Outpatient robotic assisted retroperitoneal lymph node dissection.

Robotic assisted laparoscopic retroperitoneal lymph node dissection (RPLND) has shorter hospitalizations and less morbidity compared to open RPLND. We describe and demonstrate with video the first report of outpatient robotic RPLND.

Harm-to-Benefit of Three Decades of Prostate Cancer Screening in Black Men.

BACKGROUND: Prostate-specific antigen screening has profoundly affected the epidemiology of prostate cancer in the United States. Persistent racial disparities in outcomes for Black men warrant re-examination of the harms of screening relative to its cancer-specific mortality benefits in this population. METHODS: We estimated overdiagnoses and overtreatment of prostate cancer for men of all races and for Black men 50 to 84 years of age until 2016, the most recent year with treatment data available, using excess incidence relative to 1986 based on the Surveillance, Epidemiology, and End Results registry and U.S. Census data as well as an established microsimulation model of prostate cancer natural history. Combining estimates with plausible mortality benefit, we calculated numbers needed to diagnose (NND) and treat (NNT) to prevent one prostate cancer death. RESULTS: For men of all races, we estimated 1.5 to 1.9 million (range between estimation approaches) overdiagnosed and 0.9 to 1.5 million overtreated prostate cancers by 2016. Assuming that half of the 270,000 prostate cancer deaths avoided by 2016 were attributable to screening, the NND and the NNT would be 11 to 14 and 7 to 11 for men of all races and 8 to 12 and 5 to 9 for Black men, respectively. Alternative estimates incorporating a lag between incidence and mortality resulted in a NND and a NNT for Black men that reached well into the low single digits. CONCLUSIONS: Complementary approaches to quantifying overdiagnosis indicate a harm-benefit tradeoff of prostate-specific antigen screening that is more favorable for Black men than for men of all races considered together. Our findings highlight the need to account for the increased value of screening in Black men in clinical guidelines. (Funded by the Patient-Centered Outcomes Research Institute, the National Cancer Institute, the Bristol Myers Squibb Foundation, and the Damon Runyon Cancer Research Foundation.).

Role of Prophylactic Antibiotics in Transperineal Prostate Biopsy: A Systematic Review and Meta-analysis.

CONTEXT: Transperineal prostate biopsy is associated with a significantly lower risk of infectious complications than the transrectal approach. In fact, the risk of infectious complications with transperineal prostate biopsy is so low that the utility of administering periprocedural antibiotics with this procedure has come under question. OBJECTIVE: To perform a systematic review and meta-analysis to assess for differences in the rates of infectious complications (septic, nonseptic, and overall) after performing transperineal prostate biopsy with and without the administration of periprocedural antibiotic prophylaxis. EVIDENCE ACQUISITION: Three electronic databases (PubMed, Embase, and MEDLINE) were searched, and studies were included if they included patients who underwent transperineal prostate biopsy, were published after January 2000, included information on periprocedural antibiotic administration, and reported postbiopsy complications. Preferred Reporting Items for Systematic Reviews and Meta-analyses and Agency for Healthcare Research and Quality guidelines were utilized. EVIDENCE SYNTHESIS: A total of 106 unique studies describing 112 cohorts of patients were identified, of which 98 (37 805 men) received antibiotic prophylaxis and 14 (4772 men) did not receive it. All patients were included in the analysis of septic complications. In total, there were 19/37 805 (0.05%) episodes of sepsis in the group of men who received antibiotics, which was similar to the no antibiotic group with 4/4772 (0.08%) episodes (p = 0.2). For overall infections (septic plus nonseptic), there were 403/29 880 (1.35%) versus 58/4772 (1.22%) events among men with evaluable data who received and did not receive antibiotic prophylaxis, respectively (p = 0.8). Restricting our analysis to studies with a comparable low number of biopsy cores (<25 cores), there remained no difference in the rates of sepsis between groups, but there was a small, statistically significant lower risk of infectious complications with antibiotic administration-67/12 140 (0.55%) versus 58/4772 (1.22%; p < 0.01). CONCLUSIONS: The likelihood of septic infections after transperineal prostate biopsy is low with and without antibiotic prophylaxis. The omission of periprocedural antibiotics with this procedure stands to benefit patients by avoiding potential drug reactions. Furthermore, this practice is in line with calls throughout the medical community for improved antibiotic stewardship. PATIENT SUMMARY: In a large systematic review and meta-analysis, we evaluated infectious complications after transperineal prostate biopsy with or without the administration of prophylactic antibiotics. We conclude that prophylactic antibiotics do not decrease the rate of postbiopsy sepsis but may have a small benefit in terms of preventing less serious infections.

Novel nomograms to predict muscle invasion and lymph node metastasis in upper tract urothelial carcinoma.

