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The Journal of Urology Nov 1998We assess pain and quality of life following radical retropubic prostatectomy and determine whether intraoperative anesthetic management has any long-term effects on... (Clinical Trial)
Clinical Trial Randomized Controlled Trial
PURPOSE
We assess pain and quality of life following radical retropubic prostatectomy and determine whether intraoperative anesthetic management has any long-term effects on outcomes.
MATERIALS AND METHODS
A total of 110 patients undergoing radical retropubic prostatectomy were randomly assigned to receive epidural and/or general anesthesia. Patients responded to a questionnaire mailed 3 and 6 months following surgery that assessed prostate symptoms, pain related to surgery, quality of life and mood.
RESULTS
No long-term effects of anesthesia were observed. Of the 103 respondents (94%) at 3 months 49% had some pain related to surgery. Although pain was not related to anesthesic technique, patients who had it at 3 months used significantly more pain medication on postoperative day 3. Pain at 3 months was mild, averaging 1.5 on a scale of 0 to 10, and associated with poor perceptions of overall health (p <0.02), and reduced physical (p <0.01) and social (p <0.01) functioning. Pain at 3 months was associated with higher levels of preoperative anxiety (p <0.05). At 6 months 36 of 90 patients (35%) had some pain related to surgery and the impact was similar.
CONCLUSIONS
Long-term effects of intraoperative anesthesic technique were not apparent. Mild pain following radical retropubic prostatectomy was common and associated with reduced quality of life, particularly social functioning. Affective distress, particularly anxiety, before surgery and use of pain medications following surgery may be predictors of chronic pain following radical retropubic prostatectomy.
Topics: Affect; Anesthesia, Epidural; Anesthesia, General; Chronic Disease; Follow-Up Studies; Humans; Multivariate Analysis; Pain; Prostatectomy; Quality of Life; Surveys and Questionnaires
PubMed: 9783947
DOI: No ID Found -
BJU International Nov 2013To compare functional outcomes, i.e. urinary incontinence (UI), voiding symptoms and quality of life, after open (ORP) and robot-assisted radical prostatectomy (RARP).
OBJECTIVE
To compare functional outcomes, i.e. urinary incontinence (UI), voiding symptoms and quality of life, after open (ORP) and robot-assisted radical prostatectomy (RARP).
PATIENTS AND METHODS
Between September 2009 and July 2011, 180 consecutive patients underwent radical prostatectomy; of these, 116 underwent ORP and 64 underwent RARP. We prospectively assessed the functional outcomes of each group during the first year of follow-up. We measured UI on the 3 days before surgery (24-h pad test) and daily after surgery until total continence, defined as 3 consecutive days of 0 g urine leak, was achieved. Additionally, all patients were assessed before surgery and at 1, 3, 6 and 12 months after surgery using the International Prostate Symptom Score (IPSS) and the King's Health Questionnaire (KHQ). All patients received pelvic floor muscle training until continence was achieved. Kaplan-Meier analyses and Cox regression with correction for covariates were used to compare time to continence. A Mann-Whitney U-test was used to assess IPSS and KHQ.
RESULTS
Patients in the RARP group had a significantly lower D'Amico risk group allocation and underwent more nerve-sparing surgery. Other characteristics were similar. Patients in the RARP group regained continence sooner than those in the ORP group (P = 0.007). In the RARP group, the median time to continence (16 vs 46 days, P = 0.026) was significantly shorter and the median amount of first day UI (44 vs 186 g, P < 0.01) was significantly smaller than in the ORP group. After correction for all covariates, the difference remained significant (P = 0.036, hazard ratio [HR] 1.522 (1.027-2.255). In addition, younger men, men with positive surgical margins and men without preoperative incontinence achieved continence sooner. A comparison of time to continence between groups with a sufficient number of patients (intermediate risk and/or bilateral nerve-sparing) still showed a faster return of continence after RARP, but the effect decreased in size and was nonsignificant (HR>1.2, P > 0.05). Only six patients (two in the RARP and four in the ORP group) still had UI after 1 year. Patients in the RARP group had significantly better IPSS scores at 1 (P = 0.013) and 3 (P = 0.038) months, and scored better in almost all KHQ aspects.
