Age-stratified outcomes after radical prostatectomy in a randomized setting (LAP-01): do younger patients have more to lose?

OBJECTIVE: Age is known to have an impact on outcomes after radical prostatectomy (RP). However, age differences can be investigated from a cross-sectional as well as from a longitudinal perspective. This study combines both perspectives. MATERIALS AND METHODS: LAP-01 is the first multicenter randomized patient blinded trial comparing outcomes after robotic-assisted and laparoscopic RP. This study stratified the entire population that received nerve-sparing surgery and was potent at baseline by the following ages: ≤ 60 years, 61-65 years, and > 65 years. Potency was assessed using the IIEF-5. The EORTC QLQ-C30 was used for global health perception and the EORTC QLQ-PR25 for urinary symptoms. Continence was assessed by the number of pads used. Longitudinal change was assessed using either validated anchor-based criteria or the 1 or 0.5-standard-deviation criterion. Worsening of continence was measured by increasing numbers of pads. RESULTS: 310 patients were included into this study. Older patients had a significantly higher risk for worsening of continence at 3 and 6 months (OR 2.21, 95% CI [1.22, 4.02], p = 0.009 and OR 2.00, 95% CI [1.16, 3.46], p = 0.013, respectively); at 12 months, the odds of worsening did not differ significantly between age groups. Potency scores were better in younger patients from a cross-sectional perspective, but longitudinal change did not differ between the age groups. In contrast, global health perception was better in older patients from a cross-sectional perspective and longitudinal decreases were significantly more common among the youngest patients, at 12 months (36.9% vs. 24.4%, p = 0.038). CONCLUSION: From a cross-sectional perspective, function scores were better in younger patients, but from a longitudinal perspective, age differences were found in continence only. In contrast, global health scores were better in older patients from a cross-sectional and longitudinal perspective. TRIAL REGISTRATION: The LAP-01 trial was registered with the U.S. National Library of Medicine clinical trial registry (clinicaltrials.gov), NCT number: NCT03682146, and with the German Clinical Trial registry (Deutsches Register Klinischer Studien), DRKS ID number: DRKS00007138.

Extended Pelvic Lymph Node Dissection Does Not Affect Functional Outcomes during Bilateral Nerve-Sparing Radical Prostatectomy.

INTRODUCTION: A possible association between extended pelvic lymph node dissection (ePLND) in radical prostatectomy (RPE) and functional outcomes such as erectile function (EF) and continence recovery has been previously considered. This association stems from the direct proximity of ePLND to the pelvic plexus. In this paper, we aimed to critically examine an association of ePLND with functional outcomes in patients who underwent bilateral nerve-sparing RPE. METHODS: 272 out of 782 patients from a randomized, patient-blinded, multicenter trial were retrospectively classified into two groups based on the D'Amico criteria: 114 had no PLND and 158 had ePLND. Continence (no pad/safety pad) and EF (Index of Erectile Function-5 [IIEF-5] questionnaire ≥17; sufficient erection for sexual intercourse) were assessed at 3, 6, and 12 months as well as postsurgical complications (Clavien-Dindo Classification). RESULTS: After 12 months of follow-up, no significant difference for potency could be found between men without and subjected to ePLND: IIEF-5 ≥17 (23.2% vs. 27.2%; p = 0.55) and sufficient erection for intercourse (44.1% vs. 45.6%; p = 0.84). A multiple linear regression analysis demonstrated that while preoperative EF (p < 0.001), pathological tumor stage (p = 0.027), and robot-assisted bilateral nerve-sparing RPE (p < 0.001) were independent predictors of EF recovery, the same did not apply to ePLND. No association was detected for continence recovery (94.2% vs. 89.7%; p = 0.22) and complications of any grade after surgery (11.4% vs. 16.5%; p = 0.24). CONCLUSION: ePLND is not associated with increased risk of erectile dysfunction, incontinence or complications after bilateral nerve-sparing RPE.

3D-electron microscopic characterization of interstitial cells in the human bladder upper lamina propria.