OBJECTIVES: To develop accurate preoperative nomograms for prediction of muscle-invasive disease and lymph node metastasis in upper tract urothelial carcinoma (UTUC), to assist surgeons in risk stratifying patients and help guide treatment decisions. MATERIALS/METHODS: The National Cancer Database was used to identify all patients from 2004 to 2016 with UTUC who underwent extirpative surgery and lymphadenectomy. Univariate and multivariate logistic regression was performed to identify variables predicting muscle-invasive and node-positive disease. The data set was split 80:20 into a derivation and validation cohort and used to generate and test two nomograms. Nomograms were assessed using area under the curve (AUC) and calibration plots. RESULTS: A total of 6,143 patients met inclusion criteria. Predictors of muscle-invasive disease were age, grade, lymphovascular invasion (LVI), tumor size, and positive clinical lymph node status. Predictors of node-positive disease were grade, LVI, tumor size, and positive clinical lymph node status. The accuracy of the final nomogram predicting muscle-invasive disease was 80.0% (AUC 0.800, corrected C-index 0.813), and the accuracy of the nomogram predicting node-positive disease was 87.8% (AUC 0.878, corrected C-index 0.887). CONCLUSIONS: With data readily available after imaging and biopsy (age, tumor grade, LVI status, tumor size, and clinical lymph node status), we developed the first preoperative nomograms to quantitatively predict muscle-invasive disease and lymph node metastasis in UTUC, with an accuracy of 80.0% and 87.8% respectively. This information could be helpful to assist surgeons with pre-operative risk stratification.

Sociodemographic Disparities in Access to Chemotherapy for Bladder Cancer.

BACKGROUND: We sought to evaluate sociodemographic disparities in access to neoadjuvant (NAC) and adjuvant (AC) chemotherapy in the United States and their effect on survival. METHODS: The National Cancer Database was used to identify all patients from 2004 to 2016 eligible for NAC and AC. Univariate and multivariate logistic regression was performed to identify sociodemographic predictors associated with receipt of NAC and AC. Kaplan-Meier and Cox proportional hazard models were used for survival analysis. RESULTS: A total of 17,121 patients were eligible for NAC, and 18,962 for AC. Older (OR 0.94, P < .001), Medicare (OR 0.88, P = .047), Medicaid (OR 0.66, P = .001), uninsured (OR 0.47, P < .001), rural (OR 0.70, P = .042), and community hospital patients (OR 0.72, P < .001) were less likely to receive NAC. Older, (OR 0.95, P < .001), female (OR 0.79, P < .001), Medicaid (OR 0.71, P = .003), uninsured (OR 0.60, P = .001), and lower income patients (OR 0.86, P = .017) were less likely to receive AC. In NAC-eligible patients, older (HR 1.02, P < .001), Medicare (HR 1.11, P = .024), Medicaid (HR 1.25, P = .012), and community hospital patients (HR 1.09, P = .021) were at an increased risk of death. In AC-eligible patients, older (HR 1.01, P < .001), Black (HR 1.15, P = .011), Medicaid (HR 1.14, P = .042), lower income (HR 1.07, P = .038) and community hospital patients (HR 1.07, P = .021) were at an increased risk of death. CONCLUSIONS: Significant sociodemographic disparities currently exist in the United States in access to neoadjuvant and adjuvant chemotherapy for bladder cancer. Uninsured and Medicaid insurance status are the strongest predictors of not receiving chemotherapy. Efforts must be made to deliver this critical standard-of-care treatment to these patients.

Developments in optimizing transperineal prostate biopsy.

PURPOSE OF REVIEW: Prostate biopsy is a very commonly performed office procedure leading to the diagnosis of the most prevalent solid-organ malignancy in American men. Although the transrectal technique for prostate biopsy remains the gold standard, there is increasing interest in the transperineal approach as it offers a clean, percutaneous approach that significantly decreases the risk for infection. In this review, we discuss emerging developments in transperineal prostate biopsy that may optimize the way biopsies are performed in clinical practice. RECENT FINDINGS: Similarly, to transrectal biopsy, the transperineal approach also allows for the performance of systematic and MRI-targeted biopsy cores. As transperineal biopsy obviates the translocation of rectal bacteria to the prostate or bloodstream, in contrast to transrectal biopsy, it is feasible to forgo peri-procedural antibiotics in accordance with professional guidelines. This may attenuate antimicrobial resistance that may be associated with augmented prophylaxis. In addition, although transperineal biopsy may be traditionally performed under general anesthesia using a template grid, it may also be performed freehand under local anesthesia or sedation. Avoiding prophylactic antibiotics and general anesthesia as well as reducing infections/hospitalizations for transperineal biopsy scaled nationally will likely result in significant healthcare savings. SUMMARY: Transperineal biopsy with combined systematic and MRI-targeted cores, offers several advantages over conventional transrectal biopsy. Transperineal biopsy under local anesthesia and without periprocedural antibiotic is emerging as a promising method for prostate cancer diagnosis and surveillance.

