European Association of Urology Biochemical Recurrence Risk Classification as a Decision Tool for Salvage Radiotherapy-A Multicenter Study.

BACKGROUND: The European Association of Urology (EAU) has proposed a risk stratification for patients harboring biochemical recurrence (BCR) after radical prostatectomy (RP). OBJECTIVE: To assess whether this risk stratification helps in choosing patients for salvage radiotherapy (SRT). DESIGN, SETTING, AND PARTICIPANTS: Analyses of 2379 patients who developed BCR after RP (1989-2020), within ten European high-volume centers, were conducted. Early and late SRT were defined as SRT delivered at prostate-specific antigen values <0.5 and ≥0.5 ng/ml, respectively. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariable Cox models tested the effect of SRT versus no SRT on death and cancer-specific death. The Simon-Makuch method tested for survival differences within each risk group. RESULTS AND LIMITATIONS: Overall, 805 and 1574 patients were classified as having EAU low- and high-risk BCR. The median follow-up was 54 mo after BCR for survivors. For low-risk BCR, 12-yr overall survival was 87% versus 78% (p = 0.2) and cancer-specific survival was 100% versus 96% (p = 0.2) for early versus no SRT. For high-risk BCR, 12-yr overall survival was 81% versus 66% (p < 0.001) and cancer-specific survival was 98% versus 82% (p < 0.001) for early versus no SRT. In multivariable analyses, early SRT decreased the risk for death (hazard ratio [HR]: 0.55, p < 0.01) and cancer-specific death (HR: 0.08, p < 0.001). Late SRT was a predictor of cancer-specific death (HR: 0.17, p < 0.01) but not death (p = 0.1). CONCLUSIONS: Improved survival was recorded within the high-risk BCR group for patients treated with early SRT compared with those under observation. Our results suggest recommending early SRT for high-risk BCR men. Conversely, surveillance might be suitable for low-risk BCR, since only nine patients with low-risk BCR died from prostate cancer during follow-up. PATIENT SUMMARY: The impact of salvage radiotherapy (SRT) on cancer-specific outcomes stratified according to the European Association of Urology biochemical recurrence (BCR) risk classification was assessed. While men with high-risk BCR should be offered SRT, surveillance might be a suitable option for those with low-risk BCR.

Anesthetic Technique (Spinal vs. General Anesthesia) in Holmium Laser Enucleation of the Prostate: Retrospective Analysis of Procedural and Functional Outcomes among 1,159 Patients.

OBJECTIVE: The aim of the study was to compare procedural efficacy, early and late functional outcomes in holmium laser enucleation of the prostate (HoLEP) under spinal anesthesia (SA) versus general anesthesia (GA). METHODS: We retrospectively reviewed patients undergoing HoLEP at our institution between 2012 and 2017. Standard pre-, peri-, and postoperative characteristics were compared according to anesthetic technique. Multivariable logistic regression analyses (MVAs) were employed to study the impact of SA on procedural efficacy and postoperative complications. RESULTS: Our study cohort consisted of 1,159 patients, of whom 374 (32%) underwent HoLEP under SA. While a medical history of any anticoagulation/antiplatelet therapy except low-dose acetylsalicylic acid was significantly more common among patients undergoing GA (16% vs. 10%, p = 0.001), no other significant differences in preoperative characteristics were noted including age, body mass index, American Society of Anesthesiologists Classification (ASA), prostate size, or International Prostate Symptom Score (IPSS), and quality of life scores. Patients under SA exhibited shorter times of enucleation 42 min (interquartile range [IQR]:27-59 vs. 45 min [IQR: 31-68], p = 0.002), and combined time of enucleation/morcellation/coagulation (57 min [IQR: 38-85] vs. 64 min [IQR: 43-93], p = 0.002), as well as fewer complications (Clavien-Dindo ≥3) (12 [3.2%] vs. 55 [7%], p = 0.013). These associations were confirmed in MVA. Patients did not differ significantly with regard to early micturition including post-void residual volume and maximum flow-rate improvement. At a median follow-up of 33 months (IQR: 32-44), patients with SA had a lower IPSS score (median 3 [IQR: 1-6] vs. 4 [IQR: 2-7], p = 0.039). However, no significant differences were observed with respect to any urinary incontinence, urge symptoms, and postoperative pain. CONCLUSION: In this large retrospective series, HoLEP under SA was a safe and efficacious procedure with comparable early and long-term functional outcomes.

[Cross-sectoral patient care in the district of Hamburg Harburg: an example of urological cooperation]. / Sektorenübergreifende Versorgung im Landkreis Hamburg-Harburg: Beispiel einer urologischen Kooperation.

