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BACKGROUND: Artificial intelligence (AI) chatbots, such as ChatGPT, have made significant progress. These chatbots, particularly popular among health care professionals and patients, are transforming patient education and disease experience with personalized information. Accurate, timely patient education is crucial for informed decision-making, especially regarding prostate-specific antigen screening and treatment options. However, the accuracy and reliability of AI chatbots' medical information must be rigorously evaluated. Studies testing ChatGPT's knowledge of prostate cancer are emerging, but there is a need for ongoing evaluation to ensure the quality and safety of information provided to patients. OBJECTIVE: This study aims to evaluate the quality, accuracy, and readability of ChatGPT-4's responses to common prostate cancer questions posed by patients. METHODS: Overall, 8 questions were formulated with an inductive approach based on information topics in peer-reviewed literature and Google Trends data. Adapted versions of the Patient Education Materials Assessment Tool for AI (PEMAT-AI), Global Quality Score, and DISCERN-AI tools were used by 4 independent reviewers to assess the quality of the AI responses. The 8 AI outputs were judged by 7 expert urologists, using an assessment framework developed to assess accuracy, safety, appropriateness, actionability, and effectiveness. The AI responses' readability was assessed using established algorithms (Flesch Reading Ease score, Gunning Fog Index, Flesch-Kincaid Grade Level, The Coleman-Liau Index, and Simple Measure of Gobbledygook [SMOG] Index). A brief tool (Reference Assessment AI [REF-AI]) was developed to analyze the references provided by AI outputs, assessing for reference hallucination, relevance, and quality of references. RESULTS: The PEMAT-AI understandability score was very good (mean 79.44%, SD 10.44%), the DISCERN-AI rating was scored as "good" quality (mean 13.88, SD 0.93), and the Global Quality Score was high (mean 4.46/5, SD 0.50). Natural Language Assessment Tool for AI had pooled mean accuracy of 3.96 (SD 0.91), safety of 4.32 (SD 0.86), appropriateness of 4.45 (SD 0.81), actionability of 4.05 (SD 1.15), and effectiveness of 4.09 (SD 0.98). The readability algorithm consensus was "difficult to read" (Flesch Reading Ease score mean 45.97, SD 8.69; Gunning Fog Index mean 14.55, SD 4.79), averaging an 11th-grade reading level, equivalent to 15- to 17-year-olds (Flesch-Kincaid Grade Level mean 12.12, SD 4.34; The Coleman-Liau Index mean 12.75, SD 1.98; SMOG Index mean 11.06, SD 3.20). REF-AI identified 2 reference hallucinations, while the majority (28/30, 93%) of references appropriately supplemented the text. Most references (26/30, 86%) were from reputable government organizations, while a handful were direct citations from scientific literature. CONCLUSIONS: Our analysis found that ChatGPT-4 provides generally good responses to common prostate cancer queries, making it a potentially valuable tool for patient education in prostate cancer care. Objective quality assessment tools indicated that the natural language processing outputs were generally reliable and appropriate, but there is room for improvement.
Subject(s)
Patient Education as Topic , Prostatic Neoplasms , Humans , Male , Patient Education as Topic/methods , Artificial IntelligenceABSTRACT
INTRODUCTION: Despite recent evidence on the surgical outcomes of robotic-assisted surgery (RAS), other patient centre outcomes, including quality of life (QOL), are lacking. This study aims to examine changes in QoL trajectories following RAS across different surgical specialities. PATIENTS AND METHODS: A prospective cohort study was conducted for patients undergoing urologic, cardiothoracic, colorectal or benign gynaecological RAS, between June 2016 and January 2020 at a tertiary referral hospital in Australia. QoL was measured using the 36-item Short-Form Health Survey at pre-operative, 6 weeks and 6 months postoperatively. Physical and mental summary scores and utility index were primary outcomes, and sub-domains were secondary outcomes. STATISTICAL ANALYSIS USED: Mixed-effects linear regressions were used to determine changes in QoL trajectories. RESULTS: Of the 254 patients undergoing RAS, 154 underwent urologic, 36 cardiothoracic, 24 colorectal and 40 benign gynaecological surgery. Overall, the average age was 58.8 years and most patients were male (75.1%). Physical summary scores significantly decreased from pre-operative to 6 weeks' post-operative in urologic and colorectal RAS; with all surgical specialities at least returning to pre-operative levels within 6 months postoperatively. Mental summary scores consistently increased from pre-operative to 6 months postoperatively for colorectal and gynaecological RAS. CONCLUSIONS: RAS contributed to positive changes in QoL, with physical health returning to the pre-operative level and mental health improvements across specialities, in the short term. While degrees of post-operative changes varied amongst specialities, significant improvements demonstrate benefits in RAS.
