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.     

Evaluation of combined oncological and functional outcomes after radical prostatectomy: trifecta rate of achieving continence, potency and cancer control--a literature review

The first objective of radical prostatectomy is cancer control. However, the success of RP should be also measured by the long-term morbidity outcomes and by the maintenance of quality of life. We performed a review of the literature for combined results of continence, erectile function, and cancer control after radical prostatectomy. Since 2003 and the first report of "trifecta," only 7 series have yet reported such combined results (trifecta rate range: 20%-76%). The preoperative risk (D'Amico) predicted for quality of life outcomes and biochemical recurrence is an aggregate endpoint, the trifecta.     

Age-stratified outcomes after robotic-assisted laparoscopic radical prostatectomy

We sought to evaluate post-operative return of urinary and sexual function in men undergoing robotic-assisted laparoscopic radical prostatectomy (RLRP). Prospective assessment of urinary continence and sexual function was performed in patients undergoing RLRP. Subjective assessment involved the use of the validated RAND-36 Item Health Survey/UCLA Prostate Cancer Index questionnaire. Questionnaires were completed pre-operatively and at 1, 3, 6 and 12 months post-operatively. Subset analyses were performed to assess the effect of age on functional outcomes. A total of 338 consecutive patients underwent RLRP between February 2003 and August 2005. Included patients for evaluation comprised of 21, 129, and 150 patients, aged <50, 50–59, and ≥60 years old, respectively. Kaplan–Meier curve analysis demonstrated that younger men (<60 years) achieved subjective continence significantly earlier than older age group (≥60 years) (P = 0.02). Continence rates, however, equalized among all age groups at 1 year follow-up. Younger men (<50 years) also demonstrated a quicker and greater return of sexual function (P = 0.01), which persisted through assessment at 1 year post-operatively. Our results suggest that younger men may have an earlier return of continence and potency when compared to men > 60 years. Despite this finding, continence outcomes appear to be equal among age groups after 1 year of follow-up. Moreover, men < 60 years continue to report superior potency outcomes compared to men > 60 years at 1 year post-operatively. Such findings are valuable in counseling patients undergoing RLRP.     

Patient-reported validated functional outcome after extraperitoneal robotic-assisted nerve-sparing radical prostatectomy.

BACKGROUND AND OBJECTIVES: Erectile function after prostate surgery is an important criterion for patients when they are choosing a treatment modality for prostate cancer. Improved visualization, dexterity, and precision afforded by the da Vinci robot allow a precise dissection of the neurovascular bundles. We objectively assessed erectile function after robot-assisted extraperitoneal prostatectomy by using the SHIM (IIEF-5) validated questionnaire. METHODS: Between July 2003 and September 2004, 150 consecutive men underwent da Vinci robot-assisted extraperitoneal radical prostatectomy for clinically localized prostate cancer. The IIEF-5 questionnaire was used to assess postoperative potency in 67 patients who were at least 6 months postsurgery. Erectile function was classified as impotent (<11), moderate dysfunction (11 to 15), mild dysfunction (16 to 21), and potent (22 to 25). All patients used oral pharmacological assistance postprocedure. RESULTS: Sixty-seven patients were available to complete the IIEF-5 questionnaire 6 months to 1 year postprostatectomy. Twelve patients were excluded from the study who abstained from all sexual activity after surgery for emotional or social reasons. Of the 55 patients evaluated, 22 (40%) were impotent, 3 (5.5%) had moderate ED, 12 (21.8%) had mild ED, and 18 (32.7%) were fully potent. The table compares IIEF-5 scores with nerve-sparing status. Of patients who had bilateral nerve sparing, 28/45 (62.2%) had mild or no ED within 6 to 12 months postsurgery, and all expressed satisfaction with their current sexual function or rate of improvement after robotic prostatectomy. CONCLUSION: Robot-assisted extraperitoneal prostatectomy provides comparable outcomes to those of open surgery with regards to erectile function. Assessment of the ultimate maximal erectile function will require continued analysis, as this is likely to further improve beyond 6 to 12 months.     

Patient-reported validated functional outcome after extraperitoneal robotic-assisted nerve-sparing radical prostatectomy.

BACKGROUND AND OBJECTIVES: Erectile function after prostate surgery is an important criterion for patients when they are choosing a treatment modality for prostate cancer. Improved visualization, dexterity, and precision afforded by the da Vinci robot allow a precise dissection of the neurovascular bundles. We objectively assessed erectile function after robot-assisted extraperitoneal prostatectomy by using the SHIM (IIEF-5) validated questionnaire. METHODS: Between July 2003 and September 2004, 150 consecutive men underwent da Vinci robot-assisted extraperitoneal radical prostatectomy for clinically localized prostate cancer. The IIEF-5 questionnaire was used to assess postoperative potency in 67 patients who were at least 6 months postsurgery. Erectile function was classified as impotent (<11), moderate dysfunction (11 to 15), mild dysfunction (16 to 21), and potent (22 to 25). All patients used oral pharmacological assistance postprocedure. RESULTS: Sixty-seven patients were available to complete the IIEF-5 questionnaire 6 months to 1 year postprostatectomy. Twelve patients were excluded from the study who abstained from all sexual activity after surgery for emotional or social reasons. Of the 55 patients evaluated, 22 (40%) were impotent, 3 (5.5%) had moderate erectile dysfunction (ED), 12 (21.8%) had mild ED, and 18 (32.7%) were fully potent. The table compares IIEF-5 scores with nerve-sparing status. Of patients who had bilateral nerve sparing, 28/45 (62.2%) had mild or no ED within 6 to 12 months postsurgery, and all expressed satisfaction with their current sexual function or rate of improvement after robotic prostatectomy. CONCLUSION: Robot-assisted extraperitoneal prostatectomy provides comparable outcomes to those of open surgery with regards to erectile function. Assessment of the ultimate maximal erectile function will require continued analysis, as this is likely to further improve beyond 6 to 12 months.     

