Robot-assisted vs open retropubic radical prostatectomy: a propensity score-matched comparative analysis based on 15 years and 18,805 patients.

PURPOSE: To compare oncological, functional, and surgical outcomes of a large cohort of patients who underwent open retropubic radical prostatectomy (ORP) or robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: Data from 18,805 RPs performed with either the open or the robot-assisted approaches at a single tertiary referral center between 2008 and 2022 were analyzed. The impact of surgical approach on biochemical recurrence-free survival, salvage radiotherapy-free survival, and metastasis-free survival was analyzed by log-rank test and Kaplan-Meier analysis in a propensity score (PS)-based matched cohort. Intraoperative and postoperative surgical outcomes were assessed. One-week, 3-month, and 12-month continence rates and 12-month erectile function (EF) were analyzed. RESULTS: No statistically significant differences in oncological outcomes were found between ORP and RARP. A slight statistically significant difference in favor of RARP was noted in urinary continence at 3 months (RARP vs. ORP: 81% vs. 77%, p = 0.007) and 12 months (91% vs. 89.3%, p = 0.008), respectively. The rate of EF was statistically significantly higher (60%) after RARP than after ORP (45%, p < 0.001). CONCLUSION: Both RARP and ORP yielded similar oncological outcomes. RARP offered a slight advantage in terms of continence recovery, but its clinical significance may be less meaningful. RARP resulted in significantly improved postoperative EF, suggesting a potential influence of both surgical experience and minimally invasive approach.

Impact of COVID-19 on the time to counseling and treatment of prostate cancer.

PURPOSE: This study investigates how the COVID-19 pandemic (CP) impacted the timeline between initial diagnosis (ID) of prostate carcinoma and subsequent therapy consultation (TC) or radical prostatectomy (RP) due to the implementation of a "minimal contact concept," which postponed clinical examinations until the day of admission. METHODS: We analyzed patient data from a tertiary care center from 2018 to September 2021. The focus was on comparing the time intervals from ID to TC and from ID to RP before and during the CP. RESULTS: Of 12,255 patients, 6,073 (61.6%) were treated before and 3,791 (38.4%) during the CP. The median time from ID to TC reduced from 37 days (IQR: 21 - 58d) pre-CP to 32 days (IQR: 20 - 50d) during CP (p < 0.001). Similarly, the time from ID to RP decreased from 98 days (IQR: 70 - 141d) to 75 days (IQR: 55 - 108d; p < 0.001) during the CP. There was a significant decrease in low-risk tumor cases at ID (18.9% vs. 21.4%; p = 0.003) and post-RP (4% vs. 6.7%; p < 0.001) during the CP. CONCLUSION: Our findings suggest that the COVID-19 pandemic facilitated more timely treatment of prostate cancer, suggesting potential benefits for both low-risk and aggressive tumor management through expedited clinical procedures.

Feasibility, acceptability, and behavioral outcomes of a multimodal intervention for prostate cancer patients: Experience from the MARTINI lifestyle program.

BACKGROUND: Prostate cancer (PCa) is the most frequently diagnosed malignant tumor in men. The potential benefit of a healthy lifestyle contrasts sharply with the observed poor adherence to current international lifestyle guidelines. Thus, well-designed sustainable interventions of aftercare that can be translated into routine practice are highly recommended. The present pilot study aimed to evaluate the feasibility and acceptability of a multimodal lifestyle intervention program in PCa patients after radical prostatectomy (RP). METHODS: In a single-arm study, carried out at the Martini-Klinik of the University Medical Center Hamburg-Eppendorf, Germany, 59 eligible men with locally advanced PCa were recruited within 3-6 months after RP and assigned to a multimodal lifestyle program. The program consisted of 10 weekly 6-7 h course days, with a focus on dietary control, physical activity (per World Cancer Research Fund recommendations) and psychological support. Primary objectives were feasibility, acceptability, completion rate, and safety. In addition, changes in lifestyle, psychological well-being, clinical and laboratory values were assessed. The study was registered in the German Clinical Trials Register (No. DRK S00015288 [MARTINI-Lifestyle-cohort] [www.germanctr.de]). RESULTS: A high program acceptance was observed. Only three participants (5%) dropped out of the program prematurely. Personal feedback reflected appreciation for participation, personal gain through new knowledge and through the group experience. Without exception, all participants have taken part in follow-up examinations and no adverse events or incidents occurred. In addition, changes in lifestyle habits, clinical parameters and improved quality of life were detected. CONCLUSION: The MARTINI lifestyle program appears feasible and safe, and acceptance of the multimodal intervention was high among PCa patients. These encouraging results favor conducting a large multicenter trial to implement the program into routine practice and to evaluate the effectiveness of the intervention on survival and quality of life.

