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Aktuelle Urologie Jun 2024Surgical approaches for benign prostatic hyperplasia have evolved and diversified over the past decades. While numerous studies document the efficacy of surgical... (Review)
Review
Surgical approaches for benign prostatic hyperplasia have evolved and diversified over the past decades. While numerous studies document the efficacy of surgical procedures for moderate prostate sizes, there remains insufficient data for large prostate volumes >200 ml, leaving important questions unanswered regarding their effectiveness and safety. Consequently, selecting and adapting suitable therapeutic options for this specific patient group often poses a significant challenge. In this context, this review comprehensively summarizes and discusses current insights into surgical treatment options for large prostate volumes (>200 ml) following an extensive literature review.In summary, the surgical treatment of prostate volumes >200 ml is a challenge regardless of the chosen surgical method. Minimally invasive approaches should be considered standard practice today. Anatomical endoscopic enucleation of the prostate is a size-independent method and has the lowest morbidity. As it may be performed in spinal anaesthesia, endoscopic enucleation is feasible in patients with an increased anaesthetic risk. In extremely large prostate glands, the procedure poses challenges even for highly experienced surgeons. Especially in obese patients, the surgeon should be familiar with different exit strategies. Robot-assisted simple prostatectomy provides a minimally invasive alternative that may also treat pathologies such as diverticula or large bladder stones in the same surgical session. Due to its transabdominal approach, the morbidity and anaesthetic risk is comparatively higher. Each centre and surgeon should individually decide in which method they have the greatest expertise and which option is best suited for the specific case. In cases of limited expertise, it is advisable to refer patients to a centre with appropriate specialization.
Topics: Humans; Male; Prostatic Hyperplasia; Robotic Surgical Procedures; Prostatectomy; Endoscopy; Prostate; Minimally Invasive Surgical Procedures
PubMed: 38806034
DOI: 10.1055/a-2307-3887 -
BMC Cancer May 2024The proposed trial is to examine the feasibility of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT)-guided...
Protocol for CHAMPION study: a prospective study of maximal-cytoreductive therapies for patients with de novo metastatic hormone-sensitive prostate cancer who achieve oligopersistent metastases during systemic treatment with apalutamide plus androgen deprivation therapy.
BACKGROUND
The proposed trial is to examine the feasibility of prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT)-guided cytoreduction plus apalutamide and androgen deprivation therapy (ADT) for newly diagnosed metastatic hormone-sensitive prostate cancer (mHSPC) at oligometastatic state.
METHODS
CHAMPION (NCT05717582) is an open-label, single-arm, phase II trial, planning to enroll newly diagnosed mHSPC cases with oligometastases (≤ 10 distant metastatic sites in conventional imaging). Patients will receive 6 cycles of apalutamide plus ADT. Patients with oligometastatic disease at PSMA PET/CT after 3 treatment cycles will receive cytoreductive radical prostatectomy. PSMA PET/CT-guided metastasis-directed external radiation therapy will be determined by the investigators. Apalutamide plus ADT will be continued for 2 weeks postoperatively. The primary endpoint is the proportion of patients with undetectable prostate-specific antigen (PSA), no disease progression, and no symptom deterioration after 6 cycles of apalutamide plus ADT. Secondary endpoints include the percentage of patients with PSA ≤ 0.2 ng/mL and oligometastases by the end of 3 treatment cycles, PSA response rate, and safety. Fleming's two-stage group sequential design will be adopted in the study, where the null hypothesis is that the rate of patients with an undetectable PSA is ≤ 40% after 6 cycles of treatment, while the alternate hypothesis is an undetectable PSA of > 60%; with one-sided α = 0.05, power = 0.80, and an assumed dropout rate of 10%, the required number of patients for an effective analysis is 47. Enrolment in the study commenced in May 2023.
DISCUSSION
The multi-modal therapy based on treatment response may improve the prognosis of newly diagnosed mHSPC patients with oligometastases.
TRIAL REGISTRATION
The study is registered with Clinical Trials.Gov (NCT05717582). Registered on 8th February 2023.
Topics: Humans; Male; Thiohydantoins; Androgen Antagonists; Prostatic Neoplasms; Prospective Studies; Neoplasm Metastasis; Positron Emission Tomography Computed Tomography; Antineoplastic Combined Chemotherapy Protocols; Aged; Prostate-Specific Antigen; Middle Aged; Clinical Trials, Phase II as Topic; Prostatectomy
PubMed: 38796422
DOI: 10.1186/s12885-024-12395-3 -
International Braz J Urol : Official... May 2024Robot-assisted radical prostatectomy (RARP) has become a popular surgical approach for localized prostate cancer due to its favorable oncological and functional...