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BACKGROUND: A barrier to the uptake of robotic-assisted surgery (RAS) continues to be the perceived high costs. A lack of detailed costing information has made it difficult for public hospitals in particular to determine whether use of the technology is justified. This study aims to provide a detailed description of the patient episode costs and the contribution of RAS specific costs for multiple specialties in the public sector. METHODS: A retrospective descriptive costing review of all RAS cases undertaken at a large public tertiary referral hospital in Sydney, Australia from August 2016 to December 2018 was completed. This included RAS cases within benign gynaecology, cardiothoracic, colorectal and urology, with the total costs described utilizing various inpatient costing data, and RAS specific implementation, maintenance and consumable costs. RESULTS: Of 211 RAS patients, substantial variation was found between specialties with the overall median cost per patient being $19,269 (Interquartile range (IQR): $15,445 to $32,199). The RAS specific costs were $8828 (46%) made up of fixed costs including $4691 (24%) implementation and $2290 (12%) maintenance, both of which are volume dependent; and $1848 (10%) RAS consumable costs. This was in the context of 37% robotic theatre utilisation. CONCLUSIONS: There is considerable variation across surgical specialties for the cost of RAS. It is important to highlight the different cost components and drivers associated with a RAS program including its dependence on volume and how it fits within funding systems in the public sector.
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Robotic Surgical Procedures , Australia , Humans , Public Health , Public Sector , Retrospective StudiesABSTRACT
PURPOSE: Inguinal hernia is a known sequel of radical prostatectomy which contributes to patient morbidity and health care expenditure. In this systematic review we evaluated the incidence of inguinal hernia associated with minimally invasive radical prostatectomy, in addition to predictive factors and preventive measures. MATERIALS AND METHODS: We searched PubMed® and Embase® between 2000 and February 2018 using the search terms inguinal hernia and radical prostatectomy. RESULTS: In concordance with search terms and selection criteria we identified a total of 155 reports with 27 studies eligible for inclusion. Collated results demonstrated a variable prevalence of inguinal hernia after laparoscopic radical prostatectomy and robotic assisted radical prostatectomy ranging from 4.3% to 8.3% and from 3% to 19.4 %, respectively. There was a higher mean prevalence of inguinal hernia after robotic assisted prostatectomy. Factors predicting inguinal hernia following minimally invasive radical prostatectomy included low body mass index, poor stream and straining prior to prostatectomy detected on symptom score instruments, a patent processus vaginalis or an intraoperative incidental inguinal hernia. Herniotomy or herniorrhaphy with onlay mesh repair was the most commonly reported intraoperative repair technique at the time of minimally invasive radical prostatectomy. Recurrence of repaired incidental hernia is rare. CONCLUSIONS: Inguinal hernia is common after minimally invasive radical prostatectomy. There is a lack of high level evidence to clarify risk factors and preventive strategies for inguinal hernia after minimally invasive radical prostatectomy. There is a justification for randomized controlled trials to further evaluate this under recognized clinical problem.
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Hernia, Inguinal/epidemiology , Laparoscopy/adverse effects , Postoperative Complications/epidemiology , Prostatectomy/adverse effects , Robotic Surgical Procedures/adverse effects , Hernia, Inguinal/etiology , Hernia, Inguinal/prevention & control , Herniorrhaphy , Humans , Incidence , Laparoscopy/methods , Male , Postoperative Complications/etiology , Postoperative Complications/prevention & control , Prostatectomy/methods , Prostatic Neoplasms/surgery , Risk Factors , Robotic Surgical Procedures/methodsABSTRACT
Background/Objectives: The presence of seminal vesicle invasion (SVI) in prostate cancer (PCa) is associated with poorer postoperative outcomes. This study evaluates the predictive value of magnetic resonance imaging (MRI) and prostate-specific membrane antigen positron emission tomography/computed tomography (PSMA PET/CT) for SVI in PCa. Methods: This cohort study included consecutive robotic prostatectomy patients for PCa at three Australian tertiary referral centres between April 2016 and September 2022. MRI and PSMA PET/CT results, clinicopathological variables, including age, BMI, prostate-specific antigen (PSA), PSA density, DRE, Biopsy Gleason score, Positive biopsy cores, PIRADS v2.1 score, MRI volume and MRI lesion size were extracted. The sensitivity, specificity, and accuracy of MRI and PSMA PET/CT for predicting SVI were compared with the histopathological results by receiver operating characteristic (ROC) analysis. Subgroup univariate and multivariate analysis was performed. Results: Of the 528 patients identified, 86 had SVI on final pathology. MRI had a low sensitivity of 0.162 (95% CI: 0.088-0.261) and a high specificity of 0.963 (95% CI: 0.940-0.979). The PSMA PET/CT had a low sensitivity of 0.439 (95% CI: 0.294-0591) and a high specificity of 0.933 (95% CI: 0.849-0.969). When MRI and PSMA PET/CT were used in combination, the sensitivity and specificity improved to 0.514 (95%CI: 0.356-0.670) and 0.880 (95% CI: 0.813-0.931). The multivariate regression showed a higher biopsy Gleason score (p = 0.033), higher PSA (p < 0.001), older age (p = 0.001), and right base lesions (p = 0.003) to be predictors of SVI. Conclusions: MRI and PSMA PET/CT independently underpredicted SVI. The sensitivity and AUC improved when they were used in combination. Multiple clinicopathological factors were associated with SVI on multivariate regression and predictive models incorporating this information may improve oncological outcomes.
