Mr Joseph Norris is a Specialty Registrar in Urology in the London Deanery. He is currently undertaking an MRC Doctoral Fellowship at UCL, under the supervision of Professor Mark Emberton. His research interest is prostate cancer that is inconspicuous on mpMRI.
Every year the BJUI awards three prizes to trainee urologists who have played a significant role in contributing to the work published in the journal. The prizes go towards travel costs enabling the trainees to visit international conferences. In 2020, due to the coronavirus pandemic leading to the cancellation of many of these conferences, the usual prize-giving ceremonies have not taken place so here we are introducing you to the prize winners and their work. We hope they will be able to spend their prize money in 2021.
This is awarded to authors who are trainees based anywhere in the world other than the Americas and Europe. Usually presented at the USANZ annual meeting. In 2020 the prize was awarded to Sho Uehara for his work on artificial intelligence in prostate cancer diagnosis.
Sho Uehara received a Ph.D. from the graduate school of Tokyo Medical and Dental University, Tokyo, Japan, in 2018. He is now working as a urologist and an assistant professor at the university hospital. His research interests include prostate cancer diagnostics, and utilization of machine learning for them.
Membership of academic societies:
JUA (The Japanese Urological Association), EAU (European Association of Urology) and AUA (American Urological Association)
The Coffey-Krane prize is awarded to an author who is a trainee based in The Americas. Normally presented at the AUA annual conference. Dr Nathan Wong received this year’s award for his work on using machine learning to predict biochemical cancer recurrence following prostatectomy.
Dr Nathan Wong is an assistant professor and associate program director in the Department of Urology at Westchester Medical Center and New York Medical College. He specializes in urologic oncology and robotics surgery. His main interests are in technology, clinical trials and surgical education. He completed a Society of Urologic Oncology fellowship at Memorial Sloan Kettering Cancer Center in New York City and urology residency at McMaster University in Hamilton, Ontario in Canada.
John Blandy prize
This prize is for authors who are trainees based in Europe. Presented at the BAUS annual conference; the winner gives a presentation. This year the prize went to Nicholas Raison for his work on a RCT on cognitive training in robotic surgery.
Nicholas Raison is Vattikuti fellow at the MRC Centre for Transplantation and Mucosal Cell Biology, King’s College London and a Urology Specialist Registrar in the London Deanery.
This is the final Article of the Week selected by the outgoing Editor-in-Chief from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.
If you only have time to read one article this week, we recommend this one.
Enrico Checcucci*, Sabrina De Cillis*, Angela Pecoraro*, Dario Peretti*, Gabriele Volpi*, Daniele Amparore*, Federico Piramide*, Alberto Piana*, Matteo Manfredi*, Cristian Fiori*, Riccardo Autorino†, Prokar Dasgupta‡, Francesco Porpiglia* and on behalf of the Uro-technology and SoMe Working Group of the Young Academic Urologists Working Party of the European Association of Urology
*Department of Urology, San Luigi Gonzaga Hospital, University of Turin, Turin, Italy, †Division of Urology, VCU Health, Richmond, VA, USA, and ‡King’s College London, Guy’s Hospital, London, UK
To summarize the clinical experiences with single‐port (SP) robot‐assisted radical prostatectomy (RARP) reported in the literature and to describe the peri‐operative and short‐term outcomes of this procedure.
Material and Methods
A systematic review of the literature was performed in December 2019 using Medline (via PubMed), Embase (via Ovid), Cochrane databases, Scopus and Web of Science (PROSPERO registry number 164129). All studies that reported intra‐ and peri‐operative data on SP‐RARP were included. Cadaveric series and perineal or partial prostatectomy series were excluded.
The pooled mean operating time, estimated blood loss, length of hospital stay and catheterization time were 190.55 min, 198.4 mL, 1.86 days and 8.21 days, respectively. The pooled mean number of lymph nodes removed was 8.33, and the pooled rate of positive surgical margins was 33%. The pooled minor complication rate was 15%. Only one urinary leakage and one major complication (transient ischaemic attack) were recorded. Regarding functional outcomes, pooled continence and potency rates at 12 weeks were 55% and 42%, respectively.
The present analysis confirms that SP‐RARP is safe and feasible. This novel robotic platform resulted in similar intra‐operative and peri‐operative outcomes to those obtained with the standard multiport da Vinci system. The advantages of single incision can be translated into a preservation of the patient’s body image and self‐esteem and cosmesis, which have a great impact on a patient’s quality of life.