INTRODUCTION
Robot-assisted radical prostatectomy (RARP) has become a popular surgical approach for localized prostate cancer due to its favorable oncological and functional outcomes, as well as lower morbidity. In cases of intermediate- and high-risk prostate cancer, bilateral pelvic lymphadenectomy (PLND) is recommended as an adjunct to RARP (1-3). Despite its benefits, PLND can lead to surgical complications, with postoperative lymphocele formation being the most common. Most postoperative lymphoceles are clinically insignificant with variable incidence, reaching up to 60% of cases 4. However, a small percentage of patients 2-8% may experience symptomatic lymphoceles (SL), which can cause significant morbidity (4, 5).
SURGICAL TECHNIQUE
We perform our RARP technique with our standard approach in all patients (6). After vesicourethral anastomosis a modified PF created to prevent symptomatic lymphocele. We start by suturing the peritoneal fold on the right side, medially to the vas deferens, followed by a similar stitch on the left side to approximate the edges in the midline. A running suture bunches the bladder peritoneum from both sides, passing through the pubic bone periosteum to secure it in place (7). This approach keeps the lateral pelvic gutters open for lymphatic drainage, while allowing fluid drainage from the true pelvis into the abdomen. A pelvic ultrasound was done for all patients at 6 weeks post operative, and additional clinical follow-up was carried out at 3 months following surgery.
CONSIDERATIONS
We have demonstrated a modified technique of peritoneal flap (PBFB) with an initial decrease in postoperative symptomatic lymphoceles, the technique is feasible, safe, does not add significant morbidity, and does not require a learning curve.
PubMed: 38787614
DOI: 10.1590/S1677-5538.IBJU.2024.0278 -
Current Urology Reports Jul 2024Devastating complications of the bladder outlet resulting from prostate cancer treatments are relatively uncommon. However, the combination of the high incidence of... (Review)
Review
PURPOSE OF REVIEW
Devastating complications of the bladder outlet resulting from prostate cancer treatments are relatively uncommon. However, the combination of the high incidence of prostate cancer and patient longevity after treatment have raised awareness of adverse outcomes deteriorating patients' quality of life. This narrative review discusses the diagnostic work-up and management options for bladder outlet obstruction resulting from prostate cancer treatments, including those that require urinary diversion.
RECENT FINDINGS
The devastated bladder outlet can be a consequence of the treatment of benign conditions, but more frequently from complications of pelvic cancer treatments. Regardless of etiology, the initial treatment ladder involves endoluminal options such as dilation and direct vision internal urethrotomy, with or without intralesional injection of anti-fibrotic agents. If these conservative strategies fail, surgical reconstruction should be considered. Although surgical reconstruction provides the best prospect of durable success, reconstructive procedures are also associated with serious complications. In the worst circumstances, such as prior radiotherapy, failed reconstruction, devastated bladder outlet with end-stage bladders, or patient's severe comorbidities, reconstruction may neither be realistic nor justified. Urinary diversion with or without cystectomy may be the best option for these patients. Thorough patient counseling before treatment selection is of utmost importance. Outcomes and repercussions on quality of life vary extensively with management options. Meticulous preoperative diagnostic evaluation is paramount in selecting the right treatment strategy for each individual patient. The risk of bladder outlet obstruction, and its severest form, devastated bladder outlet, after treatment of prostate cancer is not negligible, especially following radiation. Management includes endoluminal treatment, open or robot-assisted laparoscopic reconstruction, and urinary diversion in the worst circumstances, with varying success rates.
Topics: Humans; Male; Urinary Bladder Neck Obstruction; Prostatic Neoplasms; Prostatectomy; Postoperative Complications; Urinary Diversion
PubMed: 38750347
DOI: 10.1007/s11934-024-01206-8 -
Asian Journal of Andrology May 2024In this nonsystematic review of the literature, we explored the changing landscape of detection and treatment of low- and intermediate-risk prostate cancer (PCa)....
In this nonsystematic review of the literature, we explored the changing landscape of detection and treatment of low- and intermediate-risk prostate cancer (PCa). Through emphasizing improved cancer assessment with histology classification and genomics, we investigated key developments in PCa detection and risk stratification. The pivotal role of prostate magnetic resonance imaging (MRI) in the novel diagnostic pathway is examined, alongside the benefits and drawbacks of MRI-targeted biopsies for detection and tumor characterization. We also delved into treatment options, particularly active surveillance for intermediate-risk PCa. Outcomes are compared between intermediate- and low-risk patients, offering insights into tailored management. Surgical techniques, including Retzius-sparing surgery, precision prostatectomy, and partial prostatectomy for anterior cancer, are appraised. Each technique has the potential to enhance outcomes and minimize complications. Advancements in technology and radiobiology, including computed tomography (CT)/MRI imaging and positron emission tomography (PET) fusion, allow for precise dose adjustment and daily target monitoring with imaging-guided radiotherapy, opening new ways of tailoring patients' treatments. Finally, experimental therapeutic approaches such as focal therapy open new treatment frontiers, although they create new needs in tumor identification and tracking during and after the procedure.
