Active Observation of Biochemical Recurrence without Treatment following Radical Prostatectomy: Long-Term Analysis of Outcomes.

Biochemical recurrence (BCR) following radical prostatectomy (RP) is an unreliable predictor of prostate cancer (PC) progression. This study was a retrospective cohort analysis of prospectively collected data (407/1895) of men with BCR at a tertiary referral center. Patients were assessed for active observation (AO) compared with a treatment group (TG) utilizing doubling time (DT) kinetics. Risk assessment was based on the initial DT (>12 vs. <12 months), then based on the DT pattern (changed over time). Those with unstable, rapidly decreasing DTs received treatment. Those with increasing and slowly decreasing DTs prompted observation. The primary outcome was PC mortality, safety, and efficacy of observations based on DT kinetics. The secondary outcome was BCR patients managed with or without treatment. The median follow-up was 7.5 years (IQR 3.9−10.7). The PCSM in TG and AO was 10.7% and 0%, respectively (p < 0.001). The initial DT was >12 months in 73.6% of AO versus 22.6% of TG (p < 0.001). An increasing DT pattern was observed in 71.5% of AO versus 32.7% of TG (p < 0.001). Utilizing the Cleveland Clinic's PCSM nomogram, at 10 years, predicted and observed PCSM was 8.6% and 9.5% (p = 0.78), respectively. In conclusion, one-third of patients with BCR post-RP were managed without treatment using DT kinetics, avoiding treatment-related complications, quality-of-life issues, and expenses.

Prostate-Specific Antigen Doubling Time Kinetics following Radical Prostatectomy to Guide Need for Treatment Intervention: Validation of Low-Risk Recurrences.

Biochemical recurrence (BCR) following radical prostatectomy (RP) has a limited ability to predict prostate cancer (PC) progression, leading to overtreatment, decreased quality of life, and additional expenses. Previously, we established that one-third of men with BCR in our group experienced low-risk recurrences that were safely observed without treatment. Our retrospective cohort analysis of 407 BCR patients post RP validates the use of PSA doubling time (DT) kinetics to direct active observation (AO) versus treatment following RP. The primary outcome was no need for treatment according to the predictive value of models of ROC analysis. The secondary outcome was PC-specific mortality (PCSM) according to Kaplan−Meier analysis. A total of 1864 men underwent RP (June 2002−September 2019); 407 experienced BCR (PSA > 0.2 ng/dL, ×2), with a median follow-up of 7.6 years. In adjusted regression analysis, initial PSADT > 12 months and increasing DT were significant predictors for AO (p < 0.001). This model (initial PSADT and DT change) was an excellent predictor of AO in ROC analysis (AUC = 0.83). No patients with initial PSADT > 12 months and increasing DT experienced PCSM. In conclusion, the combination of PSADT > 12 months and increasing DT was an excellent predictor of AO. This is the first demonstration that one-third of BCRs are at low risk of PCSM and can be managed without treatment via DT kinetics.

Retrospective Concomitant Nonrandomized Comparison of "Touch" Cautery Versus Athermal Dissection of the Prostatic Vascular Pedicles and Neurovascular Bundles During Robot-assisted Radical Prostatectomy.

BACKGROUND: During robotic-assisted radical prostatectomy (RARP), the use of electrocautery near the neurovascular bundles (NVBs) frequently results in thermal injury to the cavernous nerves. The cut and "touch" monopolar cautery technique has been suggested to reduce desiccating thermal injury caused by bipolar energy when vessels are sealed. OBJECTIVE: To compare potency outcomes between an athermal technique (AT) and touch cautery (TC) to transect the prostatic vascular pedicles (PVPs) and dissect the NVBs. DESIGN, SETTING, AND PARTICIPANTS: A retrospective concomitant nonrandomized study of AT versus TC was performed in 733 men. A total of 323 undergoing AT had "thin" pedicles, easily suitable for suture ligation. TC was based on "thick" pedicles (n = 230) difficult to suture ligate. Men were excluded for an International Index of Erectile Function (IIEF-5) score of <15 or adjuvant therapies (n = 180). SURGICAL PROCEDURE: Single-surgeon RARP. MEASUREMENTS: Patient-reported outcomes with erectile function (EF) recovery defined as two affirmative answers to erections sufficient for intercourse (ESI; "are erections firm enough for penetration?" and "are the erections satisfactory?"), IIEF-5 scores 15-25, and a novel percent fullness score comparing pre- versus postoperative erection fullness. Logistic regression models assessed the correlation between cautery technique, covariates, and EF recovery. RESULTS AND LIMITATIONS: In an unadjusted analysis, preoperative IIEF-5, age, body mass index (BMI), and prostate weight were significant predictors of potency recovery. Follow-up was similar (AT 52.7 mo vs TC 54.6 mo, p = 0.534). In logistic regression, preoperative IIEF-5, age, and BMI were significant predictors of EF recovery, defined as IIEF-5 scores 15-25, ESI, and percent fullness >75%. Results were similar when IIEF-5 and percent fullness were assessed continuously. CONCLUSIONS: During transection of the PVPs and dissection of the NVBs, TC did not impact EF recovery significantly, compared with an AT. PATIENT SUMMARY: Electrocautery can be applied safely, with similar outcomes to those of an athermal technique.

