Financial Toxicity After Robot-Assisted Radical Prostatectomy and Its Relation with Oncologic, Functional Outcomes.

PURPOSE: The aim of the study was to evaluate frequency of financial toxicity among patients who underwent robot-assisted radical prostatectomy for prostate cancer. MATERIALS AND METHODS: Data of 1,479 robot-assisted radical prostatectomy patients between 2006-2021 reporting no financial toxicity in preoperative assessments were included retrospectively. Financial toxicity was measured with financial impact of European Organisation for Research and Treatment of Cancer-quality of life questionnaire-C30. Financial impact scores were collected preoperatively, 6, 12, 18, and 24 months after robot-assisted radical prostatectomy. RESULTS: The frequency of financial toxicity was 8.3% (122/1379; 95% CI 7.0-9.8) at any point in time throughout 2 years of follow-up. Patients reporting financial toxicity (63 [58-68]) were significantly younger than patients who had no financial toxicity (65 [61-69]; P = .001). There was no statistically significant difference between financial toxicity+ and financial toxicity- groups in terms of salvage radiotherapy (P = .8) and positive surgical margin (P = .2) rates. In functional assessments, clinically significant International Prostate Symptom Score and International Consultation on Incontinence Questionnaire-Short Form score increase of financial toxicity+ patients (34% and 62%) were more frequent than financial toxicity- patients (23% and 47%; P = .004 and P = .002, respectively). In multivariable analysis, age at robot-assisted radical prostatectomy, International Prostate Symptom Score, International Consultation on Incontinence Questionnaire-Short Form, and quality of life scores were associated with financial toxicity (P < .001, OR 0.95 [95% CI 0.92-0.98]; P = .015, OR 2.4 [95% CI 1.2-4.7]; P = .032, OR 1.5 [95% CI 1.2-2.5]; P = .01, OR 0.09 [95% CI 0.01-0.57], respectively). Patients who underwent robot-assisted radical prostatectomy before retirement (≤65 years) had a 1.6-fold increased financial toxicity risk (P = .003, 95% CI 1.1-2.3). CONCLUSIONS: Financial toxicity after robot-assisted radical prostatectomy is low in mid-term follow-up. Patients who report urological symptoms after robot-assisted radical prostatectomy should also be evaluated for financial toxicity. Required measures against financial toxicity should be taken especially in the follow-up of younger cancer survivors.

Sexual Satisfaction in Men Suffering From Erectile Dysfunction After Robot-Assisted Radical Prostatectomy for Prostate Cancer: An Observational Study.

BACKGROUND: Preservation of erectile function is an important postoperative quality of life concern for patients after robot-assisted radical prostatectomy (RARP) for prostate cancer. Although erectile function may recover, many men continue to suffer from erectile dysfunction (ED). AIM: This study aims to determine whether satisfaction with sexual life improves in patients with ED after RARP and which factors are associated with satisfaction during follow-up. METHODS: A review was carried out of a prospectively maintained database of patients with prostate cancer who underwent a RARP between 2006 and 2019. The "International Index of Erectile Function" questionnaire was used to describe ED (range 5-25), overall satisfaction with sexual life and sexual desire (range for both: 2-10). Patients with ED due to RARP were compared with those without ED after RARP. Mixed effect model was used to test differences in satisfaction over time. Mann-Whitney U tests and multiple logistic regression were used to assess factors associated with being satisfied at 24 and 36 months. OUTCOMES: The main outcomes of this study are the overall satisfaction with sexual life score over time and factors which influence sexual satisfaction. RESULTS: Data of 2808 patients were reviewed. Patients whose erectile function was not known (n = 643) or who had ED at the baseline (n = 1281) were excluded. About 884 patients were included for analysis. They had an overall satisfaction score of 8.4. Patients with ED due to RARP had mean overall satisfaction scores of 4.8, 4.8, 4.9, and 4.6 at 6 mo, 12 mo, 24 mo, and 36 mo. These scores were significantly lower than those of patients without ED at every time point. In multiple regression analysis, higher overall satisfaction score at the baseline and higher sexual desire at 24 and 36 months' follow-up were associated with satisfaction with sexual life at 24 and 36 months' follow-up. No association was found for erectile function. CLINICAL IMPLICATIONS: Interventions focusing on adjustment to the changes in sexual functioning might improve sexual satisfaction; especially for those men who continue to suffer from ED. STRENGTHS & LIMITATIONS: Strengths of this study are the large number of patients, time of follow-up, and use of multiple validated questionnaires. Our results must be interpreted within the limits of retrospectively collected, observational data. CONCLUSION: Satisfaction with sexual life in men with ED due to RARP may take a long time to improve. One could counsel patients that sexual satisfaction is based on individual baseline sexual satisfaction and the return of sexual desire after RARP. Albers LF, Tillier CN, van Muilekom HAM, et al. Sexual Satisfaction in Men Suffering From Erectile Dysfunction After Robot-Assisted Radical Prostatectomy for Prostate Cancer: An Observational Study. J Sex Med 2021;18:339-346.