PubMed: 38738954
DOI: 10.4103/aja20249 -
Health Economics May 2024This paper examines the effect of new medical technology (robotic surgery) on efficiency gains and productivity changes for surgical treatment in patients with prostate...
This paper examines the effect of new medical technology (robotic surgery) on efficiency gains and productivity changes for surgical treatment in patients with prostate cancer from the perspective of a public health sector organization. In particular, we consider three interrelated surgical technologies within the English National Health System: robotic, laparoscopic and open radical prostatectomy. Robotic and laparoscopic techniques are minimally invasive procedures with similar clinical benefits. While the clinical benefits in adopting robotic surgery over laparoscopic intervention are unproven, it requires a high initial investment cost and carries high on-going maintenance costs. Using data from Hospital Episode Statistics for the period 2000-2018, we observe growing volumes of prostatectomies over time, mostly driven by an increase in robotic-assisted surgeries, and further analyze whether hospital providers that adopted a robot see improved measures of throughput. We then quantify changes in total factor and labor productivity arising from the use of this technology. We examine the impact of robotic adoption on efficiency gains employing a staggered difference-in-difference estimator and find evidence of a 50% reduction in length of stay (LoS), 49% decrease in post-LoS and 44% and 46% decrease in postoperative visits after 1 year and 2 years, respectively. Productivity analysis shows the growth in radical prostatectomy volume is sustained with a relatively stable number of urology surgeons. The robotic technique increases total production at the hospital level between 21% and 26%, coupled with a 29% improvement in labor productivity. These benefits lend some, but not overwhelming support for the large-scale hospital investments in such costly technology.
PubMed: 38733282
DOI: 10.1002/hec.4838 -
The Journal of Urology Jul 2024Limited high-quality studies have compared robot-assisted laparoscopic prostatectomy (RALP) vs open retropubic radical prostatectomy. We sought to compare their... (Randomized Controlled Trial)
Randomized Controlled Trial Comparative Study
Perioperative, Oncological, and Functional Outcomes Between Robot-Assisted Laparoscopic Prostatectomy and Open Radical Retropubic Prostatectomy: A Randomized Clinical Trial.
PURPOSE
Limited high-quality studies have compared robot-assisted laparoscopic prostatectomy (RALP) vs open retropubic radical prostatectomy. We sought to compare their postoperative outcomes in a randomized setting.
MATERIALS AND METHODS
In a single center, 354 men with newly diagnosed prostate cancer were assessed for eligibility; 342 were randomized (1:1). The primary outcome was 90-day complication rates. Functional outcomes and quality of life were assessed over 18 months, and oncological outcomes, biochemical recurrence-free survival, and additional treatment over 36 months.
RESULTS
From 2014 to 18, 327 patients underwent surgery (retropubic radical prostatectomy = 156, RALP = 171). Complications occurred in 27 (17.3%) vs 19 (11.1%; = .107). Patients undergoing RALP experienced lower median bleeding (250.0 vs 719.5 mL; < .001) and shorter hospitalization time. Urinary EPIC (Expanded Prostate Cancer Index Composite) median scores were better for RALP over 18 months, with higher continence rate at 3 months (80.5% vs 64.7%; = .002), 6 months (90.1% vs 81.6%; = .036) and 18 months (95.4% vs 78.8%; < .001). Sexual EPIC and Sexual Health Inventory for Men median scores were higher with RALP up to 12 months, while the potency rate was superior at 3 months (23.9% vs 5.3%; = .001) and 6 months (30.6% vs 6.9%; < .001). Quality of life over the 18 months and oncological outcomes over 36 months were not significantly different between arms.
CONCLUSIONS
Complications at 90 days were similar. RALP showed superior sexual outcomes at 1 year, improved urinary outcomes at 18 months, and comparable oncological outcomes at 36 months.
TRIAL REGISTRATION
Prospective Analysis of Robot-Assisted Surgery; NCT02292914. https://clinicaltrials.gov/ct2/show/NCT02292914?cond=NCT02292914&draw=2&rank=1.
Topics: Humans; Male; Prostatectomy; Robotic Surgical Procedures; Prostatic Neoplasms; Laparoscopy; Middle Aged; Quality of Life; Aged; Postoperative Complications; Treatment Outcome
PubMed: 38723593
DOI: 10.1097/JU.0000000000003967 -
Prostate Cancer and Prostatic Diseases May 2024Urethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH). This study aimed to evaluate the contemporary...
