Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA GUIDELINE PART II-Surgical Evaluation and Treatment.

PURPOSE: Surgical therapies for symptomatic bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH) are many, and vary from minimally invasive office based to high-cost operative approaches. This Guideline presents effective evidence-based surgical management of male lower urinary tract symptoms secondary/attributed to BPH (LUTS/BPH). See accompanying algorithm for a detailed summary of procedures (figure[Figure: see text]). MATERIALS/METHODS: The Minnesota Evidence Review Team searched Ovid MEDLINE, Embase, Cochrane Library, and AHRQ databases to identify eligible studies published between January 2007 and September 2020, which includes the initial publication (2018) and amendments (2019, 2020). The Team also reviewed articles identified by Guideline Panel Members. When sufficient evidence existed, the body of evidence was assigned a strength rating of A (high), B (moderate), or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, information is provided as Clinical Principles and Expert Opinions (table[Table: see text]). RESULTS: Twenty-four guideline statements pertinent to pre-operative and surgical management were developed. Appropriate levels of evidence and supporting text were created to direct urologic providers towards suitable and safe operative interventions for individual patient characteristics. A re-treatment section was created to direct attention to longevity and outcomes with individual approaches to help guide patient counselling and therapeutic decisions. CONCLUSION: Pre-operative and surgical management of BPH requires attention to individual patient characteristics and procedural risk. Clinicians should adhere to recommendations and familiarize themselves with criteria that yields the highest likelihood of surgical success when choosing a particular approach for a particular patient.

Performance Feedback May Not Improve Radical Prostatectomy Outcomes: The Surgical Report Card (SuRep) Study.

PURPOSE: Oncologic, urinary, and sexual outcomes are important to patients receiving prostate cancer surgery. The objective of this study was to determine if providing surgical report cards (SuReps) to surgeons resulted in improved patient outcomes. MATERIALS AND METHODS: A prospective before-and-after study was conducted at The Ottawa Hospital. A total of 422 consecutive patients undergoing radical prostatectomy were enrolled. The intervention was provision of report cards to surgeons. The control cohort was patients treated before report card feedback (pre-SuRep), and the intervention cohort was patients treated after report card feedback (post-SuRep). The primary outcomes were postoperative erectile function, urinary continence, and positive surgical margins. RESULTS: Baseline characteristics were similar between groups. Almost all patients (99%) were continent and the majority (59%) were potent prior to surgery. Complete 1-year followup was available for 400 patients (95%). Nerve sparing surgery increased from 70% pre-SuRep to 82% post-SuRep (p=0.01). There was a nonstatistically significant increase in the proportion of patients with a positive surgical margin post-SuRep (31% pre-SuRep vs 39% post-SuRep, p=0.08). There was no difference in postoperative erectile function (17% vs 18%, p=0.7) and a decrease in continence (75% vs 65%, p=0.02) at 1 year postoperatively. CONCLUSIONS: The SuRep platform allows accurate reporting of surgical outcomes that can be used for patient counseling. However, the provision of surgical report cards did not improve functional or oncologic outcomes. Longer durations of feedback, report card modifications, or targeted interventions are likely necessary to improve outcomes.

Relationship of preoperative androgen levels and metabolic syndrome with quality of life and erectile function in patients who are to undergo radical prostatectomy.

This study aims to investigate whether clinical and biological preoperative characteristics of patients who were to undergo radical prostatectomy were associated with impairment in patient-reported quality of life (QoL) and erectile dysfunction immediately before intervention. We evaluated patient-reported outcomes among 1019 patients (out of 1343) of the AndroCan study, willing to score the Aging Male Symptom (AMS) and the International Index of Erectile Function 5-item (IIEF-5) auto-questionnaires. Univariate linear regression and robust multiple regression were used to ascertain the relationship between demographic, clinical, and hormonal parameters and global AMS or IIEF-5 scores. As a result, most patients (85.1') of the Androcan cohort agreed to complete questionnaires. Significantly higher IIEF-5 global scores were found in non-Caucasian and obese patients, with larger waist circumference, metabolic syndrome, diabetes mellitus, cardiovascular disease, hypertension, high blood sugar, concomitant medications, and hypogonadism, while the AMS global score was significantly higher in patients with larger waist circumference, metabolic syndrome, high blood pressure, raised glycemia, and concomitant medication. The IIEF-5 global score was correlated to age, dehydroepiandrosterone (DHEA), fat mass percentage, and androstenediol (D5). The AMS global score was significantly correlated to DHEA, D5, and DHEA sulfate. Finally, the multivariate models showed that QoL and erectile function were significantly affected, before surgery, by symptoms and signs that are usually considered as pertaining to the metabolic syndrome, while sexual hormones are essentially correlated to erectile dysfunction.