Management of bone health in patients with cancer: a survey of specialist nurses.

BACKGROUND: Patients with cancer can experience bone metastases and/or cancer treatment-induced bone loss (CTIBL), and the resulting bone complications place burdens on patients and healthcare provision. Management of bone complications is becoming increasingly important as cancer survival rates improve. Advances in specialist oncology nursing practice benefit patients through better management of their bone health, which may improve quality of life and survival. METHODS: An anonymised online quantitative survey asked specialist oncology nurses about factors affecting their provision of support in the management of bone metastases and CTIBL. RESULTS: Of 283 participants, most stated that they worked in Europe, and 69.3% had at least 8 years of experience in oncology. The most common areas of specialisation were medical oncology, breast cancer and/or palliative care (20.8-50.9%). Awareness of bone loss prevention measures varied (from 34.3% for alcohol intake to 77.4% for adequate calcium intake), and awareness of hip fracture risk factors varied (from 28.6% for rheumatoid arthritis to 74.6% for age > 65 years). Approximately one-third reported a high level of confidence in managing bone metastases (39.9%) and CTIBL (33.2%). International or institution guidelines were used by approximately 50% of participants. Common barriers to better specialist care and treatment were reported to be lack of training, funding, knowledge or professional development. CONCLUSION: This work is the first quantitative analysis of reports from specialist oncology nurses about the management of bone metastases and CTIBL. It indicates the need for new nursing education initiatives with a focus on bone health management.

Prostate-Specific Membrane Antigen PET/CT Combined with Sentinel Node Biopsy for Primary Lymph Node Staging in Prostate Cancer.

Our objective was to determine the diagnostic capabilities of combined prostate-specific membrane antigen (PSMA) PET/CT and sentinel node (SN) biopsy in PSMA PET/CT-negative patients for primary lymph node (LN) staging in prostate cancer (PCa) patients. Methods: Between January 2017 and March 2019, retrospectively, all consecutive patients with diagnosed intermediate- or high-risk primary PCa who underwent preoperative PSMA PET/CT (68Ga or 18F-DCFPyL) followed by robot-assisted radical prostatectomy and extended pelvic LN dissection (ePLND) were included. All patients without suspected LN metastases on PSMA PET/CT were considered candidates for SN biopsy with indocyanine green-99mTc-nanocolloid or 99mTc-nanocolloid with free indocyanine green used as tracers. The ePLND was used as a reference standard. Results: Of 53 patients, 22 had positive PSMA PET/CT results and 31 underwent subsequent SN biopsy after negative PSMA PET/CT results. In total, 23 patients (43%) were pN1, of whom 6 (26%) had negative PSMA PET/CT results and underwent subsequent SN biopsy. The combined use of SN biopsy and PSMA PET/CT identified all pN1 patients (100% sensitivity; 95% confidence interval, 86%-100%) and performed correct nodal staging in 50 of 53 patients (94% diagnostic accuracy; 95% confidence interval, 84%-99%). SN biopsy identified significantly smaller LN metastases (median diameter, 2.0 mm; interquartile range, 1.0-3.8 mm) than PSMA PET/CT (median diameter, 5.5 mm; interquartile range, 2.6-9.3 mm; P = 0.007). Conclusion: Combining both modalities led to a 94% accuracy for nodal staging in diagnosed intermediate- and high-risk primary PCa. Adding SN biopsy in patients with negative PSMA PET/CT results increased the combined sensitivity to 100% for detecting nodal metastases at ePLND. This diagnostic accuracy may provide valuable information for directing further treatment in PCa patients, such as the use of PSMA PET/CT and SN biopsy rather than ePLND as the preferred approach for staging before radiotherapy.