AIMS: To explore the ultrastructure of interstitial cells in the upper lamina propria of the human bladder, to describe the spatial relationships and to investigate cell-cell contacts. METHODS: Focused ion beam scanning electron microscopy (FIB-SEM), 3-View SEM and confocal laser scanning microscopy were used to analyze the 3D ultrastructure of the upper lamina propria in male and female human bladders. RESULTS: 3View-SEM image stacks as large as 59 × 59 × 17 µm3 (xyz) at a resolution of 16 × 16 × 50 nm3 and high resolution (5 × 5 × 10 nm3 ) FIB-SEM stacks could be analyzed. Interstitial cells with myoid differentiation (mIC) and fibroblast like interstitial cells (fIC) were the major cell types in the upper lamina propria. The flat, sheet-like ICs were oriented strictly parallel to the urothelium. No spindle shaped cells were present. We furthermore identified one branched cell (bIC) with several processes contacting urothelial cells by penetrating the basal membrane. This cell did not make any contacts to other ICs within the upper lamina propria. We found no evidence for the occurrence of telocytes in the upper lamina propria. CONCLUSIONS: Comprehensive 3D-ultrastructural analysis of the human bladder confirmed distinct subtypes of interstitial cells. We provide evidence for a foremost unknown direct connection between a branched interstitial cell and urothelial cells of which the functional role has still to be elucidated. 3D-ultrastructure analyses at high resolution are needed to further define the subpopulations of lamina propria cells and cell-cell interactions.

Assessment of different continence definitions in the context of the randomized multicenter prospective LAP-01 trial-Does the best definition change over time?

BACKGROUND: A uniform definition of continence is urgently needed to allow the comparison of study results and to estimate patient outcomes after radical prostatectomy (RP). To identify a practical definition that includes both objective and subjective aspects in a tangible way, we assessed different continence definitions and evaluated which best reflects the patients' subjective perception of continence. METHODS: Our analyses included 718 patients that underwent either robot-assisted radical prostatectomy (RARP) or laparoscopic radical prostatectomy (LRP) in a multicenter randomized patient-blinded trial. Continence was assessed through patient questionnaires prior to and at 3, 6 and 12 months after surgery which included the number of pads used per day, the ICIQ-SF and the question "Do you suffer from incontinence? (yes/no)" to assess subjective continence. We used Krippendorff's Alpha to calculate the agreement of different continence definitions with the subjective perception. RESULTS: At 3 months, the "0/safety pad" definition shows the highest agreement by alpha = 0.70 (vs. 0.63 for "0 pads" and 0.37 for "0-1 pad"). At 6 and 12 months "0 pads" is the better match, with alpha values of 0.69 (vs. 0.62 and 0.31) after 6 months and 0.70 (vs. 0.65 and 0.32) after 12 months. The ICIQ-SF score shows good correlation with the subjective continence at 3 months (alpha = - 0.79), the coefficient then decreasing to - 0.69 and - 0.59 at 6 and 12 months. CONCLUSION: The best continence definition according to the patients' perspective changes over time, "0 pads" being the superior criterion in the long-term. We recommend using the 0-pad definition for standardized continence reporting, as it is simple yet as accurate as possible given the inevitably high subjectivity of continence perception. Trial registration The LAP-01 trial was registered with the U.S. National Library of Medicine clinical trial registry (clinicaltrials.gov), NCT number: NCT03682146, and with the German Clinical Trial registry (Deutsches Register Klinischer Studien), DRKS ID number: DRKS00007138.

Associations between parent-child relationship, self-esteem, and resilience with life satisfaction and mental wellbeing of adolescents.

Purpose: Mental wellbeing and life satisfaction play an important role in the development of adolescents, yet factors potentially influencing these states have not been sufficiently studied, especially in Vietnam. This study aims to fill the research gaps by exploring the associations of the parent-child relationship, self-esteem, and resilience on the mental wellbeing and satisfaction with life of adolescents. Methods: A cross-sectional study was conducted from June to July 2020 on 1,023 adolescents from 10 to 18 years old living in Vietnam. To assess the satisfaction with life as well as the mental wellbeing of participants, this study used the Satisfaction with life and The World Health Organization-Five Wellbeing Index scale. Results: More than 70% of participants reported having conflicts with their parents (74.6% of those conflicted with their father ad 73.9% of those conflicted with their mother), while 26.3% stated dissatisfaction with life. The mean score of mental wellbeing was 61.5 (SD = 23.0). Higher academic performance, self-esteem, resilience, encounter loneliness and isolation within own family, and having support and sharing from family members had a positive effect on life satisfaction and mental wellbeing. Female participants had higher satisfaction with life score (Coef = 0.77; 95%CI = 0.10; 1.44) but they had a lower mental wellbeing score (Coef = -6.00; 95%CI = -8.57; -3.44) than male participants. High school students had lower both satisfaction with life and mental wellbeing scores than secondary students. Conclusion: The results highlight the importance of being aware of the influence that expectations (of higher grades) and bias (toward male children) imposed by parents, teachers, and society on the mental wellbeing of youths, especially in Asian cultures. Strengthening the family bond and encouraging young people to share their feeling is also crucial to enhancing the mental health condition of adolescents.

