Adjuvant versus early Salvage radiation therapy for prostate cancer with adverse pathological features on radical prostatectomy-Do we finally have an answer?

Background: The presence of adverse pathological features like extraprostatic extension, seminal vesicle involvement, or positive margins at radical prostatectomy incurs a high risk of postoperative recurrence. Currently, adjuvant radiotherapy (ART) is the standard of care in these patients, while early salvage radiotherapy (eSRT) is a potential alternative strategy. Aims: The purpose of this paper is to review the latest evidence comparing outcomes of adjuvant versus early SRT in this clinical scenario. Materials and Methods: A systematic review of Google Scholar, PubMed/Medline, and EMBASE was done to identify relevant studies published in the English language, regarding outcomes of adjuvant radiotherapy and early SRT in post radical prostatectomy patients. Twelve studies, including six randomized trials, four retrospective studies, one systematic review, and one metanalysis were included in the final analysis. Results: We found that initial randomized trials demonstrated better event-free survival with adjuvant radiotherapy when compared to observation alone. However, ART was associated with increased risk of overtreatment and thus increased radiation-related toxicity rates. Conclusion: Preliminary evidence from recently reported RCTs suggests that eSRT may provide equivalent oncological outcomes to ART in prostate cancer patients with adverse pathology on radical prostatectomy while decreasing unnecessary treatment and radiation-related toxicity in a significant proportion of patients. However, the final verdict would be delivered after the long-term metastasis-free survival and overall survival outcomes are available.

Robot-assisted radical prostatectomy in indian men of age 75 years and above: a propensity score-matched analysis.

Older men undergoing robot-assisted radical prostatectomy (RARP) have been thought to have worse perioperative, functional and oncological outcomes than younger men. However, there is a dearth of matched studies on this subject in the currently available literature. Our study is a matched pair analysis of perioperative, oncological and functional outcomes of RARP in men < 75 years of age versus ≥ 75 years (62 in each group). There was no statistically significant difference in complications, length of stay, pathological stage, positive surgical margins (PSM) and nodal involvement. Older men were less likely to undergo nerve sparing in our study (8.0 vs 75.8% p = 0.01). Potency rates were too low to be compared. The 1-year continence rates, time to continence and the proportion of men with biochemical recurrence (BCR) were similar between the groups. Men ≥ 75 years developed BCR much earlier than < 75 years (30 versus 78 months p = 0.07). However, this was not statistically significant. Age ≥ 75 years was associated with a statistically insignificant 53.5% rise in the risk of BCR. It was also not associated with any increased risk of postoperative complications or PSM. RARP is a safe procedure in senior adults. The oncological and functional outcomes of RARP in senior adults are similar to younger men.

Does prior transurethral resection of prostate affect the functional and oncological outcomes of robot-assisted radical prostatectomy? A matched-pair analysis.

Robot-assisted radical prostatectomy (RARP) is challenging in men with prior history of transurethral resection of the prostate (TURP). Few studies analyze this peculiar group of patients, and hence we sought to investigate the outcome of RARP in post-TURP men. We interrogated our prospectively maintained database containing 643 patients who underwent RARP from January 2012 to December 2020. We matched 36 men with prior history of TURP consecutively to 72 men without prior TURP. The groups were matched for age, body mass index (BMI), Charlson comorbidity index (CCI), serum PSA, International Society of Urological Pathology (ISUP) grade groups and clinical stage. Men with prior history of stricture surgeries, pelvic radiation, ablative laser procedures, Urolift and Rezum were excluded from the study. Fisher's Exact test/Chi-square was used for the comparison of categorical variables. Mann-Whitney test (Independent group/Unpaired data) and Wilcoxon sign rank test (for paired data) were employed to analyze continuous variables. The complication rates, median day of drain removal and length of hospital stay were similar between the groups. The TURP group required bladder neck reconstruction twice as often as the non-TURP group (58.3% versus 29.1%, p = 0.0035) and a longer duration of postoperative catheterization (10 versus 8 days, p = 0.0005). The rate of positive surgical margins was higher in the TURP group (30.5% versus 25%, p = 0.5414), albeit statistically insignificant. Biochemical recurrence (BCR) at one year (48.8% versus 60%, p = 0.0644) and zero pad/one safety-pad continence rates at one, three, six and twelve months were also not significantly different (14.3%, 35.4%, 59.2%, 81.6% for non TURP group versus 9.1%, 28.6%, 53.6%, 76.0% for TURP group). On multivariate analysis, prior TURP was not associated with a higher risk of BCR, margin positivity or incontinence. The oncological and functional outcomes of RARP post-TURP are comparable to men without prior TURP.

