Radical prostatectomy for locally advanced and high-risk prostate cancer: A systematic review of the literature.

CONTEXT: The role of radical prostatectomy (RP) in high-risk prostate cancer (PCa) is increasing. PURPOSE: To review the existing literature and determine the value of RP in high-risk and locally advanced PCa. DOCUMENTARY SOURCE: MEDLINE, Embase and the Cochrane Central Register of Controlled Trials were searched from 01/2000 through 05/2016 according to the PRISMA guidelines. SELECTION OF STUDIES: Forty-two studies describing outcomes of RP among 52,546 patients with high-risk and locally advanced PCa. RESULTS: Mortality was approximately 0-1% and Clavien≥3 complications ranged from 1.8% to 12%. Biochemical recurrence-free and metastasis-free survival ranged from 40 to 94% and 90 to 96.1% at 5 years and from 27 to 68% and 64.4 to 85.1% at 10 years, respectively. Overall and cancer specific survival ranged from 55.2 to 98.6% and 89.8 to 100% at 5 years and from 58 to 84% and 65 to 96% at 10 years, respectively. The 12-mo continence rates ranged from 32% to 96.2% and the erectile function recovery ranged from 60% to 64%. LIMITS: Studies were heterogeneous especially regarding the definition of high-risk disease and the use of adjuvant treatments. CONCLUSIONS: The utilization of RP in high-risk and locally advanced PCa is increasing. Existing data support the advantages of RP in this group of patients. However, uniformity in definitions and indications are a prerequisite in order to establish its role as an important therapeutic arm in a multimodality management strategy.

[Focus on molecular imaging in prostate cancer]. / Mise au point sur l'imagerie moléculaire dans le cancer de la prostate.

INTRODUCTION: Prostate cancer is the most frequent cancer in men in France and it is a public health issue. This cancer is heterogenous. There is a clinical need of an accurate non-invasive imaging method to improve diagnosis, guide the choice of therapy and evaluate its efficacy. We undertook to critically review the different molecular imaging probes, currently used or in clinical trial. METHOD: A systematic review of the literature was performed in Pubmed/Medline database by searching for articles in French or English published on PET tracer in prostate cancer in clinical application. RESULTS: Several PET tracers are under investigation because of the low performance of the FDG in prostate cancer. In France, only two new PET tracers have the marketing authorization: the NaF and choline, but these tracers have several limitations. The NaF analyses only bone metastasis. The choline has changed the recurrence of prostate cancer but is not effective for recurrence with low PSA, furthermore its sensitivity is low for the detection of lymph nodes metastasis in initial disease. Several tracers in trial including the PSMA offer encouraging prospects in initial staging and for recurrences. CONCLUSION: An accurate knowledge in molecular biology allowed to develop the metabolic imagery. Many new tracers are under evaluation in prostate cancer. The indication of each of them needs to be established.

Laparoendoscopic single site (LESS) radical prostatectomy: a review of the initial experience.

Surgical treatment for prostate cancer has changed dramatically in recent years due to the incorporation of minimally invasive techniques in the surgical armamentarium. Open surgical approaches to the prostate have largely given way to laparoscopic and robotic techniques. In order to further reduce incisional morbidity and improve cosmesis, there has been a recent interest in laparoendoscopic single site (LESS) approaches to the prostate. Despite a rising interest, there is little available data on these procedures. We performed a systematic review of the literature using MEDLINE, OVID, and Web of Science to identify all publications including LESS radical prostatectomy to date. Manual bibliographic review of cross-referenced items was also performed. We attempt to identify and summarize existing data on these procedures both with and without robotic assistance. Additionally, we review the emerging devices, instruments, cameras, and ports that have made these procedures possible. Next, we offer insight into how this rapidly moving field may transition in the future. Finally, we provide our commentary on this surgical approach, its impact on urology, and how it may help us evolve in the future.

Molecular imaging for prostate cancer: Performance analysis of 68Ga-PSMA PET/CT versus choline PET/CT. / Toma de imágenes molecular del cáncer de próstata: análisis de rendimiento de 68Ga-PSMA PET/TC frente a PET/TC colina.