Association of Individual and Neighborhood Characteristics to Problematic Internet Use among Youths and Adolescents: Evidence from Vietnam.

INTRODUCTION: This study aimed to determine latent profiles from the Problematic Internet Use Questionnaire Short Form-6 (PIUQ-SF-6) score of Vietnamese youths and adolescents, which supports the diagnosis of problematic internet use among a large sample size. Moreover, it also explored factors that affect each latent profile of the PIUQ-SF-6 score among participants. METHODS: A sample of 1477 Vietnamese people, aged 14 to 24, across five provinces participated in the study. Multinomial logistic regression determined factors related to the levels of the Problematic Internet Use Questionnaire Short Form-6 (PIUQ-SF-6) after using latent profile analysis. RESULTS: Participants were divided into three profiles, including those at low, moderate, and high risk of internet addiction. The high-risk latent profile was obtained for 23.1% of adolescents, and the remaining percentages were, respectively, 40.2% and 36.7% of adolescents belonging to the moderate and low-risk groups. Moreover, factors including age, living alone, high Kessler psychological distress scale, excessive time on the internet, living in central cities, and high neighborhood disorder scores were found to be related to moderate- and high-risk internet addiction profiles. CONCLUSIONS: Factors analyzed according to individual and social characteristics further explore the reasons underlying increasing internet addiction among Vietnamese youths and inform early interventions.

Robotic-assisted Versus Laparoscopic Radical Prostatectomy: 12-month Outcomes of the Multicentre Randomised Controlled LAP-01 Trial.

BACKGROUND: Recently, our LAP-01 trial demonstrated superiority of robotic-assisted laparoscopic radical prostatectomy (RARP) over conventional laparoscopic radical prostatectomy (LRP) with respect to continence at 3 mo. OBJECTIVE: To compare the continence, potency, and oncological outcomes between RARP and LRP in the 12-mo follow-up. DESIGN, SETTING, AND PARTICIPANTS: In this multicentre, randomised, patient-blinded controlled trial, patients referred for radical prostatectomy to four hospitals in Germany were randomly assigned (3:1) to undergo either RARP or LRP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Continence was assessed as a patient-reported outcome through validated questionnaires. Secondary endpoints included potency and oncological outcomes. Data were statistically analysed by bivariate tests and multivariable models. RESULTS AND LIMITATIONS: At 12 mo, follow-up data were available for 701 of 782 patients. Continence at 6 and 12 mo after surgery was better in RARP patients, however no longer statistically significant (p = 0.068 and 0.38, respectively). Patients who were potent at baseline and underwent nerve-sparing surgery reported significantly higher potency after RARP, as defined by the capability to maintain an erection sufficient for intercourse at 3 (p = 0.005), 6 (p = 0.018), and 12 mo (p = 0.013). There were no statistically significant differences in oncological outcomes at 12 mo. It is a limitation that the influence of different anastomotic techniques was not investigated in this study. CONCLUSIONS: Both LRP and RARP offer a high standard of therapy for prostate cancer patients. However, robotic assistance offers better functional outcomes in specific areas such as potency and early continence in patients who are eligible for nerve-sparing RP. PATIENT SUMMARY: We compared outcomes 12 mo after radical prostatectomy between robotic-assisted and conventional laparoscopy. Both methods were equivalent with respect to oncological outcomes. Better recovery of continence in patients with robotic-assisted surgery, which was observed at 3 mo, blurred up to 12 mo. A benefit of robotic-assisted surgery was also observed in potency.

Parent-Child Relationship Quality and Internet Use in a Developing Country: Adolescents' Perspectives.

Objective: The goal of the study was to explore the relationship between parent-children relationships related to using the internet among kids and potentially associated factors. Materials and Methods: A sample of 1.216 Vietnamese students between the ages of 12 and 18 agreed to participate in the cross-sectional online survey. Data collected included socioeconomic characteristics and internet use status of participants, their perceived changes in relationship and communication between parents and children since using the internet, and parental control toward the child's internet use. An Ordered Logistic Regression was carried out to determine factors associated with parent-children relationship since using the internet. Results: The characteristics of the relationship between children and their parents since using the Internet were divided into three levels: deterioration (7.0%), stability (78.2%), and improvement (14.8%). The topics that children most often communicate with their parents include learning, housework, and future directions. Two-way interactive activities, such as supporting parents to use the Internet, have a positive impact on the parent-child relationship. Stubborn parental control, such as establishing rules about contact or allowing Internet access and setting up global positioning system (GPS) to track negatively affecting parent-child relationships. Conclusion: Findings indicated that changes in the quality of the parent-child relationship were self-assessed by participants regard to kids' internet use, especially in the COVID-19 epidemic context. Educational campaigns and programs to raise awareness of parents as to the dangers and negative influences that their children may encounter online, psychology of children's behaviors and effects of different responding strategies are recommended.

