The Australian laparoscopic non robotic radical prostatectomy experience - analysis of 2943 cases (USANZ supplement).

OBJECTIVES: To analyse the Australian experience of high-volume Fellowship-trained Laparoscopic Radical Prostatectomy (LRP) surgeons. MATERIALS AND METHODS: 2943 LRP cases were performed by nine Australian surgeons. The inclusion criteria were a prospectively collected database with a minimum of 100 consecutive LRP cases. The surgeons' LRP experience commenced at various times from July 2003 to September 2009. Data were analysed for demographic, peri-operative, oncological and functional outcomes. RESULTS: The mean age of patients were 61.5 years and mean preoperative PSA 7.4 ng/ml. Mean operating time was 168 minutes with conversion to open surgery in 0.5% and a blood transfusion rate of 1.1%. Overall mean length of stay was 2.5 days. 73.6% of pathological specimens were pT2 and 86.3% had Gleason Score >7. Overall positive surgical margins (PSM) occurred in 15.9% with pT2 PSM 9.8%, pT3a PSM 30.8% and pT3b PSM 39.2%. Mean urinary continence at 12 months was 91.4% (data available from five surgeons). Mean 12 months potency after bilateral nerve spare was 47.2% (data available from four surgeons). Biochemical recurrence occurred in 10.6% (mean follow up 17 months). CONCLUSION: The Australian experience of Fellowship trained surgeons performing LRP demonstrates favourable peri-operative, oncological and functional outcomes in comparison to published data for open, laparoscopic and robotic assisted radical prostatectomy. In our Australian centres, LRP remains an acceptable minimally invasive surgical treatment for prostate cancer despite the increasing use of robotic assisted surgery.

Is transperineal prostate biopsy more accurate than transrectal biopsy in determining final Gleason score and clinical risk category? A comparative analysis.

OBJECTIVES: To assess the degree of upgrading and increase in clinical risk category of transperineal template biopsy (TTB) compared with transrectal ultrasonography-guided prostate biopsy (TRUSB). Upgrading of TRUSB Gleason grade and sum after radical prostatectomy (RP) is well recognised. TTB may offer a more thorough mapping of the prostate than TRUSB, as well as a more accurate assessment of the tumour. In this retrospective cohort study of prospectively collected data, we compare the initial TRUSB and TTB Gleason grade and sum with the final assessment at RP. PATIENTS AND METHODS: Following Ethics Committee approval, 431 laparoscopic and robotic RP specimens of two urologists, fellowship-trained in minimally invasive RP, were examined in the private sector between April 2009 and October 2013. Final RP Gleason grade and sum were compared with the initial prostate biopsy. All pathological assessments were performed by a dedicated uropathology unit, experienced in prostate pathology. Upgrading was defined either as an increase in the primary Gleason grade, or as identification of a higher grade tertiary pattern at final RP analysis. Increase in clinical risk category was defined as an increase from low- (Gleason ≤6), to either intermediate- (Gleason 7) or high-risk disease (Gleason 8-10); or as an increase from intermediate- to high-risk disease. The chi-squared test was used to compare categorical variables, while the Wilcoxon rank sum was used for continuous quantitative variables. RESULTS: The 431 RP specimens comprised 283 in which the prostate cancer was diagnosed at TRUSB and 148 diagnosed at TTB. There was no difference between TRUSB and TTB in mean prostate weight (46.4 vs 44.2 g), final RP pathological stage (pT2: 187 vs 102; pT3 97 vs 48; P = 0.65) or mean tumour volume (2.15 vs 2.14 mL). Overall, 33.22% of TRUSB and 30.41% of TTB were upgraded, which was not significantly different (P = 0.55). Similarly there was no difference in whether there was an increase to a higher Gleason sum (TRUSB 23.3% vs TTB 20.9%; P = 0.57). TTB was more reflective of the actual clinical risk category, with TRUSB more likely to show an increase in clinical risk (TRUSB 22.3% vs TTB 14.2%; P = 0.04). CONCLUSIONS: In this series, TTB more accurately predicted clinical risk category than TRUSB. TTB should be considered before active surveillance, to ensure that occult higher risk disease has not been under diagnosed. Upgrading and increase in clinical risk category was relatively common in each group highlighting the need for improved pretreatment staging accuracy.

