the treatment of cavernous nerve injury erectile dysfunction. This article presents the main causes, mechanisms, and treatment of cavernous nerve injury erectile dysfunction and combines them with new treatment strategies.
Topics: Animals; Biomarkers; Cell- and Tissue-Based Therapy; Erectile Dysfunction; Gene Expression; Genetic Therapy; Humans; Male; Nerve Regeneration; Peripheral Nerve Injuries; Prostatectomy; Prostatic Neoplasms
PubMed: 34970630
DOI: 10.1155/2021/5353785 -
The Journal of Urology Jan 2022Our goal was to evaluate the comparative effectiveness of robot-assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) in a multicenter study. (Comparative Study)
Comparative Study
PURPOSE
Our goal was to evaluate the comparative effectiveness of robot-assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) in a multicenter study.
MATERIALS AND METHODS
We evaluated men with localized prostate cancer at 11 high-volume academic medical centers in the United States from the PROST-QA (2003-2006) and the PROST-QA/RP2 cohorts (2010-2013) with a pre-specified goal of comparing RALP (549) and ORP (545). We measured longitudinal patient-reported health-related quality of life (HRQOL) at pre-treatment and at 2, 6, 12, and 24 months, and pathological and perioperative outcomes/complications.
RESULTS
Demographics, cancer characteristics, and margin status were similar between surgical approaches. ORP subjects were more likely to undergo lymphadenectomy (89% vs 47%; p <0.01) and nerve sparing (94% vs 89%; p <0.01). RALP vs ORP subjects experienced less mean intraoperative blood loss (192 vs 805 mL; p <0.01), shorter mean hospital stay (1.6 vs 2.1 days; p <0.01), and fewer blood transfusions (1% vs 4%; p <0.01), wound infections (2% vs 4%; p=0.02), other infections (1% vs 4%; p <0.01), deep venous thromboses (0.5% vs 2%; p=0.04), and bladder neck contractures requiring dilation (1.6% vs 8.3%; p <0.01). RALP subjects reported less pain (p=0.04), less activity interference (p <0.01) and higher incision satisfaction (p <0.01). Surgical approach (RALP vs ORP) was not a significant predictor of longitudinal HRQOL change in any HRQOL domain.
CONCLUSIONS
In high-volume academic centers, RALP and ORP patients may expect similar long-term HRQOL outcomes. Overall, RALP patients have less pain, shorter hospital stays, and fewer post-surgical complications such as blood transfusions, infections, deep venous thromboses, and bladder neck contractures.
Topics: Aged; Humans; Laparoscopy; Male; Middle Aged; Prospective Studies; Prostatectomy; Prostatic Neoplasms; Quality of Life; Robotic Surgical Procedures; Treatment Outcome
PubMed: 34433304
DOI: 10.1097/JU.0000000000002176 -
European Urology Focus Jul 2021The main challenge in radical prostatectomy is complete excision of malignant tissue, while preserving continence and erectile function. Positive surgical margins (PSMs)... (Review)
Review
CONTEXT
The main challenge in radical prostatectomy is complete excision of malignant tissue, while preserving continence and erectile function. Positive surgical margins (PSMs) occur in up to 38% of cases, are associated with tumour recurrences, and may result in debilitating additional therapies. Despite surgical developments for prostate cancer (PCa), no technology is yet implemented to assess surgical margins of the entire prostatic surface intraoperatively.
OBJECTIVE
The aim of this systematic review is to provide an overview of novel imaging methods developed for intraoperative margin assessment in PCa surgery, which are compared with standard postoperative histopathology.
EVIDENCE ACQUISITION
A literature search of the last 10 yr was conducted in the Scopus, PubMed, and Embase (Ovid) databases. Eligible articles had to report the PSM rate according to their intraoperative margin assessment technology in comparison with standard histopathology.
EVIDENCE SYNTHESIS
The search resulted in 616 original articles, of which 11 were included for full-text review. The main technical developments in PCa margin assessment included optical coherence tomography, photodynamic diagnosis with 5-aminolevulinic acid, spectroscopy, and enhanced microscopy. These techniques are described and their main advantages, limitations, and applications in the clinical setting are discussed.
