Prospective evaluation of combined oncological and functional outcomes after laparoscopic radical prostatectomy: trifecta rate of achieving continence,potency and cancer control at 2 years

Study Type – Therapy (outcomes research)
Level of Evidence 2c What’s known on the subject? and What does the study add? The first objective of radical prostatectomy (RP) is cancer control. However, the success of RP should also be measured by the most unforgiving long‐term morbidity outcomes and by the maintenance of quality‐of‐life. Incontinence and erectile dysfunction have clearly negative repercussions on a patient’s quality‐of‐life although most men are usually satisfied with treatment and accept these subsequent disorders. Outcomes of continence, erectile function and cancer control after RP are well described in isolation. However, combined oncological and functional results are lacking, especially in laparoscopic procedures. Separate presentation of cancer control and functional results does not provide sufficient patient information, and the report of combined outcomes is a necessary point of discussion between the urologist and his patient. Thus, we reported the combined oncological and functional outcomes 2 years after extraperitoneal laparoscopic radical prostatectomy.

OBJECTIVE

To determine the proportion of patients who are continent, potent and cancer‐free (trifecta rate) 2 years after extraperitoneal laparoscopic radical prostatectomy (ELRP).

PATIENTS AND METHODS

We included patients who underwent an ELRP at our department and who were followed for at least 2 years. Those who were impotent or incontinent before the surgery were excluded from the analysis. Overall, 911 men were included. All patients prospectively completed objective, self‐administered questionnaires before the medical visit, concerning their voiding and sexual disorders, before surgery and 12 and 24 months after ELRP. Biochemical recurrence was defined as any detectable serum PSA (≥0.2 ng/mL). Potency was defined as the ability to achieve an erection sufficient for penetration with or without the use of phosphodiesterase‐5 enzyme inhibitor. Urinary continence was defined as absence, or occasional use, of a pad for anticipated vigorous activity. The primary study endpoint was the trifecta rate (cancer control, continence and potency) at 2 years after the surgery. Factors associated with the trifecta outcome were assessed in univariate analysis.

RESULTS

Median age and PSA level were 62.2 years and 9.9 ng/mL, respectively. A trifecta outcome was achieved in 29.7 and 54.4% of patients at 12 and 24 months, respectively. The 2‐year trifecta rate reached 63.5% in patients undergoing bilateral nerve‐sparing surgery and 73.5% in men aged <60 years. Age <60 years, PSA level <10 ng/mL, organ‐confined disease and bilateral nerve‐sparing procedure were significantly associated with the 2‐year trifecta outcome. A total of 84.8% of patients were both cancer‐free and continent at 24 months, regardless of erectile function.

CONCLUSIONS

Two years after ELRP, the trifecta outcome is achieved in 54.4% of patients who remained potent and continent. This rate reaches 63.5% in patients undergoing a bilateral nerve‐sparing procedure. Combined results of good cancer control and continence recovery are reported in 84.8% of patients, regardless of erectile function.     

Functional outcomes and oncological efficacy of Vattikuti Institute prostatectomy with Veil of Aphrodite nerve-sparing: an analysis of 154 consecutive patients

OBJECTIVES: To report updated results, at 1 year of follow-up, of a modified nerve-sparing robotic radical prostatectomy that preserves the lateral prostatic fascia (Veil of Aphrodite). PATIENTS AND METHODS: From January to December 2003, 154 consecutive men had a Vattikuti Institute prostatectomy with Veil of Aphrodite nerve-sparing by one surgeon. A prospective database recorded patient demographics, intraoperative, peri-operative, and pathological variables. Peri-operative complications were recorded using the Clavien classification. Patients had serum prostate-specific antigen (PSA) levels measured every 3 months and self-administered the International Prostate Symptom Score and Sexual Health Inventory for Male questionnaires before and at 1 year after surgery. RESULTS: The men had a mean age of 57.4 years, a mean body mass index of 27.2 kg/m(2), and a mean PSA level before surgery of 5.11 ng/mL. The mean operative duration was 122 min. At 1 year, 96% of the men reported having had intercourse and 71% had recovered normal erectile function. One man had a Clavien grade II complication, 4.6% of men with organ-confined disease had positive surgical margins, and no patient had a PSA recurrence at 12 months; 97% of the men were continent at 1 year, and the median time to continence was 14 days. CONCLUSION: Veil of Aphrodite nerve-sparing surgery provides better recovery of sexual function at 1 year than in contemporary series from centres of excellence, without compromising cancer control and urinary function.     