Ultrasensitive prostate-specific antigen level as a predictor of biochemical progression after robot-assisted radical prostatectomy: Towards risk adapted follow-up.

BACKGROUND: Ultrasensitive prostate-specific antigen (USPSA) is useful for stratifying patients according to their USPSA-based risk. Aim of our study was to determine the usefulness of USPSA as predictor of biochemical recurrence (BCR) after robot-assisted radical prostatectomy (RARP). METHODS: This retrospective study included 213 prostate cancer patients who had a postoperative USPSA between 0.01 and 0.2 ng/mL and at least 2 years of follow-up. We developed predictive models for BCR with PSA ≥0.2 and ≥0.5 ng/mL. RESULTS: A total of 103 patients (48.3%) had BCR at a median follow-up of 13.3 months. Higher postoperative USPSA (odds ratio [OR] = 4.73, P < 0.01), bilateral positive surgical margin in both sides (OR = 1.32, P = 0.044), higher average PSA rise (OR = 1.67, P = 0.031), ISUP grade group ≥3 (OR = 1.48, P = 0.003), and shorter interval since RARP (OR = 0.58, P < 0.001) were independent predictors of BCR with PSA ≥0.2 ng/mL. Higher postoperative USPSA (OR = 3.85, P < 0.01), bilateral positive surgical margin (OR = 1.34, P = 0.011), ISUP grade group ≥3 (OR = 1.5, P = 0.002), and shorter interval since RARP (OR = 0.61, P = 0.001) were independent predictors of BCR with PSA ≥0.5 ng/mL. The areas under the curve for the first and second model were 0.865 and 0.834, respectively. CONCLUSION: Ultrasensitive PSA after RARP is a useful prognostic indicator of BCR which could guide postoperative risk stratification and layout follow-up scheduling.

Validation and head-to-head comparison of three nomograms predicting probability of lymph node invasion of prostate cancer in patients undergoing extended and/or sentinel lymph node dissection.

PURPOSE: The updated Winter nomogram is the only nomogram predicting lymph node invasion (LNI) in prostate cancer (PCa) patients based on sentinel node (SN) dissection (sLND). The aim of the study was to externally validate the Winter nomogram and examine its performance in patients undergoing extended pelvic lymph node dissection (ePLND), ePLND combined with SN biopsy (SNB) and sLND only. The results were compared with the Memorial Sloan Kettering Cancer Center (MSKCC) and updated Briganti nomograms. METHODS: This retrospective study included 1183 patients with localized PCa undergoing robot-assisted laparoscopic radical prostatectomy (RARP) combined with pelvic lymphadenectomy and 224 patients treated with sLND and external beam radiotherapy (EBRT), aiming to offer pelvic radiotherapy only in case of histologically positive SNs. In the RARP population, ePLND was applied in 956 (80.8%) patients,while 227 (19.2%) patients were offered ePLND combined with additional SNB. RESULTS: The median numbers of removed nodes were 10 (interquartile range, IQR = 6-14), 15 (IQR = 10-20) and 7 (IQR = 4-10) in the ePLND, ePLND + SNB, and sLND groups, respectively. Corresponding LNI rates were 16.6%, 25.5% and 42%. Based on the AUC, the performance of the Briganti nomogram (0.756) in the ePLND group was superior to both the MSKCC (0.744) and Winter nomogram (0.746). The Winter nomogram, however, was the best predictor of LNI in both the ePLND + SNB (0.735) and sLND (0.709) populations. In the calibration analysis, all nomograms showed better accuracy in the low/intermediate risk patients, while in the high-risk population, an overestimation of the risk for LNI was observed. CONCLUSION: The SN-based updated nomogram showed better prediction in the SN population. The results were also comparable, relative to predictive tools developed with (e)PLND, suggesting a difference in sampling accuracy between SNB and non-SNB. Patients who benefit most from the nomogram would be those with a low/intermediate risk of LN metastasis.