CONCLUSION
In this prospective trial, patients treated with RARP tended to regain urinary continence sooner than patients treated with ORP, but in subgroup analyses statistical significance disappeared and effect size decreased dramatically, indicating that the results must be interpreted with caution.
Topics: Humans; Male; Middle Aged; Prospective Studies; Prostatectomy; Quality of Life; Robotics; Treatment Outcome; Urinary Incontinence; Urination Disorders
PubMed: 23937206
DOI: 10.1111/bju.12258 -
The Journal of Urology Jan 2017Robot-assisted surgery has been rapidly adopted in the U.S. for prostate cancer. Its adoption has been driven by market forces and patient preference, and debate... (Comparative Study)
Comparative Study Observational Study
PURPOSE
Robot-assisted surgery has been rapidly adopted in the U.S. for prostate cancer. Its adoption has been driven by market forces and patient preference, and debate continues regarding whether it offers improved outcomes to justify the higher cost relative to open surgery. We examined the comparative effectiveness of robot-assisted vs open radical prostatectomy in cancer control and survival in a nationally representative population.
MATERIALS AND METHODS
This population based observational cohort study of patients with prostate cancer undergoing robot-assisted radical prostatectomy and open radical prostatectomy during 2003 to 2012 used data captured in the SEER (Surveillance, Epidemiology, and End Results)-Medicare linked database. Propensity score matching and time to event analysis were used to compare all cause mortality, prostate cancer specific mortality and use of additional treatment after surgery.
RESULTS
A total of 6,430 robot-assisted radical prostatectomies and 9,161 open radical prostatectomies performed during 2003 to 2012 were identified. The use of robot-assisted radical prostatectomy increased from 13.6% in 2003 to 2004 to 72.6% in 2011 to 2012. After a median followup of 6.5 years (IQR 5.2-7.9) robot-assisted radical prostatectomy was associated with an equivalent risk of all cause mortality (HR 0.85, 0.72-1.01) and similar cancer specific mortality (HR 0.85, 0.50-1.43) vs open radical prostatectomy. Robot-assisted radical prostatectomy was also associated with less use of additional treatment (HR 0.78, 0.70-0.86).
CONCLUSIONS
Robot-assisted radical prostatectomy has comparable intermediate cancer control as evidenced by less use of additional postoperative cancer therapies and equivalent cancer specific and overall survival. Longer term followup is needed to assess for differences in prostate cancer specific survival, which was similar during intermediate followup. Our findings have significant quality and cost implications, and provide reassurance regarding the adoption of more expensive technology in the absence of randomized controlled trials.
Topics: Age Factors; Aged; Biopsy, Needle; Disease-Free Survival; Humans; Immunohistochemistry; Kaplan-Meier Estimate; Male; Middle Aged; Neoplasm Grading; Propensity Score; Proportional Hazards Models; Prostatectomy; Prostatic Neoplasms; Retrospective Studies; Risk Assessment; Robotic Surgical Procedures; SEER Program; Survival Analysis; Treatment Outcome
PubMed: 27720782
DOI: 10.1016/j.juro.2016.09.115 -
Urology Jan 2018To investigate payment variation for 3 common urologic cancer surgeries and evaluate the potential for applying bundled payment programs to these procedures.
OBJECTIVE
To investigate payment variation for 3 common urologic cancer surgeries and evaluate the potential for applying bundled payment programs to these procedures.
METHODS
Using 2008-2011 Surveillance, Epidemiology, and End Results-Medicare linked data, we identified all beneficiaries aged greater than 65 years who underwent cystectomy, prostatectomy, or nephrectomy for cancer. Total episode payments were determined by aggregating hospital, professional, and post-acute care claims from the index surgical hospitalization through 90 days post discharge. Total episode payments were then compared to examine hospital level-variation within each procedure type and the specific payment components (ie, index hospitalization, professional, readmission, and post-acute care) driving spending variation.
RESULTS
Ninety-day episodes of care were identified for 1849 cystectomies, 8770 prostatectomies, and 4304 nephrectomies. We observed wide variation in mean episode payments for all 3 conditions (cystectomy mean $35,102: range $24,112-$57,238, prostatectomy mean $10,803: range $8,816-$17,877, nephrectomy mean $17,475: range $11,681-$26,711). Majority of payment variation was attributable to index hospitalization and post-acute care for cystectomy and nephrectomy and professional payments for prostatectomy. The most expensive hospitals by procedure each demonstrated a unique opportunity for spending reduction due to individual differences in component payment patterns between hospitals.