INTRODUCTION: There is a need for a precise and reliable imaging to improve the management of prostate cancer. In recent years the PET/CT with choline has changed the handling of prostate cancer in Europe, and it is commonly used for initial stratification or for the diagnosis of a biochemical recurrence, although it does not lack limitations. Other markers are being tested, including the ligand of prostate-specific membrane antigen (PSMA), that seems to offer encouraging prospects. The goal of this piece of work was to critically review the role of choline and PSMA PET/CT in prostate cancer. EVIDENCE ACQUISITION: A systematic literature review of databases PUBMED/MEDLINE and EMBASE was conducted searching for articles fully published in English on the PET marker in prostate cancer and its clinical application. EVIDENCE SYNTHESIS AND DISCUSSION: It seems as 68Ga-PSMA PET/CT is better than PET/CT in prostate cancer to detect primary prostate lesions, initial metastases in the lymph nodes and recurrence. However, further research is required to obtain high-level tests. Also, other PET markers are studied. Moreover, the emergence of a new PET/MR camera could change the performance of PET imaging.

Updated postoperative nomogram incorporating the number of positive lymph nodes to predict disease recurrence following radical prostatectomy.

BACKGROUND: A significant number of patients with minimal lymph node disease at radical prostatectomy (RP) and pelvic lymph node dissection (PLND) have better than expected long-term outcomes. We explored whether stratification by number of positive nodes enhances our institutional prediction model for biochemical recurrence after RP. METHODS: A total of 7789 patients underwent RP and pelvic lymph node dissection from 1995 to 2012 at a tertiary referral center. We compared two recurrence prediction models: one incorporated lymph node invasion and the other tracked the number of positive nodes. Existing and updated models' discrimination was assessed using Harrell's c-index and calibration. The 10-fold cross-validation was performed to correct for model overfitting. RESULTS: Of the 491 patients (6.3%) harboring nodal disease, 387 (5.0%) had 1-2 positive nodes and 104 (1.3%) had ⩾3 positive nodes. Data on number of positive nodes did not improve the c-index for the cohort as a whole. When we assessed discrimination for node-positive patients only, c-index for the model with number of positive nodes was 0.01 (95% confidence interval 0.001-0.024) higher than the model with lymph node invasion. Illustrative examples were provided by reclassification tables using number of positive lymph nodes. For instance, 40 of 7789 patients would be reclassified with a cutoff point of 50% for biochemical recurrence at 1 year, and 36 of 7789 patients would be reclassified with a cutoff point of 40% for biochemical recurrence at 10 years. CONCLUSIONS: Stratification by number of positive lymph nodes provided additional discriminative ability for evaluating risk in node-positive patients. Pending external validation, this model could be used for patient counseling and clinical trial stratification in this subpopulation.

[Teaching laparoscopic urologic oncology. The Memorial Sloan-Kettering Cancer Center experience]. / Formación en oncología urológica laparoscópica. La experiencia del Memorial Sloan-Kettering Cancer Center.

OBJECTIVE: We outline the structure of the clinical and training program of laparoscopic urologic oncology at Memorial Sloan-Kettering Cancer Center. We discuss the steps and key elements necessary in acquiring lapa roscopic proficiency. MATERIAL AND METHOD: The program lasts 2 years and trains fellows and faculty. For fellows, the program consists of a 6 months high volume laparoscopic oncology rotation, during which dry lab, animal lab, vide review and operating room experience are required. For faculty, the program consists of 1 accredited continuin medical education course, 20 hours of dry lab, 1 session animal lab, observation of laparoscopic cases, first assistant in a minimum of 15 laparoscopic cases, performing laparoscopic cases under mentoring. RESULTS: 8 fellows have completed the training, 4 of whom have completed their fellowship and are in academic centers, performing advanced laparoscopy. The laparoscopic approach represents on average 80% of their urologic practice. Three attendings are performing laparoscopic surgery with mentoring. CONCLUSION: The goals of a surgical education program should be the standardization of the acquisition o surgical skills and assessment of the performance in a uniform setting to ensure the maintenance of the acquisition of skills and to develop programs to teach new skills.

Number of metastatic lymph nodes as determinant of outcome after salvage radical prostatectomy for radiation-recurrent prostate cancer. / Número de ganglios linfáticos metastásicos como determinante de los resultados de la prostatectomía radical de rescate en el cáncer de próstata de recidivante tras radioterapia.

