Comparison of Adjuvant Chemotherapy for Upper Tract versus Lower Tract Urothelial Carcinoma: A Systematic Review and Meta-Analysis.

INTRODUCTION: Principles of management for upper tract urothelial carcinoma (UTUC) are mostly derived from knowledge of lower tract urothelial carcinoma (LTUC), however recent research indicates that these may be disparate diseases. In this review, we sought to compare the responsiveness of these tumors to similar treatment, platinum-based chemotherapy used in the adjuvant setting. MATERIALS AND METHODS: PubMed, EMBASE, and Web of Science were searched using a systematic search strategy. Disease-free survival (DFS), cancer-specific survival (CSS) and overall survival (OS) in patients with LTUC and UTUC treated with adjuvant chemotherapy were compared. Review Manager V 5.3 was used for meta-analyses. RESULTS: Adjuvant chemotherapy was associated with improved DFS (HR 0.41, 95%CI 0.31-0.54), CSS (HR 0.29, 95%CI 0.17-0.50) and OS (HR 0.51, 95%CI 0.38-0.70) rates in LTUC. The effectiveness of adjuvant chemotherapy in UTUC was less pronounced with respect to DFS (HR 0.61, 95%CI 0.1-0.93) and CSS (HR 0.70, 95%CI 0.56-0.90) rates, and there was no effect on OS (HR 0.87, 95%CI 0.69-1.10). Differences in CSS and OS were significant (p < 0.0001) in favor of adjuvant chemotherapy for LTUC versus UTUC. CONCLUSION: Despite similar histology, we found significant differences in responsiveness to adjuvant chemotherapy between LTUC and UTUC. This may add to the already growing knowledge that these are disparate diseases. Newer systemic treatments for urothelial carcinoma may prove more effective than platinum-based chemotherapy in the adjuvant setting for UTUC.

Outcomes following robotic-assisted laparoscopic prostatectomy: Pentafecta and Trifecta achievements.

BACKGROUND: Functional and oncologic outcomes following radical prostatectomy play a major role in patient satisfaction after treatment. This study was designed to assess the functional and oncologic outcome after robotic assisted radical prostatectomy (RARP) in a single surgeon series of patients. METHODS: A prospectively maintained database of patients undergoing robotic radical prostatectomy in a referral academic center was queried for functional and oncologic outcome. Patients undergoing RARP between 2010 and 2013 were included. Analysis was performed with SPSS and SAS, χ2, Mann-Whitney and t-test were used when appropriate. RESULTS: Overall, 566 patients were included in the analysis. The Trifecta and Pentafecta was 73.9% and 64.1%, respectively. Patients achieving Pentafecta were younger (P<0.001), had lower PSA level (P=0.04), lower Biopsy Gleason (P<0.01), lower risk prostate cancer (P<0.01) and fewer comorbidities (P=0.03). The patients were followed up for a median of 27.4 months in Trifecta and 20.6 months in Pentafecta group. At 12-month follow-up the continence and potency rate was 90.6% and 84.1%, respectively. CONCLUSIONS: Although preoperative counseling for RARP surgery using Pentafecta criteria offers more precise information and reasonable expectations than using the Trifecta, further research is required to prepare a standard reporting outline.

Abdominal Mass After Robotic Assisted Laparoscopic Prostatectomy: Spigelian Type Trocar Hernia.

Prostate cancer is the most common cancer in men. Men are diagnosed at early stages of prostate cancer with the use of prostate specific antigen. Surgical removal of the prostate is the standard treatment in localized prostate cancer. Complications after surgical procedures are inevitable. Although robotic prostatectomy has resulted in decreased complications compared to open surgery, complications occur. After an uneventful robotic assisted laparoscopic prostatectomy in a 71-year-old gentleman, with history of chronic cough and continued low dose glucocorticoid use, the patient returned to hospital with complain of a tender abdominal mass in right lower quadrant. After performing a computed tomography of the contrast, a Spigelian type trocar hernia was noted. The patient underwent a laparoscopic diagnostic surgery followed by small bowel resection and abdominal wall defect repair. The patient was discharged home with no other complains.

The Modulating Effects of Benign Prostate Enlargement Medications on Upgrading Predictors in Patients with Gleason 6 at Biopsy.

