The Added Value of Baseline Health-Related Quality of Life in Predicting Survival in High-Risk Prostate Cancer Patients Following Radical Prostatectomy.

PURPOSE: Several studies have shown baseline health-related quality of life to be a valuable prognostic indicator of survival outcomes for various cancer entities in the metastatic setting. To date, there is no evidence regarding the prognostic value of baseline health-related quality of life for patients undergoing radical prostatectomy due to localized prostate cancer. MATERIALS AND METHODS: A total of 1,029 patients with high-risk prostate cancer according to National Comprehensive Cancer Network® risk stratification and prospectively assessed baseline health-related quality of life prior to radical prostatectomy were identified. Patients were stratified by global health status domain of the QLQ-C30 questionnaire. Oncologic endpoints were biochemical recurrence-free survival and metastasis-free survival. Multivariable Cox regression models were performed to assess prognostic significance of baseline global health status on survival outcomes. Harrell's discrimination C-index was applied to calculate the predictive accuracy of the model and previously described risk stratification models. Decision curve analysis was applied to test the clinical net benefit associated with adding global health status to our multivariable model (P < .05). RESULTS: Median follow-up was 43 months. In multivariable analysis, global health status was confirmed as an independent predictor for increased biochemical recurrence-free survival (HR .97, 95% CI .96-.99; P = .001) and metastasis-free survival (HR .96, 95% CI .93-.99; P = .013), indicating a relative risk reduction of 2.9% for biochemical recurrence-free survival and 3.7% for metastasis-free survival per 1-point increase of baseline global health status. Adding baseline health-related quality of life to our model and to the Cancer of the Prostate Risk Assessment and National Comprehensive Cancer Network score improved discrimination in predicting biochemical recurrence-free survival and metastasis-free survival of the respective models. Decision curve analysis revealed a net benefit over all threshold probabilities. CONCLUSIONS: Our findings highlight baseline health-related quality of life to be a valuable and robust prognostic factor for patients with localized high-risk prostate cancer prior to radical prostatectomy. Baseline health-related quality of life increased prognostic accuracy of biochemical recurrence-free survival and metastasis-free survival.

Salvage cystectomy and ileal conduit urinary diversion as a last-line option for benign diseases-perioperative safety and postoperative health-related quality of life.

AIMS: Radical cystectomy and urinary diversion impact various dimensions of patients' health-related-quality-of-life (HRQOL). Yet, less is known about salvage cystectomy as a last-line option for treatment-refractory benign diseases. Therefore, our aim is to provide HRQOL data from a contemporary cohort of open salvage cystectomies for benign conditions. METHODS: Fifty-four consecutive patients were enrolled in one single tertiary referral center. Analysis was limited to patients undergoing urinary diversion via ileal conduit (IC). Complications were assessed via Clavien-Dindo-scale. HRQOL was measured using the validated European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-BLM30 questionnaire. HRQOL QLQ-C30 domains were measured preoperatively and up to 3 years postoperatively. Longitudinal changes were analyzed using Friedman's rank test. Primary endpoint was good general HRQOL based on QLQ-C30 global health status (GHS). Multivariate analysis was performed using logistic regression models with a step-wise backward selection procedure. RESULTS: Longitudinal analysis of HRQOL subdomains revealed significantly improved pain (p = .005) and fatigue (p = .002) scores as well as improved social functioning (p = .038). Furthermore, general HRQOL (GHS scores) improved significantly during the follow-up period (28.0 vs. 50.6 [36 months], p = .045). In multivariate analysis, the indication for salvage cystectomy could not be identified as an independent predictor for good general HRQOL. We observed a total number of 10 (41.7%) high-grade (Clavien ≥III) 90 day-complications. Limitations include limited follow-up rates at respective time-points. CONCLUSION: Salvage cystectomy and IC can be safely performed as a last-line treatment for benign conditions and increases general HRQOL in the long-term follow-up. Thus, it can play a role in a holistic approach for a challenging clinical setting.

Impact of previous transurethral prostate surgery on health-related quality of life after radical prostatectomy: Does the interval between surgeries matter?