BACKGROUND: Ensuring future urological care at the interface between out- and inpatient care is challenging due to demographic developments with an increasing proportion of urological diseases, the simultaneous threat of a shortage of physicians, and the increasing outpatient treatment of complex urological diseases. OBJECTIVES: The cross-sectoral cooperation model between a university maximum care provider and the urologic joint practice with a hospital affiliation (BAG) presented below can serve as an ideal model for outpatient-inpatient care. MATERIALS AND METHODS: Since 2016, there has been close cooperation between the BAG in Winsen/Buchholz and the University Medical Center Hamburg-Eppendorf (UKE). In addition to direct patient transfer and the continuous pre- and posttreatment of patients, two residents from the UKE rotate to the BAG every year. RESULTS: The BAG benefits from this cooperation through planning security and support in everyday patient care, while the UKE benefits from patient transfer as well as surgical and "basic urological" training of residents. By avoiding duplicate examinations and earlier discharge of patients into outpatient follow-up care, resources are spared. Meaningful patient preselection enables minor interventions to be performed close to home via the BAG, whereas complex cases are carried out at a center of excellence. CONCLUSIONS: The cooperation is seen positively by all parties without exception and, above all, as a benefit for the patient's wellbeing. The optimal training and further education of young urologists in this expanding field can thus be supported and should be integrated into urological resident training.

Salvage Radiotherapy versus Observation for Biochemical Recurrence following Radical Prostatectomy for Prostate Cancer: A Matched Pair Analysis.

BACKGROUND: Salvage radiotherapy (SRT) improves oncologic outcomes in prostate cancer (PCa) patients who develop biochemical recurrence (BCR) after radical prostatectomy (RP). However, evidence on hard clinical endpoints is scarce. We compare long-term oncologic outcomes of SRT versus no radiotherapy (noRT) in patients with BCR after RP. PATIENTS AND METHODS: Within a multi-institutional database, we identified patients with BCR after RP between 1989 and 2016 for PCa. Patients with lymph node invasion, with adjuvant radiotherapy, or with additional androgen deprivation therapy at BCR were excluded. In all patients with SRT, SRT was delivered to the prostatic bed only. Propensity score matching (PSM) was performed to account for differences in pathologic tumor characteristics. Kaplan-Meier analyses and Cox regression models tested the effect of SRT versus no RT on metastasis-free (MFS) and overall survival (OS). RESULTS: Of 1832 patients with BCR, 32.9% (n = 603) received SRT without ADT. The median follow-up was 95.9 months. Median total SRT dose was 70.2 Gy. After 1:1 PSM, at 15 years after RP, MFS and OS rates were 84.3 versus 76.9% (p < 0.001) and 85.3 versus 74.4% (p = 0.04) for SRT and noRT, respectively. In multivariable Cox regression models, SRT was an independent predictor for metastasis (HR: 0.37, p < 0.001) and OS (HR: 0.64, p = 0.03). CONCLUSION: This is the first matched-pair analysis investigating the impact of SRT versus observation only in post-RP recurrent PCa. After compensating for established risk factors, SRT was associated with better long-term MFS and OS. These results on clinical endpoints underline the curative potential of SRT.

Urethral Stricture Formation Following Cuff Erosion of AMS Artificial Urinary Sphincter Devices: Implication for a Less Invasive Explantation Approach.

OBJECTIVES: The objective of this study is to describe a standardized less invasive approach in patients with artificial urinary sphincter (AUS) explantation due to cuff erosion and analyze success and urethral stricture rates out of a prospective database. Evidence regarding complication management is sparse with heterogenous results revealing high risk of urethral stricture formation despite simultaneous urethroplasty in case of AUS explantation. PATIENTS AND METHODS: Data of all patients undergoing AUS implantation due to stress urinary incontinence (SUI) in our tertiary center were prospectively collected from 2009 to 2015. In case of cuff erosion, AUS explantation was carried out in an institutional standardized strategy without urethroplasty, urethral preparation or mobilization nor urethrorrhaphy. Transurethral and suprapubic catheters were inserted for 3 weeks followed by radiography of the urethra. Further follow-up (FU) consisted of pad test, uroflowmetry, postvoiding residual urine (PVR), and radiography. Primary endpoint was urethral stricture rate. RESULTS: Out of 235 patients after AUS implantation, 24 (10.2%) experienced cuff erosion with consecutive explantation and were available for analysis. Within a median FU of 18.7 months after AUS explantation, 2 patients (8.3%) developed a urethral stricture. The remaining 22 patients showed a median Qmax of 17 ml/s without suspicion of urethral stricture. Median time to reimplantation was 4 months (IQR 3-4). CONCLUSION: We observed a considerably low stricture formation and could not prove an indication for primary urethroplasty nor delay in salvage SUI treatment possibilities. Therefore, the presented standardized less invasive explantation strategy with consequent urinary diversion seems to be safe and effective and might be recommended in case of AUS cuff erosion.

