Open Radical Retropubic Prostatectomy Research Articles

Patterns of minimally invasive radical prostatectomy (MIRP) versus open radical retropubic prostatectomy (ORP) in patients older than 70

Patterns of minimally invasive radical prostatectomy (MIRP) versus open radical retropubic prostatectomy (ORP) in patients older than 70

Robotic-assisted laparoscopic radical prostatectomy after aborted retropubic radical prostatectomy.

Robotic-assisted laparoscopic prostatectomy (RALP) has surged in popularity since US Food and Drug Administration approval in 2000. Advantages include improved visualization and increased instrument dexterity within the pelvis. Obesity and narrow pelves have been associated with increased difficulty during open retropubic radical prostatectomy (RRP), but the robotic platform theoretically allows one to perform a radical prostatectomy despite these challenges. We present an example of a RALP performed following an aborted RRP. A 49-year-old male with intermediate risk prostate cancer and body mass index of 38kg/m(2) presented for RALP after RRP was aborted by an experienced open surgeon following incision of the endopelvic fascia due to poor visualization, a prominent pubic tubercle, and a narrow pelvis. The enhanced visualization and precision of the robotic platform allowed adequate exposure of the prostate and allowed us to proceed with an uncomplicated prostatectomy, which was not possible to perform easily via an open approach. The bladder was densely adherent to the pubis and the anterior prostatic contour and apex were difficult to develop due to a dense fibrotic reaction from the previous endopelvic fascia incision. However, we were able to successfully complete RALP with subtle technical modifications. Estimated blood loss was 160mL and operating time was 145min. The patient's pathology was significant for a positive peri-prostatic lymph node and he has been referred to radiation oncology for adjuvant radiotherapy and androgen deprivation therapy. At 3months follow-up he had a prostate-specific antigen level of 0.06 ng/mL, partial erections, and mild urinary incontinence requiring one pad per day. Superior intracorporeal laparoscopic visualization and improved instrument dexterity afforded by the robotic surgical platform may make RALP the preferred approach in obese men or men with difficult pelvic anatomy who are deemed poor RRP candidates.

Factors Associated with the Adoption of Minimally Invasive Radical Prostatectomy in the United States

Minimally invasive radical prostatectomy has supplanted radical retropubic prostatectomy in popularity despite the absence of strong comparative effectiveness data demonstrating its superiority. We examined the influence of patient, surgeon and hospital characteristics on the use of minimally invasive radical prostatectomy vs radical retropubic prostatectomy. Using SEER (Surveillance, Epidemiology and End Results)-Medicare linked data we identified 11,732 men who underwent radical prostatectomy from 2003 to 2007. We assessed the contribution of patient, surgeon and hospital characteristics to the likelihood of undergoing minimally invasive radical prostatectomy vs radical retropubic prostatectomy using multilevel logistic regression mixed models. Patient factors (36.7%) contributed most to the use of minimally invasive radical prostatectomy vs radical retropubic prostatectomy, followed by surgeon (19.1%) and hospital (11.8%) factors. Among patient specific factors Asian race (OR 1.86, 95% CI 1.27-2.72, p = 0.001), clinically organ confined tumors (OR 2.71, 95% CI 1.60-4.57, p <0.001) and obtaining a second opinion from a urologist (OR 3.41, 95% CI 2.67-4.37, p <0.001) were associated with the highest use of minimally invasive radical prostatectomy while lower income was associated with decreased use of minimally invasive radical prostatectomy. Among surgeon and hospital specific factors, higher surgeon volume (OR 1.022, 95% CI 1.015-1.028, p <0.001), surgeon age younger than 50 years (OR 2.68, 95% CI 1.69-4.24, p <0.001) and greater hospital bed size (OR 1.001, 95% CI 1.001-1.002, p <0.001) were associated with increased use of minimally invasive radical prostatectomy, while solo or 2 urologist practices were associated with decreased use of minimally invasive radical prostatectomy (OR 0.48, 95% CI 0.27-0.86, p = 0.013). The adoption of minimally invasive radical prostatectomy vs radical retropubic prostatectomy is multifactorial, and associated with specific patient, surgeon and hospital related factors. Obtaining a second opinion from another urologist was the strongest factor associated with opting for minimally invasive radical prostatectomy.

Radical Prostatectomy After Previous Transurethral Resection of the Prostate: Robot-Assisted Laparoscopic Versus Open Radical Prostatectomy in a Matched-Pair Analysis