Introducing a new, simple scoring system to evaluate oncological and functional outcome after radical prostatectomy

OBJECTIVE: To create a scoring system which takes into account oncological outcome and functional results (continence and erectile function) of patients after radical prostatectomy. MATERIAL AND METHODS: A total of 146 consecutive men underwent radical prostatectomy for localized prostate cancer and were evaluated 1 year after surgery. Biochemical recurrence was defined as a single postoperative prostate-specific antigen (PSA) level of > 0.2 ng/ml. Continence, defined as not using a pad, and potency, defined as the ability to achieve and maintain an erection suitable for sexual intercourse, were evaluated by means of a prospective, self-administered questionnaire. Each patient received 4 points (if PSA was <0.2 ng/ml) or 0 points (if PSA was >0.2 ng/ml) for oncological outcome, 2 points (if continent) or 0 points (if incontinent) for urinary continence and 1 point (if potent) or 0 points (if impotent) for erectile function. The total score was calculated, with higher scores indicating a better outcome. The unique feature of this scoring system is that each individual score represents a particular clinical status regarding oncological and functional outcome. RESULTS: One year after surgery, 121 (82.8%) patients had PSA levels of <0.2 ng/ml, 103 (70.5%) were continent and 53 (36.3%) were potent. Patients with a total score of > or =4 points had good cancer control and could be further subdivided into those who were continent and potent (7 points; 22.6%), those who were continent but had erectile dysfunction (ED) (6 points; 34.2%), those who were incontinent and potent (5 points; 8.2%) and those who were incontinent and had ED (4 points; 17.8%). Similarly, patients with a score of <4 points had no cancer control and could be further subdivided into those who were continent and potent (3 points; 3.4%), those who were continent but had ED (2 points; 10.3%), those who were incontinent and potent (1 point; 2.1%) and those who were incontinent and had ED (0 points; 1.3%). CONCLUSIONS: This scoring system includes the three most important outcomes after radical prostatectomy, namely cancer control, continence and erectile function. It may allow us to better evaluate, communicate and compare the results of radical prostatectomy in a multinational, multicenter setting.     

Nerve-sparing robotic prostatectomy in preoperatively high-risk patients is safe and efficacious

ObjectiveGiven the higher likelihood of extraprostatic extension in high-risk patients, many urologists will sacrifice the neurovascular bundles in such patients in an attempt to decrease the risk of positive surgical margins. In contrast, we frequently perform nerve-sparing in high-risk patients. We analyzed our outcomes in patients with preoperatively high-risk prostate cancer according to the D'Amico risk group classification, and stratified by nerve-sparing status.Materials and methodsAn institutional database of 1,503 robotic-assisted laparoscopic prostatectomies (RALP) was queried for patients presenting with PSA > 20 ng/ml, Gleason 8 or higher on biopsy, or clinical stage T2c or higher. Interfascial nerve-sparing was performed whenever oncologically feasible. Validated questionnaires were used to assess baseline and postoperative functional outcomes.ResultsAdequate follow-up was available in 123 high-risk patients. Mean serum PSA was 10.8. Bilateral, unilateral, and non-nerve-sparing was performed on 58%, 15%, and 27%, respectively. On final histopathology, 42% were organ confined; 55 patients had extraprostatic extension, and 35 had seminal vesicle invasion. Positive surgical margins occurred in 31%: 15% focal and 16% extensive. Favorable pathologic outcomes (organ-confined and negative surgical margins) were observed in 40%. Biochemical recurrence occurred in 20%. Nerve-sparing was associated with more favorable pathologic features, possibly due to selection bias. When controlling for adverse pathologic features, nerve-sparing was not associated with higher rates of positive surgical margins or biochemical recurrence. At a median follow-up of 13 months, 78% were continent and 56% were potent. The “trifecta” of continence, potency, and freedom from recurrence was achieved in 28 patients (23%).ConclusionsNerve-sparing robotic-assisted laparoscopic prostatectomy can be safely performed in patients with preoperatively high risk prostate cancer. Histopathologic and short-term oncologic outcomes at 13-month median follow-up are comparable to those in open surgical series from similar cohorts.     