Impact of surgically maximized versus native membranous urethral length on 30-day and long-term pad-free continence after robot-assisted radical prostatectomy.

BACKGROUND: Pelvic multiparametric magnetic resonance imaging (mpMRI)-determined membranous urethral length (MUL) and its surgical maximization have been reported to impact early- and long-term pad-free urinary continence after robot-assisted radical prostatectomy (RARP). OBJECTIVE: The objective of this study was to present evidence (data and video) of important effects on post-RARP continence recovery from both innate mpMRI-assessed and surgical preservation of MUL. DESIGN SETTING AND PARTICIPANTS: Of 605 men undergoing RARP, 580 with complete follow-up were included: Group 1, prior (N = 355), and Group 2, subsequent (N = 225) to technique change of MUL maximization. Effect of innate, mpMRI-assessed MUL on postoperative continence was assessed. SURGICAL PROCEDURE: Before technique change, the dorsal venous complex was stapled before transection of the membranous urethra. After the change, the final step of extirpation was transection of the dorsal venous complex and periurethral attachments, thus facilitating surgical maximization of MUL. MEASUREMENTS: Primary and secondary outcomes for technique change and mpMRI-assessed MUL were both patient-reported 30-day and 1-year pad-free continence after RARP, respectively. RESULTS: Preoperative prostate-specific antigen, age, and disease aggressiveness were significantly higher in Group 2. After technique change and surgical maximization of MUL, 30-day and 1-year pad-free continence were both significantly improved (p < 0.05). In multivariate analysis, maximization of MUL significantly increased the likelihood of both early- and long-term continence recovery. For men undergoing MUL preservation, mpMRI-assessed MUL>1.4 cm also independently predicted higher 30-day (odds ratio: 4.85, 95% confidence interval: 1.24-18.9) and 1-year continence recovery (odds ratio: 11.26, 95% confidence interval: 1.07-118). CONCLUSIONS: Prostatic rotation and circumferential release of apical attachments and maximization of MUL improves continence after RARP. Separately, innate MUL>1.4 cm independently increased 30-day and 1-year continence recovery. PATIENT SUMMARY: Surgeon efforts to maximize MUL during radical prostatectomy are highly encouraged, as maximally preserved MUL likely improves post-RARP continence recovery. In addition, individual patients' mpMRI-assessed MUL (approximately >1.4 cm) independently limits continence recovery.

Internal and External Validation of a 90-Day Percentage Erection Fullness Score Model Predicting Potency Recovery Following Robot-assisted Radical Prostatectomy.