Oncologic outcomes of organ-confined Gleason grade group 4-5 prostate cancer after radical prostatectomy.

BACKGROUND: Organ-confined prostate cancer (CaP) at radical prostatectomy (RP) is associated with good long-term outcomes. However, information for aggressive Gleason organ-confined CaP is scant. To investigate the impact of Gleason grade group (GG) 4-5 on long-term oncologic outcomes after RP. METHODS: Within a high-volume center database we identified patients who harbored organ-confined CaP (pT2) at RP between 1992 and 2017. Only patients with negative surgical margins, without lymph node invasion and without neo- and/or adjuvant androgen deprivation therapy and/or adjuvant radiotherapy were included. Patients with GG1 were excluded. Kaplan-Meier analyses and Cox regression models tested the effect of GG4 and GG5 on biochemical recurrence-free (BFS), metastasis-free (MFS), overall survival (OS) and cancer-specific mortality (CSM) free survival. RESULTS AND LIMITATIONS: Of 10,855 identified pT2 patients, 0.1% (n=81) and 0.1% (n=114) harbored GG4 and GG5, respectively. At 10-years after RP, BFS, MFS, OS and CSM-free rates were 80.3 vs. 68.6 vs. 55.4% (P<0.001), 96.7 vs. 89.9. vs. 83.4% (P<0.001), 93.2 vs. 78.3 vs. 72.6% (P<0.001) and 99.3 vs. 98.0 vs. 82.7% (P<0.001) for GG2 and GG3 vs. GG4 vs. GG5, respectively. In multivariable Cox regression models, GG5 represented an independent predictor for biochemical recurrence (Hazard ratio [HR] 3.00, P<0.001), metastasis (HR 5.01, P<0.001), death (HR 2.72, P<0.01) and cancer-specific death (HR 30.1, P<0.001). Conversely, GG4 represented an independent predictor for death (HR 2.10, P=0.04) and cancer-specific death (HR 6.09, P=0.01) but not for biochemical recurrence and metastasis. CONCLUSION: GG4/5 in organ-confined CaP is rare. But its associated with worse oncologic outcomes after RP, namely biochemical recurrence, metastasis, death and cancer-specific death. Patients with organ-confined GG4/5 and negative margins should be closely followed and may be candidates for risk stratification by genomic markers.

Regression Discontinuity Analysis of Salvage Radiotherapy in Prostate Cancer.

There is a lack of randomized evidence comparing early (eSRT) to late (lSRT) salvage radiotherapy (SRT) after radical prostatectomy (RP) for prostate cancer (PCa). Moreover, the existing evidence is often affected by lead-time bias. We sought to address this gap in a cohort of 1458 PCa patients undergoing SRT for biochemical recurrence (BCR) after RP in two tertiary care centers between 1992 and 2013. Using a quasi-randomized study design known as regression discontinuity (RD) and adjusting for lead-time bias, we compared metastasis-free survival (MFS) at 5 and 10 years after surgery between eSRT (prostate-specific antigen [PSA] <0.5 ng/ml) and lSRT (PSA ≥ 0.5 ng/ml). Overall, 1049 patients (71.9%) underwent eSRT and 409 (28.1%) lSRT at a mean follow-up of 84 mo (interquartile range (IQR) 52-120.4). The MFS rate decreased nonsignificantly at the proposed cutoff by 0.04 (95% confidence interval [CI]: -0.06 to 0.19) at 5 years and by 0.07 (95% CI: - 0.12 to 0.32) at 10 years. Cox regression analysis revealed a hazard ratio for the cutoff examined of 1.3 (95% CI: 0.8-2.4; p = 0.2). In conclusion, in a quasirandomized study design accounting for lead-time bias, eSRT (PSA < 0.5 ng/ml) did not improve MFS. Our results underline the need for level-one evidence to compare eSRT and lSRT. PATIENT SUMMARY: We compared early versus late salvage radiotherapy (SRT) for biochemical recurrence after radical prostatectomy by simulating a randomized trial. We found that early SRT (initiated at prostate-specific antigen <0.5 ng/ml) compared to late SRT did not improve metastasis-free survival.

Association of neurovascular bundle preservation with oncological outcomes in patients with high-risk prostate cancer.