Extraperitoneal robot-assisted laparoscopic radical prostatectomy: a single-center experience beyond the learning curve

Objectives

To report our surgical technique and outcomes after extraperitoneal robot-assisted laparoscopic radical prostatectomy (RALRP).

Materials and methods

At Henri Mondor’s Hospital, we performed the first RALRP in 2001 and started to perform routinely RALRP since 2006. Preoperative characteristics, perioperative parameters, functional and oncological outcomes were collected in a prospective database and studied. All parameters were tested in patients undergoing RALRP beyond the learning curve of each surgeon. The overall cohort included 792 patients.

Results

RALRP offers interesting results in terms of hospital stay, operative time, and blood loss. The overall rate of complications was low, especially concerning the rates of anastomosis’ complications. An extraprostatic extension was seen in 42.8 % of specimens. The overall rate of positive margins was 30.7 % of specimens. In our cohort, after a mean follow-up of 19 months, 8.7 % of PSA failure has been reported. The rate of continence was 77.4 % at 6 months and 96.8 % at 2 years. The rate of potency was 17 % at 3 months and 60.9 % at 2 years. The 2-year rate was 86.7 % in case of intrafascial dissection. A trifecta outcome was achieved in 44 and 53 % of men at 12 and 24 months, respectively.

Conclusions

The extraperitoneal approach confers interesting results in terms of perioperative parameters as previously described in series using a transperitoneal approach. Functional outcomes in terms of continence and potency recovery after extraperitoneal seem equivalent to those reported after transperitoneal RALRP. Longer follow-up is warranted to confirm our favorable mid-term oncologic outcomes.     

Early continence in patients with localized prostate cancer. A comparison between open retropubic (RRPE) and endoscopic extraperitoneal radical prostatectomy (EERPE)

ObjectiveThe study examined and compared continence rates in prostate cancer patients who had undergone either open retropubic prostatectomy (RRPE) or endoscopic extraperitoneal radical prostatectomy (EERPE). The core question was whether the surgical approach had an effect on the patients' continence status 3 months after surgery.MethodsWe conducted a multicentric, longitudinal study in 7 German hospitals. Three hundred fifty prostate cancer patients (166 EERPE, 184 RRPE) were asked to self-assess symptoms associated with urinary incontinence (UI) 1 day before and 3 months after prostatectomy. Symptoms of UI were assessed using the EORTC QLQ-PR25 questionnaire. Urinary continence was defined according to (1) the use of no protective pad, (2) the use of up to a single protective pad in a 24-hour period, and (3) according to the patient's self-assessment. A binary regression model was employed to predict early continence status.ResultsThree months after prostatectomy, 44% of patients who underwent EERPE and 40% of patients who underwent RRPE were completely continent. Patients who underwent nerve-sparing prostatectomy and patients younger than 65 years had a better chance of regaining urinary continence earlier. The surgical approach had no significant impact on the patients' continence status. Limitations of the study are a drop-out rate of 39% and sociodemographic and clinical differences between both treatment groups.ConclusionsThree months after prostatectomy, there were no significant differences between both treatment groups regarding urinary continence. The surgical approach had no significant effect on the patients' continence status. Higher age and non-nerve-sparing surgery are associated with a longer period of convalescence.     

Continence,potency and oncological outcomes after robotic‐assisted radical prostatectomy: early trifecta results of a high‐volume surgeon

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

? To evaluate early trifecta outcomes after robotic‐assisted radical prostatectomy (RARP) performed by a high‐volume surgeon.