Selecting lymph node-positive patients for adjuvant therapy after radical prostatectomy and extended pelvic lymphadenectomy: An outcome analysis of 100 node-positive patients managed without adjuvant therapy.

Objective: The aim of the study is to evaluate the effect of deferred androgen deprivation therapy on biochemical recurrence (BCR) and other survival parameters in node-positive prostate cancer patients after robot-assisted radical prostatectomy with bilateral extended pelvic lymph node dissection (RARP + EPLND). Materials and methods: Of the 453 consecutive RARP procedures performed from 2011 to 2018, 100 patients with no prior use of androgen deprivation therapy were found to be lymph node (LN) positive and were observed, with initiation of salvage treatment at the time of BCR only. Patients were divided into 1 or 2 LNs (67)-and more than 2 LNs (33)-positive groups to assess survival outcomes. Results: At a median follow-up of 21 months (1-70 months), the LN group (p < 0.000), preoperative prostate-specific antigen (PSA, p = 0.013), tumor volume (TV, p = 0.031), and LND (p = 0.004) were significantly associated with BCR. In multivariate analysis, only the LN group (p = 0.035) and PSA level (p = 0.026) were statistically significant. The estimated BCR-free survival rates in the 1/2 LN group were 37.6% (27%-52.2%), 26.5% (16.8%-41.7%), and 19.9% (9.6%-41.0%) at 1, 3, and 5 years, respectively, with a hazard of developing BCR of 0.462 (0.225-0.948) compared with the more than 2 LN-positive group. Estimated 5-year overall survival, cancer-specific, metastasis-free, and local recurrence-free survival rates were 88.4% (73.1%-100%), 89.5% (74%-100%), 65.1% (46.0%-92.1%), and 94.8% (87.2%-100.0%), respectively, for which none of the factors were significant. Based on cutoff values for PSA, TV, and LND of 30 ng/mL, 30%, and 10%, respectively, the 1/2 LN group was substratified, wherein the median BCR-free survival for the low- and intermediate-risk groups was 40 and 12 months, respectively. Conclusions: Nearly one fourth and one fifth of 1/2 node-positive patients were BCR-free at 3 and 5 years after RARP + EPLND. Further substratification using PSA, TV, and LN density may help in providing individualized care regarding the initiation of adjuvant therapy.

Radical Cystectomy in England from 2013 to 2019 on 12,644 patients: An analysis of national trends and comparison of surgical approaches using Hospital Episode Statistics data.

Introduction: We evaluate the data of 12,644 Radical Cystectomies in England (Open, Robotic and Laparoscopic) with trends in the adaption of techniques and post-operative complications. Methods: This analysis utilised national Hospital Episode Statistics (HES) from NHS England. Results: There was a statistically significant increase (P < .001) in the number of Robotic assisted radical cystectomies from 10.8% in 2013-2014 and 39.5% in 2018-2019.The average LOS reduced from 12.3 to 10.8 days for RARC from 2013 to 2019 similarly the LOS reduced from 16.2 to 14.3 for ORC. The rate of sepsis (0-90 days) did rise from 5% to 14.5% between 2013-2014 and 2017-2018 for the entire cohort (P < .001). Acute renal failure (ARF) increased over the years from 9.5% to 17% (P < .001). The rate for fever, UTI, critical care activity and ARF were higher for ORC than RARC (P < .001).The comparison of all episodes within 90 days for conduit versus non-conduit diversions showed significantly higher rates of sepsis, infections, UTI and fever in non-conduit group .Overall complications were significantly higher in non-conduit group throughout the duration except was year 2016-17(P < .001).The robotic approach has increased in last 5 years with nearly 40% of the cystectomies now being robotically in 2018-19 from the initial percentage of 10.8% in 2013-14. Conclusion: This evaluation of the HES data from NHS England for 12,644 RC confirms an increase in the adoption of Robotic Cystectomy. Our data confirms the need to develop strategies with enhanced recovery protocols and post-operative close monitoring following Radical Cystectomy in order to reduce post-operative complications.