Prostate cancer: a presentation of clinicopathologic prognosticators among Filipino and American men at radical prostatectomy.

Lower incidence and mortality rates from prostate cancer (PCa) have been shown in Asian men in general compared to Westerners. This is the first study detailing the clinicopathologic features of resected prostate cancer in Filipino men living in the Philippines (PH). This study investigated the supposed "lower risk" Filipino and "higher risk" American PCa patients from the PH and the United States of America (USA), respectively. We examined 348 (176 from PH, 172 from USA) radical prostatectomy cases. The clinicopathologic features of both groups (age at time of diagnosis, preoperative prostate-specific antigen [pre-op PSA] level, Gleason score [GS], Grade groups [GG], margin involvement, extraprostatic extension [EPE], seminal vesicle invasion [SVI], and regional lymph node [RLN] metastasis) were compared. Six of seven prognosticators examined were more strongly associated with Filipinos than with Americans. Filipinos were older at diagnosis (PH: 64.32 ± 6.56 years vs USA: 58.98 ± 8.08 years) and had higher pre-op PSA levels (PH: 21.39 ± 46.40 ng ml-1 vs USA: 7.63 ± 9.19 ng ml-1). Filipino men had more advanced grade, GG 2 with minor pattern 5 (PH: 6.2% vs USA: 2.9%) and GG 5 (PH: 14.8% vs USA: 3.5%). Likewise, other adverse pathological features in margin positivity (PH: 52.3% vs USA: 23.8%), focal EPE (PH: 14.2% vs USA: 2.3%), and SVI (PH: 17.1% vs USA: 5.8%) were more commonly observed in Filipinos. This study reveals the prognostic disadvantage of Filipinos versus Americans and highlights an important difference of Filipinos from other studied Asian ethnicities that have repeatedly been shown to have lower-risk PCa. This study, the first on Filipino PCa patients with RP, suggests the need to modify Western-based risk stratification when employed in other countries like the PH.

Metabolic syndrome, levels of androgens, and changes of erectile dysfunction and quality of life impairment 1 year after radical prostatectomy.

Robust data evaluating the association of preoperative parameters of the patients with quality of life after radical prostatectomy are lacking. We investigated whether clinical and biological preoperative characteristics of the patients were associated with impaired patient-reported quality of life (QoL) and sexual outcomes 1 year after radical prostatectomy. We evaluated patient-reported outcomes among the 1343 men participating in the AndroCan trial (NCT02235142). QoL and erectile dysfunction (ED) were assessed before and 1 year after radical prostatectomy using validated self-assessment questionnaires (Aging Male's Symptoms [AMS] and the 5-item abridged version of the International Index of Erectile Function [IIEF5]). At baseline, 1194 patients (88.9%) accepted to participate. A total of 750 (55.8%) patients answered the 1-year postoperative questionnaires. Out of them, only 378 (50.4% of responders) provided answers that could be used for calculations. One year after prostatectomy, ED had worsened by 8.0 (95% confidence interval [CI]: 7.3-8.7; P < 0.0001) out of a maximum of 20. The global AMS score has worsened by 2.8 (95% CI: 1.7-3.8; P < 0.0001). ED scores 1 year postsurgery were positively correlated with preoperative age and percentage of fat mass, and negatively correlated with total cholesterol, dehydroepiandrosterone (DHEA), and androstenediol (D5); AMS were poorly correlated with preoperative parameters. QoL and sexual symptoms significantly worsened after radical prostatectomy. Baseline bioavailable testosterone levels were significantly correlated with smaller changes on AMS somatic subscores postprostatectomy. These findings may be used to inform patients with newly diagnosed prostate cancer.