PATIENTS AND METHODS

? We evaluated prospectively 1100 consecutive patients who underwent RARP performed by one surgeon. In all, 541 men were considered potent before RARP; of these 404 underwent bilateral full nerve sparing and were included in this analysis. ? Baseline and postoperative urinary and sexual functions were assessed using self‐administered validated questionnaires. ? Postoperative continence was defined as the use of no pads; potency was defined as the ability to achieve and maintain satisfactory erections for sexual intercourse >50% of times, with or without the use of oral phosphodiesterase type 5 inhibitors; Biochemical recurrence (BCR) was defined as two consecutive PSA levels of >0.2 ng/mL after RARP. ? Results were compared between three age groups: Group 1, ≤55 years, Group 2, 56–65 years and Group 3, >65 years.

RESULTS

? The trifecta rates at 6 weeks, 3, 6, 12, and 18 months after RARP were 42.8%, 65.3%, 80.3%, 86% and 91%, respectively. ? There were no statistically significant differences in the continence and BCR‐free rates between the three age groups at all postoperative intervals analysed. ? Nevertheless, younger men had higher potency rates and shorter time to recovery of sexual function when compared with older men at 6 weeks, 3, 6 and 12 months after RARP (P < 0.01 at all time points). ? Similarly, younger men had higher trifecta rates at 6 weeks, 3 and 6 months after RARP compared with older men (P < 0.01 at all time points).

CONCLUSION

? RARP offers excellent short‐term trifecta outcomes when performed by an experienced surgeon. ? Younger men had higher overall trifecta rates when compared with older men at 6 weeks, 3 and 6 months after RARP.     

Immediate Continence Rates in RALRP: A Comparison of Three Techniques

Methods:We retrospectively analyzed the patients who underwent RALRP for localized prostate cancer by a single surgeon in our clinic from January 1, 2009–February 1, 2016. Continence was defined as no leakage or use of a safety pad for minimal leakage. The main outcome measure was continence at postoperative week 1 and months 1, 6, and 12.Results:Between 2009 and 2016, 239 patients underwent RALRP for localized prostate disease. Seventy-four patients underwent a standard approach (group 1), 88 had posterior reconstruction (group 2), and 77 had posterior reconstruction with total anatomic restoration (group 3). After 1 week, 24.3% of the patients in group 1 (18/74), 31.8% in group 2 (28/88), and 45.8% in group 3 (33/72) were continent (P = .02). One month after the surgery, continence rates for groups 1, 2, and 3 were 56.7, 67, and 75%, respectively (0.065). After 6 and 12 months, continence rates for groups 1, 2, and 3 were 72.9 and 87.8%, 81.8 and 89.7%, and 84.7 and 91.6%, respectively (P = .178 and .7484).Conclusion:Anatomic restoration improves continence rates in the early period after RALRP. Even though other parameters were higher in the total restoration group, immediate continence (at 1 week) was significantly better.     

The role of radical prostatectomy in patients with pretreatment prostate-specific antigen > or = 40 ng/mL

OBJECTIVE: To assess the efficacy of radical prostatectomy (RP) in men presenting with markedly elevated prostate-specific antigen (PSA) levels, the records of 17 patients presenting with serum PSA values > or = 40 ng/mL, who underwent RP at Walter Reed Army Medical Center (WRAMC) between 1990 and 1995, were reviewed. METHODS: Pathologic and clinical data (staging, Gleason score, recurrences, adjuvant and neo-adjuvant treatment, most recent PSA value, urinary continence, and sexual function) for each patient was examined. The Kaplan-Meier method was used to analyze the disease-free survival (DFS) for PSA and clinical recurrence. Urinary continence and potency were also assessed. RESULTS: With a mean follow-up of 6.21 years (median 5.28 y), all 17 patients are alive. Five patients have no evidence of disease (NED), and 12 are alive with prostate cancer. Fifteen patients have PSA values between 0.1 and 3.0 ng/mL, and two patients have PSA values that have returned to pretreatment levels. Eleven patients received neo-adjuvant and/or adjuvant therapy. Fourteen men (82.3%) are continent and seven (41.1%) are potent. Survival analysis demonstrates a PSA DFS of 52.9% at five years and 26.5% at nine years; while, clinical DFS was 92.3% at five years and 58.0% at nine years. CONCLUSIONS: This study suggests a possible surgical role in treating patients presenting with significantly elevated PSA values. While surgery alone is unlikely to cure prostate cancer in these patients, surgery in conjunction with hormonal or radiation therapy may prolong survival with acceptable effects on urinary continence and potency.     