Outcome of patients with epithelialized cavity formation after excessive vesicourethral anastomotic leak post radical prostatectomy.

PURPOSE: Excessive vesicourethral anastomotic leak (EVAL) is a rare but severe complication after radical prostatectomy (RP). Epithelialized vesicourethral cavity formation (EVCF) usually develops during prolonged catheterization. To our knowledge, there is no description of postoperative outcomes, complications, or functional assessment of these patients who received conservative therapy after EVAL. METHODS: We identified 70 patients (0.56%) with radiographic evidence of EVCF out of 12,434 patients who received RP in 2016-2020 at our tertiary care center. Postoperative radiographic cystograms (CG) were retrospectively re-examined by two urologists individually. We assessed urinary continence (UC), the need for intervention due to anastomotic stricture formation, urinary tract infection (UTI), and symphysitis during the first year of follow-up post-RP. RESULTS: The median age was 66 years [interquartile range (IQR) 61-70 years], the median body mass index was 27.8 kg/m2 (IQR 25.5-30.3 kg/m2), and the median prostate specific antigen before RP was 7.1 ng/ml (IQR 4.7-11.8 ng/ml). The median catheter insertion time was 44.5 days (IQR 35.2-54 days). One-year continence follow-up was available for 27 patients (38.6%), of which 22 (81.5%) reported the use of ≤ one pad, two patients reported the use of two (7.4%) pads/24 h, and three (11.1%) patients reported use > two pads/24 h. Overall, four (5.7%) patients needed surgical reintervention for anastomotic stricture, eight (11.5%) patients presented with symphysitis, and 55 (77.1%) presented with UTI. CONCLUSION: UC in 81.5% 1-year post-RP suggests that conservative treatment in EVAL is a treatment option with an acceptable outcome on UC and should be considered before reintervention for anastomotic insufficiency.

Advances, Limitations and Future Challenges in the Management of Immunotherapy for Hematological Diseases and Solid Tumors.

Our immune system is able to attack cancer cells by recognizing cellular mistakes and destroying them [...].

New strategy for the identification of prostate cancer: The combination of Proclarix and the prostate health index.

OBJECTIVES: Prostate health index (PHI) and, more recently, Proclarix have been proposed as serum biomarkers for prostate cancer (PCa). In this study, we aimed to evaluate Proclarix and PHI for predicting clinically significant prostate cancer (csPCa). PATIENTS AND METHODS: Proclarix and PHI were measured using samples of 344 men from two different centers. All patients underwent prostate biopsy, and among those, 188 men with PCa on biopsy had an additional radical prostatectomy (RP). All men had a prostate-specific antigen (PSA) between 2 and 10 ng/ml. Evaluation of area under the curve (AUC) and performance at predefined cut-offs of Proclarix and PHI risk scores as well as the linear combination thereof was performed to predict csPCa. PSA density was used as an independent comparator. RESULTS: The cohort median age and PSA were 65 (interquartile range [IQR]: 60-71) and 5.6 (IQR: 4.3-7.2) ng/ml, respectively. CsPCa was diagnosed in 161 (47%) men based on the RP specimen. ROC analysis showed that Proclarix and PHI accurately predicted csPCa with no significant difference (AUC of 0.79 and 0.76, p = 0.378) but significantly better when compared to PSA density (AUC of 0.66, p < 0.001). When using specific cut-offs, Proclarix (cut-off 10) revealed higher specificity and positive predictive value than PHI (cut-off 27) at similar sensitivities. The combination of Proclarix and PHI provided a significant increase in the AUC (p ≤ 0.007) compared to the individual tests alone and the highest clinical benefit was achieved. CONCLUSION: Results of this study show that both Proclarix and PHI accurately detect the presence of csPCa. The model combining Proclarix and PHI revealed the synergistic effect and improved the diagnostic performance of the individual tests.