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Purpose: This case series describes the experiences and outcomes of multiple Australian surgeons performing robotic-assisted bladder diverticulectomy (RABD), highlighting the procedural effectiveness and safety, for both benign and malignant indications for diverticulectomy. Methods: Outcomes were analyzed from 13 experienced Australian urologists who performed RABD between 2016 and 2023. Retrospective analysis was performed on prospectively collected data, which included patient demographics, diverticulum characteristics, surgical approaches, and post-operative outcomes. Surgical techniques included the extravesical and intravesical approaches, with the focus on maintaining oncological principles in cases of malignancy. Results: A total of 28 patients underwent RABD, with the majority being male and a mean age of 63.9 years. All surgeons utilized a four-port transperitoneal approach and opted for the extravesical dissection of the diverticular neck; one case utilized both an extravesical and a trans-diverticular approach. Functional outcomes demonstrated symptomatic resolution in patients with nonmalignant diverticula, whereas oncological outcomes indicated clear margins in 90% of malignant cases. The average length of the procedure was 106 minutes, with minimal blood loss and a mean hospital stay of 2.67 days. Early complications occurred in 14% with the majority Clavien-Dindo grade II. Conclusion: Robotic bladder diverticulectomy, predominantly via the transperitoneal extravesical approach, has emerged as a safe, effective, and reliable surgical intervention for both malignant and nonmalignant bladder diverticula. The consistent surgical approach and excellent outcomes demonstrated in this case series reinforce the procedure's potential as a safe option, even in the setting of malignancy within a diverticulum.
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OBJECTIVE: To evaluate the impact of laparoscopic sacrocolpopexy on symptoms, health-related quality of life (HRQL) and sexuality among women with symptomatic urogenital prolapse (UGP). PATIENTS AND METHODS: A prospective analysis was carried out including 148 women with symptomatic UGP. Baseline characteristics, medical and obstetric history were recorded. The Pelvic Organ Prolapse Quantification (POP-Q) classification was used to stage the UGP. Validated tools were used to evaluate symptoms (Pelvic Floor Distress Inventory, PFDI-20) and HRQL (Pelvic Floor Impact Questionnaire, PFIQ-7). Sexual function was evaluated using the Pelvic organ prolapse urinary Incontinence Sexual Questionnaire (PISQ-12). Measurements were recorded at the preoperative examination, then at 3 and 12 months after surgery. We compared the follow-up results with preoperative data. RESULTS: The anatomical results at 3 months showed a significant correction (P < 0.05) relative to the preoperative values, on the three pelvic floor parameters measured, with a clinical relapse rate of 6.3%. This improvement remained significant after 12 months (P < 0.05). There was no difference between the results obtained at 3 months and those at 12 months. At 3 months compared with the preoperative data, there was a significant improvement in PFDI-20 total mean score (32.24 vs 94.31, P < 0.05). At 12 months, the improvement remained significant (38.06 vs 94.31, P < 0.05) for all scores compared with the preoperative scores. Again, there was no difference between results at 3 months, and those at 12 months. The results showed a significant improvement in the PFIQ-7 score at 3 (16.61 vs 64.04, P < 0.05) and 12 months (18.21 vs 64.04, P < 0.05). There was no significant difference between the scores at 3 months and those at 12months. The total PISQ-12 score was linked significantly to urinary symptoms (P < 0.05), pelvic symptoms (P < 0.05) but not with ano-rectal ones. At 3 months, the total mean PISQ-12 score had improved significantly compared with the preoperative score (35.42 vs 32.07, P < 0.05). At this time, only two items of the PISQ-12 questionnaire were significantly increased: 'existence of negative emotions during sexual activity' (P < 0.05) and 'the avoidance of sexual activity because of prolapse' (P < 0.05). The total mean score remained significantly improved at 12 months (36.56 vs 32.07, P < 0.05) and there was no statistical difference compared with the results at 3 months. CONCLUSIONS: Laparoscopic sacrocolpopexy resulted in the early improvement (primarily during the first 3 months) of all symptoms, HRQL and sexual function. This improvement was persistent in the medium term. Symptoms linked with UGP had different effects on sexuality fields. Anatomical improvement was not related to an improvement in all sexual fields.