Evaluation of pelvic floor muscle strength before and after robotic-assisted radical prostatectomy and early outcomes on urinary continence

The aim of the study was to evaluate the effect of pelvic floor muscle (PFM) assessment and training before and after robot-assisted laparoscopic radical prostatectomy (RARP) in improving PFM strength and urinary continence. We performed an analysis of a database of patients who underwent robot-assisted laparoscopic radical prostatectomy (RARP) performed by two urologists from 2011 to 2013. Pelvic floor muscle (PFM) activation and strength were graded by a trained pelvic floor physiotherapist. Patients were given an exercise program, grouped according to the strength of their pelvic floor as graded by assessment, to complete before and after surgery. PFM strength was recorded preoperatively, 4 days post-catheter removal and 4 weeks post-catheter removal. Continence was recorded at 4 weeks postop and was defined as the requirement of no continence aids. A total of 98 patients had RARP and a preoperative physiotherapy assessment plus postoperative appointments at around 1 and 4 weeks post-RARP. The majority of men improved their PFM strength regardless of preoperative strength with no significant predictors of postoperative strength found. Age was the only significant predictor of postoperative incontinence. In this pilot study, a majority of patients increased their pelvic floor strength with time. Pelvic floor physiotherapy is an important modifiable patient factor, which does have an impact in improving patients’ urinary continence by strengthening the pelvic floor muscles. Patient age influences response to pelvic floor physiotherapy.     

Comparison between robotic-assisted laparoscopic radical prostatectomy and radiotherapy with regard to oncologic control and functional outcome in elderly patients with prostate cancer

ObjectiveFrom 2006 to 2014, more than 800 patients had received robotic-assisted laparoscopic radical prostatectomy (RaLRP) at our hospital. Based on our single-center experience, the procedure has been found to be safe and feasible among these patients with regard to oncologic control and functional outcome. We compared these patients with those who received radiotherapy (RT; all aged > 75 years) and attempted to clarify whether there is any benefit with regard to oncologic control, functional outcome, and comorbidity.Materials and methodsWe performed a retrospective review of 188 prostate cancer patients aged > 75 years in our hospital over a period of 5 years (79 patients had received RaLRP and 109 patients had received RT). Cancer control result was determined based on the 1-year biochemical recurrence (BCR) rate. In the surgical group, BCR was defined as a sustained increase, on two separate occasions, in the serum total prostate-specific antigen (PSA; >0.2 ng/mL) level, whereas in the RT group it was defined as an increase in the PSA level of ≥2 ng/mL above the nadir PSA level. Functional results were determined based on the continence rate, clinical condition of low urinary tract symptoms, and other complications.ResultsRegarding oncologic control (1-year BCR rate), there was no difference between the two groups (RaLRP vs. RT: 20.93% vs. 23.95%, p = 0.6950). The 1-year continence rate in the RaLRP group was 90.69%. By contrast, 80.20% of the patients in the RT group suffered from low urinary tract symptoms requiring medication and 21.87% of the patients suffered from bladder outlet obstruction, which may require other interventions; approximately 28.12% of the patients suffered from radiation cystitis and 12.5% of patients suffered from radiation proctitis.ConclusionOur analysis shows that there is no difference in oncologic outcome between the two groups; however, there is still a lack of reliable evidence owing to the short duration of follow up. It was also difficult to confirm whether there are any benefits in functional outcomes between these two procedures. However, despite the old age of the patients, RaLRP could offer a good 1-year continence outcome.     

经腹膜外腹腔镜下前列腺癌根治术及其控尿技术

目的 探讨腹膜外途径腹腔镜前列腺癌根治术及其控尿技术的应用价值。方法 前列腺癌患者28例，年龄60～75岁，平均68岁。PSA0．7～23．6ng／ml。TNM分期：T1N0M011例，T2N0M015例，T3aN0M2例。均行腹膜外途径腹腔镜前列腺癌根治术。，术中充分剪开盆筋膜，分离至前列腺尖部，缝扎背血管复合体。分离膀胱颈部（前列腺交界处），横断并尽可能保护颈部括约肌。仔细观察盆底肌肉并于近端剪开前列腺尖部，尽可能保护盆底括约肌，最后缩小并重建膀胱颈口，间断吻合膀胱和尿道。结果 28例手术均顺利完成，手术时间180～380min，平均240min；出血量400～1200ml，平均800ml，15例出血量〉500ml者输血200～800ml。术后病理示切缘阴性25例，3例前列腺尖部切缘阳性者术后加用全雄激素阻断治疗3个月。患者均于术后2周拔除导尿管，3例术后出现轻度尿失禁，经提肛训练等辅助治疗3个月后好转，能自主排尿。术后3个月时PSA0．02～0．10ng／ml。随访1个月～2年，未见肿瘤复发转移。结论 腹腔镜下经腹膜外途径前列腺癌根治术安全、有效，值得临床推广。