OBJECTIVE: To investigate the oncologic safety of neurovascular bundles (NVB) preservation at radical prostatectomy (RP) in patients with high-risk and/or locally advanced prostate cancer (PCa). MATERIAL AND METHODS: Within a two-institutional high-volume center database we identified patients who harbored high-risk PCa at RP (2000-2017). Only patients with D'Amico high-risk PCa were included. Kaplan-Meier and multivariable Cox regression models tested the effect of NVB preservation on biochemical recurrence (BCR), metastasis and overall survival (OS). Subgroup analyses focused on patients with clinical stage T3 and/or biopsy ISUP grade 5 and pathologic stage T3. RESULTS: Of 4351 patients with D'Amico high-risk, 35.7% vs. 38.0% vs. 26.3% underwent bilateral vs. unilateral vs. no NVB preservation, respectively. At 120 months after RP BCR-free, metastasis-free survival and OS rates were 62.2% vs. 44.3% vs. 27.1% (p < 0.001), 83.7% vs. 66.7% vs. 60.3% (p < 0.001), and 91.8% vs. 87.5% vs. 72.3% (p < 0.001) for bilateral vs. unilateral vs. no NVB preservation, respectively. In multivariable Cox regression models, bilateral and unilateral compared to no NVB preservation did not increase the risk for BCR, metastasis or death in the entire cohort and in subgroups with clinical stage T3 and/or biopsy ISUP grade 5, as well as pathologic stage T3. CONCLUSIONS: NVB preservation was not associated with worse oncological outcome in patients with high-risk and/or locally advanced PCa and may be offered to well-selected patients who are at risk of harboring nonorgan-confined PCa.

Combined systematic versus stand-alone multiparametric MRI-guided targeted fusion biopsy: nomogram prediction of non-organ-confined prostate cancer.

OBJECTIVE: Based on unfavorable oncological and functional outcomes of non-organ-confined (NOC) prostate cancer (PCa), defined as ≥ pT3, pN1 or both, we aimed to develop a NOC prediction tool based on multiparametric MRI-guided targeted fusion biopsy (TBx). MATERIALS AND METHODS: Analyses were restricted to 594 patients with simultaneous PCa detection at systematic biopsy (SBx), TBx and subsequent radical prostatectomy (RP) at our institution. Development (n = 396; cohort 1) and validation cohorts (n = 198; cohort 2) were used to develop and validate the NOC nomogram. A head-to-head comparison was performed between stand-alone TBx model and combined TBx/SBx model. Second validation was performed in patients with positive TBx, but negative SBx (n = 193; cohort 3). RESULTS: The most parsimonious TBx model included three independent predictors of NOC: pretreatment PSA (OR 1.05 95% CI: 1.01-1.08), highest TBx-detected Gleason pattern (3 + 3 [REF] vs. ≥ 4 + 5; OR 9.3 95% CI 3.8-22) and presence of TBx-detected perineural invasion (OR 2.2 95% CI: 1.3-3.6). The combined TBx/SBx model had the same predictors. For the stand-alone TBx and combined TBx/SBx model, external validation yielded accuracy of 76.5% (95% CI: 69.3-83.1) and 76.6% (95% CI: 69.4-83.6) within cohort 2. The external validation of the stand-alone TBx model yielded 72.4% (95% CI: 65.0-79.6) accuracy within cohort 3. CONCLUSION: Our stand-alone TBx-based nomogram can identify PCa patients at the risk of NOC, using three simple variables, with the similar accuracy as the TBx/SBx-based model. It is non-inferior to combined TBx/SBx-based model and performs with sufficient accuracy in specific patients with positive TBx, but negative SBx.

The Role of Magnetic Resonance Imaging and Positron Emission Tomography/Computed Tomography in the Primary Staging of Newly Diagnosed Prostate Cancer: A Systematic Review of the Literature.

CONTEXT: Management of newly diagnosed prostate cancer (PCa) is guided in part by accurate clinical staging. The role of imaging, including magnetic resonance imaging (MRI) and positron emission tomography/computed tomography (PET/CT), in initial staging remains controversial. OBJECTIVE: To systematically review the studies of MRI and/or PET/CT in the staging of newly diagnosed PCa with respect to tumor (T), nodal (N), and metastatic (M) staging (TNM staging). EVIDENCE ACQUISITION: We performed a systematic review of the literature using MEDLINE and Web of Science databases between 2012 and 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines. EVIDENCE SYNTHESIS: A total of 139 studies (83 on T, 47 on N, and 24 on M status) were included. Ninety-nine (71%) were retrospective, 39 (28%) were prospective, and one was a randomized controlled trial (RCT). Most studies on T staging examined MRI, while PET/CT was used primarily for N and M staging. Sensitivity for the detection of extraprostatic extension, seminal vesicle invasion, or lymph node invasion ranged widely. When imaging was incorporated into existing risk tools, gain in accuracy was observed in some studies, although these findings have not been replicated. For M staging, most favorable results were reported for prostate-specific membrane antigen (PSMA) PET/CT, which demonstrated significantly better performance than conventional imaging. CONCLUSIONS: A variety of studies on modern imaging techniques for TNM staging in newly diagnosed PCa exist. For T and N staging, reported sensitivity of imaging modalities such as MRI or PET/CT varied widely due to data heterogeneity, small sample size, and low event rates resulting in large confidence intervals and a high level of uncertainty. Therefore, uniformity in data presentation and standardization on this topic are needed. The most promising technique for M staging, which was evaluated recently in an RCT, is PSMA-PET/CT. PATIENT SUMMARY: We performed a systematic review of currently available imaging modalities to stage newly diagnosed prostate cancer. With respect to local tumor and lymph node assessment, performance of imaging ranged widely. However, prostate-specific membrane antigen positron emission tomography/computed tomography showed favorable results for the detection of distant metastases.