[Surgical and interventional management of benign prostatic obstruction: Guidelines from the Committee for Male Voiding Disorders of the French Urology Association]. / Traitement chirurgical et interventionnel de l'obstruction sous-vésicale liée à une hyperplasie bénigne de prostate : revue systématique de la littérature et recommandations de bonne pratique clinique du Comité des Troubles Mictionnels de l'Homme.

OBJECTIVE: The aim of the Male Lower Urinary Tract Symptoms Committee (CTMH) of the French Urology Association was to propose an update of the guidelines for surgical and interventional management of benign prostatic obstruction (BPO). METHODS: All available data published on PubMed® between 2018 and 2020 were systematically searched and reviewed. All papers assessing surgical and interventional management of adult patients with benign prostatic obstruction (BPO) were included for analysis. After studies critical analysis, conclusions with level of evidence and French guidelines were elaborated in order to answer the predefined clinical questions. RESULTS/GUIDELINES: Offer a trans-uretral incision of the prostate to treat patients with moderate to severe lower urinary tract symptoms (LUTS) with a prostate volume<30cm3, without a middle lobe. TUIP increases the chances of preserving ejaculation. Propose mono- or bipolar trans-urethral resection of the prostate (TURP) to treat patients with moderate to severe LUTS with a prostate volume between 30 and 80cm3. Vaporization by Greenlight™ or by bipolar energy can be offered as an alternative to TURP. Offer a Greenlight™ laser vaporization to patients at risk of bleeding. Offer endoscopic prostate enucleation to surgically treat patients with moderate to severe LUTS as an alternative to TURP and open prostatectomy (OP). Minimally invasive prostatectomy is an alternative to OP in centers without access to adequate endoscopic procedures. Embolization of the prostatic arteries may be offered in the event of a contraindication or refusal of surgery for prostates with a volume>80cm3. Prostatic uretral lift is an alternative in patients interested in preserving their ejaculatory function and with a prostate volume<70cm3 without a middle lobe. Aquablation and Rezum™ are under evaluation and should be offered in research protocols. CONCLUSION: Major changes in surgical management of BPO have occurred and aim at reducing morbidity and improving quality of life of patients.

Objective assessment of intraoperative skills for robot-assisted radical prostatectomy (RARP): results from the ERUS Scientific and Educational Working Groups Metrics Initiative.

OBJECTIVE: To develop and seek consensus from procedure experts on the metrics that best characterise a reference robot-assisted radical prostatectomy (RARP) and determine if the metrics distinguished between the objectively assessed RARP performance of experienced and novice urologists, as identifying objective performance metrics for surgical training in robotic surgery is imperative for patient safety. MATERIALS AND METHODS: In Study 1, the metrics, i.e. 12 phases of the procedure, 81 steps, 245 errors and 110 critical errors for a reference RARP were developed and then presented to an international Delphi panel of 19 experienced urologists. In Study 2, 12 very experienced surgeons (VES) who had performed >500 RARPs and 12 novice urology surgeons performed a RARP, which was video recorded and assessed by two experienced urologists blinded as to subject and group. Percentage agreement between experienced urologists for the Delphi meeting and Mann-Whitney U- and Kruskal-Wallis tests were used for construct validation of the newly identified RARP metrics. RESULTS: At the Delphi panel, consensus was reached on the appropriateness of the metrics for a reference RARP. In Study 2, the results showed that the VES performed ~4% more procedure steps and made 72% fewer procedure errors than the novices (P = 0.027). Phases VIIa and VIIb (i.e. neurovascular bundle dissection) best discriminated between the VES and novices. LIMITATIONS: VES whose performance was in the bottom half of their group demonstrated considerable error variability and made five-times as many errors as the other half of the group (P = 0.006). CONCLUSIONS: The international Delphi panel reached high-level consensus on the RARP metrics that reliably distinguished between the objectively scored procedure performance of VES and novices. Reliable and valid performance metrics of RARP are imperative for effective and quality assured surgical training.