CONCLUSIONS
Several imaging methods are suggested in literature for the detection of positive margins during PCa surgery. Despite promising qualifications of the mentioned technologies, many struggle to find implementation in the clinic. Surgical conditions hampering the signal, long imaging times, and comparison with histopathology are mutual challenges. The next step towards reduction of PSMs in PCa surgery includes evaluation of these technologies in large clinical trials.
PATIENT SUMMARY
In this review, new technologies are reported that can assist the surgeon by detecting insufficient removal of all tumorous tissue during surgery, instead of the standard postoperative histopathological assessment. Currently, it is not clear whether these technologies improve the patient outcome directly; however, the review shows potential future implementations.
Topics: Humans; Male; Margins of Excision; Neoplasm Recurrence, Local; Prostate; Prostatectomy; Technology
PubMed: 32088139
DOI: 10.1016/j.euf.2020.02.004 -
Current Urology Reports May 2023This study reviews contemporary literature on RASP and HoLEP to evaluate perioperative outcomes, common complications, cost analytics, and future directions of both... (Review)
Review
PURPOSE OF REVIEW
This study reviews contemporary literature on RASP and HoLEP to evaluate perioperative outcomes, common complications, cost analytics, and future directions of both procedures.
RECENT FINDINGS
RASP is indicated for prostates > 80 mL, while HoLEP is size-independent. No notable differences were found in operative time, PSA nadir (surrogate for enucleation volume), re-catheterization rates, or long-term durability. Prolonged incontinence and bladder neck contracture rates are low for both surgeries. Patients experience similar satisfaction outcomes and improvements in uroflowmetry and post-void residual volumes. HoLEP demonstrates shorter hospitalizations, lower transfusion rates, lower costs, and higher rates of same-day discharge. RASP offers a shorter learning curve and lower rates of early postoperative urinary incontinence. HoLEP is a size-independent surgery that offers advantages for patients seeking a minimally invasive procedure with the potential for catheter-free same-day discharge. Future directions with single-port simple prostatectomy may offer parity in same-day discharge, but further research is needed to determine broader feasibility.
Topics: Male; Humans; Prostate; Prostatic Hyperplasia; Robotic Surgical Procedures; Lasers, Solid-State; Holmium; Laser Therapy; Prostatectomy; Treatment Outcome
PubMed: 36800115
DOI: 10.1007/s11934-023-01146-9 -
Australian Journal of General Practice Apr 2020Prostate cancer is a common tumour type in Australian men.
BACKGROUND
Prostate cancer is a common tumour type in Australian men.
OBJECTIVE
The aim of this article is to review important changes in prostate cancer diagnosis and management over the past five years, particularly as they pertain to general practice.
DISCUSSION
The management of prostate cancer has changed significantly in recent years, particularly the use of imaging, with the introduction of prostate magnetic resonance imaging as routine in the diagnostic pathway, and the increasing use of prostate-specific membrane antigen positron emission tomography for early stratification in the salvage setting for failure of primary treatment in localised disease. In addition, upfront combinations of androgen deprivation therapy with other systemic treatments have yielded significant gains in overall survival for patients with metastatic disease. There has also been an increasing recognition of the association between germline DNA repair defects and progressive disease, and interest in the potential to identify patients for therapies that target these defects. There have been significant changes in how prostate cancer is diagnosed and managed in the past five years, with the introduction of new clinical pathways that were unprecedented just a decade previously.
Topics: Australia; Disease Management; Drug Therapy; Humans; Magnetic Resonance Imaging; Male; Population Surveillance; Prostate; Prostatectomy; Prostatic Neoplasms; Recurrence; Steroid Synthesis Inhibitors
PubMed: 32233346
DOI: 10.31128/AJGP-09-19-5055 -
The Journal of Sexual Medicine Sep 2020After radical prostatectomy (RP), climacturia is a prevalent and distressing problem. To date, no specific predictors have been identified.
BACKGROUND
After radical prostatectomy (RP), climacturia is a prevalent and distressing problem. To date, no specific predictors have been identified.
