Robotic radical prostatectomy in kidney transplant recipients: A propensity‐matched cohort study

Is COVID-19 infection more severe in kidney transplant recipients?

IntroductionTo assess the oncological outcomes of robotic radical prostatectomy in a country where there are no on-going national screening programs for prostate cancer.Material and methodsBetween November 2009 and November 2014, 220 robotic radical prostatectomies were performed at our Robotic Surgery Center. We already have the complete data for the 2-year follow-up of the first 105 patients, who were therefore included in the study group. Pre-operative (age, prostate-specific antigen, body-mass index, prostate volume, clinical staging, biopsy characteristics), post-operative (surgical technique, surgical margin status, lymph node status, pathological stage, Gleason score) and follow-up parameters (biochemical recurrence) were assessed.ResultsThe global rate of positive surgical margins was 34.3%, with rates of 17.2% in stage pT2 and 55.3% in stage pT3. The most frequent localization for positive surgical margins was at the base and apex of the prostate. The positive surgical margins rate was correlated with the pre-operative prostate-specific antigen, clinical and pathological Gleason score, lymph node status and the number of positive biopsy cores. The rate of biochemical recurrence at the 2-year follow-up was 11.8%. The most important predictors for the biochemical recurrence were the positive surgical margins, pathological staging and Gleason score on the prostatectomy specimen.ConclusionsRobotic surgery is validated by the oncological results at medium follow-up (2 years) for localized and locally advanced prostate cancer, even in countries where there is no on-going national screening program.

Objectives: To compare racial differences and pelvis dimensions between Caucasians and African Americans (AAs) and to develop a risk calculator and scoring system to predict the risk of prolonged operative time and presence of positive surgical margins (PSM) based on these dimensions. Materials and Methods: A retrospective review of 88 consecutive patients undergoing robot-assisted laparoscopic prostatectomy with a preoperative prostate MRI conducted. Data extraction included demographic, perioperative, and postoperative oncologic outcomes. Prostate-specific antigen (PSA) was obtained within 3 months postsurgery. Wilcoxon rank sum and Fisher's exact tests were used to compare continuous and categorical data, respectively. Single and multivariable regression analysis were used to determine contribution of each factor to the composite outcomes. A risk score was created based on this analysis for predicting the composite outcome. Results: We identified 88 consecutive patients with localized prostate cancer that underwent a preoperative prostate MRI. No statistically significant differences were found with respect to age, body mass index, or any postoperative outcome. PSA was lower at diagnosis (6.49 vs 9.72, p = 0.006) and operative times were shorter in Caucasians. Rates of PSM (13 vs 14, p = 0.35), biochemical recurrence (4 vs 2, p = 0.69), and complications did not vary between the groups. Caucasians had wider/shallower pelvis dimensions. Based on these variables, we found that the log (odds of OR time >3 hours or PSM) = -5.333 + 1.158 (if AA) +0.105 × PSA +0.076 × F -0.035 × G with an area under the receiver operating characteristic curve = 0.73. Using the predefined variables, patients can be risk stratified for PSM or prolonged operative times. Conclusions: Several pelvis dimensions were found to be shorter/narrower in AAs and were associated with longer operative times. The presented risk calculator and stratification system may be used to predict prolonged operative time or having PSM.