Subject(s)
Coitus/psychology , Gynecologic Surgical Procedures , Laparoscopy , Quality of Life , Urinary Incontinence/surgery , Uterine Prolapse/surgery , Adult , Aged , Aged, 80 and over , Female , Follow-Up Studies , France/epidemiology , Gynecologic Surgical Procedures/methods , Humans , Middle Aged , Postoperative Period , Preoperative Period , Prospective Studies , Sacrococcygeal Region , Surveys and Questionnaires , Treatment Outcome , Urinary Incontinence/epidemiology , Urinary Incontinence/psychology , Uterine Prolapse/epidemiology , Uterine Prolapse/psychologyABSTRACT
UNLABELLED: What's known on the subject? and what does the study add?: Local relapse of renal cell carcinoma following radical nephrectomy is rare, and surgical removal provides the only opportunity for cure. Open surgery has been established as the usual approach for these tumours. It is, however, associated with significant morbidity. Our study describes the largest series of laparoscopic treatment of local relapse of renal cell carcinoma with the longest follow-up. We show that the laparoscopic approach is feasible in expert centres. It provides faster recovery and fewer complications with satisfactory oncological outcomes in selected patients. OBJECTIVE: To assess the feasibility and oncological outcomes of laparoscopic treatment for local relapse of renal cell carcinoma. PATIENTS AND METHODS: Nine patients were treated by a pure laparoscopic approach for local recurrence of a renal tumour between 2005 and 2011 by a single surgeon (HB), following an initial open radical nephrectomy for the primary tumour. Clinical and histopathological data were collected prospectively and analysed retrospectively. Seven patients were treated by a transperitoneal approach and two patients had a retroperitoneal approach. RESULTS: Relapse occurred within a mean time of 83 months (7-168) following nephrectomy. Recurrent tumour size varied from 2.5 to 4.5 cm. All surgeries were performed laparoscopically without need for conversion. Mean operative duration was 144 min (40-240), mean estimated blood loss was 430 mL (50-1300) and mean hospital stay was 4.5 days (3-6). Three patients had Clavien grade I intraoperative complications. Late complications were noted in two patients (Clavien I and IIIb). Pathology confirmed clear cell carcinoma in all patients with an absence of sarcomatoid features and negative surgical margins. Three patients had neoadjuvant treatment and two patients had adjuvant treatment. In all, 67% of patients were disease free with a mean follow-up period of 3 years. CONCLUSIONS: Surgical removal of isolated local recurrence remains the only possibility of cure in patients with renal cell carcinoma. We demonstrated that the laparoscopic approach is a safe and feasible alternative treatment option for selected cases with low morbidity and satisfactory oncological outcomes.
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Carcinoma, Renal Cell/surgery , Kidney Neoplasms/surgery , Laparoscopy , Neoplasm Recurrence, Local/surgery , Nephrectomy/methods , Aged , Feasibility Studies , Female , Humans , Male , Middle Aged , Retrospective Studies , Treatment OutcomeABSTRACT
Purpose: This study aimed to evaluate what objectives are most important to men undergoing radical prostatectomy to allow treating physicians to personalize perioperative counselling and improve patient quality of life outcomes. Materials and Methods: A predefined search protocol of the Medline and Embase databases was performed from database inception to May 2023. The search was limited to English language and full text. All articles with a specific consideration of patient objectives, preferences or reasons for decision to undergo radical prostatectomy were included for review. Results: Ten articles out of 375 screened met inclusion criteria for review. All 10 articles utilized a qualitative design and originated across 5 countries across the developed world. A common theme of men placing importance on having their tumor physically removed was found. Methodologies allowing free response beyond predefined categories identified a breadth of considerations including personal circumstance, personal belief and current function in the decision-making process. An investigation on radical prostatectomy performed robotically found some men placed preference on the quicker treatment time with surgery compared to radiation therapy, reflective of shorter recovery times with the robotic approach. Conclusion: Variability in results across studies highlights the heterogeneity in patient preferences. Directed investigation of patient objectives with an open-ended questioning approach would personalize the perioperative experience and may improve patient satisfaction and quality of life outcomes.