BACKGROUND: Presence of lymph node metástasis (LNM) at salvage radical prostatectomy (sRP) is associated with poor outcome. Predictors of outcome in this context remain undetermined. ThE objective was to assess the role of number of positive lymph node on outcome of patients with LNM after sRP and for radio-recurrent prostate cancer. MATERIAL AND METHODS: We analyzed data from a consecutive cohort of 215 men treated with sRP at a single institution. We used univariate Cox proportional hazard regression models for biochemical recurrence (BCR) and metastatic outcomes, with prostate-specific antigen, Gleason score, extraprostatic extension, seminal vesicle invasion, time between radiation therapy and sRP, and number of positive nodes as predictors. RESULTS: Of the 47 patients with LNM, 37 developed BCR, 11 developed distant metastasis and 4 died with a median follow-up of 2.3 years for survivors. The risk of metastases increased with higher pre-operative PSA levels (HR 1.19 per 1ng/ml; 95% CI: 1.06-1.34; P=.003). The remaining predictors did not reach conventional levels of significance. However, removal of 3 or more positive lymph nodes demonstrated a positive association, as expected, with metastatic disease (HR 3.44; 95% CI: 0.91-13.05; P=.069) compared to one or 2 positive nodes. Similarly, the presence of extraprostatic extension, seminal vesicle invasion and Gleason grade greater than 7 also demonstrated a positive association with higher risk of metástasis, with hazard ratios of 3.97 (95% CI: 0.50, 31.4; P=.2), 3.72 (95% CI: 0.80-17.26; P=.1), and 1.45 (95% CI: 0.44-4.76; P=.5), respectively. CONCLUSIONS: In patients with LNM after sRP for radio-recurrent prostate cancer, the risk of distant metástasis is likely to be influenced by the number of positive nodes (3 or more), high preoperative PSA, Gleason grade and advanced pathologic stage. These results are consistent with the findings of number of nodes (1 to 2 vs. 3 or more nodes positive) as a prognostic indicator after primary radical prostatectomy and strengthen the plea for a revision of the nodal staging for prostate cancer.

The diffusion of minimally invasive radical prostatectomy in the United States: a case study of the introduction of new surgical devices.

BACKGROUND: The diffusion of minimally invasive radical prostatectomy (MIRP) in the United States may have led to adverse patient outcomes due to rapid surgeon adoption and collective inexperience. We hypothesized that throughout the early period of minimally invasive surgery, MIRP patients had inferior outcomes as compared with those who had open radical prostatectomy (ORP). METHODS: We used the Surveillance, Epidemiology and End RESULTS-Medicare dataset and identified men who had ORP and MIRP for prostate cancer from 2003-2009. Study endpoints were receipt of subsequent cancer treatment, and evidence of postoperative voiding dysfunction, erectile dysfunction (ED) and bladder outlet obstruction. We used proportional hazards regression to estimate the impact of surgical approach on each endpoint, and included an interaction term to test for modification of the effect of surgical approach by year of surgery. RESULTS: ORP (n=5362) and MIRP (n=1852) patients differed in their clinical and demographic characteristics. Controlling for patient characteristics and surgeon volume, there was no difference in subsequent cancer treatments (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.76-1.05), although MIRP was associated with a higher risk of voiding dysfunction (HR 1.31, 95% CI 1.20-1.43) and ED (HR 1.43, 95% CI 1.31-1.56), but a lower risk of bladder outlet obstruction (HR 0.86, 95% CI 0.75-0.97). There was no interaction between approach and year for any outcome. When stratifying the analysis by year, MIRP consistently had higher rates of ED and voiding dysfunction with no substantial improvement over time. CONCLUSIONS: MIRP patients had adverse urinary and sexual outcomes throughout the diffusion of minimally invasive surgery. This may have been a result of the rapid adoption of robotic surgery with inadequate surgeon preparedness.

Inadequate documentation and resection for gastric cancer in the United States: a preliminary report.

