Re: Expectant Management of Veterans with Early-Stage Prostate Cancer

Abstract

available at http://www.ncbi.nlm.nih.gov/pubmed/26540451 Editorial Comment: The decision to place a man on active surveillance is becoming more commonplace in urological practice with the demonstration of acceptable cancer specific and metastasis-free survival at 10 and 15 years of followup. Nonetheless, active surveillance as a paradigm continues to suffer from the absence of standardized consensus driven selection criteria in determining which cases should be managed without treatment. This article does not specifically evaluate active surveillance as a treatment paradigm, but instead evaluates factors associated with expectant management in a Veterans Administration (VA) population. Men diagnosed with prostate cancer in 2008 within the VA health care system were evaluated by chart review to identify those in whom active surveillance, watchful waiting or expectant management was chosen as a primary strategy. The authors note that in addition to geographic variation, urban vs rural location and ethnicity, the most predictive factors regarding choice for expectant management were age and tumor risk category. Men who were older and had lower risk disease were most likely to be managed expectantly. The authors saw no correlation with comorbidity index, suggesting that urologists did not consider risk of comorbid death as a factor in determining the need for treatment. This study is illustrative of the need for better tools with which urologists can assess comorbidity and the relationship to longevity when making decisions regarding prostate cancer treatment. However, one should consider the potential for several confounding factors. First, decision making in the VA system does not always parallel other health care systems. Having overseen a busy VA department in the past, I know that our perception of comorbidity in a system with a high prevalence 744 LAPAROSCOPY/NEW TECHNOLOGY of comorbidity is different than when evaluating and treating a healthier population. Additionally attitudes regarding prostate cancer therapy may differ in this population. Most importantly, this study evaluated men diagnosed in 2008, before much of the contemporary literature regarding the safety of surveillance, the influence of comorbidity on treatment outcome/benefit and the contemporary screening guidelines. In sum, the goal for longevity assessment of these men, as in the case of cancer risk assessment, should be individualized as older men are not always sick and younger men are not always healthy. Samir S. Taneja, MD Suggested Reading Loeb S, Berglund A and Stattin P: Population based study of use and determinants of active surveillance and watchful waiting for low and intermediate risk prostate cancer. J Urol 2013; 190: 1742. Laparoscopy/New Technology Re: Retropubic Intracorporeal Placement of a Suburethral Autologous Sling during Robot-Assisted Radical Prostatectomy to Improve Early Urinary Continence Recovery: Preliminary Data A. Cestari, M. Ferrari, M. Ghezzi, M. Sangalli, M. Zanoni, F. Fabbri, F. Sozzi, C. Lolli, V. Dell’Acqua and P. Rigatti Department of Urology, Advanced Urotechnology Center, Scientific Institute “Istituto Auxologico Italiano,” Milan, Italy J Endourol 2015; 29: 1379e1385. doi: 10.1089/end.2015.0292 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26131781available at http://www.ncbi.nlm.nih.gov/pubmed/26131781 Editorial Comment: In an effort to improve postoperative continence rates after robotic radical prostatectomy the authors report their results with a novel retropubic suburethral sling of autologous vas deferens placed at surgery. The segment of vas is placed immediately below the plane of the reconstructed Rocco stitch at the level of the urethrovesical anastomosis and then anchored to the pubic periosteum. The authors randomized 60 patients and assessed continence. There were no differences in pad use at 5 and 10 days postoperatively, but the sling group used fewer pads at 1, 3, 6 and 12 months postoperatively. There were no complications attributable to the sling. Confirmation by others is encouraged as such innovations to improve quality of life are welcome. Jeffrey A. Cadeddu, MD Suggested Reading Menon M, Muhletaler F, Campos M et al: Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial. J Urol 2008; 180: 1018. Re: Instrument Life for Robot-Assisted Laparoscopic Radical Prostatectomy and Partial Nephrectomy: Are Ten Lives for Most Instruments Justified? W. W. Ludwig, M. A. Gorin, M. W. Ball, E. M. Schaeffer, M. Han and M. E. Allaf Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland Urology 2015; 86: 942e945. doi: 10.1016/j.urology.2015.05.047 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/26276575available at http://www.ncbi.nlm.nih.gov/pubmed/26276575 Editorial Comment: Most robotic instruments have a predetermined life span of 10 uses. However, some, such as scissors, require exchange due to dulling of the blades before 10 uses, increasing procedural costs. It is also likely that some tools, such as needle drivers, could be used far more than 10 times, saving money. In this study more than 1,500 robotic radical prostatectomy and 300 robotic