The 5-year functional outcomes after radical prostatectomy： a real-life experience in Korea

We investigated the functional outcomes regarding erectile function and urinary continence up to 5 years following radical prostatectomy （RP） in a cohort of Korean men. We retrospectively analyzed the clinicopathologic data of 85 Korean men who received open uni- or bilateral nerve-sparing RP for clinically localized prostate cancer and were followed up for at least 5 years postoperatively. From medical records, patients＇ status regarding urinary and erectile function at baseline and postoperative followups after RP was assessed. At 24 and 60 months after RP, proportions of subjects continent （no pads used） were 89.4% and 97.6%, respectively （P = 0.007）. Excluding subjects （n = 24） who preoperatively reported having severe erectile dysfunction or lacked relevant informations, proportions of subjects capable of having vaginal intercourse regardless of erectile aid usage were 47.5% and 37.7% at 24 and 60 months from RP, respectively （P = 0.022）. Patient＇s age at surgery （P = 0.047） and salvage radiation therapy （P = 0.026） were observed to be significant predictors of having erections sufficient for intercourse at 60 months from RP in multivariate analysis. Our results showed that while patients＇ postoperative status regarding urinary continence at 2 years from RP is generally maintained or improved at 5 year point, erectile function was observed to significantly declined from 2 years to 5 years following RP. Such decline in erectile function following RP may be more significant among men who were relatively older at surgery or those who received salvage therapy during postoperative follow-ups.     

Impact of preoperative antiandrogen medication and nerve-sparing surgery on the outcome of radical prostatectomy

Objectives  Radical prostatectomy in antiandrogen-medicated patients, as well as nerve-sparing surgery, has increased within recent years. We investigated the impact of antiandrogen medication on loss of blood and of nerve-sparing surgery on continence and potency. Methods  A total of 401 men who underwent radical prostatectomy between January 1995 and September 1999 at our clinic were asked about antiandrogenic medication prior to radical prostatectomy and about daily life activities, overall satisfaction, voiding ability, and sexual activities. Consumption of erythrocyte concentrates and cryoprecipitated plasma was taken from the records. Results  The average follow-up was 36 months. Seventy-two percent (n = 289) of our patients replied. Sixty-seven men (23%) who replied to our questionnaire had received antiandrogen medication prior to radical prostatectomy. In 53 (18%) of the men, the nerve-sparing technique was used. In antiandrogen-medicated patients, we observed a significantly elevated consumption of erythrocyte concentrates (antiandrogen-medicated 0.93, not antiandrogen-medicated 0.44; P = 0.013) and of cryoprecipitated plasma (antiandrogen-medicated 0.39, not antiandrogen-medicated 0.08; P = 0.010). Patients who underwent the nerve-sparing technique reported better results in daily life activities, general health status, International Prostate Symptom Score (IPSS), and continence. Conclusion  Our results point to a higher quality of life in patients who had undergone nerve-sparing surgery. J. Hodzic and P. Jedrusik contributed equally. Dedicated to the late Harald Schulze, director of the Department of Urology, Klinikum Dortmund.     