To determine whether previous transurethral resection of the prostate (TURP) compromises the surgical outcome and pathologic findings in patient who underwent either radical robot-assisted laparoscopic prostatectomy (RALP) or open retropubic radical prostatectomy (RRP) after TURP, because TURP is reported to complicate radical prostatectomy and there are conflicting data. From July 2008 to July 2010, 357 patients underwent RALP. Of these, 19 (5.3%) patients had undergone previous TURP. Operative and perioperative data of patients were compared with those of matched controls selected from a database of 616 post-RRP patients. Matching criteria were age, clinical stage, the level of preoperative prostate-specific-antigen, the biopsy Gleason score, the American Society of Anesthesiologists classification score, and prostate volume assessed during transrectal ultrasonography. All RRP and RALP procedures were performed by experienced surgeons. Mean time to prostatectomy was 67.4 months in the RALP group and 53.1 months in the RRP group. Mean operative time was 217 ± 51.9 minutes for RALP and 174 ± 57.7 minutes for RRP (P<0.05). The overall positive surgical margin rate was 15.8% in both groups (pT(2) tumors: 10.5% for RALP and 5.3% for RRP; P=1.0). Mean estimated blood loss was 333 ± 144 mL in RALP patients and 1103 ± 636 mL in RRP patients (P<0.001). The difference between preoperative and postoperative hemoglobin levels was 3.22 ± 0.98 g/dL for RALP and 5.85 ± 1.95 g/dL for RRP (P=0.0002). The RALP and RRP groups also differed in terms of hospital stay (8.58 ± 1.17 vs 11.74 ± 5.22 days; P=0.0037), duration of catheterization (7.95 ± 5.69 vs 11.78 ± 6.97 days; P=0.0016), postoperative complications according to the Clavien classification system (6 vs 15 patients; P=0.0027), and transfusion rate (0% vs 10.5%; P<0.001). RALP offers advantages over open radical prostatectomy after previous surgery. Although both techniques are associated with adequate surgical outcomes, RALP appeared to be preferable in our population of patients with previous prostate surgery.

Comparative Hospital Cost-analysis of Open and Robotic-assisted Radical Prostatectomy

To perform a contemporary comparative cost-analysis of robotic-assisted laparoscopic radical prostatectomy (RARP) and open radical retropubic prostatectomy (RRP). All patients undergoing RARP (n = 115) or RRP (n = 358) by 1 of 4 surgeons at a single institution during a 15-month period were retrospectively reviewed. The hospital length of stay (LOS), operative time, hospital charges, reimbursement, and direct and indirect hospital costs were analyzed and compared. The mean LOS between patients undergoing RARP (1.2 ± 0.6 days) and RRP (1.4 ± 0.8 days) was not significantly different. The operating room supply costs per case were almost 7 times greater for RARP ($2852 ± $528) than for RRP ($417 ± $59; P < .05). The ancillary, cardiology, imaging, administrative, laboratory, and pharmacy costs were not significantly different between the 2 approaches. The mean total costs per case for RARP exceeded the total costs for RRP by 62% ($14 006 ± $1641 vs $8686 ± $1989; P < .05). Payment to the hospital from all sources was nearly equivalent: $10 011 for RRP and $9993 for RARP. Therefore, the average profit for each RRP was $1325 and each RARP lost $4013. In the present single-institution analysis, the total actual costs associated with RARP were significantly greater than those for RRP and were attributable to the robotic equipment and supplies.

Comparison of 90‐day re‐admission rates between open retropubic radical prostatectomy (RRP), laparoscopic RP (LRP) and robot‐assisted laparoscopic prostatectomy (RALP)

Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? With the increased use of laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic prostatectomy (RALP), a growing number of publications have sought to compare these more advanced techniques to retropubic RP (RRP). Many studies have found RALP and LRP to be associated with lower blood loss, postoperative pain, and hospital stay when compared with RRP. The present study showed that, after adjusting for potential confounders, patients undergoing RALP had a lower risk of 90-day re-admission than patients undergoing RRP. However, there was no significant difference in the odds of being re-admitted ≤ 90 days after RP between patients undergoing a LRP and RRP. • To examine the risk of 90-day re-admission among patients undergoing retropubic radical prostatectomy (RRP), laparoscopic RP (LRP), and robot-assisted laparoscopic prostatectomy (RALP) in Taiwan. • We identified 2741 hospitalised patients who underwent a RP. Of these 2741 cases, 1773 patients underwent RRP, 694 LRP, and 274 RALP. • We performed a conditional (fixed-effect) logistic regression model to explore the odds of 90-day re-admission from RP among patients undergoing RRP, LRP, and RALP. • In all, 257 of the 2741 (9.4%) sampled subjects were re-admitted ≤ 90 days of the index RP. • Patients undergoing a RALP had a significantly lower incidence rate of 90-day re-admission than patients undergoing a RRP or LRP (3.6% vs 10.7% vs 8.2%, P < 0.001). • Compared with patients undergoing a RRP, the odds ratio (OR) of 90-day re-admission for patients undergoing a RALP was only 0.35 (95% confidence interval [CI] 0.19-0.68) after adjusting for patient age, geographic region, year of surgery, Charlson Co-morbidity Index score, and surgeon age and the number of RP cases/year. • However, there was no significant difference in the odds of being re-admitted ≤ 90 days of RP between patients undergoing a LRP and RRP. • The adjusted odds of 90-day re-admission for patients undergoing a RALP were 0.46 (95% CI 0.23-0.94) those of patients undergoing a LRP. • Our study shows that patients undergoing a RALP had a lower adjusted risk of 90-day re-admission than patients undergoing RRP. However, no significant differences were identified between LRP and RRP.