Clinicopathologic Significance of Anterior Prostate Cancer: Comparison With Posterior Prostate Cancer in the Era of Multiparametric Magnetic Resonance Imaging.

Anterior prostate cancer (APC) has been considered an indolent tumor, most commonly arising in the transition zone (TZ). More recently, detection of APC has been facilitated through multiparametric magnetic resonance imaging and improved biopsy techniques, enabling earlier detection. The pathologic features and clinical significance of pure APC in a large contemporary series of well-characterized tumors have, to date, not been elucidated. Cases with APC defined as cancer present anterior to the urethra only were identified from 1761 consecutive radical prostatectomy specimens accessioned between January 2015 and August 2016. The clinicopathologic features of these cases were compared with those of pure posterior prostate cancer (PPC) and the features of anterior peripheral zone (APZ) cancers were compared with those of TZ cancers. In addition, the tumor series from 2015 to 2016 was compared with a cohort of 1054 patients accessioned before the utilization of multiparametric magnetic resonance imaging in the routine workup of patients with prostate cancer. In the 2015-2016 series, there were 188 (10.7%) patients with APC compared with 5.4% in the series from the pre-multiparametric magnetic resonance imaging era. No difference was observed between APC and PPC with regards to patient age or mean serum prostate-specific antigen at presentation. Mean tumor volume and positive surgical margin (PSM) rates were significantly higher in APC. In contrast, PPC was more commonly high grade with more frequent extraprostatic extension (EPE). None of the cases of APC had infiltration of the seminal vesicle or lymph node involvement, in contrast to PPC, with almost 14% of cases in each category. The 3- and 5-year biochemical recurrence-free survival was significantly higher in APC when compared with PPC, although this was not retained on multivariable analysis which included tumor location. On division of APCs according to anatomic zone of origin, 45% were APZ cancer and 37% TZ cancer. On comparison of APZ and TZ cancers, there were no significant differences in mean age and serum prostate-specific antigen at presentation as well as tumor volume, Gleason score, and PSM rate. High-grade malignancy (Gleason score >3 + 4=7) was seen in 26% of TZ cancers which compared with 44% of APZ cancers and 56% of PPC cancers. The rate of EPE was significantly higher in APZ when compared with TZ cancer ( P< 0.0005); however, the biochemical recurrence rate was not significantly different between the groups. The prevalence of APC in radical prostatectomy specimens has increased in recent times, in association with earlier detection at a stage amenable to curative surgical treatment. APC, when compared with PPC, is less commonly high grade with less frequent EPE, despite the APC group having larger tumors and a higher PSM rate at presentation. However, not all anterior cancers are indolent. Anterior cancers are more commonly seen in the APZ than the TZ and APZ cancers appear more locally aggressive than TZ cancers.

Preliminary results of robot-assisted laparoscopic radical prostatectomy (RALP) after fellowship training and experience in laparoscopic radical prostatectomy (LRP).

OBJECTIVE: • To ascertain whether prior experience in laparoscopic radical prostatectomy (LRP) shortens the 'learning curve' and therefore improves early patient outcomes when transitioning to robot-assisted laparoscopic RP (RALP). PATIENTS AND METHODS: • Retrospective analysis of prospectively collected data of the most recent 87 cases of LRP compared with the initial 73 cases of RALP. • LRP was performed via a five-port extraperitoneal approach, while transperitoneal RALP was performed using a four-arm da Vinci S unit. RESULTS: • The median operative duration for RALP (skin-to-skin, including docking time) rapidly reduced, although never exceeded 3.5 h, for each consecutive set of 10 cases. • Oncological outcomes were preserved with no cases of pT2 positive surgical margins (PSMs) in any group. pT3 PSM rates were not significantly different at 50% and 38% for LRP and RALP, respectively. • Penetrative intercourse rates at 3 months for bilateral nerve-sparing procedures in preoperatively potent patients were similar, at 50% for LRP (median Sexual Health Inventory for Men [SHIM] 17) and 48.1% for RALP (median SHIM 18). The pad-free rate at 3 months was significantly better for RALP at 59.7%, compared with 39.8% for LRP (P= 0.043). • Complications were minimal and comparable for the two groups except for a higher LRP radiological anastomotic leak rate of 16 vs 1% (P= 0.004). CONCLUSION: • In this comparative series fellowship training and prior experience in LRP resulted in no significant RALP learning curve with regards to oncological and functional outcomes, while maintaining a low complication rate. • A short learning curve existed for operative duration but this improved rapidly and there were no prolonged cases. • Differences in early continence and radiological leaks may reflect changing from an interrupted anastomosis (LRP) to a continuous anastomosis with posterior rhabdosphincter reconstruction (RALP).