Assessing the Outcome of Holmium Laser Enucleation of the Prostate by Age, Prostate Volume, and a History of Blood Thinning Agents: Report from a Single-Center Series of >1800 Consecutive Cases.

Purpose: To assess perioperative outcomes of holmium laser enucleation of the prostate (HoLEP) in a real-world scenario and with a focus on demanding patient factors, such as large prostate size, advanced patient age, and anticoagulation therapy (AT). Materials and Methods: We retrospectively analyzed HoLEP procedures at our institution between 2010 and 2016. After stratification by prostate volume, age, and AT, perioperative and early voiding characteristics were compared. A multivariable regression model was employed to identify predictors of prolonged time of catheterization (defined as being above group's median). Results: The study cohort consisted of 1816 men with a median age of 71 years (interquartile range [IQR]: 66-76), a median prostate volume of 80 mL (IQR: 58-105), and American Society of Anesthesiologists score ≥3 in 618 men (34%). Median time of enucleation and morcellation was 43 minutes (IQR: 31-60) and 10 minutes (IQR: 6-18), respectively. Perioperative blood transfusions were administered in 44 (2.4%) cases, severe postoperative complications (Clavien-Dindo grade ≥3b) occurred in 61 (3.3%) cases. The median time of catheterization was 2 days (IQR: 2-2), with prolonged catheterization occurring in 277 (15%) cases. After adjustment, large prostates (fourth volume quartile [106-280 mL]) (odds ratio [OR]: 1.8, 95% confidence interval [CI]: 1.3-2.6, p = 0.001), therapeutic low-molecular-weight heparin bridging regimen (OR: 2.2, 95% CI: 1.4-3.6, p = 0.037), low-dose acetylsalicylic acid (OR: 1.5, 95% CI: 1.0-2.2, p = 0.015), and a history of direct oral anticoagulation (OR: 2.3, 95% CI: 1.2-4.0, p = 0.022), but not patient age, were independently associated with prolonged catheterization. Conclusions: We confirm HoLEP as safe and efficient; however, patients with large prostates and patients with a history of AT are at risk of prolonged catheterization.

Retrograde ejaculation after holmium laser enucleation of the prostate (HoLEP)-Impact on sexual function and evaluation of patient bother using validated questionnaires.

BACKGROUND: A vast body of literature has focused on erectile function after Holmium Laser Enucleation of the Prostate (HoLEP). Interestingly, retrograde ejaculation (RE), despite its frequency has sparsely been investigated. OBJECTIVES: To study patient perception and impact of RE on sexuality following HoLEP. MATERIALS AND METHODS: We retrospectively analyzed 2,131 patients undergoing HoLEP 2006-2015 at our institution. Patients were followed via standardized questionnaires namely International Index of Erectile Function (IIEF) as well as Male Sexual Health Questionnaire Ejaculatory Short Form (MSHQ-EjD-SF). Exclusion criteria were missing/follow-up <6 months, missing data on MSHQ-EjD-SF and IIEF score, resulting in 535 assessable patients. Multivariable logistic regression was employed to identify independent predictors of satisfaction with overall sex life (IIEF question 13). RESULTS: Median follow-up was 50 months (IQR: 30-78). Overall, 495 (92.5%) patients reported RE. Patients differed significantly with respect to age (P = .036), IPSS at follow-up (P = .01), and erectile function (P < .001), whereas no other statistically significant differences were observed. In multivariable logistic regression analyses, presence of RE was not independently associated with satisfaction with overall sex life (OR: 2.7, 95% CI: 0.70-10.5, P = .1). However, in the cohort of patients exhibiting RE, patients who stated "feeling bothered by RE" had lower satisfaction with overall sex life (OR: 0.23, 95% CI: 0.13-0.38, P < .001). Bother by RE varied according to erectile function and did not impact overall satisfaction in men with superior erectile function. CONCLUSIONS: RE is a very common event after HoLEP but in this retrospective analysis was not associated with overall satisfaction with sex life. Contrary, satisfaction with sex life is impaired in patients who feel bothered by RE. Proper patient selection will pose key to identify patients in which RE bother will offset the benefits of LUTS relief.