Robot-Assisted Laparoscopic Prostatectomy Versus Open: Comparison of the Learning Curve of a Single Surgeon

Because of the increased use of robot-assisted laparoscopic prostatectomy (RALP) for the management of localized prostate cancer, surgeons in training face the issues of developing skills in both open surgery and the robotic console. This study compares prospectively the safety and efficacy of the first 50 open radical retropubic prostatectomy (RRP) procedures and the first 50 RALP procedures, performed by the same surgeon in the same institution. The patients' baseline demographic, clinical, and oncologic parameters were prospectively recorded. The study end points included oncologic outcome, functional outcomes (at 3 months), and perioperative parameters. Complications were classified according to the modified Clavien system. No statistically significant differences were noted between the two groups in terms of preoperative patient characteristics and oncologic parameters. The operative time and mean estimated blood loss were lower in the RALP group (P<0.001), but no statistically significant difference was noted in regard to transfusion rates (P=0.362). Mean hospital stay was lower in the RALP group (P<0.001). The minor (Clavien I+II) and major (Clavien III+IV) complication rates were comparable between the two groups. The overall positive margin (PSM) rates were 20% and 18% for RRP and RALP, respectively (P=0.799), while for pT(3) disease, the PSM rates were 26.1% and 22.2%% for RRP and RALP, respectively (P=0.53). The 3-month continence rates were 88% and 90% for RRP and RALP, respectively (P=0.749). For preoperatively potent patients, 3-month potency rates were comparable between the two groups (60.6% and 62.1% in the RRP and the RALP group, respectively, P=0.893). The early learning curve for RALP appears safe and results in equivalent functional and oncologic outcome, when compared with the results of open surgery.

181 FIRST SENTINEL BASED NOMOGRAM PREDICTING THE PROBABILITY OF LYMPH NODE INVOLVEMENT IN PROSTATE CANCER PATIENTS UNDERGOING RADIO GUIDED LYMPH NODE DISSECTION AND RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Staging I1 Apr 2012181 FIRST SENTINEL BASED NOMOGRAM PREDICTING THE PROBABILITY OF LYMPH NODE INVOLVEMENT IN PROSTATE CANCER PATIENTS UNDERGOING RADIO GUIDED LYMPH NODE DISSECTION AND RADICAL PROSTATECTOMY Alexander Winter, Thomas Kneib, Niels Schatke, Martin Rohde, Rolf-Peter Henke, and Friedhelm Wawroschek Alexander WinterAlexander Winter Oldenburg, Germany More articles by this author , Thomas KneibThomas Kneib Göttingen, Germany More articles by this author , Niels SchatkeNiels Schatke Oldenburg, Germany More articles by this author , Martin RohdeMartin Rohde Oldenburg, Germany More articles by this author , Rolf-Peter HenkeRolf-Peter Henke Oldenburg, Germany More articles by this author , and Friedhelm WawroschekFriedhelm Wawroschek Oldenburg, Germany More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.233AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES For sentinel pelvic lymph node dissection (sPLND) a staging accuracy comparable to extended (e) PLND has been shown in prostate cancer (PC). In the European Association of Urology Guidelines methods of histologic detection of LN metastases with high sensitivity, such as sPLND or ePLND are regarded as suitable for LN staging in PC. All existing nomograms predicting the probability of LN involvement (LNI) in PC are based on series of conventional PLND. A LNI nomogram based on sPLND does not exist until now. Our aim was to develop and internally validate the first nomogram predicting the probability of LNI in PC patients receiving sPLND. METHODS A retrospective analysis of 1296 consecutive patients (median age 65.3 years, range 41-78) treated with open sPLND and radical retropubic prostatectomy (2005–2009) was performed. Median preoperative prostate-specific antigen (PSA) was 7.4 ng/ml. Clinical T-categories were: T1 in 54.8%, T2 in 42.4%, T3 in 2.8%. Biopsy Gleason sums (GS) were: <6 in 55.1%, 7 in 39.5%, >8 in 5.4%. Multivariate logistic regression models tested the association between predictors and LNI. Predictor variables included preoperative PSA (<4, 4<10, 10<20, >20 ng/ml), clinical T-category (T1c, T2, T3), and GS (<6, 7, >8). Regression-based coefficients were used to develop a nomogam predicting LNI. Bootstrap resampling were used to generate 95%-confidence intervals for predicted probabilities. Accuracy was quantified using the area under the receiver operating characteristics curve (AUC). The extent of over- or underestimation of the observed LNI rate was explored graphically. RESULTS The median number of LN removed was 10 (range 1-34). Overall, 17.8% of patients had LNI. LNI was found in 10.1% of patients with PSA <10 ng/ml. All variables were statistically significant uni- and multivariate predictors of LNI (p<0.001). The bootstrap-corrected predictive accuracy for the three-variable model was high (AUC: 82%) and exceeded the univariate predictive accuracy of any individual predictor (PSA: 69%, clinical T-category: 75%, GS: 69%). The calibration plot showed a high level of consistency between predicted and actual probabilities in low and intermediate predicted probability ranges (<30%). CONCLUSIONS The first sentinel based nomogram can highly accurately predict LNI at sPLND. For the first time clinicians and patients can use a nomogram to help make important decisions regarding the indication of sPLND. An external validation of the nomogram is still outstanding. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e76 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Alexander Winter Oldenburg, Germany More articles by this author Thomas Kneib Göttingen, Germany More articles by this author Niels Schatke Oldenburg, Germany More articles by this author Martin Rohde Oldenburg, Germany More articles by this author Rolf-Peter Henke Oldenburg, Germany More articles by this author Friedhelm Wawroschek Oldenburg, Germany More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