BACKGROUND: We previously reported a new post-radical prostatectomy (RP) prediction model for men with normal baseline erectile function (EF) using 90-d postoperative erection fullness to identify men who might benefit from early EF rehabilitation. OBJECTIVE: To prospectively internally and externally validate the use of this risk assessment model in predicting 1- and 2-yr post-RP EF recovery. DESIGN, SETTING, AND PARTICIPANTS: We randomly assigned 297 patients with a preoperative International Index of Erectile Function 5 score of 22-25 undergoing robot-assisted RP by a single surgeon to a training set and internal validation set at a ratio of 2:1. A prospective external validation set included 91 patients treated by five high-volume surgeons. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Potency was defined as erections sufficient for intercourse. To predict 1- and 2-yr potency recovery, logistic regression models were developed in the training set based on 90-d erection fullness of 0-24% or 25-100%. The resultant models were applied to the internal and external validation sets to calculate risk scores for 1- and 2-yr potency for each patient. Predictive validity was assessed using receiver operating characteristic (ROC) curves. RESULTS AND LIMITATIONS: Percentage erection fullness was an independent predictor of 1- and 2-yr potency recovery in all data sets. Internal validation confirmed strong reliability in predicting 2-yr potency outcomes (area under the ROC curve [AUC] 0.87) and external validation illustrated similar reliability in predicting 1-yr potency outcomes (AUC 0.80). In the external validation, the model predicted a mean 1-yr potency recovery rate of 39.7% (standard deviation 3.2%), compared to the actual rate of 36.26%. Limitations include the short follow-up for this cohort. CONCLUSIONS: We present internal and external validation of a 90-d percentage erection fullness score, confirming that this metric is a robust predictor of post-RP EF recovery. PATIENT SUMMARY: Percentage erection fullness at 3 mo after radical prostatectomy discriminates patients with a low or a high probability of recovery of erectile function (EF), which can facilitate identification of a need for early EF rehabilitation.

Diminished long-term recovery of peak flow rate (PFR) after robotic prostatectomy in men with baseline PFR <10 mL/s and incidental association with high-risk prostate cancer.

OBJECTIVE: The aim of this study was to evaluate the effects of robot-assisted radical prostatectomy (RARP) on uroflowmetry (UF) parameters among men with baseline peak flow rates (PFR) <10 mL/s. METHODS: A single-surgeon RARP database of 1082 men who underwent prospective UF testing was analyzed. Men filled out International Prostate Symptom Score questionnaires and underwent uroflowmetry and post-void bladder ultrasound before surgery and at each follow-up visit. Patients were divided into 2 groups based on preoperative PFR: those with PFR <10 mL/s (n = 158) and those with PFR ≥10 mL/s (n = 924). Univariate and multivariate regression models tested the association of preoperative characteristics in predicting postoperative PFR improvement. Within the PFR <10 mL/s group, preoperative variables were analyzed to predict pathologic outcomes. RESULTS: Three months after RARP, men with baseline PFR <10 mL/s had a 3-fold improvement in PFR (from mean of 7.0 to 24.2 mL/s), whereas in men with PFR ≥10 mL/s there was a 50% improvement (from mean of 19.7 to 28.9 mL/s; P < .001). Improvement in PFR remained stable for >5 years, but mean postoperative PFR was 20% lower in men with baseline PFR <10 mL/s. Preoperative prostate-specific antigen (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.59-0.95) and PFR (OR 0.52; 95% CI 0.34-0.80) were independent predictors of the percentage improvement in men with baseline PFR <10 mL/s. Preoperative PFR ≤7 mL/s was an independent predictor of Gleason score ≥8 (P = .016), seminal vesicle invasion (P = .010), and lymph node invasion (0.029). CONCLUSIONS: After RARP, PFR improved significantly, with the improvement persisting over long-term follow-up. However, men with baseline PFR <10 mL/s had a 20% lower postoperative PFR over 5 years, suggesting permanent damage to the bladder and the need for early treatment to maintain bladder health. There appears to be an association between baseline PFR ≤7 mL/s and adverse pathologic features.

Lymph node yield during radical prostatectomy does not impact rate of biochemical recurrence in patients with seminal vesicle invasion and node-negative disease.