PURPOSE: To assess the impact of previous transurethral surgery for benign prostate enlargement (BPE) and time interval between procedures on functional outcomes and health-related quality of life (HRQOL) after radical prostatectomy (RP). METHODS: A propensity score-matched patient cohort [n = 685, (513 without previous BPE surgery, 172 with BPE surgery)] was created and HRQOL was pre- and postoperatively assessed using validated questionnaires (EORTC QLQ-C30). Urinary continence was measured via ICIQ-SF questionnaire and pad usage. Multivariable analysis included binary logistic and Cox regression models (p < 0.05). RESULTS: Median follow-up was 18 months. There was no significant difference in recurrence-free survival in multivariate analysis (HR 0.66, 95%CI 0.40-1.07, p = 0.093). We observe higher mean ICIQ-SF scores (5.7 vs. 8.2, p < 0.001) and daily pad usage (1.3 vs. 2.5, p < 0.001), and decreased continence recovery (OR 0.46, 95%CI 0.30-0.71, p < 0.001) for patients with BPE surgery. Postoperative general HRQOL scores were significantly lower for patients with previous BPE surgery (70.6 vs. 63.4, p = 0.003). In multivariate analysis, continence recovery (OR 5.19, 95%CI 3.10-8.68, p < 0.001) but not previous BPE surgery (0.94, 0.57-1.54, p = 0.806) could be identified as independent predictors of good general HRQOL. There was no significant correlation between time interval between both surgeries and continence (p = 0.408), and HRQOL (p = 0.386) outcomes. CONCLUSIONS: We observe favourable continence outcomes for patients without previous BPE surgery. Our results indicate that RP can be safely performed after transurethral BPE surgery, regardless of the time interval between both interventions.

Schwann cell-mediated delivery of glial cell line-derived neurotrophic factor restores erectile function after cavernous nerve injury.

OBJECTIVES: To evaluate the time-course of functional recovery after cavernous nerve injury using glial cell line-derived neurotrophic factor-transduced Schwann cell-seeded silicon tubes. METHODS: Sections of the cavernous nerves were excised bilaterally (5 mm), followed by immediate bilateral surgical repair. A total of 20 study nerves per group were reconstructed by interposition of empty silicon tubes and silicon tubes seeded with either glial cell line-derived neurotrophic factor-overexpressing or green fluorescent protein-expressing Schwann cells. Control groups were either sham-operated or received bilateral nerve transection without nerve reconstruction. Erectile function was evaluated by relaparotomy, electrical nerve stimulation and intracavernous pressure recording after 2, 4, 6, 8 and 10 weeks. The animals underwent re-exploration only once, and were killed afterwards. The nerve grafts were investigated for the maturation state of regenerating nerve fibers and the fascular composition. RESULTS: Recovery of erectile function took at least 4 weeks in the current model. Glial cell line-derived neurotrophic factor-transduced Schwann cell grafts restored erectile function better than green fluorescent protein-transduced controls and unseeded conduits. Glial cell line-derived neurotrophic factor-transduced grafts promoted an intact erectile response (4/4) at 4, 6, 8 and 10 weeks that was overall significantly superior to negative controls (P < 0.001). Maximum intracavernous pressure on electrostimulation was significantly elevated using glial cell line-derived neurotrophic factor-transduced grafts compared with negative controls (P = 0.018) and unseeded tubes (P = 0.034). Return of function was associated with the electron microscopic evidence of preganglionic myelinated nerve fibers and postganglionic unmyelinated axons. CONCLUSIONS: Schwann cell-mediated delivery of glial cell line-derived neurotrophic factor presents a viable approach for the treatment of erectile dysfunction after cavernous nerve injury.

Plasma vaporisation of the prostate: initial clinical results.

BACKGROUND: Laser vaporisation of the prostate has had a considerable impact in recent years. In an attempt to achieve tissue vaporisation with bipolar high-frequency generators, plasma vaporisation was recently introduced. OBJECTIVE: To provide the first clinical information on bipolar plasma vaporisation of the prostate for patients with lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO). DESIGN, SETTING, AND PARTICIPANTS: Thirty patients were included in this prospective bicentre study. INTERVENTION: All patients underwent bipolar plasma vaporisation with a novel electrode (Olympus Winter & Ibe GmbH, Hamburg, Germany). MEASUREMENTS: International Prostate Symptom Score (IPSS), bother score, maximum flow rate (Q(max)), and postvoid residual were evaluated at baseline and at the time of discharge as well as at 1, 3, and 6 mo after the intervention. RESULTS AND LIMITATIONS: Mean preoperative prostate volume was 59±32 ml (range: 30-170), and mean operating time was 61±26 min (range: 20-140). Besides one reoperation (conventional transurethral prostatectomy) due to persistent obstruction, no major complication occurred intra- or postoperatively and no blood transfusion was required. Catheterisation time averaged 41±35 h (range: 18-192). Transient mild to moderate dysuria was noted in four patients (13%). At 1, 3, and 6 mo, Q(max) increased from 6.6±2.7 ml/s preoperative to 17.3±4.7 ml/s (p<0.01), 18.5±4.6 ml/s (p<0.01), and 18.1±5.0 ml/s (p<0.01), respectively. The IPSS decreased from 20.8±3.6 to 10.4±3.5 (p<0.01), 8.2±2.9 (p<0.01), and 8.1±3.1 (p<0.01), respectively. These data represent a small nonrandomised study cohort with limited follow-up. CONCLUSIONS: Our initial experience indicates that bipolar plasma vaporisation might be a safe and effective treatment option for patients with LUTS due to BOO. To define the potential role of this novel technique, randomised trials with longer follow-up are mandatory.