1806 PREDICTORS OF THE CONTEMPORARY USE OF MINIMALLY INVASIVE RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized IX1 Apr 20121806 PREDICTORS OF THE CONTEMPORARY USE OF MINIMALLY INVASIVE RADICAL PROSTATECTOMY Gurdarshan S. Sandhu, Seth A. Strope, Adam S. Kibel, Pamela L. Owens, Youssef S. Tanagho, Dorina Kallogjeri, Sam B. Bhayani, and Kenneth G. Nepple Gurdarshan S. SandhuGurdarshan S. Sandhu St. Louis, MO More articles by this author , Seth A. StropeSeth A. Strope St. Louis, MO More articles by this author , Adam S. KibelAdam S. Kibel Boston, MA More articles by this author , Pamela L. OwensPamela L. Owens St. Louis, MO More articles by this author , Youssef S. TanaghoYoussef S. Tanagho St. Louis, MO More articles by this author , Dorina KallogjeriDorina Kallogjeri St. Louis, MO More articles by this author , Sam B. BhayaniSam B. Bhayani St. Louis, MO More articles by this author , and Kenneth G. NeppleKenneth G. Nepple St. Louis, MO More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1872AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The surgical approach to the treatment of prostate cancer has changed dramatically with the introduction and adoption of new surgical technology. Clinical and socioeconomic factors may influence the utilization of minimally invasive radical prostatectomy (MIRP). Using a population-based sample from the United States, we evaluated predictors of the choice of MIRP compared to open radical retropubic prostatectomy (RRP). METHODS Hospital discharge information (State Inpatient Databases from the Healthcare Cost and Utilization Project) from ten states (Arizona, California, Florida, Iowa, Maryland, Michigan, Nebraska, New Jersey, New York, Washington) was evaluated for 2009. Using ICD-9 procedural coding, patients who underwent radical prostatectomy for prostate cancer were identified. Prostatectomy was classified as MIRP based on the presence of a secondary code for laparoscopic or robotic surgery. Demographic and socioeconomic variables assessed were age, race, insurance type, geographic location (urban vs. rural) and median income by zip code. Medical comorbidity was evaluated by the modified Elixhauser method using the Agency for Healthcare Research and Quality (AHRQ) comorbidity measure. Predictors of MIRP were assessed by univariable logistic regression, and factors with p<0.10 were included in a multivariable model. RESULTS 27,399 radical prostatectomies were performed in 10 states in 2009, of which 18,185 were MIRP (66.4%). Differences were present in patients who underwent MIRP vs. RRP (Table 1). On multivariate analysis (Table 2), MIRP was less likely to be performed in men who were older, from rural or lower income areas, or had medical comorbidities. Table 1. Differences in patients undergoing MIRP and RRP Variable MIRP RRP p value Age (mean) 61.1 61.5 <0.0001 Race <0.0001 White 76.8% 72.2% Black 10.4% 11.5% Other 12.8% 16.4% Insurance <0.0001 Private 65.3% 59.8% Medicare 30.1% 31.9% Other 4.7% 8.4% Income quartile <0.0001 1st 15.8% 19.7% 2nd 21.3% 24.6% 3rd 27.1% 26.0% 4th 35.9% 29.7% Rural location 10.1% 14.3% <0.0001 Table 2. Predictors of MIRP in 2009 based on multivariate logistic regression analysis Variable Odds Ratio 95% CI p value Age (per year older) 0.99 0.99-0.99 0.02 Black race (vs. white) 0.95 0.86-1.04 0.28 Other race (vs. white) 0.77 0.71-0.84 <0.001 Medicare (vs. private) 0.99 0.92-1.07 0.85 Other payer (vs. private) 0.59 0.53-0.67 <0.001 Income quartile 1 (vs 4) 0.80 0.73-0.87 <0.001 Income quartile 2 (vs. 4) 0.83 0.77-0.89 <0.001 Income quartile 3 (vs. 4) 0.93 0.86-0.99 0.04 Rural (vs. urban) 0.71 0.64-0.77 <0.001 Chronic blood loss anemia 0.33 0.21-0.53 <0.001 Chronic deficiency anemia 0.50 0.43-0.58 <0.001 COPD 0.88 0.79-0.97 0.01 Diabetes complicated 0.65 0.48-0.86 0.003 Electrolyte abnormality 0.71 0.60-0.84 <0.001 Hypertension 0.93 0.88-0.99 0.02 Peripheral vascular disease 0.72 0.55-0.94 0.01 CONCLUSIONS Choice of surgical approach appears to be influenced by both demographic, socioeconomic, and clinical factors. Disparities may exist in access to robotic surgery, and/or younger patients with fewer comorbidities may be offered or pursue robotic surgery as their treatment. This analysis is limited by the lack of pathologic features in this administrative data source. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e729 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gurdarshan S. Sandhu St. Louis, MO More articles by this author Seth A. Strope St. Louis, MO More articles by this author Adam S. Kibel Boston, MA More articles by this author Pamela L. Owens St. Louis, MO More articles by this author Youssef S. Tanagho St. Louis, MO More articles by this author Dorina Kallogjeri St. Louis, MO More articles by this author Sam B. Bhayani St. Louis, MO More articles by this author Kenneth G. Nepple St. Louis, MO More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Effects of robotic-assisted laparoscopic prostatectomy on surgical pathology specimens