BACKGROUND: Upgrading following prostate biopsy is very common in clinical practice. This study investigated whether the use of 5-alpha reductase inhibitors (ARI) and alpha blockers affect known clinical predictors of Gleason score upgrading or not. MATERIALS AND METHODS: A retrospective study on 998 patients treated with robotic assisted laparoscopic prostatectomy for clinically localized biopsy Gleason score 6 prostate cancer were studied. The logarithm of prostate specific antigen concentration, prostate size and tumor volume were compared on the basis of the medication history of 5-ARIs and alpha blockers in the cohort of biopsy Gleason 6 patients with benign prostatic hyperplasia history, and patients whose prostate sizes fall in the top quartile. We compared known clinical and pathologic characteristics associated with upgrading in regression models with and without the addition of medications. RESULTS: Alpha blockers, but not 5-ARI were associated with a bigger prostate. Upgrading was associated with older age (OR 1.03, 95% CI 1.01-1.06), higher BMI (OR 1.00 CI 1.01-1.08), higher log prostate specific antigen (OR 7.32, CI 3.546-15.52), smaller prostate size (OR 0.97, CI 0.96-0.98), fewer biopsy cores (OR 0.96 CI 0.92-0.99), more positive cores (OR 1.20, CI 1.08-1.34), and higher percentage of tumor at biopsy (OR 1.02, CI 1.01-1.03). Neither of the two medication classes were a significant predictor of upgrading. Medications made minimal changes in the multivariate predictive models. CONCLUSION: Although, alpha blockers were associate with bigger prostate size, the modulating effects of alpha blockers and 5-ARIs on common predictors of Gleason score upgrading was not significant.

Heterogeneity of Outcomes in D'Amico Intermediate-Risk Prostate Cancer Patients after Radical Prostatectomy: Influence of Primary and Secondary Gleason Score.

AIM: The aim of this study was to clarify and examine the outcomes of prostate cancer patients classified as intermediate risk (IR) using the D'Amico risk classification system, specifically focusing on the influence of primary and secondary biopsy Gleason score (BGS). PATIENTS AND METHODS: An institutional review board-approved database of robotic-assisted radical prostatectomies performed after 2006 was stratified by standard D'Amico criteria. IR patients were then sub-stratified by BGS. Pathologic and intermediate-term biochemical disease-free survival (BDFS) outcomes were analyzed. RESULTS: Overall, 1,090 patients were classified as D'Amico low-risk, 896 as IR, and 240 as high-risk. Of the 896 IR patients, 63 had BGS 6, 630 were 3 + 4 = 7, and 203 4 + 3 = 7. Among IR patients, as the BGS increased, there was an increasing likelihood of extracapsular extension (21, 28, and 38%, respectively; p = 0.005), positive surgical margins (14, 26, 31%; p = 0.048), and worse 3-year BDFS (96, 94, 88%; p = 0.01). Multivariable logistic regression and Cox regression analyses confirmed differences among IR groups. CONCLUSION: D'Amico IR patients demonstrate significant heterogeneity in both pathologic outcomes and BDFS. IR patients with a BGS of 6 appear to have similar intermediate-term BDFS as low-risk patients. An increasing BGS from 3 + 3 to 3 + 4 to 4 + 3 results in a higher likelihood of locally-advanced disease and intermediate-term biochemical failure.

Preoperative Statin Use Associated With Lower PSA But Similar Prostate Size and Histopathologic Outcomes: Implications for Active Surveillance?

PURPOSE: The potential effects of statins on clinical and histopathologic variables, prostate size, or PSA density (PSAD) and resulting influences on active surveillance eligibility have not been adequately explored. This study examines the effect of statins on prostate specimens following prostatectomy. MATERIALS AND METHODS: Patients that received robotic-assisted laparoscopic prostatectomy (RALP) (n = 2,632) were dichotomized according to preoperative statin use. Logistic regression was used to evaluate associations between statin use and patient clinical and pathological characteristics. RESULTS: Men using statins at the time of prostatectomy were older (61.6 ± 6.4 versus 58.8 ± 7.2 years, P < .001), and had poorer health status (P < .001). Biopsy Gleason grade, clinical stage and prostate size were similar among the two groups, although statin users had lower diagnostic PSA levels (5.5 ± 3.6 versus 6.3 ± 4.9 ng/mL, P < .001) and PSAD (.12 versus .13, P = .001). CONCLUSION: Men taking statins at the time of prostatectomy had similar histopathologic characteristics to non-users, despite having significantly lower serum PSA, being older and having similar sized prostates. This supports prior studies suggesting a PSA reduction effect of statins may warrant consideration of statin usage in decisionalgorithms for active surveillance.