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OBJECTIVES: To explore the association between preoperative mental health status and surgical outcomes following robotic-assisted radical prostatectomy (RARP). METHODS: This cohort study included consecutive patients undergoing RARP surgery for prostate cancer between October 2016 and May 2022 at a major public hospital in Sydney, Australia. The primary outcome was preoperative self-reported mental health status measured using the mental component score from the Short Form 36 survey. Other variables included patients' characteristics, surgical outcomes, postoperative quality of life, pain and decision regret. Data were analysed using linear regression analysis. RESULTS: A total of 266 men underwent RARP during the studied period. Of these, 242 patients (91%) completed the preoperative survey and were analyzed. Poorer preoperative mental health had significant univariate associations with younger age (P = .025), reduced access to economic resources (P = .043), diagnosis of a mental illness (P = .033), poorer mental health at 6 weeks and 6 months postoperatively (both P <.001), greater pain (P = .001), and higher decision regret (P = .001) 6 weeks following surgery. In the multivariate analysis, poorer preoperative mental health status was associated with younger age (P = .028) and poorer mental health at 6 weeks (P <.001) and 6 months (P = .025) postoperatively. CONCLUSION: For patients undergoing RARP, poor preoperative mental health status was associated with younger age and poorer postoperative mental health. Future studies should investigate if targeted preoperative psychological interventions would improve postoperative mental health outcomes, specifically in younger men undergoing RARP.
Subject(s)
Prostatic Neoplasms , Robotic Surgical Procedures , Male , Humans , Infant, Newborn , Robotic Surgical Procedures/adverse effects , Cohort Studies , Mental Health , Quality of Life , Treatment Outcome , Prostatectomy/adverse effects , Prostatic Neoplasms/surgery , Pain/surgeryABSTRACT
This study aims to compare surgical outcomes and in-hospital cost between robotic-assisted surgery (RAS), laparoscopic and open approaches for benign gynaecology, colorectal and urological patients and to explore the association between cost and surgical complexity. This retrospective cohort study included consecutive patients undergoing RAS, laparoscopic or open surgery for benign gynaecology, colorectal or urological conditions between July 2018 and June 2021 at a major public hospital in Sydney. Patients' characteristics, surgical outcomes and in-hospital cost variables were extracted from the hospital medical records using routinely collected diagnosis-related groups (DRG) codes. Comparison of the outcomes within each surgical discipline and according to surgical complexity were performed using non-parametric statistics. Of the 1,271 patients included, 756 underwent benign gynaecology (54 robotic, 652 laparoscopic, 50 open), 233 colorectal (49 robotic, 123 laparoscopic, 61 open) and 282 urological surgeries (184 robotic, 12 laparoscopic, 86 open). Patients undergoing minimally invasive surgery (robotic or laparoscopic) presented with a significantly shorter length of hospital stay when compared to open surgical approach (P < 0.001). Rates of postoperative morbidity were significantly lower in robotic colorectal and urological procedures when compared to laparoscopic and open approaches. The total in-hospital cost of robotic benign gynaecology, colorectal and urological surgeries were significantly higher than other surgical approaches, independent of the surgical complexity. RAS resulted in better surgical outcomes, especially when compared to open surgery in patients presenting with benign gynaecology, colorectal and urological diseases. However, the total cost of RAS was higher than laparoscopic and open surgical approaches.
Subject(s)
Colorectal Neoplasms , Laparoscopy , Robotic Surgical Procedures , Humans , Robotic Surgical Procedures/methods , Retrospective Studies , Public Health , Australia/epidemiology , Laparoscopy/methods , Hospital Costs , Postoperative Complications/epidemiology , Postoperative Complications/surgery , Colorectal Neoplasms/surgery , Treatment OutcomeABSTRACT
Objective: To describe a novel RoboSling technique performed at the time of robot-assisted radical prostatectomy (RARP) and its utility for enhancing urinary function recovery postoperatively. Materials and Methods: The surgical technique involves harvesting a vascularised, fascial flap from the peritoneum on the posterior aspect of the bladder. Following completion of prostatectomy, the autologous flap is tunnelled underneath the bladder and incorporated into the rectourethralis and vertical longitudinal detrusor fibres at the posterior bladder neck with a modified Rocco suture. After urethra-vesical anastomosis is completed, the corners of the flap are hitched up to Cooper's ligament bilaterally with V-Loc sutures, tensioned and secured creating a bladder neck sling. A prospective, longitudinal cohort study was performed of 193 consecutive patients undergoing RARP between December 2016 and September 2019. The first 163 patients underwent standard RARP, and the last 30 patients had the RoboSling technique performed concurrently. Continence outcomes were the primary outcomes assessed using pad number and Expanded Prostate Cancer Composite (EPIC)-urinary domain questionnaire. Operative time (OT), estimated blood loss (EBL), complications and oncological outcomes were secondary outcomes. Results: The two groups were comparable for demographics and clinicopathological variables. At 3 months, zero pad usage (p = 0.005) and continence rates, defined as EPIC score ≥ 85 (p = 0.007), were both higher in the RoboSling group. EBL, complication rate and positive surgical margin rate did not differ between the two groups. Superior zero pad usage was observed at 1 year in the RoboSling group (p = 0.029). The RoboSling technique added on average 16 min to OT. Conclusions: The RoboSling procedure at the time of RARP was associated with earlier return to continence without negatively impacting other postoperative outcomes. This improvement in continence outcomes was maintained long term.