AIM
In this analysis, we sought to find associated pelvic magnetic resonance imaging (MRI) parameters.
METHODS
We identified all men in our departmental database who (i) had climacturia post-RP, ≥3 episodes; (ii) underwent a pre-RP endorectal MRI; (iii) had no radiation or androgen deprivation therapy (ADT). Soft tissue and bony dimensions were measured by 2 raters blinded to clinical and pathological data.
OUTCOMES
MRI parameters included the following: maximum height, width, and depth of prostate, prostate volume, urethral width and length, lower conjugate of pelvis, bony femoral width, outer and inner levator distances and thickness. Point-biserial correlations were run on univariate associations. Logistic regression was used for the multivariable model.
RESULTS
194 consecutive pre-RP MRI studies were reviewed (56 men with and 138 without climacturia). Mean age was 60 ± 7 years, average time post-RP at assessment, 7 ± 7 months. Of MRI parameters, urethral width (r = 0.13, P = .03) and lower conjugate (r = 0.12, P = .05) were associated with presence of persistent climacturia. 2 others met criteria for multivariable analysis, prostate depth and outer levator distance. Of the non-MRI parameters, none were significantly related to climacturia and only body mass index (BMI) met criteria for multivariable analysis. On multivariable analysis, only urethral width was associated with climacturia (OR = 1.23, 95% CI: 1.01-1.49, P = .04); the wider the urethra, greater the chance of climacturia.
CLINICAL IMPLICATIONS
Improved ability to predict the occurrence of orgasm-associated incontinence in the preoperative setting.
STRENGTHS AND LIMITATIONS
Limitations include the fact that the MRI endorectal probe may have distorted pelvic tissues during imaging and that our study population size was small. However, prospective data collection, blinded measurements by 2 trained readers, and rigorous statistical analysis should be considered strengths.
CONCLUSION
By identifying preoperative risk factors, such as urethral width on MRI, we may be able to better understand the pathophysiology of this condition and furthermore may permit us to better counsel men regarding this postoperative outcome. Sullivan JF, Ortega Y, Matsushita K, et al. Climacturia After Radical Prostatectomy: MRI-Based Predictors. J Sex Med 2020;17:1723-1728.
Topics: Aged; Androgen Antagonists; Humans; Magnetic Resonance Imaging; Male; Middle Aged; Prospective Studies; Prostatectomy; Prostatic Neoplasms
PubMed: 32694068
DOI: 10.1016/j.jsxm.2020.05.021 -
International Braz J Urol : Official... 2019
Topics: Age Factors; Body Mass Index; Erectile Dysfunction; Humans; Male; Penile Erection; Prostatectomy; Recovery of Function; Robotic Surgical Procedures; Urinary Incontinence; Urination
PubMed: 31397985
DOI: 10.1590/S1677-5538.IBJU.2019.04.01 -
World Journal of Surgical Oncology Dec 2023Extraperitoneal and transperitoneal approaches are two common modalities in single-port (SP) robot-assisted radical prostatectomy (RARP), but differences in safety and... (Meta-Analysis)
Meta-Analysis Review
Perioperative, function, and positive surgical margin in extraperitoneal versus transperitoneal single port robot-assisted radical prostatectomy: a systematic review and meta-analysis.
BACKGROUND
Extraperitoneal and transperitoneal approaches are two common modalities in single-port (SP) robot-assisted radical prostatectomy (RARP), but differences in safety and efficacy between the two remain controversial. This study aimed to compare the perioperative, function, and positive surgical margin of extraperitoneal with transperitoneal approaches SP-RARP.
METHODS
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, this study is registered with PROSPERO (CRD 42023409667). We systematically searched databases including PubMed, Embase, Web of Science, and Cochrane Library to identify relevant studies published up to February 2023. Stata 15.1 software was used to analyze and calculate the risk ratio (RR) and weighted mean difference (WMD).