Validation of the updated eighth edition of AJCC for prostate cancer: Removal of pT2 substages - Does extent of tumor involvement matter?

BACKGROUND: Updates in the eighth edition of the AJCC prostate cancer staging manual include removal of the organ-confined (pT2) substages. METHODS: Retrospective analyses of 12,028 pT2 patients that underwent radical prostatectomy between 2003 and 2016 and did not receive neo- or adjuvant treatments. Kaplan-Meier curves as well as multivariable Cox-regression analyses compared biochemical recurrence (BCR), metastatic progression (MP) and overall mortality (OM) between the 3 subcategories (pT2a, pT2b and pT2c). RESULTS: After surgery, 1,441 patients were classified as pT2a, 126 as pT2b and 10.495 as pT2c. Five-year BFS rates for pT2a, pT2b and pT2c were 92.0% vs. 97.4% vs. 88.0%. For the same groups, 5-year MP-FS rates were 99.5% vs. 100% vs. 99.0% and 5-year OS rates were 98.0% vs. 98.2% vs. 97.7%. In multivariable analyses pT2 substratification did not reach independent predictor status for biochemical recurrence, MP or overall mortality. CONCLUSIONS: Substratification of pT2 prostate cancer was not predictive for further disease progression. Therefore, removing the substages simplifies the staging system without loss of important information.

Tumor characteristics, oncological and functional outcomes after radical prostatectomy in very young men ≤ 45 years of age.

PURPOSE: Age is an important prognostic factor for functional and oncological outcomes after radical prostatectomy (RP). Considering the long life-expectancy of young patients (≤ 45 years), it remains important to examine their outcomes. METHODS: Of 16.049 patients who underwent RP between 01/2006 and 12/2014 at the Martini-Klinik Prostate Cancer Center, 119 (0.7%) were ≤ 45. Known prognosticators were compared according to patient age at RP (categorical as ≤ 45, > 45 and ≤ 65, > 65 years). Kaplan-Meier plots and Cox-regressions analyzed oncological outcomes [biochemical recurrence (BCR)-free survival and metastasis-free survival (MFS)]. Logistic regressions were used for functional outcome. Urinary continence (UC) was defined as the use of 0 or 1 safety pad/day and potency as an IIEF-5 score of ≥ 18. RESULTS: Compared to their older counterparts, patients ≤ 45 years had more favorable tumor characteristics. Of all patients aged ≤ 45 years, 89% underwent bilateral and 9.3% unilateral nerve-sparing procedure. Five year BCR-free survival and MFS were 80.2% and 98.7% for patients ≤ 45 years, 72.8% and 95.0% for patients > 45 and ≤ 65 years and 70.5% and 94.9% for patients > 65 years. For the same groups, 1-year UC-rates were 97.4%, 89.4%, and 84.7% while 1.3%, 8.2%, and 11.6% used 1-2 pads/24 h. At 1-year, 75.6%, 58.6%, and 45.3% of preoperatively potent patients who underwent bilateral nerve-sparing were considered potent. Younger age was an independent predictor of favorable functional outcome also in multivariable analysis. CONCLUSIONS: Patients aged ≤ 45 years had more favorable tumor characteristics and oncological outcomes. Moreover, younger patients should be counseled about the excellent postoperative continence and potency rates.

The Impact of Anxiety and Depression on Surgical and Functional Outcomes in Patients Who Underwent Radical Prostatectomy.

BACKGROUND: Depression and anxiety are associated with worse surgical outcomes and higher complication rates among various types of general or orthopedic surgeries. OBJECTIVE: To assess the impact of depression and anxiety on surgical, oncological, and functional outcomes in radical prostatectomy (RP) patients. DATA, SETTING, AND PARTICIPANTS: Retrospective analysis of 5862 RP patients (2014-2016). INTERVENTION: RP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Baseline depression and anxiety were assessed using the Patient Health Questionnaire-4 (PHQ-4) and categorized into 0-2 (normal), 3-5 (mild), and ≥6 (moderate to severe) points. Surgical outcomes included length of hospital stay (LOS), blood loss, and complications (Clavien-Dindo grading). Functional outcomes included urinary incontinence (UI) and erectile dysfunction (ED). Oncological outcomes focused on biochemical recurrence (BCR). Kaplan-Meier plots, multivariable logistic analyses, and Cox regression analyses were used. RESULTS AND LIMITATIONS: Overall, 28% patients had abnormal PHQ-4 scores and 8% a score ≥6 points. Higher PHQ-4 was significantly associated with worse surgical outcomes (longer LOS and higher complication rates) and higher risk for UI. No statistically significant difference was found for ED. However, we observed a higher use of phosphodiesterase type 5 inhibitors and intracavernous injection therapies among men with PHQ-4 score of ≥3. BCR was not affected by PHQ-4. The main limitations are the retrospective design as well as the lack of information on concomitant medications or follow-up PHQ-4 scores. CONCLUSIONS: Higher PHQ-4 scores are significantly associated with worse surgical outcomes and higher risk for UI. Our study highlights the importance of preoperative depression and anxiety assessment to optimize quality of life and to reduce health-related costs. PATIENT SUMMARY: Patients with preoperative depression or anxiety are at higher risk for postoperative complications and urinary incontinence after radical prostatectomy.