Patterns of Benign Prostate Hyperplasia Based on Magnetic Resonance Imaging Are Correlated With Lower Urinary Tract Symptoms and Continence in Men Undergoing a Robot-assisted Radical Prostatectomy for Prostate Cancer.

OBJECTIVE: To investigate the association between benign prostatic hyperplasia (BPH) patterns, classified by magnetic resonance imaging (MRI), with lower urinary tract symptoms (LUTS) or continence, preoperatively and after robot-assisted laparoscopic radical prostatectomy (RARP). MATERIALS AND METHODS: This retrospective study included 49 prostate cancer patients, with prostate size >47 cm3, who underwent an endorectal MRI followed by RARP. Five BPH patterns were identified according to Wasserman, and additional prostate measurements were recorded. LUTS were assessed using the International Prostate Symptom Score and the PR25-LUTS-Questionnaire score. Continence was assessed using the International Consultation of Incontinence Questionnaire-Short Form. RESULTS: BPH pattern 3 (44.9%) was identified most common, followed by pattern 5 (26.6%), 1 (24.5%), and 2 and 4 (both 2%). BPH patterns were significant predictors of preoperative LUTS, with pedunculated with bilateral transition zone (TZ) and retrourethral enlargement (pattern 5) causing more severe symptoms compared with bilateral TZ and retrourethral enlargement (pattern 3) and bilateral TZ enlargement (pattern 1), whereas pattern 3 was additionally associated with more voiding symptoms compared with pattern 1. None of the BPH patterns was predictive of postoperative LUTS and continence. Independent predictors of continence at 12 months were lower preoperative PR25-LUTS score (P = .022) and longer membranous urethral length (P = .025). CONCLUSION: MRI is useful for classifying patients in BPH patterns which are strongly associated with preoperative LUTS. However, BPH patterns did not predict remnant LUTS or postoperative incontinence. Postoperative continence status was only associated with preoperative LUTS and membranous urethra length.

Stapling for prostate pedicle management during robot-assisted radical prostatectomy.

BACKGROUND: Prostate pedicle management is a crucial step during robot-assisted radical prostatectomy (RARP). Wide excision of prostate pedicle may be required to avoid positive surgical margins (PSMs) whereas preservation of neurovascular bundles requires resection close on the prostate. We studied Endo GIA™ stapling of prostate pedicle during RARP. METHODS: Retrospectively the outcome of 55 men who underwent RARP with Endo GIA™ stapling (45-mm Echelon Ethicon; group A) of the pedicle were compared with 100 men where another method for prostate pedicle management (mono- and bipolar electrocautery, Hem-o-Lock clips or titanium 10-mm clips; group B) was used. Both groups were matched for age, prostate size, clinical T-stage, Gleason Score and fascia preservation (FP) score (as a measure of nerve sparing). Surgical, oncological, functional outcome factors and costs were compared. RESULTS: The overall PSM rate was 33% in group A and 42% in group B (P=0.251). None of the cases had PSMs at the location of staples. PSMs with Endo GIA™ stapler at the periphery of the prostate were less frequent than in control group (4.1% vs. 11.5%; P=0.021). Median pedicle dissection time (7.8 [3.1-15.1] min vs. 10.5 [5.8-28.3] min; P=0.0001) and median operative time for RARP combined with lymphadenectomy (114 [70-129] min vs. 120 [67-200] min; P=0.043) tended to be shorter compared to group B. Erectile function and continence recovery at 12 months were comparable for both groups. Material costs for stapling (€730) were higher compared to variable costs in control group. CONCLUSIONS: Pedicle stapling during RARP reduced peripheral PSMs. It did not compromise functional results, provided a modest operation time gain for pedicle dissection, but is more expensive.

Prostate Cancer Unit Initiative in Europe: A position paper by the European School of Oncology.