RESULTS
A total of five studies, including 833 participants, were included in this study. The SP-TPRP group is superior to the SP-EPRP group in intraoperative blood loss (WMD: - 43.92, 95% CI - 69.81, - 18.04; p = 0.001), the incidence of postoperative Clavien-Dindo grade II and above complications (RR: 0.55, 95% CI - 0.31, 0.99; p = 0.04), and postoperative continence recovery (RR: 1.23, 95% CI 1.05, 1.45; p = 0.04). Conversely, the hospitalization stays (WMD: 7.88, 95% confidence interval: 0.65, 15.1; p = 0.03) for the SP-EPRP group was shorter than that of the SP-TPRP group. However, there was no significant difference in operation time, postoperative pain score, total incidence of postoperative complications, and positive surgical margin (PSM) rates between the two groups (p > 0.05).
CONCLUSIONS
This study demonstrates that both extraperitoneal and extraperitoneal SP-RARP approaches are safe and effective. SP-TPRP is superior to SP-EPRP in postoperative blood loss, the incidence of postoperative Clavien-Dindo grade II and above complications, and postoperative continence recovery, but it is accompanied by longer hospital stays.
Topics: Male; Humans; Robotics; Margins of Excision; Robotic Surgical Procedures; Prostate; Prostatectomy; Treatment Outcome
PubMed: 38087327
DOI: 10.1186/s12957-023-03272-7 -
JAMA Network Open Apr 2022The cost-effectiveness of different surgical techniques for radical prostatectomy remains a subject of debate. Emergence of recent critical clinical data and changes in...
IMPORTANCE
The cost-effectiveness of different surgical techniques for radical prostatectomy remains a subject of debate. Emergence of recent critical clinical data and changes in surgical equipment costs due to their shared use by different clinical specialties necessitate an updated cost-effectiveness analysis in a centralized, largely government-funded health care system such as the UK National Health Service (NHS).
OBJECTIVE
To compare robotic-assisted radical prostatectomy (RARP) with open radical prostatectomy (ORP) and laparoscopic-assisted radical prostatectomy (LRP) using contemporary data on clinical outcomes, costs, and surgical volumes in the UK.
DESIGN, SETTING, AND PARTICIPANTS
This economic analysis used a Markov model developed to compare the cost-effectiveness of RARP, LRP, and ORP to treat localized prostate cancer. The model was constructed from the perspective of the UK NHS. The model simulated 65-year-old men who underwent radical prostatectomy for localized prostate cancer and were followed up for a 10-year period. Data were analyzed from May 1, 2020, to July 31, 2021.
EXPOSURES
Robotic-assisted radical prostatectomy, LRP, and ORP.
MAIN OUTCOMES AND MEASURES
Quality-adjusted life-years (QALYs), costs (direct medical costs and costs outside the NHS), and incremental cost-effectiveness ratios (ICERs).
RESULTS
Compared with LRP, RARP cost £1785 (US $2350) less and had 0.24 more QALYs gained; thus, RARP was a dominant option compared with LRP. Compared with ORP, RARP had 0.12 more QALYs gained but cost £526 (US $693) more during the 10-year time frame, resulting in an ICER of £4293 (US $5653)/QALY. Because the ICER was below the £30 000 (US $39 503) willingness-to-pay threshold, RARP was more cost-effective than ORP in the UK. The most sensitive variable influencing the cost-effectiveness of RARP was the lower risk of biochemical recurrence (BCR). Scenario analysis indicated RARP would remain more cost-effective than ORP as long as the BCR hazard ratios comparing RARP vs ORP were less than 0.99.
CONCLUSIONS AND RELEVANCE
These findings suggest that in the UK, RARP has an ICER lower than the willingness-to-pay threshold and thus is likely a cost-effective surgical treatment option for patients with localized prostate cancer compared with ORP and LRP. The results were mainly driven by the lower risk of BCR for RARP. These findings may differ in other health care settings where different thresholds and costs may apply.
Topics: Aged; Cost-Benefit Analysis; Humans; Male; Prostatectomy; Prostatic Neoplasms; Robotic Surgical Procedures; State Medicine; United Kingdom
PubMed: 35377424
DOI: 10.1001/jamanetworkopen.2022.5740