Tumour-capsule interface measured on 18F-DCFPyL PSMA positron emission tomography/CT imaging comparable to multi-parametric MRI in predicting extra-prostatic extension of prostate cancer at initial staging.

INTRODUCTION: Nerve-sparing prostatectomy is recommended in cases of organ-confined prostate cancer but is generally contraindicated in patients with suspected extra-prostatic extension (EPE). PSMA ligand imaging has been shown to be valuable in predicting EPE when performed on a hybrid PET/MRI scanner; however, the majority of PSMA PET imaging is performed using PSMA-PET. To our knowledge, there are no established PET/CT criteria for assessing EPE. In this study, we aim to provide a reproducible method for evaluating EPE on PSMA-PET/CT imaging and assess its utility compared with MRI. METHODS: Imaging findings and histopathology were reviewed for 100 consecutive patients who underwent a radical prostatectomy after imaging with MRI and 18F-DCFPyL PSMA-PET/CT. RESULTS: A broad tumour-capsule interface measured using a standardised technique on fused PSMA-PET/CT imaging is associated with a higher risk for established EPE (P < 0.001). In our cohort, applying the criteria of tumour-capsule contact ≥ 10 mm measured on PET/CT was as sensitive as applying PI-RADS version 2 criteria to mpMRI imaging for predicting EPE (74% and 79%, respectively, P = 0.11) and had superior specificity (86% and 61%, respectively, P = 0.035). 93% of MRI-occult lesions were visualised on PSMA-PET/CT. Applying the proposed PET/CT criteria for EPE to this subgroup of 14 patients yielded a sensitivity of 67% and specificity of 92%. CONCLUSION: Our results suggest that tumour-capsule interface measured on fused F18-DCFPyL PSMA-PET/CT imaging is comparable to MRI criteria for predicting the presence of EPE. Applying PET/CT criteria may be of particular benefit in predicting EPE in patients with MRI-occult prostate cancer.

Does intrafascial dissection during nerve-sparing laparoscopic radical prostatectomy compromise cancer control?

UNLABELLED: To assess whether oncological outcomes are compromised by adopting the curtain dissection (CD) technique (high incision of the peri-prostatic fascia) during nerve-preserving radical prostatectomy (RP). PATIENTS AND METHODS: In all, 973 laparoscopic RPs (LRPs) were performed or supervised by one surgeon between March 2000 and October 2007 for cT1-3 N0M0 prostate cancer, of which 510 included bilateral neurovascular bundle preservation. A CD technique was used in 240 men and a standard dissection (StD) technique was used in 270, considered the control group. The technique was extraperitoneal, used five ports and included preservation of the seminal vesicle tips. Thermal energy was not used posterior or lateral to the prostate in either group. Patient, operative and oncological outcome variables were compared using an independent-sample t-test if continuous or with Fisher's exact test for rates. RESULTS: Patient and cancer characteristics before LRP were similar for the CD and StD groups, and there were no significant perioperative differences either. Positive margins occurred in 11.7% of the CD group and 11.1% of the StD group (P = 0.95). At a mean (range) follow-up of 11.7 (3-24) months for the CD group and 13.1 (3-24) months for the StD group, biochemical recurrence rates were 0% and 1.1%, respectively (P = 0.30). Potency (CD, 62%; StD, 61%; P = 0.89) and continence rates (StD, 97%; CD, 98%; P = 0.83) were comparable between the groups, but there was a statistically significant earlier return to continence in the CD group (P < 0.001 at 3 months). CONCLUSIONS: For carefully selected men there appears to be no compromise in cancer control with intrafascial dissection in the short term. However, equally there appears to be no significant improvement in potency after LRP. The earlier return to continence after intrafascial nerve-sparing suggests reduced dissection of periurethral supports rather than preservation of additional autonomic nerve fibres.

The impact of training on service provision in laparoscopic radical prostatectomy.