Robotic Assisted Laparoscopic Prostatectomy after High Intensity Focused Ultrasound Failure.

Background. Prostate cancer is the most common cancer diagnosed in men. As new focal therapies become more popular in treatment of prostate cancer, failure cases requiring salvage therapy with either surgical or other techniques are being reported. Objective. To report the options in treatment of prostate cancer after recurrence or failure of the primary treatment modality. Methods. We report a salvage robotic assisted laparoscopic radical prostatectomy (RALP) for prostate cancer recurrence following high intensity focused ultrasound treatment (HIFU) in the United States. Results. A 67-year-old man who underwent HIFU treatment for prostate adenocarcinoma 2 years prior was presented with a rising prostate specific antigen of 6.1 ng/mL to our clinic. A biopsy proven recurrent disease in the area of previous treatment documented the failure of treatment. The patient elected to undergo a salvage RALP. The operation time was 159 minutes. The patient was discharged from the hospital on postoperative day 1 with no complications. The catheter was removed on post-op day 10. The patient reserved sexual function and urinary continence. The PSA levels on 6 months' follow-up are undetectable. Conclusions. Salvage RALP is an effective and safe treatment choice for recurrent prostate adenocarcinoma following failed HIFU treatment if operated by an experienced surgeon.

Clinicopathological, functional, and immediate oncologic outcome assessment in men aged≤50 years with prostate cancer after robotic prostatectomy.

BACKGROUND: To define the pathologic and functional outcomes of men 50 years of age and younger with prostate cancer in a contemporary robotic cohort, this study was designed. METHODS: Patients undergoing robotic-assisted laparoscopic prostatectomy from April 2002 to April 2012 (n = 2,495) formed the base population for the current analyses. The patients were dichotomized according to their age≤50 (n = 271) and>50-year-old (n = 2,224). Clinicopathological and health-related quality-of-life outcomes were recorded and analyzed for differences. Propensity score matching was used when assessing urinary and sexual function outcome. RESULTS: Baseline prostate-specific antigen and clinical stage were similar between men older than 50 years and those younger. Younger patients had less severe disease (D׳Amico risk and Gleason scores) and smaller prostates. Young men had higher rates of erectile function at all time points, including baseline (94% vs. 83% at 12mo, P <0.01). Continence was similar at all time points except for 6 months, where younger patients experienced a faster return than older patients and then remained constant, while older patients continued to improve (96% vs. 89%, P<0.01). After matching process, the difference in erectile function at 6-month follow-up was lost. CONCLUSION: Most men aged 50 years and younger who received robotic-assisted laparoscopic prostatectomy had clinically significant prostate cancer. Although histopathologic and short-term oncologic outcomes were nearly identical when compared to older patients, younger men had a more rapid and superior return of erectile function.

Improvement of severe baseline lower urinary tract symptoms following robotic-assisted laparoscopic prostatectomy.

AIMS: This study was designed to assess lower urinary tract symptoms (LUTS) following robotic-assisted laparoscopic prostatectomy. METHODS: In a single surgeon series, 938 patients underwent robotic prostatectomy and completed International Prostate Symptom Score surveys at baseline and 6-month follow-up. Patients preoperative LUTS were categorized as mild, moderate, or severe according to the original International Prostate Symptom Score validation. Patient demographics, in addition to clinical and pathologic outcomes were obtained from an Institutional Review Board-approved database. RESULTS: Preoperatively, 55.8% of patients presented with mild, 36.4% with moderate, and 7.8% with severe LUTS. Increased prostate size trended with increased LUTS severity (P < 0.001). Patients who had severe preoperative LUTS witnessed a 57% reduction in International Prostate Symptom Score (from 24.1 to 10.7, P < 0.001). Men with moderate preoperative LUTS also witnessed a significant decrease in postoperative LUTS (from 12.1 to 8.3, P < 0.001). CONCLUSIONS: The majority of patients with moderate or severe LUTS improved significantly following robotic prostatectomy, with the largest improvements seen in the severe group. Prostate cancer patients with severe LUTS should be counseled on the beneficial role of robotic prostatectomy in an effort to improve their voiding dysfunction and as a viable cancer treatment.