New Endoscopic In-office Surgical Therapies for Benign Prostatic Hyperplasia: A Systematic Review.

CONTEXT: In recent years, new technologies have been developed to treat benign prostatic enlargement (BPE). Three of these devices may be utilized in office and are promising additions. OBJECTIVE: To systematically review all clinical trials investigating prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), and temporary implantable nitinol device (TIND), with emphasis on clinical efficacy and complications. EVIDENCE ACQUISITION: We performed a systematic review of PubMed/Medline database in November 2020 according to Preferred Reporting Items for Systematic Review and Meta-analysis guidelines. EVIDENCE SYNTHESIS: Of 168 articles identified, 18 met the inclusion criteria. Evidence consisted of few randomized controlled trials, and multiple single-arm prospective and retrospective studies. Among the three modalities, PUL demonstrates rare occurrence of serious complications but higher retreatment rates at short- and long-term follow-up. WVTT offers lower retreatment rates with a similar safety profile. TIND studies report varying rates of retreatment and complications. All technologies offer low rates of erectile and ejaculatory dysfunction, although the risk appears to be highest for WVTT (<10.8%). CONCLUSIONS: Among the emerging technologies introduced to treat BPE, the in-office PUL, WVTT, and TIND systems are valuable additions to the current surgical options. These systems offer unique advantages that should be considered in the shared decision-making process. PATIENT SUMMARY: In this report, we identified all clinical trials reporting on the efficacy and safety of the in-office prostatic urethral lift (PUL), water vapor thermal therapy (WVTT), and temporary implantable nitinol device (TIND) systems for the treatment of benign prostatic enlargement. We found that PUL and WVTT demonstrate acceptable outcomes in terms of functional improvement, retreatment, and complications. More data with longer follow-up are required to further evaluate TIND, but early results are promising.

Clipless Robotic-assisted Radical Prostatectomy and Impact on Outcomes.

BACKGROUND: The use of surgical clips for athermal dissection of the lateral prostatic pedicles and ligation during pelvic lymph node dissection (PLND) while performing robotic-assisted radical prostatectomy (RARP) has been the gold standard. Clips are used to prevent thermal injury of the unmyelinated nerve fibers and lymphceles, respectively. OBJECTIVE: To compare oncological and functional outcomes of a new technique of clipless, lateral pedicle control and PLND with RARP with bipolar energy (RARP-bi) versus the standard RARP technique with clips (RARP-c). DESIGN, SETTING, AND PARTICIPANTS: A retrospective study was conducted among 338 men who underwent RARP between July 2018 and March 2020. SURGICAL PROCEDURE: RARP-c versus RARP-bi. MEASUREMENTS: We prospectively collected data and retrospectively compared demographic, clinicopathological, and functional outcome data. Urinary as well as sexual function was assessed using the Expanded Prostate Cancer Index for Clinical Practice, and complications were assessed using Clavien-Dindo grading. Multivariable regression modeling was used to examine whether the technical approach of RARP-bi versus RARP-c was associated with positive surgical margins (PSMs) or sexual and urinary function scores. RESULTS AND LIMITATIONS: A total of 144 (43%) and 194 (57%) men underwent RARP-bi and RARP-c, respectively. Overall, there were no differences in functional and oncological outcomes between the two approaches. On multivariable regression analysis, the RARP-bi technique was not associated with significant differences in PSMs (odds ratio [OR] = 1.04, 95% confidence interval [CI] 0.6-1.8; p = 0.9), sexual function (OR = 0.4, 95% CI 0.1-1.5; p = 0.8), or urinary function (OR = 0.5, 95% CI 0.2-1.4; p = 0.2). The overall 30-d complication rates (12% vs 16%, p = 0.5) and bladder neck contracture rates (2.1% vs 3.6%, p = 0.5) were similar between the two groups. There was no difference in lymphocele complications (1.4% vs 0.52%, p = 0.58). All complications were of Clavien-Dindo grade I-II. CONCLUSIONS: Despite the concerns for an increased risk of nerve injury secondary to the use of bipolar energy for prostatic pedicle dissection, we demonstrate that this technique is oncologically and functionally similar to the standard approach with surgical clips. There was no difference in complications or lymphocele formation for techniques with versus without clips. PATIENT SUMMARY: We describe a modified technique for prostatic pedicle dissection during robotic-assisted radical prostatectomy, which utilizes bipolar energy and is associated with shorter operative time, without compromising functional or oncological outcomes.