The Prostate Cancer Programme of the European School of Oncology developed the concept of specialised interdisciplinary and multiprofessional prostate cancer care to be formalized in Prostate Cancer Units (PCU). After the publication in 2011 of the collaborative article "The Requirements of a Specialist Prostate Cancer Unit: A Discussion Paper from the European School of Oncology", in 2012 the PCU Initiative in Europe was launched. A multiprofessional Task Force of internationally recognized opinion leaders, among whom representatives of scientific societies, and patient advocates gathered to set standards for quality comprehensive prostate cancer care and designate care pathways in PCUs. The result was a consensus on 40 mandatory and recommended standards and items, covering several macro-areas, from general requirements to personnel to organization and case management. This position paper describes the relevant, feasible and applicable core criteria for defining PCUs in most European countries delivered by PCU Initiative in Europe Task Force.

Quality of life for patients treated for penile cancer.

PURPOSE: We assessed the impact of primary surgery, including penile sparing surgery vs (partial) penectomy and lymphadenectomy, on sexuality and health related quality of life. MATERIALS AND METHODS: We invited 147 patients surgically treated for penile cancer at our institution between 2003 and 2008 to complete the IIEF-15, SF-36®, IOC (version 2) and questions on urinary function. We evaluated the impact of primary surgery type and lymphadenectomy on these outcomes. We also compared patient SF-36 scores with those of an age and gender matched normative sample from the general Dutch population. RESULTS: A total of 90 patients (62%) returned a completed questionnaire. Surgery type and extent were not associated significantly with most of the study outcomes assessed. However, men who underwent (partial) penectomy reported significantly more problems than those treated with penile sparing surgery, including orgasm (effect size 0.54, p = 0.031), appearance concerns (effect size 0.61, p = 0.008), life interference (effect size 0.49, p = 0.032) and urinary function (83% vs 43%, p <0.0001). Men who underwent lymphadenectomy reported significantly more life interference (effect size 0.50, p = 0.037). The patient sample scored significantly better than the normative sample on the SF-36 physical component (p = 0.044) and the bodily pain subscale (p <0.001). CONCLUSIONS: Few differences were observed in sexuality and health related quality of life as a function of primary surgery and lymphadenectomy. However, (partial) penectomy and lymphadenectomy were associated with more problems with orgasm, body image, life interference and urination. Additional longitudinal studies are warranted to evaluate individual changes with time in these outcomes.

Impact on quality of life of radical prostatectomy after initial active surveillance: more to lose?

OBJECTIVE: The aim of this study was to determine whether deferred radical therapy for low-risk prostate cancer has an additionally unfavourable effect on quality of life (QoL). Substantial numbers of patients on active surveillance (AS) are eventually treated. MATERIAL AND METHODS: Prostate cancer patients treated with robot-assisted radical prostatectomy (RARP) in the NCI-AvL (Amsterdam, The Netherlands) received systematic QoL questionnaires preoperatively and postoperatively. Questionnaires included the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core Module and Prostate Module (EORTC-QLQ-C30 and EORTC-QLQ-PR25), International Index of Erectile Function-15 (IIEF-15) and International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF). Patients with low-risk prostate cancer who received RARP after an initial period of AS (AS-RARP group) were compared with similar patients who primarily elected surgery (direct-RARP group). RESULTS: The AS-RARP group included 29 patients who received RARP after a median period of 15.4 months of AS (range 3.0-18.8 months). Main reasons for deferred radical therapy were repeat biopsy risk reclassification (45%) and prostate-specific antigen progression (38%). The direct-RARP group included 363 patients treated after 3.3 months (range 0.1-45.5 months). RARP generally resulted in clinically relevant unfavourable changes on different QoL domains in both groups. Preoperatively the AS-RARP group showed more favourable scores on multiple QoL domains (physical functioning, p = 0.004; role functioning, p = 0.001; global health, p = 0.043; sexual activity, p = 0.001; sexual functioning, p = 0.029; IIEF-15, p = 0.042). Postoperatively, most of these more favourable scores in the AS-RARP group had changed to scores similar to the direct-RARP group, except for IIEF-15 (p = 0.027) and urinary symptoms (p = 0.001). When using a 12 month treatment delay threshold, a similar but less distinct effect was seen. CONCLUSIONS: Patients with low-risk prostate cancer who choose AS have more favourable preoperative QoL scores than patients who primarily elect radical prostatectomy, but these groups show similar postoperative QoL scores.