Significant reduction of lymphoceles after radical prostatectomy and pelvic lymph node dissection.

OBJECTIVES: To reduce the risk of symptomatic lymphocele (SLC), we present a technique using peritoneal fenestration that allows lymphatic fluid to drain into the abdomen, as SLC formation after open retropubic radical prostatectomy (ORP) with pelvic lymph node dissection (PLND) is a common adverse event. PATIENTS AND METHODS: We identified 1513 patients who underwent ORP with PLND between July 2018 and November 2019. Of those, 307 patients (20.3%) received peritoneal fenestration and 1206 (79.7%) no fenestration. The rate of LCs and the necessity for intervention were analysed by uni- and multivariable logistic regression (MLR) models. A propensity score matching was performed, as well. RESULTS: The median (interquartile range [IQR]) age was 65 (60-70) years. A median (IQR) of 16 (10-22) lymph nodes were dissected, 22 vs 14 lymph nodes in the fenestration vs non-fenestration group (P < 0.001). Overall, 189 patients (12.5%) were diagnosed with a LC after ORP, while 21 patients (6.8%) in the fenestration and 168 (13.9%) in the non-fenestration group had LCs (P = 0.001). In 70 patients (4.7%), LCs required further intervention, categorised as Clavien-Dindo Grade IIIa/b, with a smaller proportion in the fenestration group (2.9% vs 5.0% in the non-fenestration group, P < 0.001). There were no Clavien-Dindo Grade IV or V complications, in particular no abdominal complications in association with peritoneal fenestration observed. In MLR, peritoneal fenestration was associated with a reduced risk of LCs (odds ratio [OR] 0.33, 95% confidence interval [CI] 0.2-0.5; P < 0.001). The risk reduction was also shown after propensity score matching (OR 0.38, 95% CI 0.21-0.68; P = 0.001). The number needed to treat was 14. CONCLUSIONS: Peritoneal fenestration may decrease the rate of SLC after ORP with (extended) PLND. Therefore, it should be part of the operative strategy.

Evaluation of Risk Factors for Adverse Functional Outcomes after Radical Prostatectomy in Patients with Previous Transurethral Surgery of the Prostate.

INTRODUCTION: A history of transurethral surgery of the prostate is generally considered as a risk factor of adverse functional outcomes after radical prostatectomy (RP). We tested whether the risk of postoperative urinary incontinence (UIC) and erectile dysfunction (ED) after RP could be further substantiated in such patients. MATERIALS AND METHODS: We tested the effect of the following variables on UIC and ED rates 1 year after RP: residual prostate volume after transurethral desobstruction, the time from transurethral desobstruction to RP, the type of transurethral desobstruction (TURP vs. laser enucleation), age, and nerve-sparing surgery (yes vs. no). UIC was defined as usage of any pad except a safety pad. ED was defined as no sexual intercourse possible. RESULTS: Overall, 216 patients treated with RP between 2010 and 2019 in a tertiary care center were evaluated. All patients had previously undergone transurethral desobstruction. Regarding UIC analyses, only time from transurethral desobstruction to RP significantly influenced UIC rates (p = 0.003). Regarding ED rates, none of the tested variables reached statistical significance. CONCLUSION: The risk of UIC and ED after RP is substantial in men who had previously undergone transurethral desobstruction. The time from transurethral desobstruction to RP significantly impacts on the postoperative UIC rates. This observation should be further explored in future studies.

EGFR as a stable marker of prostate cancer dissemination to bones.