Patients entered into Southwest Oncology Group gastric adjuvant protocol INT 0016 (SWOG 9008) after a "curative" gastric resection were assessed to determine practice patterns of more than 300 surgeons nationwide who performed "curative" gastric resections for 453 gastric cancer patients. The most common gastric resection performed was distal in 256 patients, proximal in 118, and total in 79. Extragastric organs resected were omentum (285), spleen (59), pancreas (18), and bowel (17). The extent of lymphadenectomy as staged by Japanese rules was 246 (54.2%) D0 resections, 173 (38.1%) D1 resections, 28 (6.2%) D2 resections, and 7 (1.5%) D3 resections. Staging of the cancer was poorly documented, with no statement made regarding the status of the primary cancer in 6 per cent, liver in 10 per cent, lymph nodes in 17 per cent, and omentum in 17 per cent. The greater the lymph node clearance, the greater the chance of resecting to a level of negative lymphatics, given that 45 per cent of nodes were involved when 10 or less were removed, whereas only 17 per cent were positive when more than 40 were cleared. The lack of adequate clearance of lymph nodes and poor documentation of tumor stage suggests that a more regimented surgical approach to this uncommon cancer is required.

Número de ganglios linfáticos metastásicos como determinante de los resultados de la prostatectomía radical de rescate en el cáncer de próstata de recidivante tras radioterapia / Number of metastatic lymph nodes as determinant of outcome after salvage radical prostatectomy for radiation-recurrent prostate cancer

Antecedentes: La presencia de metástasis en los ganglios linfáticos (MGL) en la prostatectomía radical de rescate (PRs) se asocia con un mal pronóstico. Los factores predictivos de resultados en este contexto siguen siendo indeterminados. El objetivo fue evaluar el papel del número de ganglios linfáticos positivos sobre el resultado de los pacientes con MGL después de PRs y para el cáncer de próstata de radiorrecurrente. Material y métodos: Se analizaron los datos de una cohorte consecutiva de 215 hombres tratados con PRr en una sola institución. Se utilizaron los modelos de regresión de riesgos proporcionales de Cox univariante para la recurrencia bioquímica (RBQ) y los resultados metastásicos, con el antígeno prostático específico, la puntuación de Gleason, la extensión extraprostática, la invasión de vesículas seminales, el tiempo entre la terapia de radiación y PRr y el número de ganglios positivos como factores predictivos. Resultados: De los 47 pacientes con MGL, 37 desarrollaron RBQ, 11 desarrollaron metástasis a distancia y 4 fallecieron, con una mediana de seguimiento de 2,3 años para los supervivientes. El riesgo de metástasis aumentó con mayores niveles preoperatorios de PSA (HR 1,19 por 1ng/ml; IC 95%: 1,06-1,34; p=0,003). Los factores predictivos restantes no alcanzaron niveles convencionales de significación. Sin embargo, la eliminación de 3 o más ganglios linfáticos positivos demostró una asociación positiva, como se esperaba, con enfermedad metastásica (HR 3,44; IC 95%: 0,91-13,05; p = 0,069) en comparación con uno o 2 ganglios positivos. Del mismo modo, la presencia de extensión extraprostática, invasión de vesículas seminales y grado de Gleason superior a 7 también demostraron una asociación positiva con un mayor riesgo de metástasis, con índices de riesgo de 3,97 (IC 95%: 0,50-31,4; p = 0,2); 3,72 (IC 95%: 0,80-17,26; p = 0,1) y 1,45 (IC 95%: 0,44-4,76; p = 0,5), respectivamente. Conclusiones: En los pacientes con MGL después de PRr para el cáncer de próstata radiorrecurrente, es probable que el riesgo de metástasis a distancia esté influido por el número de ganglios positivos (≥ 3), alto PSA preoperatorio, grado de Gleason y estadio patológico avanzado. Estos resultados son consistentes con los hallazgos del número de ganglios (de 1 a 2 frente a 3 o más ganglios positivos) como un indicador pronóstico después de la prostatectomía radical primaria y fortalecen la petición de una revisión de la estadificación ganglionar del cáncer de próstata