Optimizing Surgical Techniques in Robot-Assisted Radical Prostatectomy.

Robot-assisted radical prostatectomy (RARP) is the most common surgical treatment of localized prostate cancer. The ideal procedure would achieve maximum oncological efficacy while minimizing associated side effects, such as erectile dysfunction and urinary incontinence. Surgeon experience and surgical technique affect RARP outcomes. Here, the authors review RARP technical modifications aimed at optimizing cancer control and postoperative urinary and sexual function.

Historical Considerations and Surgical Quality Improvement in Robotic Prostatectomy.

Laparoscopic prostatectomy was technically challenging and not widely adopted. Robotics led to the widespread adoption of minimally invasive prostatectomy, which has been used heavily, supplanting the open and traditional laparoscopic approach. The benefits of robotic prostatectomy are disputed. Data suggest that robotic prostatectomy outcomes have improved over time.

Quantifying the "Assistant Effect" in Robotic-Assisted Radical Prostatectomy (RARP): Measures of Technical Performance.

PURPOSE: Surgeons are reliant on the bedside assistant during robotic surgeries. Using a modified global rating scale (GRS), we aim to assess the association between an assistant's technical skill on surgeon performance in Robotic-Assisted Radical Prostatectomy (RARP). METHODS: Prospective, intraoperative video from RARP cases at three centers were collected. Baseline demographic and RARP-experience data were collected from participating surgeons and trainees. The dissection of the prostatic pedicle and neurovascular bundle step (NVB) was analyzed. Expert analysts scored the console surgeon performance using the Global Evaluative Assessment of Robotic Skills (GEARS), and the bedside assistant performance using a modified Objective Structured Assessment of Technical Skills (aOSATS). The primary outcome is the association between console surgeon performance, as measured by GEARS, and assistant skill, as measured by aOSATS. Spearman's rho correlations were used to test the relationship between assistant and surgeon technical performance, and a multivariable linear regression model was created to test this association while controlling for patient factors. RESULTS: 92 RARP cases were available for the analysis, comprising 14 console surgeons and 22 different bedside assistants. In only 5 (5.4%) cases, the neurovascular bundle step was completed by a trainee, and in 13 (14.1%) of cases, a staff-level surgeon acted as the bedside assistant. aOSATS score was significantly associated with robotic console experience (P = 0.011), and prior laparoscopic experience (P < 0.001). Assistant aOSATS score showed a weak but significant correlation with surgeon GEARS score during the neurovascular bundle step (spearman's rho = 0.248, P = 0.028). On linear regression, aOSATS remained a significant predictor of console surgeon performance (P = 0.016), after controlling for patient age and BMI, prostate volume, tumor stage, and presence of nerve-sparing. CONCLUSIONS: This is the first study to assess the association between assistant technical skill and surgeon performance in RARP. Additionally, we have provided validity evidence for a modified OSATS global rating scale for training and assessing bedside assistant performance.

Advanced Prostate Cancer: AUA/ASTRO/SUO Guideline PART II.

PURPOSE: The summary presented herein represents Part II of the two-part series dedicated to Advanced Prostate Cancer: AUA/ASTRO/SUO Guideline discussing prognostic and treatment recommendations for patients with castration-resistant disease. Please refer to Part I for discussion of the management of patients with biochemical recurrence without metastatic disease after exhaustion of local treatment options as well as those with metastatic hormone-sensitive prostate cancer. RESULTS: The Advanced Prostate Cancer Panel created evidence- and consensus-based guideline statements to aid clinicians in the management of patients with advanced prostate cancer. Such statements are summarized in figure 1[Figure: see text] and detailed herein. MATERIALS AND METHODS: The systematic review utilized to inform this guideline was conducted by an independent methodological consultant. A research librarian conducted searches in Ovid MEDLINE (1998 to January Week 5 2019), Cochrane Central Register of Controlled Trials (through December 2018), and Cochrane Database of Systematic Reviews (2005 through February 6, 2019). An updated search was conducted prior to publication through January 20, 2020. The methodology team supplemented searches of electronic databases with the studies included in the prior AUA review and by reviewing reference lists of relevant articles. CONCLUSIONS: This guideline attempts to improve a clinician's ability to treat patients diagnosed with advanced prostate cancer. Continued research and publication of high-quality evidence from future trials will be essential to improve the level of care for these patients.