CONCLUSION
Ninety-day episode payments for urologic cancer surgery vary widely across hospitals in the United States. The key drivers of this payment variation differ for individual procedures and hospitals. Accordingly, hospitals will need individualized data and clinical re-design strategies to succeed with implementation of episode-based payment models for urologic cancer care.
Topics: Aged; Aged, 80 and over; Cystectomy; Episode of Care; Humans; Nephrectomy; Prostatectomy; Reimbursement Mechanisms; Urologic Neoplasms
PubMed: 29051001
DOI: 10.1016/j.urology.2017.08.053 -
Scandinavian Journal of Urology Oct 2016The aim of this study was to assess the risk of serious adverse effects after radiotherapy (RT) with curative intention and radical prostatectomy (RP).
OBJECTIVE
The aim of this study was to assess the risk of serious adverse effects after radiotherapy (RT) with curative intention and radical prostatectomy (RP).
MATERIALS AND METHODS
Men who were diagnosed with prostate cancer between 1997 and 2012 and underwent curative treatment were selected from the Prostate Cancer data Base Sweden. For each included man, five prostate cancer-free controls, matched for birth year and county of residency, were randomly selected. In total, 12,534 men underwent RT, 24,886 underwent RP and 186,624 were controls. Adverse effects were defined according to surgical and diagnostic codes in the National Patient Registry. The relative risk (RR) of adverse effects up to 12 years after treatment was compared to controls and the risk was subsequently compared between RT and RP in multivariable analyses.
RESULTS
Men with intermediate- and localized high-risk cancer who underwent curative treatment had an increased risk of adverse effects during the full study period compared to controls: the RR of undergoing a procedures after RT was 2.64 [95% confidence interval (CI) 2.56-2.73] and after RP 2.05 (95% CI 2.00-2.10). The risk remained elevated 10-12 years after treatment. For all risk categories of prostate cancer, the risk of surgical procedures for urinary incontinence was higher after RP (RR 23.64, 95% CI 11.71-47.74), whereas risk of other procedures on the lower urinary tract and gastrointestinal tract or abdominal wall was higher after RT (RR 1.67, 95% CI 1.44-1.94, and RR 1.86, 95% CI 1.70-2.02, respectively).
CONCLUSION
The risk of serious adverse effects after curative treatment for prostate cancer remained significantly elevated up to 12 years after treatment.
Topics: Aged; Humans; Male; Middle Aged; Prostatectomy; Prostatic Neoplasms; Radiotherapy; Registries; Sweden; Time Factors
PubMed: 27333148
DOI: 10.1080/21681805.2016.1194460 -
Revista Latino-americana de Enfermagem 2015evaluate the general and perceived self-efficacy, psychological morbidity, and knowledge about postoperative care of patients submitted to radical prostatectomy....
OBJECTIVE
evaluate the general and perceived self-efficacy, psychological morbidity, and knowledge about postoperative care of patients submitted to radical prostatectomy. Identify the relationships between the variables and know the predictors of self-efficacy.
METHOD
descriptive, cross-sectional study, conducted with 76 hospitalized men. The scales used were the General and Perceived Self-efficacy Scale and the Hospital Anxiety and Depression Scale, in addition to sociodemographic, clinical and knowledge questionnaires.
RESULTS
a negative relationship was found for self-efficacy in relation to anxiety and depression. Psychological morbidity was a significant predictor variable for self-efficacy. An active professional situation and the waiting time for surgery also proved to be relevant variables for anxiety and knowledge, respectively.
CONCLUSION
participants had a good level of general and perceived self-efficacy and small percentage of depression. With these findings, it is possible to produce the profile of patients about their psychological needs after radical prostatectomy and, thus, allow the nursing professionals to act holistically, considering not only the need for care of physical nature, but also of psychosocial nature.
Topics: Aged; Anxiety; Cross-Sectional Studies; Depression; Humans; Male; Middle Aged; Morbidity; Postoperative Complications; Prostatectomy; Self Efficacy; Socioeconomic Factors
PubMed: 26487129
DOI: 10.1590/0104-1169.0456.2618 -
World Journal of Urology Oct 2019To define the role of focal laser ablation (FLA) as clinical treatment of prostate cancer (PCa) using the Delphi consensus method.