Oncological and functional results of antegrade radical retropubic prostatectomy for the treatment of clinically localised prostate cancer

OBJECTIVES: To present the oncological outcome of the antegrade radical prostatectomy in the whole series of consecutive patients treated over an 18-yr period, and to report the functional results and complications of the last 488 patients. PATIENTS AND METHODS: We reviewed the clinicopathological data of 845 patients treated between 1988 and 2005. Complete data on continence, potency, and complication were available on the last 488 patients treated between 2000 and 2005. RESULTS: Positive surgical margins were detected in 12.8% of patients. The mean follow-up was 49 mo. The 8-yr biochemical recurrence-free survival rates were 84.1% for pT2, 69.9% for pT3a, and 37.3% for pT3b disease (p<0.0001). The multivariate analysis showed stage, PSA, and Gleason score as significant independent predictors of biochemical recurrence-free survival. After 12 mo, 94.1% of patients were continent, and 69.6% of patients who had bilateral nerve-sparing prostatectomy were potent. Mean estimated blood loss was 223 cc; overall incidence of complication was lower than 15%. CONCLUSIONS: Antegrade radical prostatectomy provides a low incidence of positive margins and an optimal cancer control. This technique can provide a low incidence of complications, reduced blood loss, and optimal functional results in terms of recovery of continence owing to a complete definition of the anatomical boundaries of the apex. Moreover, it can provide a less challenging nerve-sparing procedure with similar results to those reported by the retrograde approach.     

Seminal monolateral nerve-sparing radical prostatectomy in selected patients

INTRODUCTION: In recent years there has been a shift in prostate cancer stage with the majority of patients nowadays being operated with cT1c disease, prostate-specific antigen levels of <10 ng/ml, and a decreased rate of seminal vesicle invasion. Recent data suggest the role of preservation of the seminal vesicle in improving continence and/or potency. We describe our preliminary experience with seminal-sparing, unilateral nerve-sparing retropubic radical prostatectomy. PATIENTS AND METHODS: 21 selected patients with clinically localized prostate cancer underwent seminal unilateral nerve-sparing retropubic radical prostatectomy (seminal-sparing group, SSG). We compared the postoperative continence, erectile function and quality of orgasm results to those obtained in a control group (CG) of 21 patients who underwent unilateral nerve-sparing radical prostatectomy. Sexual function was evaluated preoperatively and 9 months postoperatively with the 5-item International Index of Erectile Function (IIEF-5) questionnaire and with other self-administered questionnaires. The quality of orgasm was evaluated 9 months postoperatively. RESULTS: 1 month postoperatively, 95 and 28% of the patients in the SSG and CG were continent (p<0.001). The median postoperative drop in IIEF-5 score was 5 points in SSG and 14.5 points in CG (p<0.0001). Nine months postoperatively, 90 and 62% of the patients in SSG and CG, respectively (p=0.05), maintained the ability to achieve orgasm. CONCLUSIONS: In our experience seminal-sparing radical prostatectomy showed good feasibility and improved early postoperative urinary continence, erectile function and quality of orgasm, without compromised cancer control.     

新辅助内分泌治疗结合机器人辅助根治性前列腺切除术治疗高危前列腺癌的优势

目的：探讨高危前列腺癌患者行新辅助内分泌治疗（neoadjuvant hormonal therapy, NHT）后,行机器人辅助腹腔镜根治性前列腺切除术（robot-assisted laparoscopic radical prostatectomy, RALRP）较腹腔镜根治性前列腺切除术（laparoscopic radical prostatectomy, LRP） 和耻骨后根治性前列腺切除术 （ retropubic radical prostatectomy, RRP）的优势。方法：回顾性分析我院自2010年3月-2012年1月以新辅助内分泌治疗结合根治性前列腺切除术治疗的16例高危前列腺癌的临床资料。术前采取3-6个月的LHRH-a＋抗雄药物的最大程度雄激素阻断方法（maximal androgen blockage,MAB）作为NHT方案,NHT后PSA均降至0．2μg／L以下。之后,其中5例接受RALRP,5例接受LRP,6例接受RRP。三组患者治疗前基线情况（年龄、PSA水平、Gleason评分）差异无统计学意义（P〉0．05）。结果：手术均获成功。中位手术时间（operating time,OT）、失血量（esti-mated blood loss,EBL）、住院天数（hospital stay,HS）在RALRP组为225min（包括机器人到位15min）、600mI、7d,在LRP组为280min、900mi、7d,在RRP组为150min、675ml、14．5d。三组患者术后均无尿漏,术后3天拔除双侧引流管。术后病理均无切缘阳性。三组各有1例患者在术后3个月时因PSA复燃而接受辅助性内分泌治疗（P=1．00）。术后3个月时,除2例RRP组患者尚存压力性尿失禁,其余患者均恢复尿控（P=0．29）。结论：对于接受NHT的高危前列腺癌患者而言,相对于开放手术和腹腔镜根治性前列腺切除术,机器人辅助腹腔镜根治性前列腺切除术仍然是这些患者的更佳选择。     