It is generally agreed upon that an extended pelvic lymph‐node dissection (ePLND) provides valuable staging information and helps guide adjuvant therapy, and thus should be undertaken in prostate cancer patients with aggressive preoperative disease features at the time of radical prostatectomy [1,2]. However, whether it has a ‘direct’ therapeutic benefit in the aforesaid patients has remained difficult to demonstrate . The only patients that seem to derive a survival advantage from an ePLND are patients with pN1 disease  – this cited study suggested a direct therapeutic effect of an ePLND, with a 7% incremental benefit in 10‐year cancer‐specific survival per every additional LN removed (P = 0.02). However, it did not identify these patients preoperatively.
Given the significant side‐effects associated with an ePLND , it is worth asking the questions: which patients, identified preoperatively, may derive a direct therapeutic benefit from an ePLND, and who benefit indirectly only (i.e. via optimal utilisation of adjuvant therapies). The latter question has been answered [5,6]. Here, we try to answer the former.
We relied on the National Cancer Database (NCDB) to answer our question. The NCDB, a joint programme of the Commission on Cancer and the American Cancer Society, is a nationwide cancer database that contains information on ~70% of newly diagnosed tumours in the USA. We identified all patients with prostate cancer undergoing radical prostatectomy between the years 2004 and 2015. After excluding patients with clinical LN/metastatic disease (n = 2568), neoadjuvant radiotherapy, chemotherapy or hormonal therapy (n = 10 931), missing information on biopsy Gleason score, cT stage or preoperative PSA value (n = 166 696), and missing information regarding PLND (n = 95 348), a final sample of 311 061 patients was achieved. All available baseline patient/tumour characteristics and overall survival (OS) data (outcome) were noted. Preoperative LN invasion (LNI) risk was calculated using the Godoy nomogram. We used this nomogram as it was developed using the PLND data from North American men, and has been validated in them . The cut‐off of ≥10 LNs to define an ePLND was based on prior studies [5,6,7,8]. To analyse the impact of ePLND (≥10 LNs) vs none/limited PLND (0–9 LNs) on 10‐year OS, interaction between Godoy nomogram predicted LNI probability, which is based on the preoperative PSA value, clinical stage and biopsy Gleason grade, and ePLND/PLND was plotted using locally weighted methods controlling for age, comorbidities and adjuvant radiation therapy (aRT). This was called model 1 (M1). In a second model (M2), in addition to controlling for age, comorbidities and aRT, we also adjusted for receipt of adjuvant hormonal therapy (aHT). We performed this analysis as we reasoned that a survival benefit in patients undergoing an ePLND may be due to better staging and receipt of aHT. All analyses were performed with the Statistical Analysis System (SAS), version 9.4 (SAS Institute, Cary, NC, USA), with a two‐sided P < 0.05 considered as statistically significant. An Institutional Review Board waiver was obtained prior to conducting this study, in accordance with institutional regulations on dealing with de‐identified administrative data.
Table S1 provides baseline characteristics. Of the 311 061 patients, 49 470 (15.9%) patients underwent an ePLND. The median number of LNs removed in patients undergoing none/limited PLND vs ePLND were 2 and 14, respectively (P < 0.001). The median age and preoperative PSA values for the groups were 61 and 62 years (P < 0.001) and 5.5 and 6 ng/mL (P < 0.001), respectively. Patients undergoing an ePLND had more aggressive disease on pathological analysis: Gleason ≥8 disease (17.3% vs 10.0%), pT3+ stage (37.4% vs 21.9%) and pN1 disease (8.6% vs 1.5%; P < 0.001 for all). These patients also received aRT (3.9% vs 3.1%) and aHT (4.3% vs 1.9%) more frequently than patients undergoing none/limited PLND (P < 0.001 for both).
The median (interquartile range) follow‐up for the ePLND and none/limited PLND groups was 54.0 (31.3–79.9) and 57.5 (35.1–82.0) months, respectively. In interaction analyses, the lines for ePLND and none/limited PLND separated at Godoy nomogram predicted LNI risk of 20% in model M1 (Fig. 1a), indicating that patients with a preoperative LNI risk >20% derived an OS benefit from an ePLND. This finding remained preserved in model M2, which adjusted for receipt of aHT, in addition to age, comorbidities and aRT, thus indicating a ‘direct’ independent benefit of an ePLND on OS in patients with a LNI risk of >20% (Fig. 1b).
In Cox regression analyses, the first model (M1) demonstrated that patients undergoing an ePLND (hazard ratio [HR] 1.20, 95% CI 1.17–1.24) had a 9% incrementally lower hazard of 10‐year mortality than patients undergoing none/limited PLND (HR 1.29, 95% CI 1.26–1.31) for every 10% increment in Godoy nomogram predicted LNI risk, beyond the 20% cut‐off (P < 0.001). Similarly, the second model (M2) demonstrated that patients undergoing an ePLND (HR 1.18, 95% CI 1.14–1.21) had a 6% incrementally lower hazard of 10‐year mortality than patients undergoing none/limited PLND (HR 1.24, 95% CI 1.23–1.26) for every 10% increment in Godoy nomogram predicted LNI risk, beyond the 20% cut‐off (P < 0.001). This lower but preserved incremental improvement in OS after adjustment for aHT (model M2) supports our hypothesis that an ePLND is in itself a ‘direct’ independent factor in OS in patients at high‐risk of LNI.