BACKGROUND: Prostate cancer (PCa) is among the most commonly diagnosed malignancies in men. Although 5-year survival in patients with localised disease reaches nearly 100%, metastatic disease still remains incurable. Therefore, there is a need for markers indicating metastatic dissemination. METHODS: EGFR overexpression (EGFRover) was tracked in 1039 primary tumours, circulating tumour cells from 39 d'Amico high-risk patients and metastatic samples from 21 castration-resistant PCa cases. EGFR status was compared to clinical parameters and multiple molecular factors were assessed using immunohistochemistry and gene ontology analysis. The functional aspect of EGFR was evaluated by plating PC-3 cells on soft and rigid matrices. RESULTS: EGFRover was found in 14% of primary tumours, where it was associated with shorter metastasis-free survival and was an independent indicator of worse overall survival. EGFRover correlated with a pro-migratory and pro-metastatic phenotype of tumour cells as well as rich collagen fibre content. All circulating tumour cells (detected in 13% of cases) were positive for EGFR, independent of their EMT-related phenotype. EGFRover was more prevalent in castration-resistant bone metastases (29% of patients) and supported growth of human PCa cells on rigid matrices mimicking bone stiffness. CONCLUSIONS: EGFRover is a stable, EMT-independent marker of PCa disseminating to rigid organs, preferentially bones.

Tumor-Associated Release of Prostatic Cells into the Blood after Transrectal Ultrasound-Guided Biopsy in Patients with Histologically Confirmed Prostate Cancer.

BACKGROUND: Transrectal ultrasound-guided prostate biopsy (TRUS) is a standard procedure for prostate cancer diagnosis. Because prostate cancer is a multifocal disease in many patients, multiple sampling (n ≥ 10) is required, which may bear the risk of systemic spread of cancer cells. DESIGN: Using the standardized CellSearch® system that allows for the detection of single epithelial cell adhesion molecule-positive circulating tumor cells (CTCs) in blood, we investigated whether prostate biopsy is associated with release of prostatic tumor cells into the circulation. Peripheral blood was obtained before and within 30 min after performing prostate biopsy from 115 men with increased serum prostate-specific antigen. RESULTS: The number of CTCs significantly increased after biopsy in men with histologically confirmed prostate cancer (odds ratio, 7.8; 95% CI, 4.8-12.8), whereas no biopsy-related changes could be detected in men without confirmed prostate cancer. Multivariable analysis showed that biopsy-related increase of CTCs was significantly correlated with a worse progression-free survival (hazard ratio, 12.4; 95% CI, 3.2-48.6) within the median follow-up of 41 months. CONCLUSIONS: Prostate biopsies may lead to a tumor-associated release of CTCs into the blood circulation. Larger confirmatory trials with longer follow-up periods are required before any change in clinical practice can be recommended.

Outcome of patients with newly diagnosed prostate cancer with low metastatic burden treated with radical prostatectomy: a comparison to STAMPEDE arm H.

PURPOSE: STAMPEDE arm H demonstrated a survival benefit for newly diagnosed prostate cancer (PCa) patients with low metastatic burden (LMB) who additionally received radiotherapy (RT) to the primary. However, it is unknown if radical prostatectomy (RP) may achieve equivalent results, since existing studies did neither include the same selection criteria nor examine comparable endpoints as STAMPEDE arm H. METHODS: We retrospectively analysed 78 RP patients (2008-2018) with LMB (< 4 bone metastases) as defined in the subgroup analysis of STAMPEDE arm H. Like in STAMPEDE, overall (OS), metastatic progression-free (MPFS), and PCa-specific (CSS) survival at 3 years, as well as complication and continence rates were assessed. RESULTS: Median age was 64 years. Median follow-up was 36 months. Median initial prostate-specific antigen was 35 ng/ml. At 3 years, OS was 91%, MPFS was 63%, and CSS was 92%, while 81%, 67%, and 86%, respectively, were reported in the RT subgroup with LMB in STAMPEDE arm H. Clavien-Dindo grade III-IV complications were observed in 16 (21%) patients. Of 38 patients with available continence data, 28 (74%) patients were continent and 2 (5%) patients needed ≥ 3 pads/day at 1 year after RP. CONCLUSIONS: When comparing our RP cohort with the results of STAMPEDE arm H with LMB who received RT, no major disadvantage in OS and CSS may be expected. Since local treatment in patients with LMB might now be considered the new standard, RP should be further explored as local treatment option in these patients.