Background: Presence of lymph node metástasis (LNM) at salvage radical prostatectomy (sRP) is associated with poor outcome. Predictors of outcome in this context remain undetermined. ThE objective was to assess the role of number of positive lymph node on outcome of patients with LNM after sRP and for radio-recurrent prostate cancer. Material and methods: We analyzed data from a consecutive cohort of 215 men treated with sRP at a single institution. We used univariate Cox proportional hazard regression models for biochemical recurrence (BCR) and metastatic outcomes, with prostate-specific antigen, Gleason score, extraprostatic extension, seminal vesicle invasion, time between radiation therapy and sRP, and number of positive nodes as predictors. Results: Of the 47 patients with LNM, 37 developed BCR, 11 developed distant metastasis and 4 died with a median follow-up of 2.3 years for survivors. The risk of metastases increased with higher pre-operative PSA levels (HR 1.19 per 1ng/ml; 95% CI: 1.06-1.34; P = .003). The remaining predictors did not reach conventional levels of significance. However, removal of 3 or more positive lymph nodes demonstrated a positive association, as expected, with metastatic disease (HR 3.44; 95% CI: 0.91-13.05; P = .069) compared to one or 2 positive nodes. Similarly, the presence of extraprostatic extension, seminal vesicle invasion and Gleason grade greater than 7 also demonstrated a positive association with higher risk of metástasis, with hazard ratios of 3.97 (95% CI: 0.50, 31.4; P = .2), 3.72 (95% CI: 0.80-17.26;P = .1), and 1.45 (95% CI: 0.44-4.76; P = .5), respectively. Conclusions: In patients with LNM after sRP for radio-recurrent prostate cancer, the risk of distant metástasis is likely to be influenced by the number of positive nodes (3 or more), high preoperative PSA, Gleason grade and advanced pathologic stage. These results are consistent with the findings of number of nodes (1 to 2 vs. 3 or more nodes positive) as a prognostic indicator after primary radical prostatectomy and strengthen the plea for a revision of the nodal staging for prostate cancer

Formación en oncología urológica laparoscópica. La experiencia del Memorial Sloan-Kettering Cancer Center / Teaching laparoscopic urologic oncology. The memorial Sloan-Kettering Cancer Center experience

Objetivo: Presentar un breve esquema de la estructura del programa clínico y de formación en oncología urológica laparoscópica en el Memorial Sloan-Kettering Cancer Center. Describir las fases y los elementos claves necesarios para adquirir la capacitación en laparoscopia. Material y métodos: El programa dura 2 años y forma a residentes en formación y a urólogos. En el caso de los residentes, el programa consiste en una rotación en oncología con un gran volumen de procedimientos laparoscópicos, de 6 meses de duración, en el cual se adquiere experiencia en laboratorio de simulación, laboratorio animal, revisión de vídeos y experiencia en quirófano. Para los urólogos, el programa consiste en 1 curso de formación médica continuada acreditada, 20 horas de laboratorio de simulación, 1 sesión de laboratorio animal, observación de casos laparoscópicos, ejercer como primer ayudante en un mínimo de 15 procedimientos laparoscópicos y ejecución de procedimientos laparoscópicos bajo supervisión. Resultados: 8 residentes han completado el programa de formación laparoscópica, 4 de los cuales han completado su ciclo de especialización y están en centros académicos, realizando laparoscopia avanzada. El abordaje supone un promedio del 80% de su práctica urológica. Tres de los participantes están realizando cirugía laparoscópica bajo supervisión. Conclusión: Los objetivos de un programa de formación quirúrgica deberían ser la normalización de la adquisición de experiencia quirúrgica y la evaluación de los resultados en un marco uniforme para garantizar la conservación de la experiencia adquirida y desarrollar programas para enseñar nuevas técnicas

Objective: We outline the structure of the clinical and training program of laparoscopic urologic oncology at Memorial Sloan-Kettering Cancer Center. We discuss the steps and key elements necessary in acquiring laparoscopic proficiency. Material and Method: The program lasts 2 years and trains fellows and faculty. For fellows, the program consists of a 6 months high volume laparoscopic oncology rotation, during which dry lab, animal lab, video review and operating room experience are required. For faculty, the program consists of 1 accredited continuing medical education course, 20 hours of dry lab, 1 session animal lab, observation of laparoscopic cases, first assistant in a minimum of 15 laparoscopic cases, performing laparoscopic cases under mentoring. Results: 8 fellows have completed the training, 4 of whom have completed their fellowship and are in academic centers, performing advanced laparoscopy. The laparoscopic approach represents on average 80% of their urologic practice. Three attendings are performing laparoscopic surgery with mentoring. Conclusion: The goals of a surgical education program should be the standardization of the acquisition of surgical skills and assessment of the performance in a uniform setting to ensure the maintenance of the acquisition of skills and to develop programs to teach new skills