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JPMA. the Journal of the Pakistan... Aug 2023Prostate cancer is the second most commonly diagnosed malignancy in men worldwide. The prevalence has been increasing with significant differences between regions. This...
Prostate cancer is the second most commonly diagnosed malignancy in men worldwide. The prevalence has been increasing with significant differences between regions. This study assesses the prevalence of incidental prostate cancer detected in specimens removed during bladder outlet obstruction operation. A retrospective analysis of the records of patients who had either endoscopic or open prostatectomy from January 1998 to December 2021 was conducted. The variables analysed were age, procedure, date of surgery, and Gleason score. A total of 2,842 patients underwent surgery on the prostate gland during the study period. Most of the patients, i.e. 2,733 (96.2%), were pathologically diagnosed with benign prostatic hyperplasia, while only 110 (3.9%) had prostate cancer. The frequency of incidental prostate cancer following surgery for bladder outlet obstruction has decreased over the last two decades at our centre, possibly because of an increase in PSA testing.
Topics: Male; Humans; Retrospective Studies; Tertiary Care Centers; Urinary Bladder Neck Obstruction; Prostatic Neoplasms; Prostate; Neoplasms, Second Primary
PubMed: 37697767
DOI: 10.47391/JPMA.7660 -
JAMA Network Open Sep 2023Stratifying patients with biochemical recurrence (BCR) after primary treatment for prostate cancer based on the risk of prostate cancer-specific mortality (PCSM) is...
IMPORTANCE
Stratifying patients with biochemical recurrence (BCR) after primary treatment for prostate cancer based on the risk of prostate cancer-specific mortality (PCSM) is essential for determining the need for further testing and treatments.
OBJECTIVE
To evaluate the association of BCR after radical prostatectomy or radiotherapy and its current risk stratification with PCSM.
DESIGN, SETTING, AND PARTICIPANTS
This population-based cohort study included a total of 16 311 male patients with 10 364 (64%) undergoing radical prostatectomy and 5947 (36%) undergoing radiotherapy with curative intent (cT1-3, cM0) and PSA follow-up in Stockholm, Sweden, between 2003 and 2019. Follow-up for all patients was until death, emigration, or end of the study (ie, December 31, 2018). Data were analyzed between September 2022 and March 2023.
MAIN OUTCOMES AND MEASURES
Primary outcomes of the study were the cumulative incidence of BCR and PCSM. Patients with BCR were stratified in low- and high-risk according to European Association of Urology (EAU) criteria.
EXPOSURES
Radical prostatectomy or radiotherapy.
RESULTS
A total of 16 311 patients were included. Median (IQR) age was 64 (59-68) years in the radical prostatectomy cohort (10 364 patients) and 69 (64-73) years in the radiotherapy cohort (5947 patients). Median (IQR) follow-up for survivors was 88 (55-138) months and 89 (53-134) months, respectively. Following radical prostatectomy, the 15-year cumulative incidences of BCR were 16% (95% CI, 15%-18%) for the 4024 patients in the low D'Amico risk group, 30% (95% CI, 27%-32%) for the 5239 patients in the intermediate D'Amico risk group, and 46% (95% CI, 42%-51%) for 1101 patients in the high D'Amico risk group. Following radiotherapy, the 15-year cumulative incidences of BCR were 18% (95% CI, 15%-21%) for the 1230 patients in the low-risk group, 24% (95% CI, 21%-26%) for the 2355 patients in the intermediate-risk group, and 36% (95% CI, 33%-39%) for the 2362 patients in the high-risk group. The 10-year cumulative incidences of PCSM after radical prostatectomy were 4% (95% CI, 2%-6%) for the 1101 patients who developed low-risk EAU-BCR and 9% (95% CI, 5%-13%) for 649 patients who developed high-risk EAU-BCR. After radiotherapy, the 10-year PCSM cumulative incidences were 24% (95% CI, 19%-29%) for the 591 patients in the low-risk EAU-BCR category and 46% (95% CI, 40%-51%) for the 600 patients in the high-risk EAU-BCR category.
CONCLUSIONS AND RELEVANCE
These findings suggest the validity of EAU-BCR stratification system. However, while the risk of dying from prostate cancer in low-risk EAU-BCR after radical prostatectomy was very low, patients who developed low-risk EAU-BCR after radiotherapy had a nonnegligible risk of prostate cancer mortality. Improving risk stratification of patients with BCR is pivotal to guide salvage treatment decisions, reduce overtreatment, and limit the number of staging tests in the event of PSA elevations after primary treatment.