BackgroundRobotic-assisted laparoscopic prostatectomy (RALP) has greatly changed clinical management of prostate cancer. It is important for pathologists and urologists to compare RALP with conventional open radical retropubic prostatectomy (RRP), and evaluate their effects on surgical pathology specimens.MethodsWe retrospectively reviewed and statistically analyzed 262 consecutive RALP (n = 182) and RRP (n = 80) procedures performed in our institution from 2007 to 2010. From these, 49 RALP and 33 RRP cases were randomly selected for additional microscopic examination to analyze the degree of capsular incision and the amount of residual prostate surface adipose tissue.ResultsPositive surgical margins were present in 28.6% RALP and 57.5% RRP cases, a statistically significant difference. In patients with stage T2c tumors, which represent 61.2% RALP and 63.8% RRP patients, the positive surgical margin rate was 24.1% in the RALP group and 58.8% in the RRP group (statistically significant difference). For other pathologic stages, the differences in positive margins between RALP and RRP groups were not statistically significant. The incidence of positive surgical margins after RALP was related to higher tumor stage, higher Gleason score, higher tumor volume and lower prostate weight, but was not related to the surgeons performing the procedure. When compared with RRP, RALP also caused less severe prostatic capsular incision and maintained larger amounts of residual surface adipose tissue in prostatectomy specimens.ConclusionsIn this study RALP showed a statistically significant lower positive surgical margin rate than RRP. Analysis of capsular incision and amount of prostatic surface residual adipose tissue suggested that RALP caused less prostatic capsular damage than RRP.Virtual slidesThe virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1278078279667611

Editorial Comment

This series from the University of Southern California (USC) Department of Urology emphasizes the reproducible effectiveness of open radical prostatectomy (ORP) in the management of prostate cancer. As the reference standard treatment for localized prostate cancer, it is curious that ORP with pelvic lymph node dissection has largely been abandoned for robotic-assisted laparoscopic radical prostatectomy (RARP). It would appear that those extrapolating the results of open surgery to support a robotic approach are justified: removing the entire prostate gland by any technique should produce the same results. However, reasons exist—supported by this series from USC—to question such an extrapolation. Long-term Outcomes of Open Radical Retropubic Prostatectomy for Clinically Localized Prostate Cancer in the Prostate-specific Antigen EraUrologyVol. 79Issue 3PreviewTo determine long-term oncological outcomes and complication rates for patients with clinically organ confined prostate adenocarcinoma (PCa) treated with open radical retropubic prostatectomy and pelvic lymph node dissection (RRP/PLND) in the prostate-specific antigen (PSA) era. Full-Text PDF

Comprehensive report on prostate cancer misclassification by 16 currently used low‐risk and active surveillance criteria

What's known on the subject? and What does the study add? Prostate cancer characterisation, based on laboratory findings, clinical examination and histopathological cancer features that are used to define selection criteria for AS, is not ideal. Consequently, a panel of strict or more lenient criteria to select patients for AS have been published. Studies investigating the relationship between pretreatment variables and final pathology have been done in the past showing the risk of cancer misclassification for some criteria. No study has presented an overview of cancer selection using a panel of 16 currently used AS criteria that is presented in the present study. In an exactly defined cohort after radical prostatectomy, each set of criteria was used as a diagnostic test to separate between patients with more favourable (pT2, no Gleason upgrade between biopsy grading and final pathology) and unfavourable cancer features (pT3, pN+, Gleason upgrade). To the best of our knowledge a comparison of test quality criteria for AS criteria given by sensitivity, specificity, positive and negative predictive value and likelihood ratio has not yet been reported. Moreover, we showed that tumour characterisation, by a formally sufficient 12-core biopsy, in the present dataset harboured a risk of ≈20% that unfavourable cancer features were missed regardless of whether strict or more lenient selection criteria for AS were chosen. To evaluate final histopathological features among men diagnosed with prostate cancer eligible for low-risk (LR) or active surveillance (AS) criteria. Retrospective application of 16 definitions for AS or LR prostate cancer to a contemporary (January 2008 to March 2011) open retropubic radical prostatectomy (RRP) series of 1745 patients. neoadjuvant hormones, radiotherapy, inadequate histopathological reports, <10 biopsy cores. Report on the number of men with insignificant tumours (defined as: ≤pT2, Gleason score ≤6, tumour volume <0.5 mL) and men who had unfavourable tumour characteristics on final pathology (defined as: extracapsular extension or seminal vesicle invasion or lymph node metastasis or Gleason upgrading). Sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) were calculated. Eligibility of patients in the final study cohort (n = 1070) varied from 5.1% to 92.7% depending on the AS or LR criteria used. Final pathology revealed 77 insignificant cancers and 578 patients who had unfavourable histopathological criteria. The detection rate for insignificant cancers on final pathology was variable ranging from 7.8% to 28.3% depending on the AS- or LR-prediction tool used; unfavourable tumour characteristics were found in up to 33.5% on final pathology. The sensitivity, specificity, PPV and NPV were 8.5-97.9%, 24.7-97.8%, 67.7-89.1% and 45.3-78.2%, respectively. The likelihood ratio to correctly identify a patient with LR disease on final pathology ranged from 1.3 to 8. AS or LR criteria have a significant risk of cancer misclassification. Better prediction tools are needed to improve these criteria. Re-biopsy might improve safety and should be considered more frequently in patients who opt for AS.