Tissue-Based Biomarkers for the Risk Stratification of Men With Clinically Localized Prostate Cancer.

Risk stratification of men with clinically localized prostate cancer has historically relied on basic clinicopathologic parameters such as prostate specific antigen level, grade group, and clinical stage. However, prostate cancer often behaves in ways that cannot be accurately predicted by these parameters. Thus, recent efforts have focused on developing tissue-based genomic tests that provide greater insights into the risk of a given patient's disease. Multiple tests are now commercially available and provide additional prognostic information at various stages of the care pathway for prostate cancer. Indeed, early evidence suggests that these assays may have a significant impact on patient and physician decision-making. However, the impact of these tests on oncologic outcomes remains less clear. In this review, we highlight recent advances in the use of tissue-based biomarkers in the treatment of prostate cancer and identify the existing evidence supporting their clinical use.

The Consequences of Inadvertent Radical Nephrectomy in the Treatment of Upper Tract Urothelial Carcinoma.

OBJECTIVE: To determine factors associated with performing inadvertent radical nephrectomy (RN) for upper tract urothelial carcinoma (UTUC), and to assess the impact of radical nephrectomy on overall survival (OS) compared to radical nephroureterectomy (NU). METHODS: Using the National Cancer Database (NCDB), patients with UTUC of the renal pelvis who were diagnosed with renal cortical tumors and underwent RN (n = 820) with subsequent surgical pathology demonstrating urothelial carcinoma were identified. These patients were compared to those diagnosed with renal pelvis tumors who appropriately underwent NU (n = 16,464) between 2005 and 2015. Multivariable logistic regression was used to determine patient, facility and tumor-related factors associated with undergoing RN. The impact of surgery (RN vs NU) on OS was determined by Cox-regression after propensity score matching. RESULTS: A total of 4.7% patients with UTUC underwent inadvertent RN. Black race (adjusted odds ratio [aOR] 1.62, 95%CI 1.23-2.13), larger tumors, advanced tumor stage, and high-grade tumors (P < 0.0001) were associated with RN. However, surgery at a facility performing a higher volume of NU/year was associated with lower odds of having RN performed (aOR 0.85, 95%CI 0.75-0.97). After propensity score matching, the 5-year OS was 39.9% for those undergoing RN vs 49.9% for those undergoing NU (hazard ratio 1.45, 95%CI 1.30-1.62). CONCLUSION: Inadvertent RN is not uncommon, occurring in almost 5% of patients with UTUC in the NCDB. Patients who underwent RN had significantly worse OS as compared to those treated with NU. These data highlight that accurate diagnosis of UTUC is paramount and clinicians should not hesitate to perform further workup when imaging findings are equivocal.

Factors Impacting the Occurrence of Local, Distant and Atypical Recurrences after Robot-Assisted Radical Cystectomy: A Detailed Analysis of 310 Patients.

PURPOSE: Peritoneal carcinomatosis and extrapelvic lymph node metastases can be seen following robot-assisted radical cystectomy. In an attempt to identify predictors of these atypical metastases we report a detailed analysis of patients treated with robot-assisted radical cystectomy in whom recurrences developed. MATERIALS AND METHODS: A total of 310 patients underwent robot-assisted radical cystectomy for bladder cancer from 2001 to 2015. Descriptive statistics were used to compare baseline variables between patients without recurrence and those with local, distant or atypical recurrence. Univariate and multivariable regression models were used to assess the effect of variables on oncologic outcomes including recurrence location. RESULTS: At a median followup of 24 months (IQR 14-51) 81 patients had recurrence. On multivariable analysis tumor classification, lymphovascular invasion, estimated glomerular filtration rate less than 60 ml/minute/1.73 m2 and perioperative blood transfusion were significantly associated with any recurrence. Specific analyses showed that tumor and nodal classification, lymphovascular invasion and positive surgical margins were associated with all 3 recurrence locations (all p <0.05). Previous abdominal surgery was protective against atypical recurrences (HR 0.36, 95% CI 0.13-0.95, p = 0.04). Estimated glomerular filtration rate less than 60 ml/minute/1.73 m2 and perioperative blood transfusion conferred a higher risk of distant or atypical recurrence but not of local recurrence (all p <0.05). Operative time and previous pelvic radiotherapy were not associated with any recurrence locations. CONCLUSIONS: Predictors of distant recurrences, peritoneal carcinomatosis and extrapelvic lymph node metastases after robot-assisted radical cystectomy did not significantly differ and were mainly dictated by pathological tumor characteristics. Results suggest that the risk of atypical recurrence is chiefly influenced by tumor biology rather than surgical aspects.