BackgroundIdentifying predictors of positive surgical margins (PSM) and biochemical recurrence (BCR) after radical prostatectomy (RP) may assist clinicians in formulating prognosis. Aim of the study was to report the midterm oncologic outcomes, to identify the risk factors for PSM and BCR and assess the impact of the PSM on BCR-free survival following robot-assisted laparoscopic radical prostatectomy (RALP).MethodsFrom 2005 to 2010, 1679 consecutive patients underwent transperitoneal RALP. Data was retrospectively collected by an independent statistical company and analyzed in 2014. Median postoperative follow-up was 33.5 mo. BCR was defined as any detectable serum prostate-specific antigen (PSA) ≥ 0.2 ng/mL in two consecutive measurements. BCR-free survival was estimated using the Kaplan–Meier method. Univariate and multivariate analysis were applied to identify risk factors for PSM and BCR.ResultsIn pN0/pNx cancers, pathologic stage was pT2 in 1186 patients (71.8%), pT3 in 455 patients (27.6%), and pT4 in 11 patients (0.6%). PSM rate was 17.4% and 36.9% of pT2 and pT3 cancers, respectively. Pathologic Gleason score was < 7, = 7 and > 7 in 42.1%, 53% and 4.9% of the patients, respectively. Overall BCR-free survival was 73.1% at 5 years; the 5-year BCR-free survival was 87.9% for pT2 with negative surgical margins. PSA, Gleason score (both bioptic and pathologic), pathologic stage (pT) and surgeon's volume were significant independent predictors of PSM. PSA, pathologic Gleason score, pT and PSM were significant independent predictors of BCR-free survival. Seminal vesicle-sparing, nerve-sparing approach and the extent of nerve-sparing (intra vs interfascial dissection) did not negatively affect margin status or BCR rates.ConclusionsPSMs are a predictor of BCR. Being the only modifiable factor influencing the PSM rate, surgical experience is confirmed as a key factor for high-quality oncologic outcomes.

Objective To evaluate the learning curve of three–port extraperitoneal laparoscopic radical prostatectomy(ELRP) and to minimize operative time and blood loss about this procedure. Methods From August 2013 to October 2014, the data from 95 consecutive patients, who had undergone three–port ELRP for prostate cancer, were retrospectively analyzed. The mean age was 65.9±7.7 years, mean total PSA level was 15.4±12.7 μg/L, and mean body mass index(BMI) was 24.8±3.2 kg/m2. According to the number of procedures performed by the surgeon, all patients were classified into three chronologic groups, including group A(No.1–32), group B(No.33–64) and group C(No.65–95). There were no significant differences including age, BMI, tPSA, estimated prostate volume, clinical stages, history of neoadjuvant endocrine therapy, history of transurethral resection of the prostate(TURP) among group A, B and C (P>0.05). The operative outcomes analyzed were operative time, estimated blood loss, hospital stay, drainage tube indwelling days, pathological Gleason scores, pathological stages, positive surgical margin rates, biochemical recurrence rates and urinary incontinence rates. Among these 95 patients, the results of the first 32 cases were compared with those of the remaining 63 cases, the first 64 with the remaining 31. Results The average operative time in 95 patients was 81.0±18.6 min. The sloping learning curve for this surgeon showed that the operative time for all 95 cases was strongly correlated with additional experience(|rs|=0.612, P 0.05). Group A had longer operative time than that of Group B plus C(96.4±11.3 min vs 73.2±16.7 min, P 0.05). There were no significant correlation between the accumulation of experience and positive surgical margin rates, biochemical recurrence rates and urinary incontinence rates. Conclusion Our experience of three–port ELRP cases appears to be favorable with decreasing tendency in operative time, estimated blood loss with experience accumulation. Exposure to 32 surgeries, operative time and estimated blood loss reduced significantly, and after 64 cases operative time and estimated blood loss further reduced. Key words: Prostate cancer; Radical prostatectomy; Extraperitoneal approach; Laparoscopy; Learning curving

Extrafascial Versus Interfascial Nerve-sparing Technique for Robotic-assisted Laparoscopic Prostatectomy: Comparison of Functional Outcomes and Positive Surgical Margins Characteristics

MP56-08 IMPACT OF INTRAOPERATIVE FROZEN SECTIONS OF THE URETHRA ON SURGICAL MARGINS AND ONCOLOGIC OUTCOME IN PATIENTS UNDERGOING RADICAL PROSTATECTOMY