Effect of bladder neck sparing at robot-assisted laparoscopic prostatectomy on postoperative continence rates and biochemical recurrence.

OBJECTIVES: Previous studies reported improved continence recovery by bladder neck sparing (BNS) in prostate cancer patients treated with robot-assisted laparoscopic radical prostatectomy (RALP), without compromising biochemical recurrence (BCR). We compared the continence outcomes, surgical margin rates, and BCR risk of BNS vs. bladder neck reconstruction (BNR) patients during RALP. METHODS: Overall, 1,512 patients who underwent RALP with BNS or BNR between 2010 and 2017 in a single high-volume center, were identified. Logistic regression models tested the effect of BNS on continence and surgical margin rates. Cox regression models tested the effect of BNS on BCR. Continence was defined as the use of 0 or 1-safety pad per day. RESULTS: Three hundred and eighty-two vs. 1,130 patients underwent BNS vs. BNR. The median time to catheter removal was significantly shorter (5 vs. 8 days) in patients with BNS. Pad-free rates at 7 days after catheter removal were 60.0% vs. 54.5%, continence rates were 80.1% vs. 78.3% after 3 months and 85.3% vs. 89.6% after 1 year for BNS and BNR, respectively. Multivariable models revealed that BNS is an independent predictor to be pad-free at 7 days after catheter removal (OR: 1.39, P = 0.04), but no predictor for continence at 3 months (OR: 1.02, P = 0.9) and 1 year (OR: 0.78, P = 0.4) after RALP, as well as for positive surgical margin (OR: 0.95, P = 0.8) and BCR (Hazard ratio: 0.95, P = 0.9). CONCLUSION: Patients with BNS had a better chance to be pad-free at 7 days after catheter removal and had a significant shorter time to catheter removal. However, this beneficial effect disappeared with time and no differences in continence rates at 3 months and 1 year were recorded. Moreover, BNS did not negatively affect positive margin or BCR rates.

Impact of positive surgical margin length and Gleason grade at the margin on biochemical recurrence in patients with organ-confined prostate cancer.

BACKGROUND: Positive surgical margins (PSMs) represent a poor prognostic factor at radical prostatectomy (RP). To investigate the impact of PSM, its length, the focality, and the PSM Gleason, on biochemical recurrence (BCR) in organ-confined RP patients. METHODS: Within a high-volume center database, we identified patients who harbored organ-confined (pathologic stage T2 disease) prostate cancer (PCa) at RP (2010-2016). Kaplan-Meier analyses and multivariable Cox regression models were used to test the effect of the PSM on the BCR risk. RESULTS: Overall, 8770 patients were identified. Of those, 6.6% (n = 579) harbored PSM. BCR-free survival at 72 months after RP was 77.7% vs 89.0% for patients with vs without PSM (P < .001). BCR-free survival rates at 72 months were 77.4% vs 73.6% (P = .1) for unifocal vs multifocal PSM, 77.2% vs 71.8% (P = .03) for Gleason pattern 3 vs ≥4 at the margin and 88.4% vs 66.3% (P < .001) for <3 vs ≥3 mm length of margin. In multivariable Cox models PSM was an independent predictor for BCR (hazard ratio [HR] = 2.40, P < .001). However, in subgroups with PSM, only ≥3 mm PSM represented an independent predictor (HR = 1.93, P = .04), while focality and Gleason at the margin were no significant predictors. CONCLUSION: PSM represents an independent predictor for BCR in organ-confined PCa at RP. Moreover, Gleason ≥4 at the margin and ≥3 mm PSM length were associated with worse BCR-free survival. Closer surveillance of patients with organ-confined PCa at RP and PSM can help to identify those who qualify for early salvage radiotherapy.

Prostate cancer prognosis in men with other malignancies prior to radical prostatectomy.