Topics: Humans; Male; Middle Aged; Aged; Cohort Studies; Prostate-Specific Antigen; Prostate; Prostatectomy; Prostatic Neoplasms
PubMed: 37695584
DOI: 10.1001/jamanetworkopen.2023.32900 -
European Urology Oncology Sep 2023Evidence on long-term oncological efficacy is available only for open radical prostatectomy but remains scarce for robot-assisted radical prostatectomy (RARP).
Prostate Cancer-specific and All-cause Mortality After Robot-assisted Radical Prostatectomy: 20 Years' Report from the European Association of Urology Robotic Urology Section Scientific Working Group.
BACKGROUND
Evidence on long-term oncological efficacy is available only for open radical prostatectomy but remains scarce for robot-assisted radical prostatectomy (RARP).
OBJECTIVE
To validate the long-term survival rates after RARP and provide stratified outcomes based on contemporary prostate cancer (PCa) risk-stratification tools.
DESIGN, SETTING, AND PARTICIPANTS
A retrospective analysis of the European Association of Urology (EAU) Robotic Urology Section Scientific Working Group international multicenter database for RARP was performed. Patients who underwent RARP at seven pioneer robotic urology programs in Europe and the USA between 2002 and 2012 were included.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
The primary outcomes were PCa-specific mortality and all-cause mortality. The probability of cancer-specific survival (CSS) was estimated with the competing risks method, and the probability of overall survival (OS) was estimated with the Kaplan-Meier method.
RESULTS AND LIMITATIONS
A total of 9876 patients who underwent RARP between 2002 and 2012 were included. Within follow-up, 1071 deaths occurred and 159 were due to PCa. At 15 yr of follow-up, CSS and OS were 97.6% (97.2%, 98.0%) and 85.5% (84.6%, 86.4%), respectively. Stratified analyses based on EAU risk groups at diagnosis and pT stage showed favorable survival rates, with low-risk (n = 4601, 46.6%), intermediate-risk (n = 4056, 41.1%), and high-risk (n = 1219, 12.3%) patients demonstrating CSS rates of 99%, 98%, and 90% at 15 yr, respectively. Notably, patients with pT3a disease had similar survival outcomes to those with pT2 disease, with worse CSS in patients with pT3b PCa (98.9% vs 97.4% vs 86.5%). Multivariable analyses identified age, prostate-specific antigen, biopsy Gleason grade group, clinical T stage, and treatment year as independent predictors of worse oncological outcomes.
CONCLUSIONS
Our multicenter study with long-term follow-up confirms favorable survival outcomes after RARP for localized PCa. Patients with low- and intermediate-risk disease face a higher risk of mortality from causes other than PCa. On the contrary, high-risk patients have a significantly higher risk of PCa-specific mortality.
PATIENT SUMMARY
In the present study, we reported the outcomes of patients with prostate cancer (PCa) who underwent robot-assisted radical prostatectomy between 10 and 20 yr ago, and we found a very low probability of dying from PCa in patients with low- and intermediate-risk PCa.
PubMed: 37661459
DOI: 10.1016/j.euo.2023.08.005 -
BJA Open Dec 2022The nociception level (NOL) index discriminates noxious stimuli during surgery with high sensitivity and specificity. Although some studies have reported that a... (Clinical Trial)
Clinical Trial
Effect of NOciception Level-Directed analgesic management on Opioid usage in Robot-assisted laparoscopic radical prostatectomy (NOLDOR): study protocol for a single-centre single-blinded randomised controlled trial.
BACKGROUND
The nociception level (NOL) index discriminates noxious stimuli during surgery with high sensitivity and specificity. Although some studies have reported that a NOL-directed opioid protocol reduces intraoperative opioid consumption, one study implied that it might cause an unintended increase in the stress response. Therefore, we designed a study to investigate the effects of the NOL-directed opioid protocol and measure inflammatory biomarkers.
METHODS
This single-centre RCT will enrol 54 patients undergoing robot-assisted laparoscopic radical prostatectomy. Eligible patients will be randomly allocated to receive (i) NOL-directed intraoperative opioid management (NOL group) or (ii) conventional intraoperative analgesic management (control group). The remifentanil infusion rate will be determined solely using the NOL index during surgery in the NOL group. The primary outcome will be the mean intraoperative remifentanil infusion rate. Secondary outcomes will include the plasma concentrations of three perioperative inflammatory biomarkers (interleukin-6, C-reactive protein, and cortisol) and the variation in the NOL index at the start of pneumoperitoneum and with postural changes.