Is there still a role for pubovaginal slings in the treatment of SUI in the era of mid-urethral slings?

The treatment of female stress urinary incontinence (SUI) has evolved over the last decade.1 Traditional surgeries for SUI, such as the Burch colposuspension and pubovaginal slings, have slowly been supplanted by mid-urethral slings (MUS). In some centres, retropubic surgeries have become almost obsolete. This has not had a negative impact on the surgical treatment of female SUI. In fact, various databases have demonstrated almost a threefold increase in the overall number of incontinence procedures performed.2,3 The rationale for this shift in surgical procedure and for the increase in surgical volume appears to be related to decreased complication rates, shorter operative time and the simplicity of MUS surgery without compromising objective and subjective cure rates.4,5 Are surgical procedures, such as autologous rectus fascia pubovaginal sling (AF-PVS), history or do they still have a role in female SUI. Welk and Herschorn support that AF-PVS can be a vital tool in the treatment of complex SUI.1 They describe an extremely complex patient population with recurrent SUI that underwent AF-PVS at their centre. Over half of the patient population had mesh erosions, urethral diverticuli or trauma. The remaining patients underwent on average 2 prior surgical procedures to treat their SUI before undergoing an AF-PVS. Their surgical outcomes and patient satisfaction were quite commendable considering the complexity of the patient population. Average pad use decreased from 5 pads per day (PPD) preoperatively to 1 PPD postoperatively. Moreover, the patients’ rating of their overall quality of life was reasonable (62% scored from 4 [mixed] to 7 [delighted]). There is, however, an underlying concern from an education perspective that permeates throughout the paper concerning the shift to MUS.1 Although AF-PVS, Burch colposuspension and other retropubic surgeries may be indicated in various surgical settings for female SUI, graduating urology residents may not have the surgical acumen and experience to perform them. Wu and colleagues found that the number of retropubic suspension surgeries in the United States fell from 52.8% of SUI procedures in 1998 to 13.8% in 2007.2 As the number of pubovaginal slings performed in academic centres continues to fall, graduating urology residents may not be adequately exposed to these procedures to perform them competently and safely. As a result, these operations have the potential to become largely historical procedures or isolated in tertiary referral centres. Alarms have already been sounded concerning graduating Canadian urology residents’ surgical exposure to open radical nephrectomy and open radical retropubic prostatectomy.6 Perhaps these “complex surgical incontinence surgeries,” need to be added to that list.

Incidence and location of positive surgical margins following open, pure laparoscopic, and robotic-assisted radical prostatectomy and its relation with neurovascular preservation: a single-institution experience.

To evaluate whether robotic-assisted radical prostatectomy (dvRP) provides adequate local control of the disease, incidence of positive surgical margins (PSMs) obtained with dvRP was compared with that of laparoscopic radical prostatectomy (LRP) and with that of open radical retropubic prostatectomy (RRP) performed in a single institution by the same surgeons. We also studied whether neurovascular bundle preservation modified PSM rates. The records were retrospectively reviewed from electronic medical data, and three groups of 100 patients were organized. Group1 included 100 patients who underwent RRP prior to the incorporation of minimally invasive techniques. Group2 included the first 100 patients who underwent LRP, and group3 was made up of the first 100 patients who underwent dvRP. All surgical specimens were analyzed by the same pathologist. We used the technique described by Patel etal. for dvRP. LRP was performed using a five-trocar extraperitoneal approach as previously published by the authors. RRP was performed using retrograde dissection as described by Walsh etal. The final decision of preserving neurovascular bundles was made during surgery. Using D'Amico's risk classification, the dvRP group had a lower percentage of patients with low risk (dvRP versus LRP p=0.017; dvRP versus RRP p=0.0108). No statistically significant differences were found within high- and intermediate-risk groups. A higher percentage of patients with pT3 disease was found in the dvRP group compared with the RRP group (p=0.0408). There were no statistically significant differences regarding PSMs among groups (RRP: 25, LRP: 14, dvRP: 18), although when we compared the total number of PSMs we found that the dvRP group had 18 PSMs versus 21 and 50 PSMs for LRP and RRP, respectively. All three groups had more PSMs located posterolaterally. There was a higher percentage of nerve-sparing procedures in the dvRP group (dvRP: 91 patients, LRP: 47 patients, RRP: 5 patients) (p<0.0001). No statistically significant differences were found in the PSM rates between the three techniques analyzed. The number of nerve-sparing procedures in the dvRP group was statistically higher. However, this preservation did not modify PSM rates.