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BACKGROUND: The aim of this study was to evaluate genomic risk of patients with persistent prostate specific antigen (PSA) using mRNA expression analysis and a validated prognostic genomic-risk classifier. METHODS: Monocentric retrospective study including all patients who underwent radical prostatectomy (RP) by one surgeon and Decipher Test from October 2013 to December 2018. PSA persistent population was defined as all patients with two consecutive PSA>0.1 ng/mL at follow-up after the surgery. Neurovascular Structure-adjacent Frozen-section Examination (NeuroSAFE) was performed intraoperatively for research of positive surgical margins. Multivariate analysis was performed for persistent PSA (pPSA) predictors. A specific localized, organ-confined, and negative margins sub-population with PSA persistence was compared to a similar sub-population without PSA persistence for genomic differential expression analyses. RESULTS: A total of 564 patients were included and 61 of them had pPSA. Preoperative PSA was higher in the PSA persistent group (11.6 [6.4, 21.2] vs. 6.2 [4.7, 9.2] P=0.00010), as well as PSA density (PSAd) (0.3 [0.2, 0.5] vs. 0.2 [0.1, 0.3] P=0.0001). Postoperative characteristics, Gleason Score, and positive surgical margins were significantly higher in the PSA persistent population. 31 patients had pPSA in our specific subpopulation and were compared to 217 patients with no pPSA. On multivariate analysis, only Decipher Score (OR=5.64 [1.28; 24.89], P=0.022) and preoperative PSA (OR=1.06, [1.02; 1.09], P=0.001) were significant predictors for PSA persistence. We found two genes to be significantly upregulated with a 2.5-fold change in our specific subpopulation (SERPINB11 and PDE11A). CONCLUSIONS: We found unique genomic features of patients with pPSA, whilst confirming previous clinical findings that this condition behaves to a worse prognosis. Given this high genomic risk, further imaging studies should be performed to select patients for early treatment intensification.
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Prostate-Specific Antigen , Serpins , Male , Humans , Prostate-Specific Antigen/genetics , Margins of Excision , Retrospective Studies , Prostatectomy , Frozen SectionsABSTRACT
OBJECTIVES: To describe the innovative intraoperative technologies emerging to aid surgeons during minimally invasive robotic-assisted laparoscopic prostatectomy. METHODS: We searched multiple electronic databases reporting on intraoperative imaging and navigation technologies, robotic surgery in combination with 3D modeling and 3D printing used during laparoscopic or robotic-assisted laparoscopic prostatectomy. Additional searches were conducted for articles that considered the role of artificial intelligence and machine learning and their application to robotic surgery. We excluded studies using intraoperative navigation technologies during open radical prostatectomy and studies considering technology to visualize lymph nodes. Intraoperative imaging using either transrectal ultrasonography or augmented reality was associated with a potential decrease in positive surgical margins rates. Improvements in detecting capsular involvement may be seen with augmented reality. The benefit, feasibility and applications of other imaging modalities such as 3D-printed models and optical imaging are discussed. CONCLUSION: The application of image-guided surgery and robotics has led to the development of promising new intraoperative imaging technologies such as augmented reality, fluorescence imaging, optical coherence tomography, confocal laser endomicroscopy and 3D printing. Currently challenges regarding tissue deformation and automatic tracking of prostate movements remain and there is a paucity in the literature supporting the use of these technologies. Urologic surgeons are encouraged to improve and test these advanced technologies in the clinical arena, preferably with comparative, randomized, trials.
Subject(s)
Laparoscopy , Prostatic Neoplasms , Robotic Surgical Procedures , Robotics , Artificial Intelligence , Humans , Laparoscopy/methods , Male , Prostatectomy/methods , Prostatic Neoplasms/diagnostic imaging , Prostatic Neoplasms/pathology , Prostatic Neoplasms/surgery , Robotic Surgical Procedures/methodsABSTRACT
Robot-assisted laparoscopic prostatectomy requires a pneumoperitoneum combined with steep Trendelenburg positioning, and these conditions can be associated with impairment of cerebral autoregulation. The objective of this study was to determine if choice of anaesthetic agent affects the preservation of cerebral autoregulation during robot-assisted laparoscopic prostatectomy. We randomly assigned 30 patients to maintenance of general anaesthesia with either propofol or sevoflurane. Cerebral autoregulation was tested by administration of intravenous phenylephrine to increase mean arterial pressure from approximately 80 mmHg to 100 mmHg while assessing cerebral blood flow using transcranial Doppler ultrasonography. Autoregulation was first tested in the supine position and then approximately once every hour after Trendelenburg positioning. The main outcome measure was the result of the final autoregulation test prior to completion of surgery. At that time, we found cerebral autoregulation to be significantly impaired in six of the 15 patients receiving sevoflurane and none of the 15 patients receiving propofol (P = 0.02). However, it should be noted that some patients in the propofol group had impaired autoregulation on earlier tests. In conclusion, we found that autoregulation during robot-assisted laparoscopic prostatectomy is less likely to be impaired with propofol compared to sevoflurane anaesthesia, particularly towards the end of the surgery.