Patient-perceived Causes of Prostate Cancer: Result of an Internet-based Survey.

OBJECTIVE: To assess patients' perceived causes of prostate cancer (PCa) and relation to treatment satisfaction, an Internet-based survey study was designed. PCa is a profoundly personal disease, considering the location and common sequelae of treatment. Deeply held patient self-perceptions regarding the etiology of a patient's PCa may generate lasting beliefs that impact satisfaction with treatment selection. MATERIALS AND METHODS: Third-party web-based surveys were sent to patients receiving radical prostatectomy for clinically localized PCa. Patients were queried regarding demographic characteristics, family history, socioeconomic status, sexual function, urinary control, and factors believed to cause their PCa. RESULTS: Among respondents (293 of 524, 55.9%), 237 (81.5%) provided primary causes for PCa. Evidence-based answers were provided by 128 (53.5%) patients, whereas a wide range of non-evidence-based responses were provided by 49 (20.5%) patients. Forty patients (16.7%) were undecided, and 20 (8.3%) offered belief-based responses. Evidence-based responses were more common in patients with a family history of PCa (P <.01); however, no significant differences were seen among race, educational level, or income. Patients providing an evidence-based cause of PCa were more likely to be potent (P <.01). Providing a non-evidence-based cause for PCa was associated with considering surgery as a wrong decision in treatment selection. CONCLUSION: Among men with localized PCa, there is a wide spectrum of patient beliefs regarding the etiology of their disease that may reflect background and information sources. Further research is warranted to determine whether patient counseling should incorporate these considerations.

Are magnetic resonance imaging undetectable prostate tumours clinically significant? Results of histopathological analyses.

OBJECTIVE: To investigate whether tumours at threshold values for detection on magnetic resonance imaging (MRI) represent clinically significant tumours or not, and therefore the utility of MRI in active surveillance (AS) protocols. PATIENTS AND METHODS: A retrospective analysis of a single institution database was performed after Institutional Review Board approval. Between 2010 and 2013, 1633 patients underwent robot-assisted laparoscopic prostatectomy (RALP) at a single institution by a single surgeon. Of these, 1361 had complete clinical data and were included in analysis. Multivariate logistic regression was used to assess histopathological grade compared to tumour size whilst controlling for biopsy Gleason score, prostate-specific antigen level, body mass index, race, and age. RESULTS: Of 120 tumours <5 mm in size, four were Gleason score 4 + 3. Of 276 tumours of 5-10 mm, 22 (8.1%) were Gleason score 4 + 3 and one (0.2%) was Gleason score 8. On multivariate regression analyses, tumours of <5 mm were much less likely to be high grade (Gleason score >3 + 4) at RALP compared to larger tumours (3.3% vs 25.1%, P < 0.001), or Gleason score ⩾8 (0.0% vs 7.6%, P < 0.001). Size was further shown to significantly correlate with grade on multivariate regression (P < 0.001). CONCLUSIONS: Prostate tumours below the detection threshold for MRI (5 mm) most probably represent clinically insignificant tumours, which alone would not necessitate leaving AS in favour of more aggressive therapy. These findings point to a possible role of MRI in modern AS protocols.

Robotic Assisted Laparoscopic Prostatectomy Performed after Previous Suprapubic Prostatectomy.

Operative management of prostate cancer in a patient who has undergone previous open suprapubic simple prostatectomy poses a unique surgical challenge. Herein, we describe a case of intermediate risk prostate cancer in a man who had undergone simple prostatectomy ten years prior to presentation. The patient was found to have Gleason 7 prostate cancer on MRI fusion biopsy of the prostate for elevated PSA and underwent an uncomplicated robot assisted laparoscopic radical prostatectomy.