Advanced Prostate Cancer: AUA/ASTRO/SUO Guideline PART I.

PURPOSE: The summary presented herein represents Part I of the two-part series dedicated to Advanced Prostate Cancer: AUA/ASTRO/SUO Guideline discussing prognostic and treatment recommendations for patients with biochemical recurrence without metastatic disease after exhaustion of local treatment options as well as those with metastatic hormone-sensitive prostate cancer. Please refer to Part II for discussion of the management of castration-resistant disease. MATERIALS AND METHODS: The systematic review utilized to inform this guideline was conducted by an independent methodological consultant. A research librarian conducted searches in Ovid MEDLINE (1998 to January Week 5 2019), Cochrane Central Register of Controlled Trials (through December 2018), and Cochrane Database of Systematic Reviews (2005 through February 6, 2019). An updated search was conducted prior to publication through January 20, 2020. The methodology team supplemented searches of electronic databases with the studies included in the prior AUA review and by reviewing reference lists of relevant articles. RESULTS: The Advanced Prostate Cancer Panel created evidence- and consensus-based guideline statements to aid clinicians in the management of patients with advanced prostate cancer. Such statements are summarized in figure 1[Figure: see text] and detailed herein. CONCLUSIONS: This guideline attempts to improve a clinician's ability to treat patients diagnosed with advanced prostate cancer. Continued research and publication of high-quality evidence from future trials will be essential to improve the level of care for these patients.

A methodology for Dynamic Human Reliability Analysis in Robotic Surgery.

Surgery has changed significantly in recent years due to the introduction of advanced technologies, resulting in increased system complexity at the technical, human and organisational levels, which may lead to higher variability of patient outcome due to new error pathways. Current approaches towards a safer surgery are largely based on ex-post analysis of events and process monitoring (e.g. root cause analysis, safety checklists, safety audits). However, adopting a proactive approach enables the prior identification of critical factors and the design of safer sociotechnical systems, thanks to a multi-level (or mesoergnomics) perspective. In this paper, a methodology for performing mesoergonomics analysis of surgical procedures is proposed. It is a methodology for Dynamic Human Reliability Analysis in Robotic Surgery based on a modified version of human error assessment and reduction technique (HEART) integrated with a method for incorporating uncertainties related to the influence of personal and organisational factors on the execution of a surgical procedure. The pilot application involves a robot-assisted radical prostatectomy procedure, and the results reveal that team-related factors have the greatest impact on patient outcome variability.

Assessing the Quality of Surgical Care for Clinically Localized Prostate Cancer: Results from the CEASAR Study.

PURPOSE: Prior studies suggest that nationally endorsed quality measures for prostate cancer care are not linked closely with outcomes. Using a prospective, population based cohort we measured clinically relevant variation in structure, process and outcome measures in men undergoing radical prostatectomy. MATERIALS AND METHODS: The Comparative Effectiveness Analysis of Surgery and Radiation (CEASAR) Study enrolled men with clinically localized prostate cancer diagnosed from 2011 to 2012 with 1,069 meeting the final inclusion criteria. Quality of life was assessed using the Expanded Prostate Index Composite (EPIC-26) and clinical data by chart review. Six quality measures were assessed, including pelvic lymphadenectomy with risk of lymph node involvement 2% or greater, appropriate nerve sparing, negative surgical margins, urinary and sexual function, treatment by high volume surgeon, and 30-day and 1-year complications. Receipt of high quality care was compared across categories of race, age, surgeon volume and surgical approach via multivariable analysis. RESULTS: There were no significant differences in quality across race, age or surgeon volume strata, except for worse urinary incontinence in Black men. However, robotic surgery patients experienced fewer complications (3% vs 9.3% short-term and 11% vs 16% long-term), were more likely to be treated by a high volume surgeon (47% vs 25%) and demonstrated better sexual function. CONCLUSIONS: In this cohort we did not identify meaningful variation in quality of care across racial groups, age groups and surgeon volume strata, suggesting that men are receiving comparable quality of care across these strata. However, we did find variation between open and robotic surgery with fewer complications, improved sexual function and increased use of high volume surgeons in the robotic group, possibly reflecting differences in quality between approaches, differences in practice patterns and/or biases in patient selection.