The current American and European urological societal guidelines recommend performing an ePLND in high‐risk and unfavourable intermediate‐risk patients, especially when the estimated risk for LNI is >5% [1, 2]. However, at this cut‐off, the benefit is mainly that of accurate staging and subsequent optimal adjuvant treatment (indirect benefit). This must be balanced against the morbidity of an ePLND. In line with this, a recent exhaustive systematic review by Fossati et al.  found that ePLND, as it is currently utilised, is associated with increased risk of postoperative complications without an oncological benefit. The findings of our present study are thus timely and important. We for the first time identify patients preoperatively that may derive both direct and indirect therapeutic benefits of an ePLND. In the present study 4.5% of the 311 061 patients had a LNI risk of >20%. This constitutes a substantial number of patients. These patients should be strongly advised to receive an ePLND. For patients constituting the LNI risk group between 5% and 20%, they should still be encouraged to undergo an ePLND after discussing the risks and benefits of it, as accurate staging may improve their survival by receipt of aHT.
Our present study is not devoid of limitations. First, it is limited by its retrospective nature, an inherent drawback of all observational studies based on administrative data. Therefore, our findings should be interpreted with caution. However, randomised data on this subject are currently scarce. The two randomised trials (NCT01812902 and NCT01555086) comparing ePLND vs limited PLND have not yet matured to provide clinically meaningful information. While we await results from these trials, our present study provides an avenue to have an informed discussion with the patients with high‐risk prostate cancer about the risks/benefits of undergoing an ePLND. Second, no centralised pathological review was available in our study. While this might be considered a limitation, it is also a strength, as it implies that our results are applicable to clinical practice, regardless of pathology review variation. Lastly, the definition of our ePLND was based on number of LNs removed rather than the anatomical zones dissected . The information regarding LN zonal anatomy is not available within NCDB; however, several prior studies of anatomical ePLND have shown median LN counts between 10 and 20 [5,6,7,8], and it was 14 in our series for patients undergoing an ePLND (vs a median of two LNs for none/limited PLND), thus suggesting that the patients were likely classified appropriately into ePLND and none/limited PLND groups.
Limitations notwithstanding, our present study is the first to preoperatively identify patients in whom an ePLND may confer a direct survival advantage, in addition to superior prognostication (indirect benefit). As we identify these patients preoperatively, this may facilitate patient counselling and optimal utilisation of ePLND.
Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.
In addition to this post there is also an Editorial written by a prominent member of the urological community and a visual abstract created by Cora Griffin at King’s College London.We invite you to use the comment tools at the bottom of each post to join the conversation.
If you only have time to read one article this month, we recommend this one.
Pascal Viktorin-Baier*†, Paul M. Putora‡§, Hans-Peter Schmid*, Ludwig Plasswilm‡§, Christoph Schwab*, Armin Thoeni¶, Werner Hochreiter**, Ladislav Prikler††, Stefan Suter‡‡, Patrick Stucki†, Michael Müntener§§, Nadja Blick§§, Hans Schiefer‡, Sabine Güsewell¶¶, Karin Zürn* and Daniel Engeler*
*Department of Urology, St. Gallen Cantonal Hospital, St. Gallen, †Urology Clinic, Cantonal Hospital Lucerne, Lucerne, ‡Department of Radiation Oncology, St. Gallen Cantonal Hospital, St. Gallen, §Department of Radiation Oncology, University of Berne, ¶Clinic for Radiation-Oncology, Lindenhof Hospital Berne, Berne, **Urology Clinic, Hirslanden Clinic Aarau, Aarau, ††Urology Clinic, Uroviva Clinic Buelach, Buelach, ‡‡Urology Clinic Zug, Zug, §§Urology Clinic, Triemli Hospital, Zurich, and ¶¶Clinical Trial Unit, St. Gallen Cantonal Hospital, St. Gallen, Switzerland
To evaluate the long‐term oncological, functional and toxicity outcomes of low‐dose‐rate brachytherapy (LDR‐BT) in relation to risk factors and radiation dose in a prospective multicentre cohort.