OBJECTIVE: To address concerns about the impact of training on patient outcomes during the 'learning curve' for laparoscopic radical prostatectomy (LRP), we compare the results of our patients undergoing LRP with and without trainees performing a substantial proportion of the cases. PATIENTS AND METHODS: In all, 771 consecutive cases of LRP were performed or supervised by one surgeon during a 7.5-year period, of which 114 (15%) were training cases. A five-port transperitoneal technique was used in the first 111 patients and an extraperitoneal approach in the remaining 660. Patient, operative and oncological outcome variables were compared using an independent samples t-test if continuous or with Fisher's exact test for rates. RESULTS: There were no differences in preoperative patient or cancer characteristics with the exception of body mass index (BMI) which was lower in the training cases (medians 25 and 26 kg/m(2), P = 0.02) and patient age which was higher (medians 64 and 62 years, P < 0.001). Operative time, which was longer in training cases (medians 200 and 175 min, P < 0.001) was the only significantly different operative variable between the groups. There were no statistically significant differences in postoperative (duration of catheterization, hospitalization time, complication rates, biochemical recurrence and pad-free rates at 1 year) or pathological (gland weight, positive surgical margin rate) outcomes between the groups. As Fellows did not perform the posterior or apical dissection steps in nerve-sparing cases, no evaluation of potency outcomes is included. CONCLUSIONS: Training cases took a median of 25 min longer to complete than non-training cases. However, other perioperative measures, complications rates and cancer outcomes were similar. Adequately supervised training in LRP does indeed take additional time but is essential for the dissemination of surgical skills and preservation of acceptable outcomes.

Real-World Evidence of Prostatic Urethral Lift Confirms Pivotal Clinical Study Results: 2-Year Outcomes of a Retrospective Multicenter Study.

Introduction: This study expands results from recent prostatic urethral lift (PUL) clinical trials by examining outcomes within a large unconstrained multicenter data set. Methods: Retrospective chart review and analysis of 1413 consecutive patients who received PUL in North America and Australia was performed. International Prostate Symptom Score (IPSS), quality of life (QoL), and maximum urinary flow rate (Qmax) were evaluated at 1, 3, 6, 12, and 24 months post-procedure for all nonurinary retention subjects (Group A) and retention subjects (Group B). Within Group A outcomes were further analyzed using paired t-tests and 95% mean confidence intervals under the following parameters: IPSS baseline ≥13, age, prostate size, site of service, prostate cancer treatment, and diabetic status. Adverse events, surgical interventions, and catheterization rates were summarized in detail. Results: Compared with the randomized controlled prosatic urethral lift (L.I.F.T.) study, subjects in this retrospective study were older and less symptomatic. After PUL, mean IPSS for Group A improved significantly from baseline by at least 8.1 points throughout follow-up. No significant differences were observed between Group A and B follow-up symptom scores. Within Group A, subjects with an IPSS baseline ≥13 behaved similarly to L.I.F.T. subjects. Age, prostate volume, site of service, prior cancer treatment, and diabetic status did not significantly affect PUL outcomes. When completed in a clinic office, PUL resulted in less side effects and catheter placement compared to other sites of service. Previous prostate cancer treatment did not elevate adverse events of high concern such as incontinence and infection. Conclusion: PUL performs well in a real-world setting in terms of symptom relief, morbidity, and patient experience for all studied patient cohorts.

Curtain dissection of the lateral prostatic fascia and potency after laparoscopic radical prostatectomy: a veil of mystery.

OBJECTIVE: To assess the effect on potency recovery of incorporating a high incision of the lateral prostatic fascia (LPF) or curtain dissection (CD) into our technique of laparoscopic nerve-sparing radical prostatectomy (LNSRP). PATIENTS AND METHODS: In all, 137 bilateral neurovascular bundle (NVB) preserving LNSRPs were performed, incorporating curtain dissection (CD) of the LPF. Potency was assessed at 1, 3, 6 and 12 months using validated questionnaires and compared with a control group (CG) of standard NVB preservation. RESULTS: There were no conversions to open surgery in either group. The median operative duration in the CD group and the CG was 178 min and 174 min (P = 0.04), blood loss was 300 mL and 200 mL (P = 0.01), and the positive margin rate was 16.1% and 24.1% (P = 0.04), respectively. At a mean follow-up of 5.8 months in the CD group and 28.2 months in the CG, potency rates were 21.1% and 8.8% at 1 month (P = 0.01), and 68.4% and 67.2% at 12 months (P = 1.00), respectively. CONCLUSION: The potency rate was significantly higher in the CD group at 1 month than in the CG, thereafter the rates were similar between the groups. We think that the merit of this technique is in improved visualization of the basal prostatic contour during antegrade NVB dissection, rather than preserving important nerve fibres. This may explain the lower basal positive margin rate in the CD group of 0% vs 5.8% in the CG (P = 0.007).