Low-risk prostate cancer in India: Is active surveillance a valid treatment option?

INTRODUCTION AND OBJECTIVE: Carcinoma prostate is considered highly aggressive in Asian countries such as India. This raises an argument whether active surveillance (AS) gives a false sense of security as opposed to upfront radical prostatectomy (RP) in Indian males with low-risk prostate cancer (PCa). We analyzed our prospectively maintained robot-assisted RP (RARP) database to address this question. MATERIALS AND METHODS: Five hundred and sixty-seven men underwent RARP by a single surgical team from September 2013 to September 2019. Of these, 46 (8.1%) were low risk considering the National Comprehensive Cancer Network criteria. Gleason grade group and stage were compared before and after surgery to ascertain the incidence of upgrading and upstaging. Preoperative clinical and pathological characteristics were analyzed for association with the probability of upstaging and upgrading. RESULTS: The mean age was 60.8 ± 6.8 years. Average prostate-specific antigen level was 6.7 ± 2.0 ng/mL. 40 (86.9%) patients had a T1 stage disease and 6 (13%) patients were clinically in T2a stage. A total of 25 (54.3%) cases were either upstaged or upgraded, 19 (41.3%) showed no change, and the remaining 2 (4.3%) had no malignancy on the final RP specimen. Upstaging occurred in 8 (17.4%) cases: 5 (10.9%) to pT3a and 3 (6.5%) to pT3b. Upgrading occurred in 23 (50%) cases: 19 (41.3%) to Grade 2; 3 (6.5%) to Grade 3; and 1 (2.2%) to Grade 4. CONCLUSIONS: There is a 50% likelihood of upstaging or upgrading in Indian males with low-risk PCa eligible for AS. Decision to proceed with AS should be taken carefully.

The clinical and financial implications of a decade of prostate biopsies in the NHS: analysis of Hospital Episode Statistics data 2008-2019.

OBJECTIVE: To evaluate the clinical and financial implications of a decade of prostate biopsies performed in the UK National Health Service (NHS) through the transrectal (TR) vs the transperineal (TP) route. METHODS: We conducted an evaluation of the TR vs the TP biopsy approach in the context of 28 days post-procedure complications and readmissions. A secondary evaluation of burden of expenditure in NHS hospitals over the entire decade (2008-2019) was conducted through examination of national Hospital Episode Statistics (HES) data. RESULTS: In this dataset of 486 467 prostate biopsies (387 879 TR and 98 588 TP biopsies), rates of infection and sepsis were higher for the TR compared to the TP cohort (0.53% vs 0.31%; P < 0.001, confidence interval 99% ). Rates of sepsis have more than doubled for TR biopsies in the last 2 years compared to the previous decade (1.12% vs 0.53%). Infective complications were the main reasons for readmissions in the TR cohort, whereas urinary retention was the predominant reason for readmission in the TP cohort. Over the last decade, non-elective (NEL) readmissions seem higher for the TP group; however, in the last 2 years these have reduced compared to the TR group (3.54% vs 3.74%). The cost estimates for NEL readmissions for the entire decade were £33,589,527.00 and £7,179,926.00 respectively, for TR and TP cohorts (P < 0.001). Estimated costs per patient readmission were £2,225.00 and £1,758.00 in the TR and TP groups (P < 0.001). CONCLUSIONS: Evaluation of nearly half a million prostate biopsies in the NHS over the entire decade gives sufficient evidence for the distinct advantages of the TP route over the TR route in terms of reduced infections and burden of expenditure. In addition, there is a potential for savings both in upstream and downstream costs if biopsy is performed under a local anaesthetic.

Implementation of ERAS protocol in robot-assisted radical cystectomy with intracorporeal ileal conduit urinary diversion: An outcome analysis beyond the learning curve.