The impact of pretreatment PSA on risk stratification in men with Gleason 6 prostate cancer: Implications for active surveillance

BackgroundThere are limited data to support the safety of active surveillance in men with favorable-intermediate risk prostate cancer due only to a prostate specific antigen (PSA) above 10 ng/ml. We therefore evaluated the impact of pretreatment PSA on risk-stratification in men with Gleason 6 prostate cancer.MethodsWe identified men aged 18 to 75 with cT1-2cN0cM0, pre-treatment PSA < 20 ng/ml, Gleason 6 prostate cancer diagnosed from 2010 to 2016 in the National Cancer Database who underwent radical prostatectomy. The associations of patient and disease features with Gleason score upgrading or adverse pathologic features at prostatectomy were evaluated using logistic regression. To evaluate for non linear relationships between PSA and each outcome, we examined predicted marginal event rates standardized for baseline characteristics with PSA modeled using restricted cubic splinesResultsA total of 75,566 patients were included in the cohort. In unadjusted analyses, patients with pretreatment PSA ≥ 10 ng/ml had higher rates of Gleason core upgrading (58.8% vs. 47.9%; P< 0.001) and adverse pathologic features (19.7% vs. 10.0%; P< 0.001) compared to patients with PSA < 10 ng/ml. In multivariable analyses, PSA ≥ 10 ng/ml was associated with statistically significantly increased risks of Gleason score upgrading (OR 1.47;95%CI 1.39 – 1.55) and adverse pathologic features (OR 2.15;95%CI 2.01 – 2.30). When modeled as a non linear continuous covariate, PSA was associated with increased adjusted rates of Gleason score upgrading and adverse pathologic features without a clear dichotomization at a threshold of 10 ng/ml.ConclusionHigher pretreatment PSA was independently associated with increased risks of Gleason score upgrading and adverse pathologic features at prostatectomy. Flexible modeling of the relationship between PSA and each outcome did not support dichotomization at a threshold of 10 ng/ml. These results can be used to improve patient risk-stratification for active surveillance.     

Role of bladder neck preservation in urinary continence following radical retropubic prostatectomy

OBJECTIVE: To report our experience of the influence of bladder neck preservation on patient continence. MATERIAL AND METHODS: Radical retropubic prostatectomy with bladder neck preservation was performed in 131 patients (age range 48-73 years; mean 64.5 years). Urinary continence was evaluated using a validated questionnaire at follow-up visits and telephone interviews. All patients reporting incontinence were studied using a pad test and urodynamics. RESULTS: After a mean follow-up period of 21.7 months (range 4-47 months), 115 patients were continent (87%) and 16 incontinent. According to the International Continence Society criteria, three had severe, three moderate and 10 mild incontinence. Urodynamics revealed sphincter deficiency in 15 cases, which was associated with decreased bladder compliance in four, while decreased compliance was the only abnormality in one. Continence was recovered 0-27 months after surgery (mean 3.2 months): 40% of men were continent within the first month and 74% within the third. Histopathology revealed positive margins in 30/131 patients (22%), but exclusively at the bladder neck level in only seven (5%), and two also had positive nodes. Six patients (4.5%) presented bladder neck stenosis requiring transurethral incision. No statistically significant differences were found between the ages of continent and incontinent men or between the time to continence recovery with two different techniques of retropubic hemostasis; however, use of a nerve-sparing technique significantly reduced the time to continence recovery. CONCLUSIONS: Bladder neck preservation during radical retropubic prostatectomy does not improve the long-term results of urinary continence but does contribute substantially to its earlier recovery, thus improving the quality of life. With proper patient selection the risk of positive margins at the bladder neck level only is reasonably low.     