Patients and Methods
Data of patients from 12 Swiss centres undergoing LDR‐BT from September 2004 to March 2018 were prospectively collected. Patients with a follow‐up of ≥3 months were analysed. Functional and oncological outcomes were assessed at ~6 weeks, 6 and 12 months after implantation and annually thereafter. LDR‐BT was performed with 125I seeds. Dosimetry was done 6 weeks after implantation based on the European Society for Radiotherapy and Oncology recommendations. The Kaplan–Meier method was used for biochemical recurrence‐free survival (BRFS). A prostate‐specific antigen (PSA) rise above the PSA nadir + 2 was defined as biochemical failure. Functional outcomes were assessed by urodynamic measurement parameters and questionnaires.
Of 1580 patients in the database, 1291 (81.7%) were evaluable for therapy outcome. The median (range) follow‐up was 37.1 (3.0–141.6) months. Better BRFS was found for Gleason score ≤3+4 (P = 0.03, log‐rank test) and initial PSA level of <10 ng/mL (P < 0.001). D’Amico Risk groups were significantly associated with BRFS (P < 0.001), with a hazard ratio of 2.38 for intermediate‐ and high‐risk patients vs low‐risk patients. The radiation dose covering 90% of the prostate volume (D90) after 6 weeks was significantly lower in patients with recurrence. Functional outcomes returned close to baseline levels after 2–3 years. A major limitation of these findings is a substantial loss to follow‐up.
Our results are in line with other studies showing that LDR‐BT is associated with good oncological outcomes together with good functional results.
The clinical results from 12 Swiss centres reaffirm the benefits of Low Dose Rate Brachytherapy (LDR-BT) for the treatment of localised prostate cancer . The authors are to be commended for collating and analysing prospective, countrywide, long-term data. This is an excellent example of Good Clinical Practice for the urology community, patients, commissioning groups and for governance purposes. Prostate brachytherapy offers suitable men with prostate cancer a high chance of long-term cure but with a low risk of urinary incontinence and most retaining erectile dysfunction .
Two thirds of the patients reported in the Swiss series had low-risk cancer who would now more commonly be offered active surveillance as an initial treatment option. However our own and other large mature series have shown similar treatment efficacy of LDR-BT, either as monotherapy as in the Swiss study, or as a boost to external-beam radiotherapy, for the treatment of patients with intermediate and high risk of disease relapse [3, 4]. Indeed the ASCENDE-RT trial recently showed that men with unfavourable intermediate or high-risk prostate cancer randomised to an LDR-BT boost arm, relative to a dose-escalated external-beam radiotherapy boost, were twice as likely to be free of biochemical failure at a median follow-up of 6.5 years. A slight increase in urinary toxicity was observed which may have been an issue related to implant technique .
The authors show LDR-BT affords excellent disease control that associates with post-implant dosimetry in keeping with current treatment guidelines. They also report an association between biochemical control and seed loss. It therefore becomes unclear the extent to which implant quality or implant technique, i.e. the use of loose or stranded seeds, influenced the oncological outcome, as it would appear that more than one brachytherapy technique has been used.
In this series no prostate cancer-related deaths were reported. However the median follow-up length of 37 months is relatively short. Examples from more mature series show longer follow-up is needed to begin to document the low rates of prostate cancer-related deaths following LDR-BT. Lazarev et al  in a similar risk group distribution to the Swiss population, reported 97% prostate cancer-specific survival at 17-years with all deaths occurring more than 10 years after treatment. Morris et al  reported 99.1% cause-specific survival at 10 years with death events 9 years after treatment in low and intermediate-risk disease. Our own series showed 98% prostate-cancer-specific survival at 7 and 9 years post-implantation in high-risk (as defined by NICE) patients treated with monotherapy .
Treatment-related toxicity assessments in the Swiss series showed that baseline values are crucial to understand the impact of treatment on patient-reported outcomes. Higher post-implant scores were consistently observed in those patients with higher baseline scores. The patient-reported outcomes were similar to those from our series where sexual potency was preserved in 70-80% of men who were ≤60 years old at time of implant .
Salvage therapies are seldom given after LDR-BT as the local failure rate is low and the surgery complex. It was undertaken in only two patients in the Swiss series. In the era of mp-MRI and PSMA PET/CT scans and targeted biopsies, tumour recurrence can be better assessed. Salvage surgery has been offered to approximately 0.5% (27/4200) of our patients, by either robotic-assisted radical prostatectomy or seminal vesiculectomy if the recurrence is localised to the seminal vesicle alone.
Thisnation-wide report from the 12 Swiss centres is a welcome addition to the extensive body of evidence that attests to the excellent results and generalisability of prostate LDR-BT. The treatment is efficacious and convenient for patients with a low toxicity profile. It is a cost effective option that should be offered to all suitable patients with localised prostate cancer.