Preliminary evaluation of a novel side-fire diode laser emitting light at 940 nm, for the potential treatment of benign prostatic hyperplasia: ex-vivo and in-vivo investigations.

OBJECTIVES: To evaluate, ex vivo and in vivo, the tissue-removal capacity and coagulation properties of a diode laser emitting light at 940 nm, as in the search for potential therapeutic strategies for benign prostatic hyperplasia that cause less morbidity than transurethral resection of the prostate (TURP), various types of lasers have been tested. MATERIALS AND METHODS: A diode laser system (prototype; wavelength 940 nm, Dornier MedTech, Wessling, Germany) was evaluated in an isolated, blood-perfused ex-vivo porcine kidney model at 10-60 W (five kidneys). An in-vivo beagle model was used to investigate the effects on six prostate lobes at a generator output power level of 200 W. After the laser treatment tissue were examined histologically to compare the depth of coagulation and vaporization. RESULTS: With increasing generator output power levels there was an increasing vaporization and coagulation ability for the diode laser at 940 nm in the ex-vivo model. At 60 W the mean (sd) vaporization depth was 1.72 (0.47) mm with a coagulation zone of 9.56 (0.26) mm. In vivo, the diode laser caused rapid ablation with no intraoperative haemorrhage. Histologically, the zone of coagulation had a mean (sd) depth of 4.25 (0.15) mm at 200 W. The tissue removal capacity was estimated at 0.874-1.583 g/min in vivo. CONCLUSIONS: Our findings indicate that diode-laser vaporization at 940 nm is feasible and might be effective for acutely relieving bladder outlet obstruction in an in-vivo setting. Due to its mean coagulation zone of 4.25 mm the diode laser seems to have effective haemostatic properties.

Clinical and technical aspects of bipolar transurethral prostate resection.

This review aims to provide an overview and critical assessment of the developments in transurethral electroresection in non-conductive and conductive irrigants. In the 1970s, measurements of the electric pathway in saline were performed for different locations of the neutral electrode. It was then concluded that the current pathway and the possible hazards of burn injuries to the patient should be investigated separately for each arrangement of the neutral electrode. The position and shape of the neutral electrode have decisive effects on the current flow in the patient. Thus, different electrode arrangements of the various bipolar resection systems need to be analysed separately. Furthermore, not only electrical power, but also conductivity and quality of the lubricant gel have to be considered as critical factors with regard to electrothermal injuries of the urethra. The supposedly better cutting quality seems to be based more on subjective observations than on scientific valid data. When performing "bipolar" TUR it is necessary to consider all electrotechnical and clinical aspects, particularly with regard to the potential risk of thermoelectrical urethral damage.

Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients.

PURPOSE: Transurethral resection of the prostate has for decades been the standard surgical therapy for lower urinary tract symptoms secondary to benign prostatic hyperplasia, the most common benign neoplasm in men. To generate a contemporary reference for evolving medical and minimally invasive therapies we analyzed complications and immediate outcomes of transurethral prostate resection in a statewide multicenter study. MATERIALS AND METHODS: We prospectively evaluated 10,654 patients undergoing transurethral prostate resection in the state of Bavaria, Germany from January 1, 2002 until December 31, 2003. Case records containing 54 items concerning preoperative status, operation details, complications and immediate outcome, were recorded for each patient. RESULTS: The mortality rate for transurethral prostate resection was 0.10%. The cumulative short-term morbidity rate was 11.1%. The most relevant complications were failure to void (5.8%), surgical revision (5.6%), significant urinary tract infection (3.6%), bleeding requiring transfusions (2.9%) and transurethral resection syndrome (1.4%). The resected tissue averaged 28.4 gm. Incidental carcinoma of the prostate was diagnosed by histological examination in 9.8% of patients. Urinary peak flow rate increased significantly to 21.6 +/- 9.4 ml per second (baseline 10.4 +/- 6.8 ml per second, 1 tail p <0.0001), while post-void residual decreased to 31.1 +/- 73.0 ml (baseline 180.3 +/- 296.9 ml, 1-tail p <0.0001). CONCLUSIONS: In a large scale evaluation comprising 44 mostly nonacademic urological departments in Bavaria, unique real-world data for transurethral prostate resection were prospectively generated. This most contemporary information should be of use to potential patients and facilitate subsumption of emerging surgical and nonsurgical benign prostatic hyperplasia treatment options.