Thrombospondin 1 and cathepsin D improve prostate cancer diagnosis by avoiding potentially unnecessary prostate biopsies.

OBJECTIVES: To investigate and further validate if two novel cancer-related glycoproteins, discovered by a genetic-guided proteomics approach, can distinguish benign disease from prostate cancer (PCa) in men with enlarged prostates. PATIENTS AND METHODS: A retrospective study was performed that included men with a total prostate-specific antigen (PSA) concentration of 2.0-10 ng/mL, negative digital rectal examination and enlarged prostate (volume ≥35 mL). Serum samples were collected between 2011 and 2016 at a single centre from 474 men before they underwent prostate biopsy. Serum concentrations of thrombospondin 1 (THBS1) and cathepsin D (CTSD) glycoproteins were combined with the percentage of free PSA to total PSA ratio (%fPSA) to predict any or significant cancer at biopsy. RESULTS: The multivariable logistic regression model including THBS1, CTSD and %fPSA discriminated among biopsy-positive and biopsy-negative patients in the validation set with an area under the curve (AUC) of 0.86 (P < 0.001, 95% confidence interval (CI) 0.82-0.91), while %fPSA alone showed an AUC of 0.64 (P < 0.001, 95% CI 0.57-0.71). At 90% sensitivity for PCa, the specificity of the model was 62%, while %fPSA had a specificity of 23%. For high grade (Gleason score ≥ 7 in prostatectomy specimen) PCa, the specificity was 48% at 90% sensitivity, with an AUC of 0.83, (P < 0.001, 95% CI 0.77 to 0.88). Limitations of the study include the retrospective set-up and single-centre cohort. CONCLUSIONS: A model combining two cancer-related glycoproteins (THBS1 and CTSD) and %fPSA can improve PCa diagnosis and may reduce the number of unnecessary prostate biopsies because of its improved specificity for PCa when compared to %fPSA alone.

A comparative study of robot-assisted and open radical prostatectomy in 10 790 men treated by highly trained surgeons for both procedures.

OBJECTIVE: To compare oncological, functional and surgical outcomes of open retropubic radical prostatectomy (ORP) vs robot-assisted laparoscopic radical prostatectomy (RARP). PATIENTS AND METHODS: We identified 10 790 consecutive treated patients within our prospective database (2008-2016) who underwent either ORP (7007 patients) or RARP (3783). All procedures were performed by seven highly trained surgeons performing both surgical approaches regularly. Oncological (48-month biochemical recurrence [BCR] rate), functional (urinary continence, erectile function), and surgical outcomes (rate of nerve-sparing [NS] procedures, lymph node yield, surgical margin [SM] status, length of hospital stay [LOS], operation time, blood loss, transfusion rate, time to catheter removal) were assessed. Kaplan-Meier, multivariable Cox and logistic regression models were used to test for BCR and functional outcome differences. RESULTS: No statistically significant difference regarding oncological outcome distinguished between ORP vs RARP. For functional outcomes, the 1-week continence rates were higher in the ORP group (25.8% vs 21.8%, P < 0.001). At 3 months, no statistically significant differences were observed. At 12 months, continence rates were modestly higher in the RARP group (90.3% vs 88.8%, P = 0.01). This effect was no longer observed after stratification for age-groups. The 12-month potency rates were similar in ORP vs RARP (80.3% vs 83.6%, P = 0.33). For surgical outcomes, there was no significant difference in the rates of NS procedures, lymph node yield, SM status, and LOS. Conversely, operation time was shorter in ORP, and blood loss, transfusion rates and time to catheter removal were significantly lower in RARP. CONCLUSIONS: Both surgical approaches, performed in a high-volume centre by the same surgeons, achieve excellent, comparable oncological and functional outcomes. However, a modest advantage for RARP for surgical outcomes was observed, most likely attributable to its minimally invasive nature, and better teaching capabilities. Consequently, more than the surgical approach itself, the well-trained surgeon remains the most important factor to achieve satisfactory outcomes.