Clinical characteristics and outcomes of HIV-seropositive men treated with surgery for prostate cancer.

PURPOSE: The natural history and optimal management strategy for men with human immunodeficiency virus (HIV) and prostate cancer remain to be definitively characterized. This study was conducted to evaluate the clinical characteristics and outcomes of HIV-seropositive men treated with robotic-assisted radical laparoscopic prostatectomy for localized prostate cancer. METHODS: After Institutional Review Board approval, a prospective database of 2175 operative cases of clinically localized prostate adenocarcinoma was reviewed. Thirteen patients were identified as HIV-positive. Tumor characteristics, operative outcomes, postoperative outcomes, histology (Gleason score), local invasion, biochemical recurrence, and surgical complications were compared with HIV-negative patients. RESULTS: There were no preoperative demographic differences between the HIV-positive and HIV-negative patients. HIV-positive patients had higher prostate specific antigen (PSA) levels at time of diagnosis which was not statistically significant. However, HIV-positive patients had higher D'Amico risk assessment (p < 0.05). There was no postoperative complication. HIV-positive patients treated with robotic prostatectomy had similarly favorable perioperative and short-term biochemical recurrence-free survival outcomes. CONCLUSION: Our findings show that minimally invasive prostatectomy can be safely considered as a therapeutic option in otherwise eligible HIV-positive patients with clinically significant prostate cancer. Further research is necessary to outline a diagnostic and treatment guideline for HIV-positive men in detection and treatment of prostate cancer.

Decisional regret after robotic-assisted laparoscopic prostatectomy is higher in African American men.

OBJECTIVES: Longitudinal studies report racial disparities in prostate cancer (PCa) including greater incidence, more aggressive tumor biology, and increased cancer-specific mortality in African American (AA) men. Regret concerning primary treatment selection is underevaluated in patients with PCa. We investigated the relationships between clinicopathologic variables across racial and socioeconomic lines following robotic-assisted laparoscopic prostatectomy. MATERIALS AND METHODS: We assessed treatment decisional regret using a validated questionnaire in a total of 484 white and 72 AA patients with PCa who were followed up for a median of 16.6 months post-robotic-assisted laparoscopic prostatectomy. Socioeconomic status (SES) information was aggregated from 2010 US census zip code data. Perioperative clinicopathologic characteristics and functional outcomes were compared between groups. Univariate and multivariate regression analyses were used to evaluate the influence of race, aggregate SES, and other clinical and demographic characteristics on decisional regret. RESULTS: The majority (87.7%) of the population was not regretful of their decision to undergo treatment. However, a greater proportion of AA vs. white patients were regretful (20.6% vs. 11.2%, respectively; P = 0.03). AA and white men were similar on all functional, clinical, and pathologic features with the exception of younger age among AA men (56 vs. 60 y, respectively; P<0.001). Although there were significant differences in SES by race (P<0.001), regret did not differ by SES (ß =-1.53; P = 0.15). Race, postoperative sexual dysfunction, pad usage, and length of hospital stay, however, were significantly associated with decisional regret. CONCLUSIONS: AA men were more regretful than white men, after adjusting for clinicopathologic characteristics and postoperative functional outcomes.

Robotic-assisted laparoscopic prostatectomy in men with metabolic syndrome.