INTRODUCTION: The objective of this study was to evaluate the perioperative outcomes of patients undergoing robot-assisted radical cystectomy (RARC) with intracorporeal ileal conduit (IIC) urinary diversion treated in line with the enhanced recovery after surgery (ERAS) protocol. METHODS: After approval from the institutional ethics committee, we conducted an analysis of a prospectively maintained database of patients undergoing RARC + IIC using ERAS protocol by a single surgical team with the da Vinci Xi® system from March 2016 till December 2018. To minimize the effect of the learning curve of this complex procedure, we excluded the first thirty patients from analysis. RESULTS: Thirty-five consecutive patients (33 males and 2 females) with a median age of 69 years (range: 50-82) were evaluated. The median total console time and console time for diversion were 253 min (range: 191-370) and 80 min (range: 65-90), respectively. The median estimated blood loss was 300 cc (range: 50-500). The median length of stay was 8 days (range: 4-30). Per-urethral pelvic drain was removed at a median of 2 days (range: 1-17). Overall, complications occurred in 16/35 (45.7%) patients, of which major complications (≥Grade 3) were seen in 5/35 (14.3%) patients, without any 90-day mortality. The median follow-up for the cohort was 14 months (1-34). CONCLUSIONS: While the initial outcomes of this combined treatment strategy appear promising in terms of complication rates and perioperative parameters, greater insight is required from multi-institutional data sets and prospective comparative studies to establish the true value of RARC + IIC and ERAS protocol for bladder cancer.

"Polar flip" technique for transperitoneal laparoscopic partial nephrectomy - Evolution of a novel technique for posterior hilar tumors.

Posterior hilar renal tumor extirpation by partial nephrectomy is a unique challenge for transperitoneal laparoscopy. We describe our novel technique of "polar flip" for these tumors. Kidney is rotated by around 45 -60 degrees after mobilisation so that lower pole faces anteriorly and upper pole faces posteriorly, thereby exposing the posterior surface for maneuverability. Technical highlights are hilar control, complete kidney mobilisation, initial flipping with dissection in Gil Vernet's plane to clip posterior segmental renal artery, en mass hilar clamping in normal lie, polar flipping, dissection in Gil Vernet's plane till renal sinus fat, completion of tumor excision, selective vascular ligation, renorhaphy and nephropexy.

Are we ready for urological subspecialty-based practice in India? The resident's perspective.

INTRODUCTION: In the current era, every broad specialty has diversified into many subspecialties including urology, which is one of the most dynamic fields. The concept of early sub-specialization relies on excelling in a niche area of interest. While this concept is appealing to the most, no formal evaluation of our residency programs has ever been conducted with regard to their adequacy in terms of equipping residents to make informed sub-specialization choices. We performed a survey amongst urological residents, in an attempt to gather information on some unanswered questions related to our residency training programs and the concept of sub-specialization. METHODS: Using the Delphi principles, we conducted a survey consisting of 46 questions, amongst the Indian Urological residents (n = 85), to assess the overall exposure to various subspecialties during their residency program, and the inclination of residents towards them. RESULTS: Residents get a fair exposure to endourology, uro-oncology, female urology and reconstructive urology during their residency. However, the same did not hold true for pediatric urology, andrology and laparoscopic/robotic surgery. 90% of the residents expressed an inclination towards academic practice, while 76.5% were interested in sub-specialization. 60% of the residents felt that they had obtained adequate exposure during residency to make a decision in this regard. Less than 20% were inclined towards female urology, andrology or pediatric urology as a career option. CONCLUSION: There is a growing interest and inclination amongst Indian Urological residents to attain expertise in sub-specialised fields. However, our current residency programs need consolidated efforts to ensure an adequate exposure to all the aspects of Urology, especially in the subspecialties of pediatric urology, andrology and minimally invasive urology. Training should be optimized to a level, which enables the residents to take a well informed decision regarding their choice of subspecialised career path.

Therapeutic supine robotic retroperitoneal lymph node dissection for post-chemotherapy residual masses in testicular cancer: technique and outcome analysis of initial experience.