Context: Systematic reviews (SR) have always been used as the best evidence to compare three radical prostatectomy (RP) techniques: retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic radical prostatectomy (RARP). Despite the superiority of minimally invasive surgery in relation to perioperative outcomes, the literature still cannot establish which technique is superior in relation to oncological outcomes. A new methodology called Reverse Systematic Review (RSR) was created to gather the best evidence in the literature based on a heterogeneous sample, allowing the comparison of oncological outcomes from a population point of view. Objective: To apply the RSR to compare RP techniques in relation to oncological outcomes: positive surgical margin (PSM) and biochemical recurrence rate (BCR). Evidence Acquisition: A search was carried out in eight databases between 2000 and 2020 through SR studies referring RRP, LRP, or RARP (80 SR). All references used in these SR were captured referring to 1724 reports. Preoperative and oncological outcomes were compared and correlated among RRP, LRP, and RARP. Evidence Synthesis: Five hundred fifty-nine (32.4%) reports for RRP, 413 (23.9%) for LRP, and 752 (43.7%) for RARP, and a total of 1,353,485 patients were found. Regarding PSM, 284 reports were collected for RRP, 324 for LRP, and 499 for RARP, with rates of 23.6%, 20.7%, and 19.2%, respectively, and only the RRP with statistical difference (p < 0.001). Using a nonlinear regression model, the BCR was correlated with follow-up time at 1, 2, 3, 5, 7, and 10 years: 10%, 15%, 18%, 20%, 23%, and 38% for RRP; 6%, 9%, 13%, 20%, 23%, and 10% for LRP; and 8%, 12%, 16%, 23%, 27%, and 19% for RARP. The absence of long-term work for RARP prevented more accurate projections of BCR. Conclusions: RSR proved to be effective in generating a population and heterogeneous sample capable of demonstrating better oncological results for minimally invasive surgery (LRP and RARP) compared to RRP. It demonstrated the maturity of temporal follow-up data for RRP and LRP and the impact of absence of late follow-up from RARP studies on the long-term rate of BCR. Patient Summary: After 20 years of coexistence of the three main radical prostatectomy techniques, the RSR was able to detect better results from minimally invasive surgery in relation to PSMs and long-term BCRs.

The aim of this study was to gauge whether removal of a specimen with traction during robot-assisted laparoscopic radical prostatectomy causes a positive surgical margin or not. One hundred and sixty-nine patients with localized prostate cancer who underwent robot-assisted laparoscopic radical prostatectomy from 2009 to 2011 were included in the study. After dividing the patients into two groups, we recorded their characteristics and pre-op/post-op evaluations. There were 111 and 58 patients in groups 1 (with traction) and 2 (without traction), respectively. We evaluated the patients' ages, follow-up time, body mass index (BMI), prostate-specific antigen (PSA) values, pre-op and post-op Gleason score values, pathological stage, positive surgical margin rates, and biochemical PSA recurrence rates. There was no statistically significant difference between the groups for age, pre-op PSA values, BMI, pre-op and post-op Gleason scores, positive surgical margin rates and biochemical recurrence rates. There was a significant difference between prostate weight, tumor volume, and clinical stage. Removing the specimen with traction during robot-assisted laparoscopic radical prostatectomy does not cause a positive surgical margin. The incision should be as small as possible for cosmetic appearance.