OBJECTIVES: Metabolic syndrome (MetS), the constellation of obesity and related risk factors for cardiovascular disease, is an expanding epidemiologic concern in the United States and the developed world. However, the relationship between MetS and prostate cancer remains to be definitively assessed. We evaluated the association between obesity and MetS with prostate cancer pathology and surgical and functional outcomes. MATERIALS AND METHODS: A total of 2,639 patients underwent robotic-assisted laparoscopic prostatectomy (RALP) for localized prostate cancer between March 2003 and July 2012. Of them, 186 patients met the criteria for MetS as defined by the presence of obesity (body mass index [BMI] ≥ 30 kg/m(2)) in conjunction with 2 or more of the following: hypertension (HTN), dyslipidemia (D), and diabetes (DM). Additionally, reference cohorts of (1) 663 nonobese men without HTN, D, or DM; (2) 184 obese patients without HTN, D, or DM; and (3) 211 obese men with solitary risk factors were identified for comparison. Demographic, histopathologic, and perioperative clinical parameters were compared. RESULTS: In comparison with patients without MetS, patients with MetS had larger prostates (Odds Ratio (OR) = 1.609, 95% Confidence Interval (CI) = 1.04-2.49, P = 0.03), increased blood loss (OR = 1.592, 95% CI = 1.15-2.21, P = 0.01), and surgical complexity (OR = 4.940, 95% CI = 2.29-10.69, P<0.001). There was no statistical difference observed between these groups in regard to complication rates, pathologic grade, stage, and postoperative continence or erectile function. With the exception of larger prostates found among men with MetS, men with obesity alone and obesity with 1 additional risk factor appeared similar to those with MetS. CONCLUSIONS: Patients with MetS had similar perioperative, histopathologic, and functional outcomes compared with reference cohorts undergoing RALP. RALP is safe, feasible, and efficacious in men with MetS.

Validation of online administration of the sexual health inventory for men.

PURPOSE: Previously we reported the development of a novel, inexpensive, online method to collect health related quality of life information to facilitate responses among patients and decrease loss to followup. We validated the practice by comparing responses to the SHIM (Sexual Health Inventory for Men), a representative validated instrument, when administered on line and in the traditional paper form. MATERIALS AND METHODS: Consented patients were administered validated health related quality of life instruments, including the SHIM, in office and via e-mail. Responses to the SHIM were compared between the administration formats. Paired sample testing was done to analyze test-retest reliability, concordance was assessed by intraclass analysis and a Bland-Altman plot, and the Cronbach α was used to examine internal reliability. Criterion validity was measured using SHIM defined erectile function categories and a dichotomized potency definition (SHIM 17 or greater). RESULTS: Of the 508 men who consented to participate 359 (71%) completed the SHIM in person, 277 (55%) completed the online form (p <0.001) and 116 (23%) contemporaneously completed each instrument. Comparison of scores revealed little variation and strong correlation (r(2) = 0.83, p <0.001). Intraclass and Bland-Altman analysis revealed strong agreement between the media. The Cronbach α was excellent (0.97) for the online tool. Erectile function classification was identical in 73% of patients with only 7% differing by more than 1 class. Dichotomized potency was consistently defined in 94% of patients. CONCLUSIONS: The online administered SHIM maintains validity and provides consistent responses. Online administration can capture patients who do not complete paper questionnaires and may serve as a reliable adjunct to paper administration for validated outcomes research.

Candidacy for active surveillance may be associated with improved functional outcomes after prostatectomy.

OBJECTIVE: In an effort to curb overtreatment, active surveillance (AS) has grown in popularity as an option for men with low-risk prostate cancer. We evaluated the histopathologic and functional outcomes of patients who qualified for AS, but opted for robotic-assisted laparoscopic prostatectomy (RALP), and compared them to non-AS candidates. METHODS: An institutional database of 1,477 RALP performed by a single surgeon was queried for AS candidates, defined as PSA <10 ng/mL, biopsy Gleason score ≤6 with a minimum of 10 biopsy cores, <3 positive cores with <50% tumor volume in a single core and clinical stage ≤T2a. RESULTS: Of the 352 patients who would have qualified for AS, 159 (45%) were upgraded: 143 (41%) to Gl 3 + 4, 16 (4.5%) to 4 + 3, zero to Gleason 8 or higher. Seventeen (4.8%) patients were upstaged to pT3. AS candidates were younger and had more favorable tumor characteristics, but similar preoperative functional status. Bilateral nerve sparing was performed on 96% of AS candidates vs. 86% of non-AS candidates (P < 0.001). After 12 months of follow-up in patients who received bilateral nerve sparing, continence was higher in the AS cohort (98% vs. 92%, P < 0.001) but potency was equivalent (87% in each, P = 0.89). On multivariable analysis, candidacy for AS was independently associated with improved continence, but not potency. CONCLUSIONS: In addition to having the expected favorable histopathologic features, AS candidates who desire definitive therapy have a high likelihood of achieving excellent functional outcomes, perhaps superior to non-AS candidates, following RALP.