Multi-Institutional Assessment of Routine Same Day Discharge Surgery for Robot-Assisted Radical Prostatectomy.

PURPOSE: We assessed the multi-institutional safety of same day discharge for robot-assisted radical prostatectomy within a single health care system. MATERIALS AND METHODS: We included 358 patients undergoing planned same day discharge for robot-assisted radical prostatectomy at 6 French centers. Primary outcomes were same day discharge failure, and 30-day complication and readmission rates. Secondary outcomes included preoperative characteristics, perioperative parameters, Chung score and pain visual analogue scale at discharge, pathological features and followup. RESULTS: Mean patient age was 64.7 years. Mean operative time and blood loss were 147.5 minutes and 228 ml, respectively. Concomitant lymph node dissection and nerve sparing procedures were performed in 43% and 62% of cases, respectively. No patient required transfusion or conversion. The same day discharge failure, complication and readmission rates were 4.2%, 16.8% and 2.8%, respectively. The most frequent complications were low grade complications including urinary infection (6.4%) and ileus (2.8%). Blood loss, lymph node dissection and pain visual analogue scale were significantly correlated with same day discharge failure. Same day discharge failure was reported in 7.8% of patients with pelvic lymph node dissection compared with only 1.5% of patients who did not undergo lymph node dissection (p=0.003). ASA® score was the only factor significantly associated with postoperative complications (p=0.023). The only factor correlated with readmission was the pain visual analogue scale at discharge (p=0.017). CONCLUSIONS: This first multi-institutional evaluation confirms the safety of same day discharge robot-assisted radical prostatectomy in a single health care system and identifies for the first time factors associated with same day discharge failure and readmission. These findings may help physicians anticipate ideal same day discharge candidates and adapt postoperative followup.

Quantifying the Relationship Between Increasing Life Expectancy and Nonprostate Cancer Mortality After Radical Prostatectomy.

OBJECTIVE: To investigate the relationship between increasing life expectancy and nonprostate cancer (competing) mortality after radical prostatectomy. PATIENTS AND METHODS: We studied a single-center sample of 6809 consecutive patients who underwent radical prostatectomy between 1992 and 2016 with a median age of 65 years and a median follow-up of 7.9 years. Multivariate competing risk analyses were performed with competing mortality as endpoint. Linear trends over the years of surgery for 5-year competing mortality rates and for mean ages were calculated using linear regression analyses. We estimated the number of live years gained over time using a heuristic model-based calculation: (hazard ratio year of surgery) 24 calendar years × (hazard ratio age at surgery) gained life years = 1. RESULTS: After controlling for age, nonprostate cancer mortality decreased significantly during the observation period. Accumulated over the 24 years, this decrease of mortality corresponded to the effect of 6.3 years of calendric age. Most of the decrease in nonprostate cancer mortality (predominantly attributable to noncancer causes of death) was seen in patients aged 65 years or older (8.1 years gained), whereas there was only a marginal decrease in patients younger than 65 years (only 1 year gained). The decrease in nonprostate cancer mortality was accompanied by a slight increase of mean age at surgery (2.7 years) that did not nearly compensate the decreasing risk. CONCLUSION: Clinicians should be aware of the decreasing competing mortality risk in elderly candidates for radical prostatectomy in order to avoid undertreatment.