Long-term Outcomes of Open Radical Retropubic Prostatectomy for Clinically Localized Prostate Cancer in the Prostate-specific Antigen Era

To determine long-term oncological outcomes and complication rates for patients with clinically organ confined prostate adenocarcinoma (PCa) treated with open radical retropubic prostatectomy and pelvic lymph node dissection (RRP/PLND) in the prostate-specific antigen (PSA) era. Outcomes data were obtained from a prospectively maintained prostate cancer database. Patients with cT1/cT2 PCa undergoing RRP/PLND without neoadjuvant therapy between July 1988 and June 2008 were included. Kaplan-Meier and Cox proportional regression models were used to evaluate factors influencing biochemical recurrence, clinical recurrence, and overall survival (OS). A total of 2487 patients met inclusion criteria, and median follow-up was 7.2 years (range 1-21 years). Of the patients, 49.7% were low risk, 33.2% intermediate risk, and 16.1% high risk by D'Amico criteria, and 6% were LN+. The 10-year biochemical recurrence-free survival (BCRFS) for low-, intermediate-, and high-risk patients was 92%, 83%, and 76%, respectively (P < .001), and 10 year OS was 91%, 83%, and 74%, respectively (P < .001). BCRFS at 10 years was 76% and 88% for patients with positive and negative margins, respectively (P < .001). Of the 2487 patients, 11% developed BCR, and 3.7% experienced CR, with 9 local recurrences. The overall complication rate was 2.3%, and the cancer specific mortality rate was 2%. D'Amico risk group, margin status, and LN status are significantly correlated with outcomes in patients undergoing RRP/PLND for clinically localized PCa. Local recurrence and death from prostate cancer are rare in patients undergoing open RRP/PLND for clinically organ confined disease in the PSA era.

Clinical Experience with Limited Lymph Node Dissection for Prostate Cancer in Korea: Single Center Comparison of 247 Open and 354 Robot-Assisted Laparoscopic Radical Prostatectomy Series

PurposeThere are limited data on the role of limited pelvic lymph node dissection (PLND) in patients with prostate cancer in Korea. The objective of this study was to demonstrate our clinical experience with limited PLND and the difference in its yield between open retropubic radical prostatectomy (RRP) and robot-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer patients in Korea.Materials and MethodsWe retrospectively analyzed 601 consecutive patients undergoing radical prostatectomy and bilateral limited PLND by either RRP (n=247) or RALP (n=354) in Asan Medical Center. All patients were divided into three groups according to the D'Amico's risk stratification method. Clinicopathologic data, including the yield of lymph nodes, were thoroughly reviewed and compared among the three risk groups or between the RRP and RALP subjects.ResultsThe mean patient age was 64.9 years and the mean preoperative prostate-specific antigen was 9.8 ng/ml. The median number of removed lymph nodes per patient was 5 (range, 0 to 20). The numbers of patients of each risk group were 167, 199, and 238, and the numbers of patients with tumor-positive lymph nodes were 1 (0.6%), 4 (2.0%), and 17 (7.1%) in the low-, intermediate-, and high-risk groups, respectively. In the high-risk group, the lymph node-positive ratio was higher in RRP (14.9%) than in RALP subjects (2.4%).ConclusionsWe speculate that limited PLND may help in prostate cancer staging in intermediate- and high-risk prostate cancer groups. RRP is a more effective surgical modality for PLND than is RALP, especially in high-risk prostate cancer groups.

恥骨後式根治的前立腺全摘除術後の吻合部狭窄：頻度，危険因子および治療法の検討

Anastomotic stricture (AS) following radical prostatectomy (RP) decreases patients' quality of life. It occurs in 0.5% to 32% of men after open radical retropubic prostatectomy (RRP), although its etiology is poorly understood. In a series of patients who received RRP, we analyzed the incidence, possible predisposing factors, and management of AS after RP. Between April 1997 and March 2006, 129 consecutive patients underwent RRP in our hospital. Anastomosis between the bladder neck and urethra was performed with interrupted anastomosis using four 2-0 absorbable sutures. AS was diagnosed when a 16Fr. panendoscope could not be passed. We assessed the relationship between the management method for AS and time interval between the surgical procedure and diagnosis of the stricture. The relationships between comorbidities identified preoperatively (hypertension [HT], diabetes mellitus [DM], cardiovascular disease [CVD], cerebral infarction [CI] and smoking history) and the incidence of AS were determined. Risk factors, including age, body mass index [BMI], preoperative PSA, total prostate volume, operative time, blood loss, Foley duration, amount of stress urinary incontinence (SUI) per day, amount of drain output, pathological T stage, Gleason sum and surgical margin status were also assessed. The rate of AS after RRP was 10.9% (14/129). In 10 patients (72%), AS occurred within 3 months of surgery, in 2 (14%) it occurred at 4-12 months after surgery and in 2 (14%) more than 12 months after surgery. In univariate and multivariate analyses, intraoperative bleeding of 1,800 ml or more was independently the strongest predictor of AS. In two patients a urethral bougie was used and 11 underwent internal urethrotomy. Only 1 patient underwent transurethral resection. Of the 8 patients whose strictures were diagnosed within 3 months after surgery and underwent internal urethrotomy, 6 had recurrent anastomotic strictures. Risk factors for AS are thought to be multifactorial. Intraoperative blood loss was significantly associated with the development of anastomotic stricture. We should understand that anastomotic stricture following radical retropubic prostatectomy is not a rare morbidity and should inform patients about the possibility of postoperative AS.