Development and validation of a renal risk score in ANCA-associated glomerulonephritis.

Predicting renal outcome in antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis (GN) remains a major challenge. We aimed to identify reliable predictors of end-stage renal disease (ESRD) and to develop and validate a clinicopathologic score to predict renal outcome in ANCA-associated GN. In a prospective training cohort of 115 patients, the percentage of normal glomeruli (without scarring, crescents, or necrosis within the tuft) was the strongest independent predictor of death-censored ESRD. Regression tree analysis identified predictive cutoff values for three parameters: percentage normal glomeruli (N0 >25%, N1 10 to 25%, N2 <10%), percentage tubular atrophy and interstitial fibrosis (T0 ≤25%, T1 >25%), and estimated glomerular filtration rate at the time of diagnosis (G0 >15 ml/min/1.73 m2, G1 ≤15 ml/min/1.73 m2). Cox regression analysis was used to assign points to each parameter (N1 = 4, N2 = 6, T1 = 2, G1 = 3 points), and the resulting risk score was used to classify predicted ESRD risk as low (0), intermediate (2 to 7), or high (8 to 11 points). The risk score accurately predicted ESRD at 36 months in the training cohort (0%, 26%, and 68%, respectively) and in an independent validation cohort of 90 patients (0%, 27%, and 78%, respectively). Here, we propose a clinically applicable renal risk score for ANCA-associated GN that highlights the importance of unaffected glomeruli as a predictor of renal outcome and allows early risk prediction of ESRD.

Prostate cancer rates in patients with initially negative elastography-targeted biopsy vs. systematic biopsy.

PURPOSE: To assess whether real-time elastography-targeted biopsy (RTE-bx) is superior to the standard systematic transrectal ultrasound (TRUS)-guided biopsy in predicting subsequent prostate cancer (PCa) rates in patients with initially negative biopsy and to specifically reveal differences in the occurrence of high-grade (Gleason ≥ 4 + 3) PCa by comparing both biopsy methods. PATIENTS AND METHODS: Overall, 630 patients had an initially negative prostate biopsy between 2007 and 2015, either RTE targeted (n = 213) or systematically (n = 417). Follow-up data, ascertained by a questionnaire, of patients receiving RTE-bx were compared to data of patients receiving systematic biopsy (sbx) using Mann-Whitney-U test and Chi-square test. We performed logistic regression analyses to assess any association with PCa or high-grade PCa occurrence. RESULTS: In total, 258 (41%) patients were diagnosed with PCa at repeat biopsy whereof 54 (8.6%) harboured high-grade PCa. PCa occurred in 95 (44.6%) patients with initially negative RTE-bx and in 163 (39.1%) patients with initially negative sbx (p = 0.003). 24 (11.3%) patients receiving RTE-bx and 30 (7.2%) patients receiving sbx were diagnosed with high-grade PCa (p = 0.095). Logistic regression analyses showed that patients with the initial RTE-bx vs. those with the initial sbx neither resulted in a significant higher risk for PCa occurrence (OR 1.35 [CI 0.87-2.1]; p = 0.2) nor for high-grade PCa occurrence (OR 1.52 [CI 0.66-3.35]; p = 0.3). CONCLUSIONS: We found no statistically significant association of prior biopsy method to subsequent PCa or high-grade PCa occurrence. Referring to our analyses, RTE is not superior to sbx in predicting subsequent PCa rates and, therefore, not eligible to decide on repeat biopsy.

Obesity paradox in prostate cancer: increased body mass index was associated with decreased risk of metastases after surgery in 13,667 patients.