PURPOSE
To define the role of focal laser ablation (FLA) as clinical treatment of prostate cancer (PCa) using the Delphi consensus method.
METHODS
A panel of international experts in the field of focal therapy (FT) in PCa conducted a collaborative consensus project using the Delphi method. Experts were invited to online questionnaires focusing on patient selection and treatment of PCa with FLA during four subsequent rounds. After each round, outcomes were displayed, and questionnaires were modified based on the comments provided by panelists. Results were finalized and discussed during face-to-face meetings.
RESULTS
Thirty-seven experts agreed to participate, and consensus was achieved on 39/43 topics. Clinically significant PCa (csPCa) was defined as any volume Grade Group 2 [Gleason score (GS) 3+4]. Focal therapy was specified as treatment of all csPCa and can be considered primary treatment as an alternative to radical treatment in carefully selected patients. In patients with intermediate-risk PCa (GS 3+4) as well as patients with MRI-visible and biopsy-confirmed local recurrence, FLA is optimal for targeted ablation of a specific magnetic resonance imaging (MRI)-visible focus. However, FLA should not be applied to candidates for active surveillance and close follow-up is required. Suitability for FLA is based on tumor volume, location to vital structures, GS, MRI-visibility, and biopsy confirmation.
CONCLUSION
Focal laser ablation is a promising technique for treatment of clinically localized PCa and should ideally be performed within approved clinical trials. So far, only few studies have reported on FLA and further validation with longer follow-up is mandatory before widespread clinical implementation is justified.
Topics: Delphi Technique; Humans; Laser Therapy; Male; Practice Guidelines as Topic; Prostatectomy; Prostatic Neoplasms
PubMed: 30671638
DOI: 10.1007/s00345-019-02636-7 -
Minerva Urology and Nephrology Apr 2022Retzius-sparing Robotic Assisted Radical Prostatectomy (RS-RARP) is a novel surgical approach to radical prostatectomy. Its pioneers have suggested an improved recovery...
INTRODUCTION
Retzius-sparing Robotic Assisted Radical Prostatectomy (RS-RARP) is a novel surgical approach to radical prostatectomy. Its pioneers have suggested an improved recovery of urinary continence, while maintaining adequate cancer control. The aim of this systematic review was to explore available data on RS-RALP and compare functional, oncologic, and perioperative results of RS-RARP compared to anterior RARP.
EVIDENCE ACQUISITION
A search following PRISMA guidelines was performed including the combination of the following words: "Retzius" AND "sparing" AND "radical" AND "prostatectomy." Ninety-three articles were identified and 13 were included in the systematic review, including 3 randomized controlled trials (RCT), 4 prospective studies and 6 retrospective studies.
EVIDENCE SYNTHESIS
All available randomized trials confirmed an improved immediate continence for RS-RARP, with rates ranging 51-71%, compared to 21-48% for anterior RARP. However, this advantage was progressively lost with no significant difference found after 6 months. Moreover, a prospective study found no discrepancy in terms of quality of life across the two techniques. Erectile function was difficult to compare, as patients had different baseline erectile function across studies and rate of neurovascular preservation was not comparable. Surgical approach remains controversial regarding positive margin rate, although related to the surgeon's experience and clinical stage. Biochemical recurrence-free survival appears similar between the two approaches.
CONCLUSIONS
RS-RARP improves early urinary continence recovery compared to anterior RARP, with this advantage being lost after 3 to 6 months. Erectile function and quality of life were however comparable between the two techniques. The results concerning the rate of positive margins remained controversial. Future studies with longer follow-up are needed to better assess oncologic outcomes.
Topics: Humans; Male; Margins of Excision; Prostate; Prostatectomy; Robotic Surgical Procedures; Treatment Outcome
PubMed: 34714037
DOI: 10.23736/S2724-6051.21.04623-1 -
Cancer Mar 2022Changes in surgical technique and postoperative care that target improvements in functional outcomes are widespread in the literature. Radical prostatectomy (RP) is one...