INTRODUCTION AND OBJECTIVES
Urethral stricture (US) is a well-known complication after surgical treatment of benign prostatic hyperplasia (BPH). This study aimed to evaluate the contemporary incidence of the US after different types of BPH surgery, to identify associated risk factors and to assess its management.
METHODS
A retrospective analysis was conducted using the PearlDiver™ Mariner database, containing de-identified patient records compiled between 2011 and 2022. Specific International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes were employed to identify population characteristics and outcomes. All the most employed surgical procedures for BPH treatment were considered. Multivariable logistic regression was employed to evaluate factors associated with diagnosis of post-operative US.
RESULTS
Among 274,808 patients who underwent BPH surgery, 10,918 developed post-operative US (3.97%) within 12 months. Higher incidence of US was observed following TURP (4.48%), Transurethral Incision of the Prostate (TUIP) (3.67%), Photoselective Vaporization of the Prostate (PVP) (3.92%), HoLEP/ThuLEP (3.85%), and open Simple Prostatectomy (SP) (3.21%). Lower incidence rates were observed after laparoscopic\robot-assisted SP (1.76%), Aquablation (1.59%), Prostatic Urethral Lift (PUL) (1.07%), Rezum (1.05%), and Prostatic Artery Embolization (PAE) (0.65%). Multivariable analysis showed that patients undergoing PUL, Rezum, Aquablation, PAE, and PVP were associated with a reduced likelihood of developing US compared to TURP. US required surgical treatment in 18.95% of patients, with direct visual internal urethrotomy (DVIU) and urethroplasty performed in 14.55% and 4.50% of cases, respectively. Urethral dilatation (UD) in an outpatient setting was the primary management in most cases (76.7%).
CONCLUSIONS
The present analysis from a contemporary large dataset suggests that the incidence of US after BPH surgery is relatively low (<5%) and varies among procedures. Around 94% of US cases following BPH surgery are managed using minimally invasive treatment approaches such as UD and DVIU.
PubMed: 38714780
DOI: 10.1038/s41391-024-00841-z -
Proceedings of SPIE--the International... Feb 2024While minimally invasive laparoscopic surgery can help reduce blood loss, reduce hospital time, and shorten recovery time compared to open surgery, it has the...
While minimally invasive laparoscopic surgery can help reduce blood loss, reduce hospital time, and shorten recovery time compared to open surgery, it has the disadvantages of limited field of view and difficulty in locating subsurface targets. Our proposed solution applies an augmented reality (AR) system to overlay pre-operative images, such as those from magnetic resonance imaging (MRI), onto the target organ in the user's real-world environment. Our system can provide critical information regarding the location of subsurface lesions to guide surgical procedures in real time. An infrared motion tracking camera system was employed to obtain real-time position data of the patient and surgical instruments. To perform hologram registration, fiducial markers were used to track and map virtual coordinates to the real world. In this study, phantom models of each organ were constructed to test the reliability and accuracy of the AR-guided laparoscopic system. Root mean square error (RMSE) was used to evaluate the targeting accuracy of the laparoscopic interventional procedure. Our results demonstrated a registration error of 2.42 ± 0.79 mm and a procedural targeting error of 4.17 ± 1.63 mm using our AR-guided laparoscopic system that will be further refined for potential clinical procedures.
PubMed: 38708143
DOI: 10.1117/12.3008448 -
International Journal of Surgery Case... Jun 2024Heterotopic ossification (HO) develops when bone formation appears in soft tissues, usually after an injury or major surgery. Timely and accurately diagnosing of this...
INTRODUCTION
Heterotopic ossification (HO) develops when bone formation appears in soft tissues, usually after an injury or major surgery. Timely and accurately diagnosing of this rare event is essential due to the possibility of misdiagnosis as a maintained foreign body, infection, incisional neoplastic recurrence, and metastatic or primary neoplasms.
CASE PRESENTATION
In this study, we present a 57-year-old man who was operated for peritonitis due to perforated appendicitis, and an asymptomatic HO was accidentally found on an incisional line of previous open prostatectomy about 5 years earlier due to benign prostatic hyperplasia. A bone density lesion was seen in the fascia and on the incisional scar of previous surgery.
DISCUSSION
HO rarely occurs within an abdominal incision due to surgery. It is reported only within vertical midline incisions and mainly within the first year after the operation. Imaging confirms the diagnosis of HO in previous abdominal surgery scars, which reveals dense vertical calcification along the previous incisional scar. In the case of HO, the exclusive effective management is the entire surgical excision with primary closure, and NSAIDs are the preventive choices.
CONCLUSION
HO should be considered in patients presenting with discomfort or palpable mass or even asymptomatic patients with previous abdominal surgeries besides considering relative history such as surgical complications or neoplasms.
PubMed: 38704967
DOI: 10.1016/j.ijscr.2024.109655