OBJECTIVES: Seminal vesicle invasion (SVI) is a risk factor for poor oncologic outcome in patients with prostate cancer. Modifications to the pelvic lymph node dissection (PLND) during radical prostatectomy (RP) have been reported to have a therapeutic benefit. The present study is the first to determine if lymph node yield (LNY) is associated with a lower risk of biochemical recurrence (BCR) for men with SVI. METHODS: A total of 220 patients from 2 high-volume institutions who underwent RP without adjuvant treatment between 1990 and 2015 and had prostate cancer with SVI (i.e., pT3b) were identified, and 21 patients did not undergo lymph node dissection. BCR was defined as a postoperative PSA>0.2ng/mL, or use of salvage androgen deprivation therapy (ADT) or radiation. Multivariable Cox proportional hazards models were used to determine whether LNY was predictive of BCR, controlling for PSA, pathologic Gleason Score, pathologic lymph node status, NCCN risk category, etc. The Kaplan-Meier method was used to determine 3-year freedom from BCR. RESULTS: Median number of lymph nodes sampled were 7 (IQR: 3-12; range: 0-35) and 90.5% underwent PLND. The estimated 3-year BCR rate was 43.9%. Results from multivariable analysis demonstrated that LNY was not significantly associated with risk of BCR overall (HR = 1.00, 95% CI: 0.98-1.03; P = 0.848) for pN0 (HR = 0.99, 95% CI: 0.97-1.03; P = 0.916) or pN1 patients (HR = 0.96, 95% CI: 0.88-1.06; P = 0.468). Overall, PSA (HR = 1.02, P<0.001) and biopsy Gleason sum ≥ 8 (HR = 1.81, P = 0.001) were associated with an increased risk of BCR, and increasing LNY increased the likelihood of detecting>2 positive lymph nodes (OR = 1.27, 95% CI: 1.06-1.65, P = 0.023). CONCLUSION: Seminal vesicle invasion is associated with an increased risk of BCR at 3 years, primarily due to pathologic Gleason score and PSA. Although greater lymph node yield is diagnostic and facilitates more accurate pathologic staging, our data do not show a therapeutic benefit in reducing BCR.

Predictive modelling of 2-year potency outcomes using a novel 90-day erection fullness scale after robot-assisted radical prostatectomy.

OBJECTIVE: To introduce a patient-reported erection fullness scale (%fullness) after robot-assisted radical prostatectomy (RARP) as a qualitative adjunct to the five-item version of the International Index of Erectile Function (IIEF-5) and as a 90-day predictor of 2-year potency outcomes. PATIENTS AND METHODS: Prospective data were collected from 540 men with preoperative IIEF-5 scores of 22-25 who underwent RARP by a single surgeon, and of whom 299 had complete data at all time points up to 2 years. In addition to standard assessment tools (IIEF-5 and erections sufficient for intercourse [ESI]), the men were asked to 'indicate the fullness you are able to achieve in erections compared to before surgery?' (range: 0-100%). The primary outcome was prediction of potency (defined as ESI) at 24 months, based on 90-day %fullness tertile (0-24%, 25-74% and 75-100%). RESULTS: A total of 299 men with complete follow-up were included in the study. Significant predictors of 24-month potency included age, body mass index, pathological stage, nerve-sparing status and %fullness tertiles. When the men (preoperative IIEF-5 score 22-25) were assessed at 90 days after RARP, 181/299 (61%) had erections inadequate for intercourse. If IIEF-5 scores of 1-6 were used, 142/181 men (78%) would be targeted for early intervention. By contrast, if 0-24% fullness was used, 88/181 men (49%) would be targeted. If both the IIEF-5 score and %fullness were used, this would be reduced to 77/181 men (43%). CONCLUSIONS: We introduce %fullness as a qualitative adjunct to the IIEF-5 score, and separately as a 90-day predictor of 2-year potency recovery. This initial report is hypothesis-generating, such that the use of %fullness enables the identification of men who are most likely to benefit from early, secondary intervention.

Electronic health record problem lists: accurate enough for risk adjustment?

OBJECTIVES: To determine whether comorbidity information derived from electronic health record (EHR) problem lists is accurate. STUDY DESIGN: Retrospective cohort study of 1596 men diagnosed with prostate cancer between 1998 and 2004 at 2 Southern California Veterans Affairs Medical Centers with long-term follow-up. METHODS: We compared EHR problem list-based comorbidity assessment with manual review of EHR free-text notes in terms of sensitivity and specificity for identification of major comorbidities and Charlson Comorbidity Index (CCI) scores. We then compared EHR-based CCI scores with free-text-based CCI scores in prediction of long-term mortality. RESULTS: EHR problem list-based comorbidity assessment had poor sensitivity for detecting major comorbidities: myocardial infarction (8%), cerebrovascular disease (32%), diabetes (46%), chronic obstructive pulmonary disease (42%), peripheral vascular disease (31%), liver disease (1%), and congestive heart failure (23%). Specificity was above 94% for all comorbidities. Free-text-based CCI scores were predictive of long-term other-cause mortality, whereas EHR problem list-based scores were not. CONCLUSIONS: Inaccuracies in EHR problem list-based comorbidity data can lead to incorrect determinations of case mix. Such data should be validated prior to application to risk adjustment.