Subject(s)
Laparoscopy , Propofol , Robotics , Anesthesia, General , Head-Down Tilt/physiology , Homeostasis/physiology , Humans , Male , Propofol/pharmacology , Prostatectomy , SevofluraneABSTRACT
Purpose: This systematic review and meta-analysis investigates the efficacy of intraoperative sling procedures in reducing postprostatectomy urinary incontinence compared to having no slings. Methods: A comprehensive search of PubMed, Medline, Embase, and the Cochrane library from inception to November 2020 was performed. Risk of bias was assessed using the Cochrane Risk of Bias tool for randomized studies and Newcastle-Ottawa Scale for nonrandomized studies. The GRADE approach was used for critical appraisal of evidences and meta-analyses were conducted using random-effects models. Results: Ten studies were included (n = 1,447). Quality of evidence ranged from moderate to very low. Sling procedure was generally favorable for short-term continence outcomes, although discrepancies exist due to variability in continence definition. Sling procedure resulted in reduced urinary pad weight at 1 month postoperatively (MD: 21.55; 95%CI: 12.58 to 30.52). Patient-reported questionnaires were also favorable for the sling group for up to 3 months (IPSS; (MD: 1.44; 95%CI: 0.14 to 2.74), ICIQ-SF; (MD: 2.25; 95%CI: 1.26 to 3.24), EPIC-U; (MD: 5.30; 95%CI: 1.12 to 9.39)) postoperatively. Sling procedure improved the number of continent patients at 1 month with continence definition of zero pad use/day (RR:1.41; 95%CI: 1.10 to 1.83) but not with the definition of ≤ 1pad/day. Similarly, it reduced the time to continence with the ≤ 1 pad/day definition (MD: 0.5; 95%CI: 0.1 to 0.9) but not with the zero pad/day definition. Conclusion: The current literature suggests that intraoperative sling procedures during radical prostatectomy may promote early return of continence compared to having no sling, however, there are no long-term differences.
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PURPOSE: To assess baseline clinical and urodynamic profiles of a contemporary cohort of men undergoing radical prostatectomy (RP) as part of the ROSE (Robotic and Open Surgery for Prostate Cancer: A Prospective, Multi-centre, Comparative Study of Functional and Oncological Outcomes) study. METHODS: Men with localized prostate cancer undergoing RP were prospectively recruited to undergo clinical assessment and urodynamic testing prior to surgery as part of a clinical trial. The International Prostate Symptoms Score (IPSS) was used to determine participants' degree of lower urinary tract symptoms (LUTS). RESULTS: Eighty-five men with a median age of 64.5 years and a median prostate-specific antigen level of 6.3 ng/mL were prospectively recruited. Of patients with complete baseline data, 36 (50.7%), 28 (39.4%), and 7 (9.9%) had mild (IPSS<8), moderate (IPSS 8-19), and severe (IPSS>20) LUTS, respectively. Obstruction was identified in 18 men (29.5%), and 9 (14.8%) showed detrusor underactivity. Of the 15 patients with detrusor overactivity, 12 (80%) reported overactive bladder (OAB). Of men with urodynamic obstruction, 5 (31.3%), 10 (62.5%), and 1 (6.3%) reported mild, moderate, and severe LUTS, respectively. Of men without OAB, 4 (11.8%, P=0.002) showed filling phase abnormalities, 13 (46.4%, P=0.611) had flow rates of <15 mL/sec, and 7 (30.4%, P=0.767) showed obstruction. Of men with mild or no LUTS, 5 (20%, P=0.072) showed obstruction and 4 (16%, P=0.524) showed poor contractility. CONCLUSION: LUTS and OAB were common in men with localized prostate cancer undergoing RP. Detrusor overactivity and urodynamic filling phase abnormalities were strongly correlated with OAB. IPSS did not show a strong correlation with bladder outflow obstruction or detrusor underactivity. Urodynamic filling abnormalities were found in 11.8% of men without OAB. Symptomatic and functional assessment may therefore have a role in the preoperative counselling of patients and possibly guide postoperative management of LUTS, especially if OAB is present.
