Tag Archive for: Prostate cancer

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Article of the week: Single-port robot assisted radical prostatectomy (SP-RARP): a systematic review and pooled analysis of the preliminary experiences

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. 

Single‐port robot‐assisted radical prostatectomy: a systematic review and pooled analysis of the preliminary experiences

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

Abstract

Objective

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 da Vinci SP robotic platform

Results

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.

Conclusions

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.

COVID-19 and Prostate Cancer — Challenges and Solutions

The numbers are staggering. As of the date of this brief commentary, the World Health Organization has reported more than 4.6 million cases and upwards of 311,840 deaths worldwide from the COVID-19 pandemic. The virus responsible for the disease known as COVID-19, SARS-CoV-2, is highly infectious and the risks are clearly significant for nearly everyone. Nonetheless, the risk is much higher for some of us than for others. In particular, we have begun to understand the distinct risks faced by men with prostate cancer and the unique intersection of biological, health, and lifestyle factors in COVID-19 and prostate cancer. Although there is a great deal yet to be learned, there are indeed many aspects of the overlap between COVID-19 and prostate cancer that we have already been able to discern and which we have begun to address. Perhaps most striking, older men who are at greatest risk for prostate cancer may also be at greatest risk for COVID-19. 

New York City

Biology Makes a Difference – COVID-19 and prostate cancer share some common biological features. A gene responsible for male traits or characteristics, the androgen receptor, which is dysregulated or impaired in prostate cancer, is also important in COVID-19. Androgens can suppress the body’s immune response to infections and may explain the reason for higher rates of infection in men.  At the same time, a gene known as TMPRSS2 is also highly expressed in both COVID-19 and prostate cancer. In fact, these issues may be related—more androgens could signify greater expression of TMPRSS2 which could create greater susceptibility to the virus. These biological risks are compounded by a number of critical health conditions and lifestyle issues.

Common Risk Factors – Studies from around the world have shown that several chronic health conditions or comorbidities create greater risk for contracting the virus, becoming more severely ill, or dying from COVID-19. It is indeed concerning that many of these are the same risks we see in prostate cancer: hypertension, diabetes, COPD, and obesity. Prostate cancer patients with multiple comorbid conditions may be at even greater risk. Cancer patients in general have weakened immune systems which makes them more vulnerable to infectious disease, further compounding the unique factors affecting men with prostate cancer. Some of the lifestyle factors that may contribute to chronic health conditions also appear to be risk factors for COVID-19 infection, most importantly smoking and high levels of alcohol consumption. We are especially concerned about men who are active smokers, as smoking has been clearly linked to worse outcomes in men who have become ill with COVID-19. We believe that the guidance we generally offer to prostate cancer patients is as, if not more, relevant now in this time of the COVID pandemic—adopt healthy habits, including smoking cessation, a nutritious diet, exercise, and proper management of chronic conditions most notably diabetes.

Looking Ahead – As the pandemic evolves and we look to the future, we are focused on ways to prevent the spread of infection and to create viable treatments for those who become ill. Worldwide, more than nine million men currently face decisions about biopsy, active surveillance, surgery, radiation, hormonal therapy, or chemotherapy related to prostate cancer in the context of COVID-19 and another 3 million more will find themselves facing these decisions by the end of this year. We are working intensely to address their needs. More than 1,460 clinical trials are underway to test therapeutic interventions to treat COVID-19. What we have come to understand about the shared biology between COVID-19 and prostate cancer and common risk factors will be invaluable. We must learn everything we can about the ways in which the virus impacts lung function as it relates to prostate cancer—the respiratory symptoms that result from infection have been especially lethal—and continue to explore the role of androgens in response to new drugs. Many drugs originally intended and approved for other uses are being tested for potential “repurposing” and new drugs and vaccines are under investigation. New clinical guidelines have been established for the treatment of prostate cancer patients at risk of or for those who have contracted the virus, and these guidelines will continue to evolve and be updated.

A Global Perspective – It is critical that we understand the COVID-19 pandemic both on the level of individual experience and global impact. For prostate cancer patients, this means recognizing the way that biology, related chronic health conditions, and lifestyle choices come together to impact the risk of disease, disease severity, and outcomes. Prostate cancer patients and their doctors must come together to find the way forward during this time of unprecedented crisis and opportunities for improving outcomes and quality of life for prostate cancer patients.

Ash Tewari, Zach Dovey and Dimple Chakravarty

Article of the week: Using data from an online health community to examine the impact of prostate cancer on sleep

Every week, the Editor-in-Chief selects an Article of the Week 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 an editorial written by a prominent member of the urological community. Please use the comment buttons below to join the conversation.

If you only have time to read one article this week, we recommend this one. 

Using data from an online health community to examine the impact of prostate cancer on sleep

Rebecca Robbins*, Girardin Jean‐Louis, Nicholas Chanko, Penelope Combs, Nataliya Byrne†‡, Stacy Loeb†‡

*Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA, Department of Population Health, New York University (NYU) School of Medicine, and Department of Urology, NYU School of Medicine and Manhattan Veterans Affairs, New York, NY, USA

Previous epidemiological studies have examined the relationship between sleep disturbances and prostate cancer risk and/or survival. However, less has been published about the impact of sleep disturbance on quality of life (QoL) for prostate cancer survivors and their in home caregiver. Although prostate cancer presents numerous potential barriers to sleep (e.g., hot flashes, nocturia), current survivorship guidelines do not address sleep. In addition to its impact on QoL, sleep disturbances also mediate the impact of cancer status on missed days from work and healthcare expenditures.