Risk of complications and urinary incontinence following cytoreductive prostatectomy: a multi-institutional study.

Emerging evidence has suggested that cytoreductive prostatectomy (CRP) allows superior oncologic control when compared to current standard of care androgen deprivation therapy alone. However, the safety and benefit of cytoreduction in metastatic prostate cancer (mPCa) has not been proven. Therefore, we evaluated the incidence of complications following CRP in men newly diagnosed with mPCa. A total of 68 patients who underwent CRP from 2006 to 2014 at four tertiary surgical centers were compared to 598 men who underwent radical prostatectomy for clinically localized prostate cancer (PCa). Urinary incontinence was defined as the use of any pad. CRP had longer operative times (200 min vs 140 min, P < 0.0001) and higher estimated blood loss (250 ml vs 125 ml, P < 0.0001) compared to the control group. However, both overall (8.82% vs 5.85%) and major complication rates (4.41% vs 2.17%) were comparable between the two groups. Importantly, urinary incontinence rate at 1-year after surgery was significantly higher in the CRP group (57.4% vs 90.8%, P < 0.0001). Univariate logistic analysis showed that the estimated blood loss was the only independent predictor of perioperative complications both in the unadjusted model (OR: 1.18; 95% CI: 1.02-1.37; P = 0.025) and surgery type-adjusted model (OR: 1.17; 95% CI: 1.01-1.36; P = 0.034). In conclusion, CRP is more challenging than radical prostatectomy and associated with a notably higher incidence of urinary incontinence. Nevertheless, CRP is a technically feasible and safe surgery for selecting PCa patients who present with node-positive or bony metastasis when performed by experienced surgeons. A prospective, multi-institutional clinical trial is currently underway to verify this concept.

Analysis of Accessory Pudendal Artery Transection on Erections During Robot-Assisted Radical Prostatectomy.

PURPOSE: To compare the recovery of erections and potency following the transection of accessory pudendal arteries (APAs) in men undergoing robot-assisted radical prostatectomy (RARP) compared with men with normal vascular anatomy. MATERIALS AND METHODS: A total of 880 consecutive patients who underwent RARP from January 1, 2007 to December 31, 2014 were included with prospectively collected data in cross-sectional analysis. Erectile function (EF) was assessed preoperatively and postoperatively at 3, 6, 12, and 24 months using the International Index of Erectile Function (IIEF)-5, a percent erection fullness compared to preoperative status, and two Expanded Prostate Cancer Index (EPIC) questions: (1) are erections firm enough for penetration and (2) are they satisfactory? RESULTS: Two hundred thirty-one (33.1%) men had APAs transected. There were no significant differences in baseline demographics or clinical characteristics in men with or without APAs transected. Multivariate analyses demonstrated that age (confidence interval [95% CI]: 0.94, 0.99) and baseline IIEF-5 (95% CI: 1.15, 1.26) strongly correlated with recovery of erections and potency. Transection of APAs was not a significant predictor of erectile dysfunction (ED). CONCLUSION: Good surgical technique dictates the preservation of APAs. However, when preservation is questioned, we found that APA transection had no measurable effect on recovery of erections or potency regardless of age, preoperative ED, or number of APAs transected.

Hypothermic Cooling Measured by Thermal Magnetic Resonance Imaging; Feasibility and Implications for Virtual Imaging in the Urogenital Pelvis.

OBJECTIVE: To study the combination of thermal magnetic resonance imaging (MRI) and novel hypothermic cooling, via an endorectal cooling balloon (ECB), to assess the effective dispersion and temperature drop in pelvic tissue to potentially reduce inflammatory cascade in surgical applications. METHODS: Three male subjects, before undergoing robot-assisted radical prostatectomy, were cooled via an ECB, rendered MRI compatible for patient safety before ECB hypothermia. MRI studies were performed using a 3T scanner and included T2-weighted anatomic scan for the pelvic structures, followed by a temperature mapping scan. The sequence was performed repeatedly during the cooling experiment, whereas the phase data were collected using an integrated MR-high-intensity focused ultrasound workstation in real time. Pelvic cooling was instituted with a cooling console located outside the MRI magnet room. RESULTS: The feasibility of pelvic cooling measured a temperature drop of the ECB of 20-25 degrees in real time was achieved after an initial time delay of 10-15 seconds for the ECB to cool. The thermal MRI anatomic images of the prostate and neurovascular bundle demonstrate cooling at this interface to be 10-15 degrees, and also that cooling extends into the prostate itself ~5 degrees, and disperses into the pelvic region as well. CONCLUSION: An MRI-compatible ECB coupled with thermal MRI is a feasible method to assess effective hypothermic diffusion and saturation to pelvic structures. By inference, hypothermia-induced rectal cooling could potentially reduce inflammation, scarring, and fistula in radical prostatectomy, as well as other urologic tissue procedures of high-intensity focused ultrasound, external beam radiation therapy, radioactive seed implants, transurethral microwave therapy, and transurethral resection of the prostate.