Retroperitoneal lymph node dissection (RPLND) is a therapeutic standard of care for post-chemotherapy residual masses in testicular cancer. While a robotic approach to this procedure has the potential of decreasing the morbidity associated with this major endeavour, it is often criticised for its inability to provide a bilateral complete template resection without redocking and repositioning the patient. Herein, we present the technique and initial outcomes of a supine approach to Robotic RPLND (R-RPLND) using the da Vinci Xi® system, which obviates the need for repositioning or redocking for a bilateral full template resection. Three patients (age 21-36) with nonseminomatous germ cell tumours of the testis underwent R-RPLND for post-chemotherapy residual retroperitoneal masses with normalised tumor markers. Salient steps of the procedure were as follows: port placement in supine Trendelenburg position, docking of the da Vinci Xi® system from one side, exposure of retroperitoneum, dissection of paracaval, retrocaval, interaortocaval, paraaortic and bilateral common iliac templates, and excision of gonadal vein. Mean console time and estimated blood loss were 257 (190-305) minutes and 333 (300-400) ml, respectively. Mean lymph node yield was 52 (29-94). One patient had a common iliac vein injury which was managed robotically without further consequence. No drains were placed in all three. There were no postoperative complications and all of them were advanced to a normal diet within 24 h and discharged on the second postoperative day. Histopathology reports were suggestive of necrosis and mature teratoma without any viable tumour. There have been no recurrences in these patients at a mean follow-up of 14 (1-22) months. R-RPLND in the supine position is practical, safe and feasible in the post-chemotherapy setting of testicular cancer. It eliminates the need for repositioning the patient or redocking the robot to achieve a complete resection with adequate lymph node yields, while preserving the benefits of a minimally invasive surgical approach.

Current Status of Lymphadenectomy During Radical Nephroureterectomy for Upper Tract Urothelial Cancer-Yes, No or Maybe?

While pelvic lymphadenectomy during radical cystectomy for bladder cancer is a well-established standard of care, the same does not hold true for upper tract urothelial carcinoma (UTUC). Indeed, a template-based lymphadenectomy is rarely, if ever, performed in conjunction with radical nephroureterectomy at most centres across the globe. While multiple studies have explored the staging and therapeutic role of lymphadenectomy in cases of UTUC, there remain large gaps in our understanding of the indications, extent and safety of this procedure as an adjunct to nephroureterectomy. This article elucidates the current knowledge on outcomes, benefits and complications of template-based lymphadenectomy during radical nephroureterectomy for UTUC. We also explore the current evidence-based guidelines on this controversial topic.

Laparoscopic nephrectomy simplified - A "two-window technique" for safer approach to hilum for a novice.

Though the overall safety of laparoscopic nephrectomy (simple or radical) is well established, for a novice it remains a challenge. The classical description of laparoscopic nephrectomy entails dissection either from caudal to cephalad side or vice versa. Herein we describe our "two window technique" for managing renal hilum during laparoscopic (simple/radical) nephrectomy. Our main intention in description of this technique is to reduce the level of apprehension for a novice urologist for performing laparoscopic nephrectomy. After colon mobilization, sequential lower and upper windows are created around the hilum following which hilar vessels are dissected circumferentially when the hilum is at a stretch by traction from either of the window. There are multiple potential advantages of this method which includes easier and safer dissection especially for novice in this field by giving a safety window of application of vascular clamp in cases of vascular bleeds. Intrahilar dissection in stretched condition becomes safer with vision from all around 360° for safe application of Hem-o-lok® clips. Due to the widely exposed field, injuries to adrenal vein and lumbar veins would be minimized and the chances of missed accessory vessel would be minimized. En mass hilar control with vascular clamp in cases of partial nephrectomy is possible with same approach as well as the en block stapling is feasible in cases of nephrectomy. This needs a validation across multiple centers with comparative studies before considering it as a standard of practice. We sincerely believe that this is safe and easily reproducible by a novice.

Does Continuation of Low-Dose Aspirin During Robot-Assisted Radical Prostatectomy Compromise Surgical Outcomes?