Continencia urinaria tras prostatectomía radical. Factores pronósticos y tiempo de recuperación

ObjetivesTo assess the urinary continence after radical prostatectomy and its evolution over time. To analyse possible prognosis factorsMaterial and methodsWe have reviewed 101 patients that have undergone radical prostatectomy. We define “continent patient” as that one who doesn’t require any type of urinary protection. By means of Kaplan-Meier method, we evaluate the recovery of continence along time. We analyze potential conditional factors (age, stage, surgery technique, surgery experience,…). The statistical tools used are: chi-square, Fisher, Cox regression, T-test and Kaplan-MeierResultsMedian monitoring time: 27,33 months. 80% are continent patients, 48,7% of which reach maximum continence before the 3rd, month is due and 17,5% after the 6 months (2,5% between 9-12 months). Their probability of becoming “continents” during the first 4 months es 0,4692. patients under 70 years old recover continence before those who are over 70 years old (medians: 3,51 months and 5,67 months respectively, p = 0,0211)ConclusionsThe recovery of continence takes place progressively and a 17,5% of patients reach plain recovery in the 6-12 months period after surgery. The evaluation of the surgery treatment to correct incontinence should consider the possibility of “spontaneous” recovery in a 2,5% of patients in the 9-12 months period after surgery. Age affects negatively the recovery time; it is significantly less for patients under 70     

Relation between erectile dysfunction and urinary incontinence after nerve-sparing and non-nerve-sparing radical prostatectomy

INTRODUCTION: We investigated the status of erectile function and urinary continence after radical prostatectomy to investigate a possible relation between them and then determined whether the status of postoperative urinary continence affected erectile function. PATIENTS AND METHODS: Seventy-six patients who had no symptoms of erectile dysfunction or urinary incontinence preoperatively were included in this study. The postoperative status of erectile function and urinary continence was investigated using a self-reported patient questionnaire. RESULTS: Thirteen of 27 patients (48.1%) who underwent nerve-sparing procedures maintained erectile function, while 7 of 49 patients (14.2%) who underwent non-nerve-sparing procedures maintained it postoperatively. None of the 27 patients in the nerve-sparing procedure group reported incontinence, whereas 3 of the 49 patients (6.1%) who underwent non-nerve-sparing procedures reported moderate incontinence. However, no significant correlation between the International Index of Erectile Function-5 score and the Incontinence Impact Questionnaire score was seen. CONCLUSION: No relation between the status of urinary continence and erectile function was shown, regardless of the nerve-sparing nature of the prostatectomy.     

Urinary continence after salvage radiation therapy following radical prostatectomy, assessed by a self-administered questionnaire: a prospective study

OBJECTIVE: To evaluate urinary continence after salvage radiotherapy following radical prostatectomy (RP) for clinically localized prostate cancer. PATIENTS AND METHODS: In all, 145 men had a retropubic RP in our department between 1992 and 2000. From this group, salvage radiotherapy with the dose of 65 Gy was given to 18 patients for a rising prostatic specific antigen (PSA) level. The mean (range) age at RP was 63 (50-72) years and the initial PSA level 14.95 (4.8-34) ng/mL. The radiotherapy was given at 46 (6-96) months after RP. A self-administered questionnaire about their urinary status was mailed to the patients before and 18 months after radiotherapy. The mean follow-up after radiotherapy was 34 (20-70) months. RESULTS: Before radiotherapy, 17 patients were continent (defining continence as no regular use of pads). After salvage radiotherapy, 16 men had had no change in their urinary status, even for the one patient using pads. One patient with stress urinary incontinence showed a slight worsening of his urinary status after radiotherapy. Another patient who was continent before radiotherapy developed urgency with no urinary leakage. Fourteen men stated that they were very satisfied or satisfied about their urinary status after radiotherapy and four were mildly satisfied. Nine would undergo radiotherapy again even with their present continence status and nine probably would. CONCLUSION: Using an anonymous self-administered questionnaire, salvage radiotherapy for a rising PSA level seems to be safe and does not worsen the continence achieved after RP in most patients.