BACKGROUND
Changes in surgical technique and postoperative care that target improvements in functional outcomes are widespread in the literature. Radical prostatectomy (RP) is one such procedure that has seen multiple advances over the past decade. The objective of this study was to leverage RP as an index case to determine whether practice changes over time produced observable improvements in patient-reported outcomes.
METHODS
This study analyzed patients undergoing RP by experienced surgeons at a tertiary care center with prospectively maintained patient-reported outcome data from 2008 to 2019. Four patient-reported urinary function outcomes at 6 and 12 months after RP were defined with a validated instrument: good urinary function (domain score ≥ 17), no incontinence (0 pads per day), social continence (≤1 pad per day), and severe incontinence (≥3 pads per day). Multivariable logistic regressions evaluated changes in outcomes based on the surgical date.
RESULTS
Among 3945 patients meeting the inclusion criteria, excellent urinary outcomes were reported throughout the decade but without consistent observable improvements over time. Specifically, there were no improvements in good urinary function at 12 months (P = .087) based on the surgical date, and there were countervailing effects on no incontinence (worsening; P = .005) versus severe incontinence (improving; P = .003). Neither approach (open, laparoscopic, or robotic), nor nerve sparing, nor membranous urethral length mediated changes in outcomes.
CONCLUSIONS
In a decade with multiple advances in surgical and postoperative care, there was evidence of improvements in severe incontinence, but no measurable improvements across 3 other urinary outcomes. Although worsening disease factors could contribute to the stable observed outcomes, a more systematic approach to evaluating techniques and implementing patient selection and postoperative care advances is needed.
LAY SUMMARY
Although there have been advances in radical prostatectomy over the past decade, consistent observable improvements in postoperative incontinence were not reported by patients. To improve urinary function outcomes beyond the current high standard, the approach to studying innovations in surgical technique needs to be changed, and further development of other aspects of prostatectomy care is needed.
Topics: Humans; Laparoscopy; Male; Prostate; Prostatectomy; Urinary Incontinence
PubMed: 34724196
DOI: 10.1002/cncr.33994 -
The New England Journal of Medicine Apr 2002Recent studies of surgery for cancer have demonstrated variations in outcomes among hospitals and among surgeons. We sought to examine variations in morbidity after...
BACKGROUND
Recent studies of surgery for cancer have demonstrated variations in outcomes among hospitals and among surgeons. We sought to examine variations in morbidity after radical prostatectomy for prostate cancer.
METHODS
We used the Surveillance, Epidemiology, and End Results-Medicare linked data base to evaluate health-related outcomes after radical prostatectomy. The rates of postoperative complications, late urinary complications (strictures or fistulas 31 to 365 days after the procedure), and long-term incontinence (more than 1 year after the procedure) were inferred from the Medicare claims records of 11,522 patients who underwent prostatectomy between 1992 and 1996. These rates were analyzed in relation to hospital volume and surgeon volume (the number of procedures performed at individual hospitals and by individual surgeons, respectively).
RESULTS
Neither hospital volume nor surgeon volume was significantly associated with surgery-related death. Significant trends in the relation between volume and outcome were observed with respect to postoperative complications and late urinary complications. Postoperative morbidity was lower in very-high-volume hospitals than in low-volume hospitals (27 percent vs. 32 percent, P=0.03) and was also lower when the prostatectomy was performed by very-high-volume surgeons than when it was performed by low-volume surgeons (26 percent vs. 32 percent, P<0.001). The rates of late urinary complications followed a similar pattern. Results for long-term preservation of continence were less clear-cut. In a detailed analysis of the 159 surgeons who had a high or very high volume of procedures, wide surgeon-to-surgeon variations in these clinical outcomes were observed, and they were much greater than would be predicted on the basis of chance or observed variations in the case mix.
CONCLUSIONS
In men undergoing prostatectomy, the rates of postoperative and late urinary complications are significantly reduced if the procedure is performed in a high-volume hospital and by a surgeon who performs a high number of such procedures.
Topics: Aged; General Surgery; Hospitals; Humans; Male; Medicare; Outcome Assessment, Health Care; Postoperative Complications; Prostatectomy; Prostatic Neoplasms; SEER Program; United States; Urinary Incontinence; Urologic Diseases; Workforce
PubMed: 11948274
DOI: 10.1056/NEJMsa011788