Risk Factors and Quality of Life for Post-prostatectomy Vesicourethral Anastomotic Stenoses

To evaluate the difference in vesicourethral anastomotic stenosis (VUAS) rates after open radical retropubic prostatectomy (RRP) vs robot-assisted radical prostatectomy (RARP), and to analyze associated factors and effect on quality of life. From 2001 to 2009, a total of 1038 patients underwent RARP and 707 patients underwent open RRP. Perioperative factors and Expanded Prostate Cancer Index Composite (EPIC) quality of life scores were compared between patients who did and did not develop a VUAS. Independent significant predictors of VUAS development were identified using multivariable modeling. The incidence of VUAS in open RRP cases was higher (53/707, 7.5%) than for RARP (22/1038, 2.1%) (P<.0001). Intervention consisted of dilation in 34 of 75 cases (45.3%), internal urethrotomy in 8 of 75 (10.7%), and multiple procedures in 30 of 75 (40%). Open technique (P<.0001, odds ratio [OR]=3.0, 95% confidence interval [CI]=1.8-5.2), prostate-specific antigen (PSA) recurrence (P=.02, OR=2.2, 95% CI=1.2-4.1), postoperative hematuria (P=.02, OR=3.7, 95% CI=1.2-11.3), urinary leak (P=.002, OR=6.0, 95% CI=1.9-19.2), and urinary retention (P=.004, OR=3.5, 95% CI=1.5-8.7) were significant independent predictors of VUAS development. EPIC incontinence scores were similar between VUAS and non-VUAS patients, whereas irritative voiding scores were worse initially with VUAS but became similar by 12 months. There is a higher rate of VUAS after open RRP vs RARP. Most cases of VUAS require endoscopic intervention. Predictors include open surgery, PSA recurrence, and postoperative hematuria, urinary leak, and retention. There is no diminution of quality of life scores at 12 months.

Case-matched analysis of outcome after open retropubic radical prostatectomy in patients with previous preperitoneal inguinal hernia repair

The impact of preperitoneal mesh repair for inguinal hernia on future pelvic surgery is debatable. This retrospective study investigated the impact of previous preperitoneal inguinal hernia repair (PIHR) on outcome after open retropubic radical prostatectomy (RRP) for prostatic cancer. Patients who had open RRP and who had previously undergone PIHR were identified. They were compared with a control group of patients matched for age, body mass index and tumour risk profile who had no history of inguinal hernia repair. Outcome measures included intraoperative data, histopathology and results at follow-up. Sixty patients who had undergone open RRP after a previous PIHR were compared with 60 control patients. Operations lasted longer in the PIHR group (median (interquartile range, i.q.r.) 100 (90-120) versus 90 (85-100) min respectively; P < 0·001) and the operation was assessed as more difficult by the surgeon (P = 0·022). Hospital stay was longer for patients who had undergone PIHR (median (i.q.r.) 7 (6-9) versus 6 (5-7) days; P = 0·012) and urinary catheterization was prolonged (13 (11-14) versus 11 (11-12) days; P = 0·006). Among patients with intermediate- and high-risk disease, fewer lymph nodes were excised in the PIHR group than in the control group (median (i.q.r.) 2 (0-7) versus 8 (5-12) nodes; P < 0·001). Open RRP for prostatic cancer was more difficult to perform after previous PIHR, and was associated with a longer hospital stay and less adequate lymphadenectomy for intermediate- and high-risk prostatic cancer.

Preoperative Erectile Function Represents a Significant Predictor of Postoperative Urinary Continence Recovery in Patients Treated With Bilateral Nerve Sparing Radical Prostatectomy

The association between baseline functional status and urinary continence recovery after radical prostatectomy remains controversial. We tested the hypothesis that baseline erectile and urinary function predicts urinary continence recovery after bilateral nerve sparing radical prostatectomy. The study included 752 patients with prostate cancer treated with bilateral nerve sparing radical prostatectomy between 2003 and 2009. All patients had preoperative functional and oncological data available, including age at surgery, body mass index, prostate specific antigen, and erectile and urinary function. Preoperatively erectile and urinary function was assessed by the erectile function domain of the International Index of Erectile Function and the International Prostatic Symptoms Score. Urinary continence was defined as wearing no pads. Univariate and multivariate Cox regression models were used to test the association between predictors and urinary continence recovery after surgery. At a mean postoperative followup of 30.7 months (median 29, range 1 to 80) 611 patients (81.3%) had recovered urinary continence. Overall the urinary continence recovery rate at 1 and 3 years was 73.9% and 82.2%, respectively. On univariate Cox regression analysis patient age and the preoperative score on the erectile function domain of the International Index of Erectile Function were significantly associated with urinary continence recovery (each p ≤ 0.04). On multivariate analysis age at surgery and the preoperative erectile function domain of the International Index of Erectile Function were the only independent predictors of urinary continence recovery after bilateral nerve sparing radical prostatectomy (each p ≤ 0.04). Age and preoperative erectile function should be considered for urinary continence predictions after bilateral nerve sparing radical prostatectomy and for accurate patient counseling before surgery. Preoperative erectile function might be a marker of pelvic vascular disease, which may affect the status of the external urinary sphincter.