INTRODUCTION: Obesity might negatively affect prostate cancer (PCa) outcomes. However, evidence according to the associations between obesity and metastases-free survival after radical prostatectomy (RP) is still inconsistent. METHODS: We relied on PCa patients treated with RP at the Martini-Klinik Prostate Cancer Center between 2004 and 2015. First, multivariable Cox regression analyses examined the impact of obesity on metastases after RP. Last, in a propensity score matched cohort, Kaplan-Meier analyses assessed metastases-free survival according to body mass index (kg/m2) (BMI) strata (≥ 30 vs. < 25). RESULTS: Of 13,667 individuals, 1990 (14.6%) men were obese (BMI ≥ 30). Median follow-up was 36.4 month (IQR 13.3-60.8). Obese patients were less likely to exhibit metastases after RP (HR 0.7, 95% CI 0.5-0.97, p = 0.03). Similarly, after propensity score adjustment, obesity was associated with increased metastases-free survival (log rank p = 0.001). CONCLUSION: We recorded the obesity paradox phenomenon in PCa patients. In particular, high BMI (≥ 30) was associated with decreased risk of metastases after RP, despite an increased risk being anticipated. Whether statin use might have affected the results was not assessed. Further research is needed to unravel the controversially debated association between obesity and PCa.

The Impact of Repeat Prostate Biopsies on Oncologic, Pathological and Perioperative Outcomes after Radical Prostatectomy.

PURPOSE: The impact of repeat biopsy sessions on radical prostatectomy remains controversial regarding perioperative, pathological and oncologic outcome. MATERIALS AND METHODS: We analyzed the records of 12,624 patients who underwent radical prostatectomy from 2007 to 2013. The association of the number of biopsy sessions (range 1 to 3 or more) with pathological outcomes and perioperative complications was analyzed using the Wilcoxon matched pair test. To test the association between biopsy sessions and biochemical recurrence-free survival we used Kaplan-Meier curves and multivariable Cox regression analysis. RESULTS: Of the patients 89.2% had 1 biopsy session, 7.4% had 2 sessions and 3.4% had 3 or more sessions. Median followup was 36.6 months. In patients with 1, 2 and 3 or more biopsy sessions prostate volume (38, 44 and 45 ml) and prostate specific antigen (6.7, 7.6 and 10.1 ng/ml, respectively) were greater (each p <0.001). The perioperative outcome was more favorable. Patients with 1, 2 and 3 or more biopsy sessions more often had organ confined tumors (67.6%, 72.1% and 72.9%, p = 0.003) and higher tumor volume (3.1, 3.0 and 3.6 ml, p <0.001) but a lower tumor percent (7.5%, 3.7% and 2.4%, respectively, p <0.001). More biopsy sessions were associated with fewer lymph node metastases (1, 2 and 3 sessions 0.23, 0.13 and 0.17, respectively, p <0.001). Gleason score and surgical margin status did not differ. The overall biochemical recurrence rate was 18.9% and it was comparable among the biopsy groups. No association was found between the number of biopsies and biochemical recurrence. CONCLUSIONS: Patients with multiple biopsy sessions experience a slightly more favorable pathological outcome without an impact on the oncologic outcome. The perioperative outcome was more favorable in patients with multiple biopsies.

Defining biochemical recurrence after radical prostatectomy and timing of early salvage radiotherapy : Informing the debate.

BACKGROUND: The optimal prostate-specific antigen (PSA) level after radical prostatectomy (RP) for defining biochemical recurrence and initiating salvage radiation therapy (SRT) is still debatable. Whereas adjuvant or extremely early SRT irrespective of PSA progression might be overtreatment for some patients, SRT at PSA >0.2 ng/ml might be undertreatment for others. The current study addresses the optimal timing of radiation therapy after RP. PATIENTS AND METHODS: Cohort 1 comprised 293 men with PSA 0.1-0.19 ng/ml after RP. Cohort 2 comprised 198 men with SRT. PSA progression and metastases were assessed in cohort 1. In cohort 2, we compared freedom from progression according to pre-SRT PSA (0.03-0.19 vs. 0.2-0.499 ng/ml). Multivariable Cox regression analyses predicted progression after SRT. RESULTS: In cohort 1, 281 (95.9%) men had further PSA progression ≥0.2 ng/ml and 27 (9.2%) men developed metastases within a median follow-up of 74.3 months. In cohort 2, we recorded improved freedom from progression according to lower pre-SRT PSA (0.03-0.19 vs. 0.2-0.499 ng/ml: 69 vs. 53%; log-rank p = 0.051). Patients with higher pre-SRT PSA ≥0.2 ng/ml were at a higher risk of progression after SRT (hazard ratio: 1.8; p < 0.05). CONCLUSION: The vast majority of patients with PSA ≥0.1 ng/ml after RP will progress to PSA ≥0.2 ng/ml. Additionally, early administration of SRT at post-RP PSA level <0.2 ng/ml might improve freedom from progression. Consequently, we suggest a PSA threshold of 0.1 ng/ml to define biochemical recurrence after RP.