Laser enucleation of the prostate versus transurethral resection of the prostate: perioperative outcomes from the ACS NSQIP database.

PURPOSE: To compare the perioperative outcomes associated with laser enucleation of the prostate (LEP) and transurethral resection of the prostate (TURP) using a national database. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was reviewed for patients who underwent TURP or LEP from 2008 to 2016. Baseline demographics, comorbidities, and predisposition to bleeding were compared between TURP and LEP. The 30-day perioperative outcomes including operative time, length of hospital stay (LOS), return to the operating room (OR), bleeding requiring transfusion, and organ system-specific complications were compared between the procedures. A multivariate logistic regression analysis was performed, adjusting for the type of surgery and other covariates. RESULTS: The series included 37,577 TURP and 2869 LEP procedures. While TURP was associated with a shorter operative time (55.20 ± 37.80 min) than LEP (102.80 ± 62.30 min), the latter was associated with a shorter hospital stay (1.29 ± 2.73 days) than TURP (2.05 ± 5.20 days). Compared to TURP, LEP had 0.52 (0.47-0.58) times the odds of a LOS > 1 day and 0.67 (0.54-0.83) times the odds of developing urinary tract infections. Nevertheless, no difference was found for other postoperative complications, need for transfusion, and return to OR. CONCLUSION: Real-life data from a large national database confirmed that LEP is a safe and reproducible procedure to treat benign prostatic obstruction. Compared to TURP, LEP was associated with a lower rate of infectious complications and a shorter LOS at the expense of an increased operative time.

Pathologically Node-Positive Prostate Cancer: Casting for Cure When the Die Is Cast?

The postoperative management of men with lymph node involved prostate cancer (pN+) remains a challenge as there is a general lack of randomized trial data and a range of management strategies. Retrospective studies suggest a variable clinic course for patients with pN+ prostate cancer. Some men progress rapidly to metastatic disease despite further therapies, whereas other men can have a period of prolonged quiescence without adjuvant androgen deprivation therapy (ADT) or radiation therapy (RT). For men who have undergone radical prostatectomy, randomized trial data indicate that the addition of ADT in pN+ disease extends metastasis-free, prostate cancer-specific, and overall survival. Additional retrospective studies suggest that adding RT is potentially beneficial in this setting, improving overall and cancer-specific survival especially in men with certain pathologic parameters. Conversely, men with lower disease burden in their lymph nodes have longer times to progression and may be candidates for observation and salvage therapy as opposed to adjuvant ADT/RT.

Using video review to understand the technical variation of robot-assisted radical prostatectomy in a statewide surgical collaborative.

PURPOSE: Video assessment is an emerging tool for understanding surgical technique. Patient outcomes after robot-assisted radical prostatectomy (RARP) may be linked to technical aspects of the procedure. In an effort to refine surgical approaches and improve outcomes, we sought to understand technical variation for the key steps of RARP in a surgical collaborative. METHODS: The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a statewide quality improvement collaborative with the aim of improving prostate cancer care. MUSIC surgeons were invited to submit representative complete videos of nerve-sparing RARP for blinded analysis. We also analyzed peri-operative outcomes from these surgeons in the registry. RESULTS: Surgical video data from 20 unique surgeons identified many variations in technique and time to complete different steps. Common to all surgeons was a transperitoneal approach and a running urethrovesical anastomosis. Prior to anastomosis, 25% surgeons undertook a posterior reconstruction and 30% employed urethral suspension. 65% surgeons approached the seminal vesicle anteriorly. For control of the dorsal vein complex, suture ligation was used in 60%, and vascular stapler was 15%. The majority (80%) of surgeons employed clips for managing pedicles. In examining patient outcomes for surgeons, peri-operative outcomes were not correlated with surgeon's operative time; however, surgeons with an EBL > 400 ml had significant difference among the five different techniques employed. CONCLUSIONS: Despite the worldwide popularity of RARP, the operation is still far from standardized. Correlating variation in technique with clinical outcomes may help provide objective data to support best practices with the goal to improve patient outcomes.