CONCLUSIONS
This study is expected to accumulate evidence on the effects of NOL-directed analgesic opioid protocol and provide additional evidence regarding the variability of stress responses and the character of the NOL index.
CLINICAL TRIAL REGISTRATION
JRCTs052220034.
PubMed: 37588782
DOI: 10.1016/j.bjao.2022.100112 -
BJA Open Sep 2022The effect of inverse inspiration:expiration (I:E) ratio on functional residual capacity (FRC) during pneumoperitoneum is unclear. We hypothesised that volume-targeted...
Effects of volume-targeted pressure-controlled inverse ratio ventilation on functional residual capacity and dead space in obese patients undergoing robot-assisted laparoscopic radical prostatectomy.
BACKGROUND
The effect of inverse inspiration:expiration (I:E) ratio on functional residual capacity (FRC) during pneumoperitoneum is unclear. We hypothesised that volume-targeted pressure-controlled inverse ratio ventilation (vtPC-IRV) would increase FRC by increasing the level of auto-PEEP in low respiratory compliance situations.
METHODS
During robot-assisted laparoscopic radical prostatectomy, 20 obese patients were sequentially ventilated with four different settings for 30 min in each setting: (1) control, I:E ratio of 1:2 and baseline airway pressure (BAP) of 5 cm HO; (2) IRV2, I:E ratio of 2:1 and BAP off; (3) IRV3, I:E ratio of 3:1 and BAP off; and (4) IRV4, I:E ratio of 4:1 and BAP off. The changes in FRC were identified and compared among these settings.
RESULTS
The FRC significantly increased as the I:E ratio increased. The FRC values expressed as median (inter-quartile range) during control, IRV2, IRV3, and IRV4 were 1149 (898-1386), 1485 (1018-1717), 1602 (1209-1775), and 1757 (1337-1955) ml, respectively. Auto-PEEP increased significantly as the I:E ratio increased and correlated with FRC (rho=0.303; =0.006). Shunt and physiological dead space were significantly lower in all IRV groups than in the control group; however, there were no significant differences among the IRV groups.
CONCLUSIONS
vtPC-IRV with shortened expiratory time and increased auto-PEEP effectively increases FRC during robot-assisted laparoscopic radical prostatectomy in obese patients. FRC increases progressively as the I:E ratio increases from 1:2 to 4:1; however, an I:E ratio higher than 2:1 does not further improve the dead space.
CLINICAL TRIAL REGISTRATION
UMIN000038989.
PubMed: 37588587
DOI: 10.1016/j.bjao.2022.100020 -
Cureus Jul 2023Introduction Benign prostatic hyperplasia (BPH) is one of the most common causes of lower urinary tract symptoms in men. Holmium Laser Enucleation of the Prostate...
Adequate Mentorship Program for Holmium Laser Enucleation of the Prostate (HoLEP) Leads to Satisfactory Short-Term Outcomes in the Early Learning Curve of Young Urologists: First-Year Outcomes of a Newly Established Mentorship Training in Mexico.
Introduction Benign prostatic hyperplasia (BPH) is one of the most common causes of lower urinary tract symptoms in men. Holmium Laser Enucleation of the Prostate (HoLEP) has been recommended by international guidelines as an alternative to transurethral resection of the prostate (TURP). HoLEP's learning curve and the lack of adequate mentorship remains an obstacle for the worldwide adoption of this technique. Objective To report the first-year learning curve of a newly established mentorship program in young urologists without any previous HoLEP experience. Methods We report a cohort of patients with BPH, with prostate size ≥70 grams, treated with HoLEP, analyzed for perioperative data and complications, and short-term postoperative complications and functional outcomes, at three and six months after surgery. Results A total of 47 patients were managed with HoLEP. Mean total operative time was 149.8 ± 42.9 minutes. We experienced five (10.6%) intraoperative complications, including one intravesical resection of the prostate with bipolar energy, three conversions to TURP and one conversion to open prostatectomy. We experienced four postoperative complications, all of them Clavien-Dindo ≤2. Median International Prostate Symptom Score (IPSS) decrease at six months was -17 points from baseline. Mean post-void residual volume and prostate-specific antigen significantly decreased by the third postoperative month. Multiple linear regression showed that prostate size is directly related to increased surgical time during the early learning curve. Discussion Our experience adequately reflects the importance of HoLEP mentorship in young urologists seeking training in this technique. Both surgeons had perioperative and postoperative outcomes deemed satisfactory based on previously published learning curves. Conclusions HoLEP is a technically difficult procedure, however, adequate mentorship leads to satisfying short-term outcomes since the early stages of the learning curve in young urologists with no previous training on this technique.