Adjuvant radiation therapy is associated with better oncological outcome compared with salvage radiation therapy in patients with pN1 prostate cancer treated with radical prostatectomy.

OBJECTIVE: To analyse the comparative effectiveness of no treatment (NT) or salvage radiation therapy (sRT) at biochemical recurrence (BCR) vs adjuvant radiation therapy (aRT) in patients with lymph node (LN)-positive prostate cancer (PCa) after radical prostatectomy (RP). PATIENTS AND METHODS: A total of 773 patients with LN-positive PCa at RP, with or without additional radiation therapy (RT), in the period 2005-2013, were retrospectively analysed. Cox regression analysis was used to assess factors influencing BCR and metastasis-free survival (MFS). Propensity score-matched analyses were performed. RESULTS: The median follow-up for the entire patient group was 33.8 months. Four-year BCR-free and MFS rates were 43.3% and 86.6%, respectively, for all patients. In multivariate analysis, NT/sRT (n = 505) was an independent risk factor for BCR and metastasis compared with aRT (n = 213). The superiority of aRT was confirmed after propensity score matching. The 4-year MFS in the matched cohort was 82.5% vs 91.8% for the NT/sRT and aRT groups, respectively (P = 0.02). Early sRT (pre-RT prostate-specific antigen [PSA] ≤0.5 ng/mL) compared with sRT at PSA >0.5 ng/mL was significantly associated with a lower risk of metastasis. CONCLUSION: Patients with LN-positive PCa who received aRT had a significantly better oncological outcome than patients with NT/sRT, independent of tumour characteristics. Patients with early sRT had higher rates of response and better MFS than patients with pre-RT PSA >0.5 ng/mL.

Impact of surgeon-defined capsular incision during radical prostatectomy on biochemical recurrence rates.

PURPOSE: To determine the impact of intraoperative surgeon-defined incision of the prostatic capsule (CapI) on cancer recurrence and to give an overview of the different definitions of CapI. CapI during radical prostatectomy (RP) occurs in a non-negligible number of patients; still, its impact on biochemical recurrence (BCR) remains controversial as definition of CapI differs in literature. METHODS: We analyzed the data of 3253 consecutive RP between 2009 and 2011. Occurrence and side of intraoperative CapI was documented by the surgeon. Factors influencing CapI were addressed using logistic regressions. The impact of CapI on BCR was analyzed using Cox regressions including traditional prognosticators. RESULTS: Median follow-up was 36.2 months. Unilateral (bilateral) CapI occurred in 22.2 % (12.1 %) of patients. CapI was reported more often following open RP (p < 0.0001) and nerve-sparing procedure (p = 0.0004). Three-year BCR-free survival was 78.8, 79.9 and 82.1 % (p = 0.13) for patients with no, unilateral and bilateral CapI. In multivariate analysis, pT-stage (p < 0.0001), Gleason grade (p < 0.0005) and nodal status (p < 0.0005) were significantly associated with BCR. However, CapI had no independent impact on BCR (unilateral vs. no CapI, p = 0.55, bilateral vs. no CapI, p = 0.32). CONCLUSIONS: Intraoperative CapI occurs in a relevant number of RP and is more frequent during nerve-sparing procedure and open RP. However, there seems to be no impact of CapI and its extent on the incidence of early BCR.