ObjectiveThis systematic study aimed to assess and compare the comprehensive evidence regarding the impact of neoadjuvant hormone therapy (NHT) on surgical and oncological outcomes of patients with prostate cancer (PCa) before radical prostatectomy (RP).MethodsLiterature searches were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Using PubMed, Web of Science, Chinese National Knowledge Infrastructure, and Wanfang databases, we identified relevant studies published before July 2020. The pooled effect sizes were calculated in terms of the odds ratios (ORs)/standard mean differences (SMDs) with 95% confidence intervals (CIs) using the fixed or random-effects model.ResultsWe identified 22 clinical trials (6 randomized and 16 cohort) including 20,199 patients with PCa. Our meta-analysis showed no significant differences in body mass index (SMD = 0.10, 95% CI: −0.08–0.29, p = 0.274) and biopsy Gleason score (GS) (OR = 1.33, 95% CI: 0.76–2.35 p = 0.321) between the two groups. However, the NHT group had a higher mean age (SMD = 0.19, 95% CI: 0.07–0.31, p = 0.001), preoperative prostate-specific antigen (OR = 0.47, 95% CI: 0.19–0.75, p = 0.001), and clinic tumor stage (OR = 2.24, 95% CI: 1.53–3.29, p < 0.001). Compared to the RP group, the NHT group had lower positive surgical margins (PSMs) rate (OR = 0.44, 95% CI: 0.29–0.67, p < 0.001) and biochemical recurrence (BCR) rate (OR = 0.47, 95% CI: 0.26–0.83, p = 0.009). Between both groups, there were no significant differences in estimated blood loss (SMD = −0.06, 95% CI: −0.24–0.13, p = 0.556), operation time (SMD = 0.20, 95% CI: −0.12–0.51, p = 0.219), pathological tumor stage (OR = 0.76, 95% CI: 0.54–1.06, p = 0.104), specimen GS (OR = 0.91, 95% CI: 0.49–1.68, p = 0.756), and lymph node involvement (OR = 0.76, 95% CI: 0.40–1.45, p = 0.404).ConclusionsNHT prior to RP appeared to reduce the tumor stage, PSMs rate, and risk of BCR in patients with PCa. According to our data, NHT may be more suitable for older patients with higher tumor stage. Besides, NHT may not increase the surgical difficulty of RP.

Introduction: Active surveillance (AS) is a treatment strategy for low-risk prostate cancer (PCa) patients, with extended indication to some intermediate-risk PCa. However, active treatment is necessary in case of disease progression and robotic radical prostatectomy (RALP) is one of the treatment modalities. The aim of the study is to compare outcomes of a delayed RALP after an initial heterogeneous surveillance strategy with those of immediate RALP in a single referral center. Methods: Data from patients who underwent RALP after initial assumed "active surveillance" (referred from different institutions and backgrounds) were compared to those of patients who underwent an immediate RALP after propensity score (PS) matching. The PS analysis was performed matching ISUP score at the time of entering surveillance with ISUP at RALP for the control group; other matching covariates at the time of surgery were considered (including age, prostate-specific antigen, body mass index, prostate size, cT, pre-op Sexual Health Inventory for Men, etc.). Perioperative, functional, and oncological outcomes were compared between groups. Results: Three hundred sixty-two RALP patients were included (181 after surveillance and 181 immediate RALP). Patients after surveillance had a worse pT and ISUP score (p < 0.001); LVI and EPE were higher in the surveilled group (13% vs. 5%, p = 0.001; 38% vs. 22%, p = 0.001), without significant difference in positive surgical margin. At a median follow-up of 24 months, the risk of biochemical recurrence (BCR) was significantly higher for delayed RALP (hazard ratio: 4.0; 95% confidence interval: 1.4-12; p = 0.013), whereas potency and continence rate did not differ significantly. Conclusions: At a referral center receiving patients from diverse backgrounds, outcomes of RALP after heterogeneous surveillance strategies are variable and less predictable, maybe attributable to different protocols and surgical planning. The higher BCR rate in a high-risk surveilled cohort may suggest an increased burden of cancer-related care for RALP patients after surveillance.