Determinants of mental health among youths and adolescents in the digital era: Roles of cyber and traditional bullying, violence, loneliness, and environment factors.

Introduction: Although the pathogenesis of depressive disorders is not fully elucidated, untreated adolescent depression can lead to serious sequelae such as impaired academic performance and social functioning, substance use disorders, poor self-esteem, and increased risk for suicidal ideation and attempts. Literature on adolescent mental health in Vietnam is limited, despite increased international awareness of this critical issue. This study aimed to investigate the prevalence and associations of depressive symptoms in Vietnamese adolescents. Methods: A cross-sectional, self-administered survey was conducted in five provinces of Vietnam among adolescents aged 14 to 24 years. In addition to collecting participants' demographics, a structured questionnaire was developed to examine depressive symptoms, suicidal ideation, loneliness, and cyberbullying victimization. Depressive symptoms and loneliness were assessed via the PHQ-9 and UCLA Loneliness Scale, respectively. Two-tailed Chi-squared, Mann-Whitney, and Kruskal-Wallis tests were performed to examine associations between variables. Multivariate Logistic regression models were conducted to examine the associations between prior-defined variables and positive depressive symptoms. Results: Among 1,600 respondents, 31.8% of participants reported having mild-moderate or severe depressive symptoms. Participants within the moderate-severe depressive symptom group had significantly lower community cohesion scores than those of participants in normal and mild depressive symptom groups (p < 0.05). Youths living alone were more likely to have moderate-severe depressive symptoms (OR 2.16; 95% CI: 1.09-4.25). Cyberbullying had significant associations with depressive severity (OR 1.93; 95% CI 1.38-2.70). Conclusion: The findings of this study characterize various risk and protective factors for depression in Vietnamese youths and adolescents. The results highlight the importance of raising awareness and increasing access to educational resources for depression and other mental health illnesses. With the rising prevalence of depression, parents, teachers, and community leaders play a vital role in addressing mental health problems in adolescents.

Robotic-assisted Versus Laparoscopic Surgery: Outcomes from the First Multicentre, Randomised, Patient-blinded Controlled Trial in Radical Prostatectomy (LAP-01).

BACKGROUND: The LAP-01 trial was designed to address the lack of high-quality literature comparing robotic-assisted (RARP) and laparoscopic (LRP) radical prostatectomy. OBJECTIVE: To compare the functional and oncological outcomes between RARP and LRP at 3 mo of follow-up. DESIGN, SETTING, AND PARTICIPANTS: In this multicentre, randomised, patient-blinded controlled trial, patients referred for radical prostatectomy to four hospitals in Germany were randomly assigned (3:1) to undergo either RARP or LRP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was time to continence recovery at 3 mo based on the patient's pad diary. Secondary outcomes included continence and potency as well as quality of life in addition to oncological outcomes for up to 3 yr of follow-up. Time to continence was analysed by log-rank test and depicted by the Kaplan-Meier method. Continuous measurements were analysed by means of linear mixed models. RESULTS AND LIMITATIONS: A total of 782 patients were randomised. The primary endpoint was evaluable in 718 patients (547 RARPs; full analysis set). At 3 mo, the difference in continence rates was 8.7% in favour of RARP (54% vs 46%, p = 0.027). RARP remained superior to LRP even after adjustment for the randomisation stratum nerve sparing and age >65 yr (hazard ratio = 1.40 [1.09-1.81], p = 0.008). A significant benefit in early potency recovery was also identified, while similar oncological and morbidity outcomes were documented. It is a limitation that the influence of different anastomotic techniques was not investigated in this study. CONCLUSIONS: RARP resulted in significantly better continence recovery at 3 mo. PATIENT SUMMARY: In this randomised trial, we looked at the outcomes following radical prostate surgery in a large German population. We conclude that patients undergoing robotic prostatectomy had better continence than those undergoing laparoscopic surgery when assessed at 3 mo following surgery. Age and the nerve-sparing technique further affected continence restoration.

Four-point Peritoneal Flap Fixation in Preventing Lymphocele Formation Following Radical Prostatectomy.