Quality of life in patients with low-risk prostate cancer. A comparative retrospective study: brachytherapy versus robot-assisted laparoscopic prostatectomy versus active surveillance.

PURPOSE: To investigate the quality of life (QoL) after different treatment modalities for low-risk prostate cancer, including brachytherapy, robot-assisted laparoscopic prostatectomy (RALP), and active surveillance (AS) with validated questionnaires. MATERIALS AND METHODS: From a prospective database, we selected a total of 144 men with low-grade localized prostate cancer including 65 (45.1%) patients with RALP, 29 (20.2%) with brachytherapy, and 50 (34.7%) whose cancer was managed with AS. QoL was routinely evaluated with validated questionnaires: The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC-QLQ-C30), EORTC-QLQ-Prostate Module (PR)25, International Index of Erectile Function (IIEF)-15, International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) with a minimum follow-up of 1 year. RESULTS: In comparison with baseline scores, the brachytherapy group showed a significant decrease of QoL domain scores of voiding complaints (P=0.010), use of incontinence aids (P=0.011), sexual functioning domain (P=0.011), and erectile function (P≤0.001). In the RALP group, sexual function (P≤0.001), incontinence (P≤0.001), and erectile function were significantly affected. A decrease in sexual function was observed in 71% of men after RALP and 59% after brachytherapy. In 30% of men under AS, a decrease of erectile function score during follow-up was reported. Overall, no significant decrease in general QoL was observed neither for men under AS nor for men treated by brachytherapy or RALP. Clinical factors such as age, prostate size, prostate-specific antigen level, and nerve preservation during RALP were nonpredictive of overall QoL after treatment for the individual patient (P=0.676). CONCLUSION: Patients with low-risk prostate cancer who are treated with brachytherapy or RALP report deterioration of QoL of specific domains such as voiding, continence, and sexual functioning in comparison with AS patients. A decrease of erectile function was also observed during AS. Overall QoL was similar for all three treatments options.

Salvage radiotherapy after robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: To assess the incidence and efficacy of salvage radiotherapy (SRT) after robot-assisted radical prostatectomy (RARP). RARP has been linked to an increased use of adjuvant treatments. If RARP would result in an increased local recurrence rate, response rates to SRT could be expected to be better after RARP than after more conventional methods of prostatectomy. The incidence and efficacy of SRT in a RARP population were compared with nomogram prediction. METHODS: Patient data were prospectively registered. Biochemical recurrence (BCR) was defined as a prostate-specific antigen (PSA) ≥0.1 ng/mL. SRT was offered to men with BCR after RARP. The Stephenson nomogram predictions were compared with outcome after SRT. RESULTS: Of 1087 men, 157 (14.4%) received SRT for BCR or persistent PSA levels during a median follow-up of 1078 days after RARP. Median PSA level before SRT was 0.2 ng/mL. Three-year BCR-free rate was 64% for men after SRT. pN (pNx, pN0, pN1) and PSA level before SRT were independent predictors of the BCR interval after SRT. Men with more extensive fascia preservation were more likely to respond favorably to SRT. The Stephenson nomogram prediction showed a concordance rate of 0.66 in this RARP population. Limitations of the study are the retrospective design and limited follow-up duration. CONCLUSION: In our RARP series, the use and efficacy of SRT were comparable with open prostatectomy series. The Stephenson nomogram reliably predicted outcome in patients with RARP with SRT, suggesting that similar characteristics predict response to SRT after RARP compared with open prostatectomy.

Interview-based versus questionnaire-based quality of life outcomes before and after prostatectomy.