OBJECTIVE: To evaluate the perioperative outcomes and 90-day complication rates of continuation of low-dose aspirin through surgery in patients undergoing robot-assisted radical prostatectomy (RARP). A significant proportion of patients undergoing RARP are on antiplatelet medications for primary or secondary prevention of cardiovascular events. However, there is still a relative lack of data with regard to the advantages and complications of continuing these medications through surgery. MATERIALS AND METHODS: Our usual protocol of RARP entails continuation of low-dose aspirin (75 mg once a day) for patients who are already on antiplatelet agents. We conducted a retrospective audit of a prospectively maintained database of 116 cases of RARP performed by a single surgical team in 1 year. Patients were divided into low-dose aspirin group (AG) (n = 31) and nonaspirin group (NAG) (n = 85). The primary objective was to compare the 90-day complication rates to assess the safety profile. Secondary objective was to compare perioperative parameters such as estimated blood loss, blood transfusion rates, fall in hemoglobin (Hb) level, drain outputs on day 1, days to drain removal, lymph node yield, and margin positivity. Subgroup comparison was performed between patients on aspirin for primary prevention (n = 15) and NAG. RESULTS: Both groups were well matched for preoperative parameters except for significantly higher comorbidities and American Society of Anesthesiologists (ASA) score class in AG. Console time, blood loss, fall in Hb level, drain output, drain and catheter removal days, day of discharge, and lymph node yield were comparable. Margin positivity was significantly higher in NAG. Ninety-day complication rates were not significantly different between the two groups (p = 0.218) with only one major complication (Clavien-Dindo grade 4 hypotension requiring intensive care unit admission) in AG. Subgroup comparison demonstrated similar outcomes. CONCLUSION: Low-dose aspirin can be safely continued perioperatively during RARP, without increasing the bleeding-related complications and overall 90-day complication rates.

Robot-assisted radical nephroureterectomy with extended template lymphadenectomy for upper tract urothelial carcinoma: An outcome analysis.

INTRODUCTION: Robot-assisted radical nephroureterectomy (RANU) with extended template lymphadenectomy (E-LND) is the leading treatment option for nonmetastatic upper tract urothelial carcinoma. Due to the rarity of this disease, there is a lack of consensus regarding the best approach and the extent of lymphadenectomy. We report our technique and its initial outcomes from the retrospective evaluation of a prospectively maintained database of 11 consecutive cases of RANU + E-LND. To the best of our knowledge, our series represents the first published experience of this procedure from India. MATERIALS AND METHODS: RANU was performed in 11 patients (including two patients with simultaneous radical cystectomy) with the da Vinci Xi system. Pelvic and upper ureteric tumors were operated without re-docking or repositioning, using the port hopping feature. For the lower ureteric tumors, the patient was repositioned and the robot was re-docked to ensure completeness of pelvic lymphadenectomy. E-LND was performed in all the patients as per the templates described in previous studies. RESULTS: Median age was 67.5 years (range 52-71). Median console time and blood loss were 170 min (range 156-270) and 150 cc (range 25-500), respectively. Median hospital stay was 3 days (range 2-8). One patient developed paralytic ileus in the postoperative period (Clavien Dindo Grade 1). None had a positive surgical margin and the median lymph node yield was 22.5 (range 7-47). Median follow-up was 9 months during which one patient developed metastatic systemic recurrence. All other patients were disease free at the last follow-up. CONCLUSIONS: A robotic approach to radical nephroureterectomy with E-LND is feasible and safe and does not appear to compromise the short-term oncological outcomes as defined by lymph node yields and margin positivity. At the same time, it offers the benefits of minimal invasion and results in swifter patient recovery from this extensive surgery.

Wunderlich Syndrome due to Ruptured Pseudoaneurysm of Angiomyolipoma in First Trimester: A Rare Case Report.

Angiomyolipoma (AML) is a rare benign tumour of kidney which demonstrates rapid growth during pregnancy due to hormonal stimulation, leading to rupture. Majority of reported ruptured AMLs are in third trimester. We report a case of ruptured angiomyolipoma at 10th week of gestation, the earliest rupture known in singleton pregnancy. The AML had pseudo-aneurysm formation with extra-tumoural rupture during pregnancy, a finding never reported in literature yet. The patient had active bleeding with expanding peri-nephric haematoma during initial two days of conservative management. Hence, after counselling and taking prior informed written consent for Medical Termination of Pregnancy (MTP), computed tomography scan of abdomen with angiography followed by emergency coil embolization of the bleeding right upper polar segmental artery was done. After stabilization, MTP was done at 12th week of gestation. Counselling and consent for continuing or aborting the pregnancy is of utmost importance for best possible outcome for patient and foetus.