The Australian laparoscopic radical prostatectomy learning curve.

BACKGROUND: International estimates of the laparoscopic radical prostatectomy (LRP) learning curve extend to as many as 1000 cases, but is unknown for Fellowship-trained Australian surgeons. METHODS: Prospectively collected data from nine Australian surgeons who performed 2943 consecutive LRP cases was retrospectively reviewed. Their combined initial 100 cases (F100, n = 900) were compared to their second 100 cases (S100, n = 782) with two of nine surgeons completing fewer than 200 cases. RESULTS: The mean age (61.1 versus 61.1 years) and prostate specific antigen (7.4 versus 7.8 ng/mL) were similar between F100 and S100. D'Amico's high-, intermediate- and low-risk cases were 15, 59 and 26% for the F100 versus 20, 59 and 21% for the S100, respectively. Blood transfusions (2.4 versus 0.8%), mean blood loss (413 versus 378 mL), mean operating time (193 versus 163 min) and length of stay (2.7 versus 2.4 days) were all lower in the S100. Histopathology was organ confined (pT2) in 76% of F100 and 71% of S100. Positive surgical margin (PSM) rate was 18.4% in F100 versus 17.5% in the S100 (P = 0.62). F100 and S100 PSM rates by pathological stage were similar with pT2 PSM 12.2 versus 9.5% (P = 0.13), pT3a PSM 34.8 versus 40.5% (P = 0.29) and pT3b PSM 52.9 versus 36.4% (P = 0.14). CONCLUSION: There was no significant improvement in PSM rate between F100 and S100 cases. Perioperative outcomes were acceptable in F100 and further improved with experience in S100. Mentoring can minimize the LRP learning curve, and it remains a valid minimally invasive surgical treatment for prostate cancer in Australia even in early practice.

Early vascular unclamping reduces warm ischaemia time in robot-assisted laparoscopic partial nephrectomy.

INTRODUCTION: The aim of this study was to assess the outcomes of early vascular release in robot-assisted laparoscopic partial nephrectomy (RAPN) to reduce warm ischaemia time (WIT) and minimise renal dysfunction. RAPN is increasingly utilised in the management of small renal masses. To this end it is imperative that WIT is kept to a minimum to maintain renal function. METHODS: RAPN was performed via a four-arm robotic transperitoneal approach. The renal artery and vein were individually clamped with robotic vascular bulldog clamps to allow cold scissor excision of the tumour. The cut surface was then sutured with one or two running 3-0 V-Loc (TM) sutures, following which the vascular clamps were released. Specific bleeding vessels were then selectively oversewn and the collecting system repaired. Renorrhaphy was then completed using a running horizontal mattress 0-0 V-Loc (TM) suture. RESULTS: A total of 16 patients underwent RAPN with a median WIT of 15 minutes (range: 8-25), operative time 230 minutes (range: 180-280) and blood loss of 100 mL (range: 50-1000). There were no transfusions, secondary haemorrhages or urine leaks. There was one focal positive margin in a central 5.5 cm pT3a renal cell carcinomas (RCC). Long-term estimated glomerular filtration rate (eGFR) was not significantly different to pre-operative values. CONCLUSION: In this patient series, early vascular release effectively minimised WIT and maintained renal function without compromising perioperative safety.

Photoselective vaporization of the prostate using the 180W lithium triborate laser.

