Robotic versus open pancreaticoduodenectomy: Is there any difference for frail patients?

BACKGROUND: Old age and frailty are predictors of early postoperative results after pancreatic surgery. We analysed the results of robotic and open pancreatoduodenectomy in elderly and frail patients. METHODS: Data from the local robotic pancreatoduodenectomy database were reviewed and matched with those from open operations during the same period (2014-2020). Both old age and frailty were used to determine any correlation with postoperative outcomes. Elderly patients were defined as patients aged 70 years or more, while frailty was classified according to the validated modified Frailty Index. RESULTS: A total of 118 pancreatoduodenectomies were included in the analysis: 65 (55.1%) robotic and 53 (44.9%) open. More than 50% of patients were frail. Overall, 7.6% of patients experienced grade IV Clavien-Dindo complications, and 3.4% died within 90 days after surgery. Frail patients experienced a similar rate of severe complications after robotic vs. open operations (5.3 vs. 11.6; p = 0.439) but earlier refeeding (3 days vs. 4 days; p = 0.006) and earlier drain removal (6 days vs. 7 days; p = 0.046) when operated on by a robotic approach. The oncological outcomes, including limphnodes retrieval, residual disease, recurrences, and survival, were not influenced by the surgical approach. Non-elderly patients also showed more benefits with the robotic approach (lower complication index, earlier refeeding, and drain removal). CONCLUSIONS: Robotic pancreatoduodenectomy is associated with risks of major complications that are comparable to those of open operation in frail patients. Some perioperative parameters (refeeding, drain removal) seem to favour robotics in frail patients and younger patients, although at the price of longer operating times.

The role of prostate-specific antigen density in men with low-risk prostate cancer suitable for active surveillance: results of a prospective observational study.

BACKGROUND: Low-risk prostate cancer (PCa) is currently managed also with active surveillance (AS). However, up to 40% of patients in AS may require radical treatment at a long-term follow-up. The aim of our study is to further investigate the role of prostate-specific antigen (PSA) density in AS. METHODS: A prospective observational study on PCa naïve patients with PSA<20 ng/ml submitted to prostate biopsy was conducted. Data on family history of PCa, PSA at biopsy, and digitorectal examination were collected. Prostate volume was calculated during TRUS. Bioptic cores number, Gleason Score, and International Society of Urological Pathology (ISUP) Grade Group were recorded. Patients who subsequently underwent radical prostatectomy (RP) were selected and stratified in low, intermediate, and high Risk based on the D'Amico risk classification at biopsy and after RP. RESULTS: A total of 746 patients were enrolled. PCa was found in 320 patients (42.9%), of whom 252 underwent RP (78.8% of positive biopsies). At biopsy, patients were stratified based on the D'Amico risk classification in low, intermediate, and high risk and were 20.6%, 66.7%, and 12.7%, respectively. Definitive pathology after RP showed PCa change in the risk group in 52.4% of patients (n = 132) and PCa upgrading in 46.8% of patients (n = 118). At Student t test and logistic regression, PSA density was significantly correlated with change in the risk group and upgrading in low-risk PCa (p = 0.024) with an age adjusted odds ratio of 10.01 and 7.53, respectively. CONCLUSION: PSA density is a strong instrument in AS to decide whether to treat. However, further larger studies are needed to strongly assess this correlation.

Adverse pathology after radical prostatectomy: the prognostic role of cumulative cancer length >6-mm threshold in prostate cancer-positive biopsies.

BACKGROUND: To investigate the role of Cumulative Cancer Length (CCL) and PCa positive core number (PCapcn) in random prostate biopsies as predictors of Adverse Pathology (AP) at definitive pathology. METHODS: We prospectively enrolled patients submitted to random ultrasound guided prostate biopsies for suspect PCa in our center since 2016. Inclusion criteria were PSA <20 ng/ml or >3 ng/ml and age<71 years. Data on CCL and Grade Group (GG) at biopsy and pathology after Radical Prostatectomy (RP) were collected. AP was defined as pT3 or higher TNM, Positive Surgical Margin (>2mm) or PCa Positive Lymph Node. ROC curve was used to establish an appropriate CCL and PCapcn thresholds that were then investigated as predictors of AP at definitive pathology. RESULTS: Among 882 eligible biopsies, 344 had PCa and underwent RP. Mean age was 64 years (SD 5). Mean PSA was 7.75 (SD: 3.66). At definitive pathology there were AP features in 196 (56.9%) RP. PCapcn and CCL were statistically significantly associated with AP (p<0.0001). At multivariate age-adjusted logistic regression only PCapcn had an OR of 1.513 (CI95% 1.140-2.007) p=0.004. Through ROC curve a CCL>6mm and PCapcn >3 thresholds for AP were established (Area: 0.769; p<0.0001 CI 95% 0.698-0.840 and Area: 0.767; p<0.0001 CI 95% 0.696-0.837). When considering CCL>6mm AP had OR 5.462 (CI 95% 2.717-10.978) p<0.0001 and PCapcn >3 had OR 7.127 (CI 95% 3.366-15.090) p<0.0001. In particular, for GG 1 and 2, CCL>6mm had OR 3.989 (CI 95% 1.839-8.652) p<0.0001, while PCapcn >3 had OR 5.541 (CI 95% 2.390-12.849) p<0.0001. CONCLUSIONS: At present time, random prostate biopsies might carry useful information regarding tumor extension and aggressiveness. A CCL>6mm or PCapcn >3 might be associated with AP features, in particular for low and favorable intermediate risk PCa.