Limitations of the National Comprehensive Cancer Network® (NCCN®) Guidelines for Prediction of Limited Life Expectancy in Men with Prostate Cancer.

PURPOSE: National Comprehensive Cancer Network prostate cancer guidelines for the prediction of life expectancy recommend subtracting 50% of life table predicted longevity for those in the lowest quartile of health. However, it is unclear how to identify these men and if their survival is uniform. MATERIALS AND METHODS: We sampled records of 1,482 men diagnosed with prostate cancer from 1998 to 2004 at 2 VA hospitals. We identified men in the lowest quartile of health by age using Charlson scores, calculated their NCCN predicted life expectancy, and compared this with observed median survival in aggregate and across comorbidity subgroups. RESULTS: Men with Charlson scores of 2+ (age less than 75 years) and 3+ (age 75 years or older) comprised the lowest quartile of health. Among those younger than 65, 65 to 69, 70 to 74, 75 to 79 and 80 years or older, observed survival vs NCCN predicted life expectancy in years was similar at 10.4 vs 11.1, 10.0 vs 7.8, 6.2 vs 6.4, 4.4 vs 4.9 and 3.7 vs 3.3, respectively. Yet within the lowest quartile there was significant heterogeneity in survival among men with differing Charlson scores. For example, men age 65 to 69 years with Charlson scores 2, 3 and 4+ had an observed median survival greater than 13.3, 9.4 and 4.3 years, respectively. NCCN guidelines misclassified 10-year life expectancy in 24% and 56% of men age less than 65 and 65 to 69 years, and 5-year life expectancy in 18% of men age 70 to 74 years. CONCLUSIONS: While NCCN predictions matched observed survival on average for the lowest quartile of health, there was substantial heterogeneity in survival by Charlson scores. More granular assessments of life expectancy should be used for those at highest risk for mortality.

Quantification of Long-term Stability and Specific Relief of Lower Urinary Tract Symptoms (LUTS) After Robot-assisted Radical Prostatectomy.

OBJECTIVE: To assist in preoperative counseling by assessing long-term changes in American Urological Association symptom scores (AUAss) and lower urinary tract symptom (LUTS)-related quality of life (QOL) in patients undergoing robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS: RARP was performed on 666 men by one surgeon from 2002 to 2007 at a single institution. AUAss and QOL were queried preoperatively and at 3, 9, 15, 24-48, 60-84, and 96+ months postoperatively. LUTS subgroups were compared pre-/postsurgery using univariate and multivariate statistics. RESULTS: The mean and median follow-up for all responders was 3.0 and 2.4 years. Pad-free continence at 12 months was 89%. A subset of 174 men reported preoperative and long-term responses; average follow-up was 5.8 years (range 4.0-10.3 years). AUAss for all men declined from baseline to 5 years by 3.7 (8.6 to 4.8) whereas QOL/Bother scores decreased by 0.5 (1.7 to 1.2) (all P < .05). Men with baseline mild LUTS remained clinically unchanged with long-term AUAss. Individuals with moderate and severe preoperative LUTS had marked improvements in AUA and QOL scores (all P ≤ .05). CONCLUSION: Men with mild LUTS have short-term increases in AUAss but most return to baseline and are stable at 5 years. Benefits were found for men with preoperative moderate and severe LUTS in that 63% had significant QOL improvements and 68% reduced their AUAss to mild LUTS, persisting years after RARP. This study suggests that certain patients with preoperative urinary symptoms and bother may experience improvements in LUTS and associated QOL after RARP.

The importance of surgical margins in prostate cancer.