OBJECTIVES: Cancer survivors are often diagnosed with subsequent prostate cancer. To improve medical care of these patients, we examined the oncological outcomes in men with prostate cancer and a cancer history. PATIENTS AND METHODS: We retrospectively analyzed data from 25,422 prostate cancer patients, who underwent a radical prostatectomy between 1992 and 2016. Patients with other malignancies were identified using medical records and self-administrated questionnaires. Cox regression and Kaplan Meier analysis of a propensity score-matched patient cohort were performed to examine biochemical recurrence-free survival, metastasis-free survival, overall survival and prostate cancer-specific survival. Competing risk analysis was used to estimate other-cause mortality, other cancer-specific mortality, and prostate cancer-specific mortality. Statistical analysis was performed using R. RESULTS: Of all patients, 6.4% were diagnosed with other malignancy prior to radical prostatectomy. Patients with tumor history were older (median: 66 years vs. 64 years., P< 0,001) and showed a higher tumor volume (median: 4.0 ml vs. 3.6 ml, P = 0.02) than patients without. The risk of biochemical recurrence and metastasis development after radical prostatectomy was similar. All-cause mortality was significantly increased (hazard ratio 2.0; 95% confidence interval 1.7-2.4), while prostate cancer-specific mortality was lower (hazard ratio 0.4; 95% confidence interval 0.23-0.87) in patients with additional malignancy. In a propensity score-matched cohort overall survival was significantly adverse (P< 0.001) and prostate cancer-specific survival was higher (P= 0.003) in patients with other malignancy prior to surgery. CONCLUSION: A higher other-cause mortality in men with tumor history should be concerned in the decision-making for medical care of prostate cancer patients in favor of reserved care strategies.

External Validation of the European Association of Urology Biochemical Recurrence Risk Groups to Predict Metastasis and Mortality After Radical Prostatectomy in a European Cohort.

The impact of biochemical recurrence (BCR) after radical treatment of prostate cancer on oncological outcomes remains unclear. A new European Association of Urology BCR risk stratification (low and high risk) has been proposed. To validate these risk groups, we retrospectively analyzed data for 1125 post-radical prostatectomy (RP) BCR patients (surgery between 1992 and 2006). Univariable Kaplan-Meier plots and multivariable Cox regression models with time-dependent covariates were used to test the independent predictor status of the risk grouping on metastatic progression (MP) and prostate cancer-specific mortality (PCSM). The 5-yr MP-free and PCSM-free survival rates were significantly higher among patients with low BCR risk compared to their high-risk counterparts. In multivariable analyses, the BCR risk grouping reached independent predictor status for MP (hazard ratio [HR] 3.46; p<0.001) and PCSM (HR 5.12; p<0.001). Salvage radiation therapy, especially when delivered at prostate-specific antigen <0.5ng/ml, was highly protective. Our findings corroborate the validity of this novel BCR risk grouping, which is easily applicable in daily practice and could be valuable in decision-making for salvage therapy and clinical trials. PATIENT SUMMARY: The European Association of Urology grouping for the risk of biochemical recurrence of prostate cancer after radical prostatectomy was valid when applied in a European study cohort.

Impact of the estimated blood loss during radical prostatectomy on functional outcomes.

OBJECTIVE: To investigate the effect of the estimated blood loss (BL) during radical prostatectomy (RP) for prostate cancer (CaP) on functional outcomes. We hypothesized that the estimated BL during RP for clinically localized CaP does not affect the functional outcomes. MATERIALS AND METHODS: Patients who underwent open RP (ORP) or robotic-assisted laparoscopic RP (RALP) were identified. BL was stratified into low, medium and high: ≤500vs. >500 to 1000vs. >1,000ml for ORP and ≤150vs. >150 to 400vs. >400ml for RALP. Multivariable logistic regression models (MLRM) tested the effect of BL on functional outcomes. RESULTS: About 6,279 consecutive patients with ORP (2008-2015) and 2,720 patients with RALP (2009-2015) were identified. Low, medium, and high BL was recorded in 31.4vs. 45.7vs. 22.9% for ORP and in 39.8vs. 45.2vs.15.0% for RALP. MLRM predicting potency revealed that high BL was an independent predictor for erectile dysfunction: Odds ratios (OR) were 0.50 (P = 0.03) and 0.52 (P = 0.04) for ORP and RALP, respectively. MRLM predicting continence in ORP revealed that high BL was an independent predictor for 7-days and mid-term: ORs were 0.80 (P = 0.04) and 0.66 (P = 0.002). Moreover, high BL was an independent predictor for 7-days continence in RALP: OR were 0.68 (P = 0.009). CONCLUSION: CaP patients who sustain higher BL during RP showed worse functional outcomes. High BL during ORP or RALP represented an independent predictor of erectile dysfunction and incontinence after surgery. However, the effect of high BL on the continence was temporarily and not present at 1 year after surgery in ORP and after 3 months in RALP.