INTRODUCTION: Photoselective vaporization of the prostate (PVP) is widely used to treat benign prostatic obstruction (BPO), but there is little experience reported on the new more powerful 180W lithium triborate (LBO) laser. This study evaluates the safety and efficacy of using the 180W LBO laser to treat BPO by examining a multicentre Australian experience. METHODS: Retrospective review of prospectively collected data on all men treated by 180W LBO laser PVP by eight urologists across six Australian hospitals, from July 2011 to August 2011, was performed. Perioperative and functional outcomes were examined at baseline and 3 months. RESULTS: Of the 85 men (median age 70 years, prostate volume 51 cm(3)) identified, 27% (23/85) were in urinary retention and 44% (37/85) were taking antiplatelet/anticoagulant medication. Median operating time was 46 min, laser time 27 min, energy use 211 kJ, post-operative duration of catheterization 15 h and hospitalization 22 h. Functional outcomes from baseline to 3 months, respectively, were for IPSS 25-7; QoL 5-2; Qmax 7.7-18.4; and PVR 147-38. All improvements were statistically significant (P < 0.01). Thirty-eight percent (32/85) of patients experienced at least one adverse event. Most adverse events were low Clavien-Dindo grade I-II. There were five grade III, two grade IV and no grade V adverse events. Sixty per cent (51/85) of men were able to be discharged home voiding successfully without a catheter within 24-h post-PVP. CONCLUSIONS: Our early multicentre Australian experience indicates the 180W LBO laser PVP is an efficacious and safe treatment for BPO.

Blood loss during laparoscopic radical prostatectomy.

PURPOSE: To determine the impact of a variety of intraoperative parameters that may affect blood loss during laparoscopic radical prostatectomy (LRP). PATIENTS AND METHODS: Intraoperative blood loss was calculated for 757 consecutive LRPs performed by the same surgeon (CE) over a 6-year period. The impact of a number of intraoperative factors that may affect blood loss was studied. These factors include the operative approach (transperitoneal or extraperitoneal), neurovascular bundle (NVB) preservation, lateral prostatic fascia preservation, prostate weight, and the impact of the learning curve for the primary surgeon and trainees. Multivariate and univariate analyses were performed to determine the significance of these factors on intraoperative blood loss during LRP. RESULTS: Mean (+/-standard deviation) blood loss in the 757 patients was 263 +/- 206 mL. Five (0.7%) patients received transfusions. There was a statistically significant difference between extraperitoneal (256 +/- 207 mL) and transperitoneal (308 +/- 199 mL) LRP in terms of blood loss. Nerve preservation [standard or with preservation of the lateral prostatic fascia (LPF)] resulted in a statistically significantly increase in blood loss (205 mL vs 321 mL, respectively, P < 0.001). It also appears that lateral prostatic fascia dissection, as part of a modified NVB preservation, increases blood loss with statistical significance (295 mL vs 353 mL, respectively P < 0.001). There was no statistically significant increase in blood loss with increasing prostate weight (<30 g, 30-50 g, 50-80 g, >80 g). The learning curve also had no impact on blood loss. Trainees were able to perform LRP without an increase in blood loss when mentored by the primary surgeon (CE). CONCLUSION: There was a low requirement for transfusion in this cohort of patients undergoing LRP, and the average blood loss is comparable with the most recently reported minimally invasive prostatectomy series. Blood loss during LRP is mainly affected by nerve preservation, with an average increase of 90 mL for a standard NVB and 150 mL when the lateral prostatic fascia is preserved. It is clear, however, that although NVB preservation may increase blood loss, it does not increase the risk of transfusion for patients or impact on postoperative recovery.

Prostate cancer detection in men with an initial diagnosis of atypical small acinar proliferation.

OBJECTIVE: To determine the subsequent prostatic adenocarcinoma detection rate amongst men with an initial diagnosis of atypical small acinar proliferation (ASAP). PATIENTS AND METHODS: We reviewed the Illawarra Prostate Pathology Database over a 10-year period (January 1994 to January 2004) for specimens diagnosed as ASAP. These specimens were re-reviewed and clinical data obtained. RESULTS: Of 61 cases of ASAP, there were complete follow-up data for 31. In this group nine patients had no further biopsies at our institution; the other 22 had at least one repeat biopsy. The incidence of prostatic adenocarcinoma in this group was 17/31 (55%). This included 13 diagnoses on second biopsy, three on third biopsy and one diagnosed at another institution. CONCLUSION: This study showed a detection rate for prostatic adenocarcinoma of 55% after an initial diagnosis of ASAP, which indicates that an initial diagnosis of ASAP mandates re-biopsy.