PubMed: 37575804
DOI: 10.7759/cureus.41756 -
Frontiers in Oncology 2023To investigate the outcome of patients underwent anatomic periurethral reconstruction during robotic assisted laparoscopic radical prostatectomy (RARP).
OBJECTIVE
To investigate the outcome of patients underwent anatomic periurethral reconstruction during robotic assisted laparoscopic radical prostatectomy (RARP).
MATERIALS AND METHODS
During August 2016 to May 2018, periurethral structure anatomic reconstruction was performed during RARP in 58 consecutive patients. The control group consists of another 50 patients had no reconstruction procedure during RARP. Perioperative data of these patients were collected retrospectively, including operation time, anastomosis time, intraoperative blood loss, duration of indwelling catheter, length of hospital stay, complications, postoperative pathology, and continence outcome at 1,3,6 and 12 months.
RESULTS
All cases were successfully performed without conversion to open or laparoscopic surgery. There were no major intraoperative or postoperative complications.The percentage of patients maintain continence in the reconstruction group versus non-reconstruction group: At 1 month 84.5% (49/58)versus 70.0% (35/50), at 3 months 89.7% (52/58)versus 78.0% (39/50), at 6 months 91.3% (53/58)versus 86.0% (43/50) and 1 year after surgery 100.0% (58/58)versus 96.0% (48/50). Reconstruction group showed better continence outcome in 1 and 3 months (P<0.05). There is no statistical differences in 6 month and 1 year.
CONCLUSION
Anatomic reconstruction of periurethral structure during RARP is safe and feasible with reduced duration of indwelling catheter and better continence outcome.
PubMed: 37560465
DOI: 10.3389/fonc.2023.1221217 -
BMJ Open Aug 2023Symptom monitoring and alerting based on patient-reported outcomes have proven valuable in a postoperative setting. However, the parameters of the implemented...
Developing and validating utility parameters to establish patient-reported outcome-based perioperative symptom management in patients undergoing prostatectomy: a multicentre, prospective, observational cohort study protocol.
INTRODUCTION
Symptom monitoring and alerting based on patient-reported outcomes have proven valuable in a postoperative setting. However, the parameters of the implemented patient-centred symptom management system for patients with prostate cancer (PC) remain unclear. This study aims to develop a perioperative symptom scale (PSS) to monitor symptoms, determine the appropriate timing for symptom assessment and establish intervention criteria for physicians.
METHODS AND ANALYSIS
We will prospectively recruit 387 patients undergoing PC surgery in 3 hospitals. The Chinese version of the MD Anderson Symptom Inventory (MDASI) will be used for longitudinal symptom data collection, presurgery and 1, 2, 3, 5, 7, 14, 21, 28, 42 and 90 days post surgery. A PSS will be generated when symptoms change significantly over time. A linear mixed model will be used to determine appropriate follow-up time points. The functional status determined by MDASI interference can then be used to establish alarm thresholds.
ETHICS AND DISSEMINATION
This study was approved by the Lishui Municipal Central Hospital Ethics Committee on 13 April 2022 (No. LSMCHEC-2022-54) and the Ethics Committee of Huzhou Central Hospital on 5 July 2023 (No. HZCHEC-202306017-01), the Ethics Committee of the First Affiliated Hospital of Huzhou Normal College on 20 June 2023 (No. HZYYEC-2023KYLL055). The latest protocol used in this study was V.2.0, dated on 25 February 2023. Before publication in a peer-reviewed journal, our findings will be presented and discussed at relevant medical conferences.
TRIAL REGISTRATION NUMBER
ChiCTR2200059110.
Topics: Male; Humans; Prospective Studies; Cohort Studies; Patient Reported Outcome Measures; Prostatectomy; Prostatic Neoplasms; Observational Studies as Topic; Multicenter Studies as Topic
PubMed: 37553190
DOI: 10.1136/bmjopen-2023-074763 -
European Urology Open Science Aug 2023Transperineal focal laser ablation (TPLA) treatment for prostate cancer (PCa) is an experimental focal ablative therapy modality with low morbidity. However, a dosimetry...
Reliable Visualization of the Treatment Effect of Transperineal Focal Laser Ablation in Prostate Cancer Patients by Magnetic Resonance Imaging and Contrast-enhanced Ultrasound Imaging.