INTRODUCTION: Functional outcome and quality of life (QOL) domains are important outcomes after curative therapy for prostate cancer. Although useful for scientific purposes, QOL questionnaires may be too extensive for daily routine, and single questions or interview-assessed outcomes may be more practical alternatives. The QOL outcomes of these measures were compared. MATERIALS AND METHODS: The QOL of patients undergoing Robot-Assisted Radical Prostatectomy (RARP) in our hospital was monitored before and after treatment using both brief standardized interview questions, as well as more extensive validated questionnaires. The interview questions address erectile function and urinary continence with only one question on each subject (both four response items). Questionnaires included a total of 74 questions (EORTC-QLQ-C30, EORTC-QLQ-PR25, international index of erectile function-15, and international consultation on incontinence questionnaire-short form). RESULTS: In 925 RARP patients, pre- and postoperative interview and questionnaire QOL data were available with a median follow up of 20 months. Improvement in both erectile function and continence scores occurred up till 2 years after the RARP for both interview- and questionnaire-based evaluations. On an individual patient basis, interview scores poorly correlated with questionnaire-based domains for continence and erectile function. Single questions from the questionnaire showed better correlation with domain scores. Functional recovery of continence after 1 year was worse when assessed by questionnaire than by interview evaluation. A decrease in physical (8%) and overall QOL (12%) after prostatectomy as assessed by the EORTC-QLQ-C30 questionnaire was better predicted by questionnaire-based than interview-based scores. Continence scores had a greater impact on physical and overall QOL scores than on erectile function scores. CONCLUSION: Interview/assessed continence and erectile function outcome after RARP showed limited association with questionnaire-based evaluation and may overestimate functional recovery. Continence scores for both interviews and questionnaires were stronger correlated with physical and overall QOL than erectile function scores.

Active surveillance for low-risk prostate cancer worldwide: the PRIAS study.

BACKGROUND: Overdiagnosis and subsequent overtreatment are important side effects of screening for, and early detection of, prostate cancer (PCa). Active surveillance (AS) is of growing interest as an alternative to radical treatment of low-risk PCa. OBJECTIVE: To update our experience in the largest worldwide prospective AS cohort. DESIGN, SETTING, AND PARTICIPANTS: Eligible patients had clinical stage T1/T2 PCa, prostate-specific antigen (PSA) ≤ 10 ng/ml, PSA density <0.2 ng/ml per milliliter, one or two positive biopsy cores, and Gleason score ≤ 6. PSA was measured every 3-6 mo, and volume-based repeat biopsies were scheduled after 1, 4, and 7 yr. Reclassification was defined as more than two positive cores or Gleason >6 at repeat biopsy. Recommendation for treatment was triggered in case of PSA doubling time <3 yr or reclassification. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariate regression analysis was used to evaluate predictors for reclassification at repeat biopsy. Active therapy-free survival (ATFS) was assessed with a Kaplan-Meier analysis, and Cox regression was used to evaluate the association of clinical characteristics with active therapy over time. RESULTS AND LIMITATIONS: In total, 2494 patients were included and followed for a median of 1.6 yr. One or more repeat biopsies were performed in 1480 men, of whom 415 men (28%) showed reclassification. Compliance with the first repeat biopsy was estimated to be 81%. During follow-up, 527 patients (21.1%) underwent active therapy. ATFS at 2 yr was 77.3%. The strongest predictors for reclassification and switching to deferred treatment were the number of positive cores (two cores compared with one core) and PSA density. The disease-specific survival rate was 100%. Follow-up was too short to draw definitive conclusions about the safety of AS. CONCLUSIONS: Our short-term data support AS as a feasible strategy to reduce overtreatment. Clinical characteristics and PSA kinetics during follow-up can be used for risk stratification. Strict monitoring is even more essential in men with high-risk features to enable timely recognition of potentially aggressive disease and offer curative intervention. Limitations of using surrogate end points and markers in AS should be recognized. TRIAL REGISTRATION: The current program is registered at the Dutch Trial Register with ID NTR1718 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1718).

Metastatic castration-resistant prostate cancer. Part 2: helping patients make informed choices and managing treatment side effects.