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OBJECTIVE: To investigate the effect of prostate-specific antigen (PSA) testing on stage migration in an Australian population, and its consequences on the prognostic accuracy of the post-radical prostatectomy (RP) Kattan nomogram, as in North America widespread PSA testing has resulted in prostate cancer stage migration, questioning the utility of prognostic nomograms in this setting. PATIENTS AND METHODS: The study comprised 1008 men who had consecutive RP for localized prostate cancer between 1991 and 2001 at one institution. Two groups were assessed, i.e. those treated in 1991-96 (group 1, the early PSA era), and 1997-2001 (group 2, the contemporary PSA era). Differences in clinicopathological features between the groups were analysed by chi-squared testing and survival modelling. Individual patient data were entered into the post-RP Kattan nomogram and the efficacy assessed by receiver- operating characteristic curve analysis. RESULTS: Patients in group 2 had lower pathological stage disease (P = 0.01) and fewer cancers with Gleason score > or =8 (P < 0.001) than group 1. Multivariate analysis identified preoperative serum PSA level (P < 0.01) and Gleason score (P < 0.01) as strong predictors of biochemical relapse in both groups. In group 2 pathological stage was not significant, but margin involvement became highly significant (P = 0.004). There was no difference in the predictive accuracy of the Kattan nomogram between the groups (P = 0.253). CONCLUSIONS: These findings show a downward stage migration towards organ-confined disease after the introduction of widespread PSA testing in an Australian cohort. Despite this, the Kattan nomogram remains a robust prognostic tool in clinical practice.
Subject(s)
Neoplasm Recurrence, Local/pathology , Nomograms , Prostatectomy/methods , Prostatic Neoplasms/pathology , Adult , Aged , Epidemiologic Methods , Humans , Lymphatic Metastasis , Male , Middle Aged , Prognosis , Prostatic Neoplasms/surgeryABSTRACT
INTRODUCTION: Despite the development of new therapies for advanced prostate cancer, it remains the most common cause of cancer and the second leading cause of cancer death in men. It is critical to develop novel agents for the treatment of prostate cancer, particularly those that target aspects of androgen receptor (AR) signalling or prostate biology other than inhibition of androgen synthesis or AR binding. Neoadjuvant pharmacodynamic studies allow for a rational approach to the decisions regarding which targeted therapies should progress to phase II/III trials. CDK4/6 inhibitors have evidence of efficacy in breast cancer, and have been shown to have activity in preclinical models of hormone sensitive and castrate resistant prostate cancer. The LEEP trial aims to assess the pharmacodynamic effects of LEE011 (ribociclib), an orally bioavailable and highly selective CDK4/6 inhibitor, in men undergoing radical prostatectomy for high-risk, localised prostate cancer. METHODS AND ANALYSIS: The multicentre randomised, controlled 4:1 two-arm, phase II, open label pharmacodynamic study will recruit 47 men with high risk, localised prostate cancer who are planned to undergo radical prostatectomy. Participants who are randomised to receive the study treatment will be treated with LEE011 400 mg daily for 21 days for one cycle. The primary endpoint is the frequency of a 50% reduction in Ki-67 proliferation index from the pretreatment prostate biopsy compared to that present in prostate cancer tissue from radical prostatectomy. Secondary and tertiary endpoints include pharmacodynamic assessment of CDK4/6 cell cycle progression via E2F levels, apoptotic cell death by cleaved caspase-3, changes in serum and tumour levels of Prostate Specific Antigen (PSA), pathological regression, safety via incidence of adverse events and exploratory biomarker analysis. ETHICS AND DISSEMINATION: The protocol was approved by a central ethics review committee (St Vincent's Hospital HREC) for all participating sites (HREC/17/SVH/294). Results will be disseminated in peer-reviewed journals and at scientific conferences. DRUG SUPPLY: Novartis. PROTOCOL VERSION: 2.0, 30 May 2019 TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trials Registry (ACTRN12618000354280).
Subject(s)
Aminopyridines/pharmacology , Neoadjuvant Therapy , Prostate/drug effects , Prostatectomy , Prostatic Neoplasms , Purines/pharmacology , Adolescent , Adult , Aminopyridines/therapeutic use , Antineoplastic Agents/pharmacology , Antineoplastic Agents/therapeutic use , Apoptosis , Caspase 3/metabolism , Cell Cycle , Cell Proliferation , Clinical Trials, Phase II as Topic , Cyclin-Dependent Kinase 4/antagonists & inhibitors , Cyclin-Dependent Kinase 6/antagonists & inhibitors , Disease-Free Survival , E2F Transcription Factors/metabolism , Humans , Kallikreins , Male , Prostate/pathology , Prostate-Specific Antigen/metabolism , Prostatic Neoplasms/drug therapy , Prostatic Neoplasms/surgery , Purines/therapeutic use , Randomized Controlled Trials as Topic , Research DesignABSTRACT
We report on the case of a partial nephrectomy for a Juxtaglomerular apparatus (JGA) tumour in a 28 year old female who presented with fatigue and symptomatic hypertension, and a normal serum renin level on pre-operative work-up.