To compare the oncologic results, functional outcomes, and complications of transperitoneal (TP) and extraperitoneal (EP) robotic radical prostatectomy. From June 2007 to April 2009, 105 patients underwent TP robotic radical prostatectomy, and 155 patients underwent EP robotic radical prostatectomy. Clinicopathological and perioperative data were compared between the two groups. Postoperative complications and functional outcomes including potency and incontinence were assessed. Patient demographics were similar in the TP and EP groups. No significant differences in positive surgical margins were noted between the groups. The total operative time, number of lymph nodes removed, and estimated blood loss were also not significantly different. However, the robot console time was shorter for the EP group than for the TP group (89.1 vs. 107.8 minutes, p = 0.03). Postoperative pain scale scores were lower in the EP group than in the TP group (2.7 vs. 6.3, p < 0.001). The incidence of ileus and hernia were lower in the EP group; however, the incidence of lymphocele was higher in the EP group. Postoperative potency and continence rates were similar between the groups; however, the EP group had a faster recovery of continence compared with the TP group. The EP approach has similar oncological and perioperative results, less postoperative pain, less bowel-associated complication, and better functional outcomes than those of the TP approach. The EP approach may be an important alternative in robotic radical prostatectomy.

103 Background: There is no clear evidence to support one form of surgical approach over another with regards radical prostatectomy. The aim of this study was to analyze the literature available between 2002 and 2008 and compare positive surgical margin and complication rates for open retropubic, laparoscopic, and robotic radical prostatectomy. Methods: A total of 110,016 patients formed the basis of this meta-analysis, representing the largest compilation of radical prostatectomy patients in the literature. Summary data were abstracted on year of publication, pre-operative patient characteristics, positive surgical margins, estimated blood loss, blood transfusions, conversions, length of hospital stay, and total intra- and peri-operative complications, with a further 21 individual perioperative complications selected a priori for abstraction and analysis. Results: The open and laparoscopic surgical groups had similar overall positive surgical margin rates, with the robotic group having lower rates. Both minimally invasive approaches showed significantly lower estimated blood loss and rate of blood transfusions, and a shorter length of hospital stay when compared to an open approach. A further decrease in these parameters was seen when robotic assistance was used. Total complication rates were highest for the open approach, intermediate for the laparoscopic cohort, and lowest for the robotic group. For the individual complication analysis, the rates for death, readmission, reoperation, ureteral, bladder, and rectal injury, ileus, pneumonia, fistula, and wound infection showed significant differences between groups. Conclusions: Robotic assisted laparoscopic radical prostatectomy has overall lower perioperative morbidity and improved early oncologic outcomes compared to conventional laparoscopic or open approaches. Further studies comparing longer term oncologic and functional outcomes, as well as cost-benefit comparisons are needed before making recommendations for or against a specific type of surgery. [Table: see text]

Robot-assisted radical prostatectomy (RARP) in men with body mass index (BMI) ≥ 35kg/m2 is considered technically challenging. We conducted a retrospective matched-pair analysis to compare the oncological and functional outcomes of RARP in men with BMI ≥ 35kg/m2. We interrogated our prospectively maintained RARP database and identified 1273 men who underwent RARP from January 2018 till June 2021. Among them, 43 had BMI ≥ 35kg/m2, and 1230 had BMI < 35kg/m2. A 1:1 genetic matching was performed between these two groups for PSA, Gleason grades, clinical stage, D'Amico risk stratification, and nerve-spare extent. Continence rates and biochemical rates on 1-year follow-up were analysed. We performed statistical analysis using SPSS, and Paired tests were done using Wilcoxon sign rank-sum test. p < 0.05 was considered statistically significant. The two groups were comparable in almost all parameters except for age. Console time (p = 0.20) and estimated blood loss (p > 0.90) were not significantly different. There was no blood transfusion, open conversion or (Clavien-Dindo grade ≥ 3) intra/postoperative complication in either of the two groups. The two groups did not have any difference in biochemical recurrence rates (BCR) on 1-year follow-up (p > 0.90). Men with BMI ≥ 35 achieved continence rates equivalent to men with BMI < 35 within 1 year. On logistic regression analysis, age (p < 0.001) and extent of nerve sparing (p = 0.026) emerged as significant factors influencing continence recovery. RARP is safe in men with BMI ≥ 35kg/m2. The 1-year continence and oncological outcomes are similar to matched men with BMI < 35kg/m2 undergoing RARP.

A third injection of the BNT162b2 mRNA COVID-19 vaccine in kidney transplant recipients improves the humoral immune response