BACKGROUND: Symptomatic lymphocele following radical prostatectomy (RP) and concomitant bilateral extended pelvic lymph node dissection (ePLND) has a significant impact on postoperative recovery and may sometimes require surgical intervention. OBJECTIVE: To report on the use of four-point peritoneal flap fixation (4PPFF) during RP to reduce lymphocele occurrence following PLND. DESIGN, SETTING, AND PARTICIPANTS: Between April 2010 and May 2017, 1358 patients underwent RP with concomitant bilateral ePLND. From this cohort, 193 patients who had undergone PNLD with 4PPFF were matched in a 1:1 ratio with respect to age, body mass index, initial PSA, and number of lymph nodes removed to patients who had undergone PLND without 4PPFF. INTERVENTION: 4PPFF was performed by suturing the cut end of the ventral parietal peritoneum at four points (to the anterior and lateral pelvic side wall on both sides) following PLND so that the peritoneal surface was exposed to the iliac vessels and obturator fossa. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: All patients underwent ultrasound on postoperative days 6, 28, and 90 to test for the presence of lymphocele. For univariate analysis, a χ2 test and analysis of variance were applied, as appropriate. Statistical significance was set at p<0.05, and all p values reported were two-sided. RESULTS AND LIMITATIONS: There were no significant differences between the two groups with respect to intraoperative blood loss, positive surgical margin rate, Gleason score, clinical stage, and number of positive cores. Asymptomatic lymphocele was observed in four patients (2.07%) in the 4PPFF group compared to 16 patients (8.3%) without 4PPFF (p=0.0058). Similarly, a significant difference in the incidence of symptomatic lymphocele was observed: two patients (1.03%) in the 4PPFF group versus nine patients (4.6%) without 4PPFF (p=0.0322). There were no differences in other complication rates between the two groups. The limitations of the study are its retrospective and nonrandomised nature, with postoperative follow-up based on ultrasound imaging rather than computed tomography because of ethical considerations, which could have caused observer bias. CONCLUSIONS: 4PPFF is a safe and effective procedure in preventing lymphocele occurrence in patients undergoing RP with PLND. The increase in exposure of the PLND raw area to the peritoneal surface following this procedure may aid in increased absorption of accumulating lymph fluid. Further prospective randomised multicentre studies are warranted to confirm our observations. PATIENT SUMMARY: We report on the use of a surgical technique to decrease the collection of lymphatic fluid in the abdominal cavity following lymph node removal during radical removal of the prostate gland in patients with prostate cancer. Patients undergoing this procedure had significantly better outcomes when compared to patients operated on in the conventional approach.

Minimally invasive partial cystectomy with bilateral vesico-ureteric junction resection and reimplantation for a large paraganglioma involving urinary bladder trigone.

Paragangliomas are neuroendocrine tumours of extra adrenal origin. Although it occurs rarely in the genitourinary system, urinary bladder is the most common site. Its diagnosis warrants complete surgical excision with lymphadenectomy in case of metastatic disease. The functional status of this tumour makes intraoperative handling challenging. Surgical resection necessitates minimal manipulation of tumour thereby mitigating intraoperative physiological jeopardy. We report the possibility of minimally invasive partial cystectomy with bilateral vesico-ureteric junction resection and re-implantation for non-malignant paraganglioma involving the bladder trigone. Intraoperative frozen section is deemed necessary to achieve tumour free margin status.

Previous laparoscopic inguinal hernia repair does not adversely affect the functional or oncological outcomes of endoscopic extraperitoneal radical prostatectomy.

OBJECTIVE: To investigate whether previous laparoscopic inguinal hernia repair (LIHR) affected adversely key outcome measures in radical prostatectomy, including perioperative data, pathologic data, complications, potency, continence, and prostate-specific antigen (PSA). We have shown previously that LIHR does not preclude safe endoscopic extraperitoneal radical prostatectomy (EERPE). METHODS: EERPE is the standard approach to radical prostatectomy in our unit. Between 2001 and June 2009 we encountered 92 patients who had previously undergone LIHR who underwent our standard technique of EERPE other than modification of port placement and development of the extraperitoneal space. We recorded our standard perioperative/postoperative dataset. Twelve-month follow-up data were available from 75 of 92 patients with 6-month follow-up of the remaining 17. RESULTS: Fifty-nine patients had undergone previous unilateral total extraperitoneal hernioplasty (TEP): 16 bilateral TEP, 15 unilateral transabdominal extraperitoneal hernioplasty (TAPP), and 2 bilateral TAPP. Although we needed to modify our technique, there was no increase in our operative time (153 minutes). Where indicated, we were able to perform bilateral nerve sparing and pelvic lymphadenectomy on the contralateral side to the LIHR. There were no major complications and no blood transfusions. Our positive margin rate, continence, and potency rates did not differ from our series of 2000 consecutive EERPEs. Ninety-four-point-seven percent of men had an undetectable PSA at 12 months. CONCLUSIONS: LIHR does not adversely affect perioperative and key outcome measures in EERPE.