BACKGROUND
Transperineal focal laser ablation (TPLA) treatment for prostate cancer (PCa) is an experimental focal ablative therapy modality with low morbidity. However, a dosimetry model for TPLA is lacking.
OBJECTIVE
To determine (1) the three-dimensional (3D) histologically defined ablation zone of single- and multifiber TPLA treatment for PCa correlated with magnetic resonance imaging (MRI) and contrast-enhanced ultrasound (CEUS) and (2) a reliable imaging modality of ablation zone volumetry.
DESIGN SETTING AND PARTICIPANTS
This was a prospective, multicenter, and interventional phase I/II pilot study with an ablate-and-resect design. TPLA was performed in 12 patients with localized prostate cancer divided over four treatment regimens to evaluate potential variation in outcomes.
INTERVENTION
TPLA was performed approximately 4 wk prior to robot-assisted radical prostatectomy (RARP) in a daycare setting using local anesthesia.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
Four weeks after TPLA, ablation zone volumetry was determined on prostate MRI and CEUS by delineation and segmentation into 3D models and correlated with whole-mount RARP histology using the Pearson correlation index.
RESULTS AND LIMITATIONS
Twelve office-based TPLA procedures were performed successfully under continuous transrectal ultrasound guidance using local perineal anesthesia. No serious adverse events occurred. A qualitative analysis showed a clear demarcation of the ablation zone on T2-weighted MRI, dynamic contrast-enhanced MRI, and CEUS. On pathological evaluation, no remnant cancer was observed within the ablation zone. Ablation zone volumetry on CEUS and T2-weighted MRI compared with histology had a Pearson correlation index of = 0.94 (95% confidence interval [CI] 0.74-0.99, < 0.001) and = 0.93 (95% CI 0.73-0.98, < 0.001), respectively.
CONCLUSIONS
CEUS and prostate MRI could reliably visualize TPLA ablative effects after minimally invasive PCa treatment with a high concordance with histopathological findings and showed no remnant cancer.
PATIENT SUMMARY
The treatment effects of a novel minimally invasive ablation therapy device can reliably be visualized with radiological examinations. These results will improve planning and performance of future procedures.
PubMed: 37545846
DOI: 10.1016/j.euros.2023.06.002 -
European Urology Open Science Aug 2023Magnetic resonance imaging (MRI) underestimation of prostate cancer extent complicates the definition of focal treatment margins.
BACKGROUND
Magnetic resonance imaging (MRI) underestimation of prostate cancer extent complicates the definition of focal treatment margins.
OBJECTIVE
To validate focal treatment margins produced by an artificial intelligence (AI) model.
DESIGN SETTING AND PARTICIPANTS
Testing was conducted retrospectively in an independent dataset of 50 consecutive patients who had radical prostatectomy for intermediate-risk cancer. An AI deep learning model incorporated multimodal imaging and biopsy data to produce three-dimensional cancer estimation maps and margins. AI margins were compared with conventional MRI regions of interest (ROIs), 10-mm margins around ROIs, and hemigland margins. The AI model also furnished predictions of negative surgical margin probability, which were assessed for accuracy.
OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS
Comparing AI with conventional margins, sensitivity was evaluated using Wilcoxon signed-rank tests and negative margin rates using chi-square tests. Predicted versus observed negative margin probability was assessed using linear regression. Clinically significant prostate cancer (International Society of Urological Pathology grade ≥2) delineated on whole-mount histopathology served as ground truth.
RESULTS AND LIMITATIONS
The mean sensitivity for cancer-bearing voxels was higher for AI margins (97%) than for conventional ROIs (37%, < 0.001), 10-mm ROI margins (93%, = 0.24), and hemigland margins (94%, < 0.001). For index lesions, AI margins were more often negative (90%) than conventional ROIs (0%, < 0.001), 10-mm ROI margins (82%, = 0.24), and hemigland margins (66%, = 0.004). Predicted and observed negative margin probabilities were strongly correlated (R = 0.98, median error = 4%). Limitations include a validation dataset derived from a single institution's prostatectomy population.
CONCLUSIONS
The AI model was accurate and effective in an independent test set. This approach could improve and standardize treatment margin definition, potentially reducing cancer recurrence rates. Furthermore, an accurate assessment of negative margin probability could facilitate informed decision-making for patients and physicians.
PATIENT SUMMARY
Artificial intelligence was used to predict the extent of tumors in surgically removed prostate specimens. It predicted tumor margins more accurately than conventional methods.
PubMed: 37545845
DOI: 10.1016/j.euros.2023.05.018