Nursing patients with mCRPC presents considerable challenges to nurses. They need to draw upon a variety of skills to support and care for patients throughout the disease journey. As the majority of patients with mCRPC are elderly, they tend to have co-morbidities and possibly side effects from previous treatment that need consideration. Some patients will present at around 50 years of age and will also have specific, different needs. The majority of patients with mCRPC will have bone metastases that may cause disability and pain. The International Society of Geriatric Oncology (SIOG) has recommended that older men are treated according to health status and not chronological age. So nurses need to understand how to assess patients' status effectively, regardless of their age. This will enable nurses to provide appropriate and effective intervention and to support their patients during treatment for advancing disease. This article reviews the main methods of assessment and the nursing interventions for the common side effects associated with treatment for mCRPC.

Robot-assisted laparoscopic prostatectomy: nodal dissection results during the first 440 cases by two surgeons.

BACKGROUND: Although many studies address the learning curve for robot-assisted laparoscopic prostatectomy (RALP), little is known concerning the results for pelvic lymph node dissection (LND) during RALP. PATIENTS AND METHODS: Between 2006 and 2011, two surgeons performed 904 RALP procedures. LND was performed in 440 (48.6%) cases based on the European Association of Urology guidelines. Both surgeons had extensive experience with open LND for both prostate and bladder cancer. Clinical data were prospectively recorded into an online database. Complications were reported using the Clavien-Dindo system and documented prospectively. RESULTS: For both surgeons, the operative time for LND decreased over time during the first 150 LND procedures. After that, a mean plateau of operative time of 49 minutes for LND was reached. Nodal yield increased from a mean of 10 nodes for the first 50 cases to 14 for cases 351 to 400. The percentage of positive nodes increased significantly in these intervals from 4% to 23.1% (P<0.001, Mann Whitney U test). Overall complications by grade were not significantly different between RALP with or without LND. In 440 LND cases, 5 (1.5%) grade IIIb complications occurred. All were infection related with bowel perforation in one. Symptomatic lymphoceles necessitating drainage were present in five (1.5%) men. Thromboembolic events (0% vs 1.5%) and anastomosis dehiscence (0.2% vs 1.1%) were more common in men with LND. During the learning curve, the incidence of Clavien grade I and II but not grade III and IV complications decreased. CONCLUSION: An improvement pattern for LND during RALP is observed for operative time, nodal yield node positivity rate, and complication rate during the first 400 cases of LND.

Extended nodal dissection reduces sexual function recovery after robot-assisted laparoscopic prostatectomy.

BACKGROUND AND PURPOSE: Considering the anatomic proximity of the internal iliac lymph nodes and the pelvic plexus, it may be expected that more extensive pelvic nodal dissection is associated with an increased risk of damage to the small pelvis neural and vascular structures. We evaluate whether nodal dissection is associated with functional outcome after robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: In a series of 798 RARP procedures, 325 (40.7%) patients underwent a lymph node dissection. Continence, sexual function, and lower urinary tract symptoms (LUTS) were assessed using the International Consultation of Incontinence Questionnaire short form (ICIQ)-SF), International Index of Erectile Function-15, and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC-QLQ)-PR25 questionnaires before and at 6 months intervals after RARP. RESULTS: Preoperative ICIQ-SF, IIEF-15, and PR25-LUTS scores were similar for men with and without nodal dissection. Normal postoperative erectile function (IIEF-EF >24) at 6 months was reported by 1.7%, 9.1%, and 50.4% of men with no, unilateral, and bilateral nerve preservation and normal preoperative erectile function. All domains of the IIEF-15 score showed a negative correlation with the number of removed lymph nodes. In 70 of 325 (21%) cases with nodal dissection, more than 10 nodes were removed. Men with more than 10 nodes removed had lower IIEF-15 domain scores compared with men with 1 to 10 removed lymph nodes. The postoperative ICIQ-SF and PR25-LUTS scores were not associated with extent of nodal dissection. Nodal metastases were found in 5.9% and 15.7% of men with ≤ 10 nodes and >10 nodes removed (P=0.005). In a multivariate analysis, extent of fascia preservation (FP-score), preoperative IIEF-EF, and number of removed nodes were the strongest independent predictors of postoperative erectile function recovery. CONCLUSION: More extensive nodal dissection was associated with impaired postoperative sexual function recovery but not continence and voiding function after RARP, independent of preoperative function and nerve preservation.