Positive surgical margins (PSM) after radical prostatectomy (RP) are a predictor of biochemical recurrence (BCR), and highly dependent on surgeon, experience, and skill. The length and location PSMs are important, with significant differences between open and robotic RP. The impact of PSMs on BCR remains secondary to other clinico-pathologic variables: Gleason Score, pathologic stage, and baseline PSA. However, lower PSM rates are associated with reduced use of secondary interventions and patient anxiety of cancer recurrence.

Oncologic outcomes in men with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institution international study.

BACKGROUND: The presence of lymph nodes (LN) within the prostatic anterior fat pad (PAFP) has been reported in several recent reports. These PAFP LNs rarely harbor metastatic disease, and the characteristics of patients with PAFP LN metastasis are not well-described in the literature. Our previous study suggested that metastatic disease to the PAFP LN was associated with less severe oncologic outcomes than those that involve the pelvic lymph node (PLN). Therefore, the objective of this study is to assess the oncologic outcome of prostate cancer (PCa) patients with PAFP LN metastasis in a larger patient population. METHODS: Data were analyzed on 8800 patients from eleven international centers in three countries. Eighty-eight patients were found to have metastatic disease to the PAFP LNs (PAFP+) and 206 men had isolated metastasis to the pelvic LNs (PLN+). Clinicopathologic features were compared using ANOVA and Chi square tests. The Kaplan-Meier method was used to calculate the time to biochemical recurrence (BCR). RESULTS: Of the eighty-eight patients with PAFP LN metastasis, sixty-three (71.6%) were up-staged based on the pathologic analysis of PAFP and eight (9.1%) had a low-risk disease. Patients with LNs present in the PAFP had a higher incidence of biopsy Gleason score (GS) 8-10, pathologic N1 disease, and positive surgical margin in prostatectomy specimens than those with no LNs detected in the PAFP. Men who were PAFP+ with or without PLN involvement had more aggressive pathologic features than those with PLN disease only. However, there was no significant difference in BCR-free survival regardless of adjuvant therapy. In 300 patients who underwent PAFP LN mapping, 65 LNs were detected. It was also found that 44 out of 65 (67.7%) nodes were located in the middle portion of the PAFP. CONCLUSIONS: There was no significant difference in the rate of BCR between the PAFP LN+ and PLN+ groups. The PAFP likely represents a landing zone that is different from the PLNs for PCa metastasis. Therefore, the removal and pathologic analysis of PAFP should be adopted as a standard procedure in all patients undergoing radical prostatectomy.

Analysis of Improved Urinary Peak Flow Rates After Robot-Assisted Radical Prostatectomy.

PURPOSE: Longitudinal assessment of prostatic obstruction has historically been assessed with urinary peak flow rates (PFR). In this observational study, we assess the impact of prostate removal on preoperative and postoperative PFRs after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: A single surgeon (TA) performed RARPs between 2002 and 2007. Men underwent routine preoperative uroflowmetric testing: 550 qualified for analysis with a sufficient voided volume (VV) of 150 mL preoperatively and at least once postoperatively. Continence and self-assessed American Urological Association (AUA) symptom and urinary quality of life (QoL) questionnaires were queried. Uroflows were analyzed preoperatively, short-term (3-15 mos), long-term (>2 y), and by age decades, lower urinary tract symptoms (LUTS) groups, and pathologic weight cohorts. RESULTS: AUA and QoL scores improved from 8.1 and 1.6 at baseline to 4.4 and 1.0 at intermediate-term follow-up, P<0.01. Mean PFRs improved from a baseline 18.0 mL/s to 28.3, 30.8, and 36.5 at 3 months, 9 months, and >5 years follow- up (all P<0.001). Postvoid residual (PVR) volumes declined from 99 mL preoperatively to 24 mL at >5 years (P<0.01). Likewise, all age, LUTS, and prostate weight cohorts had significant improvements in PFR and PVR and stable voided volumes throughout the study. CONCLUSION: The natural history of prostatic obstruction for men 40 to 80 years typically reveals reduction of mean PFRs. We observed that removal of the prostate resulted on average with a near doubling of PFRs and decreased PVRs (>50%) by 3 months. After RARP, the average PFR was reset to 25-30 mL/s, and these results were seen across all age, LUTS, and prostate weight groups; the gains remained stable 2 to 4 years after operation.