A broader examination of contributors to poor sleep in prostate cancer, and the impact on patients and caregivers would be an important contribution to raise awareness of these issues in the medical community, improve survivorship care, reduce healthcare costs, and stimulate future research. The objective of our letter is to analyse sleep barriers reported by patients with prostate cancer and caregivers posted to a large online health community.

Article of the week: Likert vs PI‐RADS v2: a comparison of two radiological scoring systems for detection of clinically significant PCa

Every week, the Editor-in-Chief selects an Article of the Week 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 the article itself, there is an editorial written by a prominent member of the urological community and a video prepared by the authors; 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 week, we recommend this one. 

Likert vs PI‐RADS v2: a comparison of two radiological scoring systems for detection of clinically significant prostate cancer

Christopher C. Khoo*, David Eldred-Evans*, Max Peters, Mariana Bertoncelli Tanaka*, Mohamed Noureldin*, Saiful Miah*, Taimur Shah*, Martin J. Connor*, Deepika Reddy*, Martin Clark§, Amish Lakhani§, Andrea Rockall§, Feargus Hosking-Jervis*, Emma Cullen*, Manit Arya*, David Hrouda, Hasan Qazi, Mathias Winkler*, Henry Tam§ and Hashim U. Ahmed*

*Imperial Prostate, Division of Surgery, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Imperial Urology, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK, Department of Radiotherapy, University Medical Centre, Utrecht, The Netherlands, §Department of Radiology, Charing Cross Hospital, Imperial College Healthcare NHS Trust and Department of Urology, St. George’s Hospital, St. George’s Healthcare NHS Trust, London, UK

Abstract

Objective

To compare the clinical validity and utility of Likert assessment and the Prostate Imaging Reporting and Data System (PI‐RADS) v2 in the detection of clinically significant and insignificant prostate cancer.

Patients and Methods

A total of 489 pre‐biopsy multiparametric magnetic resonance imaging (mpMRI) scans in consecutive patients were subject to prospective paired reporting using both Likert and PI‐RADS v2 by expert uro‐radiologists. Patients were offered biopsy for any Likert or PI‐RADS score ≥4 or a score of 3 with PSA density ≥0.12 ng/mL/mL. Utility was evaluated in terms of proportion biopsied, and proportion of clinically significant and insignificant cancer detected (both overall and on a ‘per score’ basis). In those patients biopsied, the overall accuracy of each system was assessed by calculating total and partial area under the receiver‐operating characteristic (ROC) curves. The primary threshold of significance was Gleason ≥3 + 4. Secondary thresholds of Gleason ≥4 + 3, Ahmed/UCL1 (Gleason ≥4 + 3 or maximum cancer core length [CCL] ≥6 or total CCL≥6) and Ahmed/UCL2 (Gleason ≥3 + 4 or maximum CCL ≥4 or total CCL ≥6) were also used.

Table 1: Comparison of Likert and Prostate Imaging Reporting and Data System scoring.

Results

The median (interquartile range [IQR]) age was 66 (60–72) years and the median (IQR) prostate‐specific antigen level was 7 (5–10) ng/mL. A similar proportion of men met the biopsy threshold and underwent biopsy in both groups (83.8% [Likert] vs 84.8% [PI‐RADS v2]; P = 0.704). The Likert system predicted more clinically significant cancers than PI‐RADS across all disease thresholds. Rates of insignificant cancers were comparable in each group. ROC analysis of biopsied patients showed that, although both scoring systems performed well as predictors of significant cancer, Likert scoring was superior to PI‐RADS v2, exhibiting higher total and partial areas under the ROC curve.

Conclusions

Both scoring systems demonstrated good diagnostic performance, with similar rates of decision to biopsy. Overall, Likert was superior by all definitions of clinically significant prostate cancer. It has the advantages of being flexible, intuitive and allowing inclusion of clinical data. However, its use should only be considered once radiologists have developed sufficient experience in reporting prostate mpMRI.

#RudeFood: Foodporn for a purpose

The Internet is full of weird and wonderful things. Of course, we all know what is most frequently viewed and shared online. That’s right – food! Nonetheless, when celebrity chef Manu Fieldel posted a photo of his latest creation, it certainly made people look long and hard!


Soon it became clear that this naughty creation had a noble purpose – supporting a campaign to raise awareness of the so-called #BelowTheBelt cancers. While most people may have heard of prostate and bladder cancers, being relatively common, other #BelowTheBelt cancers such as penile and testicular cancers are rarer and relatively unknown. To make matters worse, these cancers affect men either exclusively or predominantly – and we all know how reluctant men can be to go to the doctors.

Hence, the #RudeFood campaign was developed by the Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group. ANZUP is the peak co-operative trials group for #BelowTheBelt cancers in Australia and New Zealand. ANZUP has and continues to develop and run many significant clinical trials, including the Enzamet and Enzarad trials for prostate cancer, the Phase III accelerated BEP trial for germ-cell tumours, the sequential BCG-mitomycin trial for bladder cancer and the Eversun and Unison trials in kidney cancer.

The week started with things heating up at ANZUP as they brought #RudeFood to the unsuspecting world!

Manu’s phallic creation was also matched by Ainsley Harriot, Sonia Meffadi and Monty Kulodrovic.

To counterpoint the raunch, there were also poignant personal connections from Simon Leong and Scott Gooding who both described family members who had suffered from prostate cancer.


Over the week, #RudeFood has certainly drawn some attention, including from media outlets such as Mamamia, news.com.au and GOAT. 

A poetic contribution on #RudeFood caught the eye of @UroPoet across the seas. Let us hope this campaign will also lead to greater awareness of #BelowTheBelt cancers and improved outcomes for those affected by them.


Shomik Sengupta is Professor of Surgery at the EHCS of Monash University and visiting urologist & Uro-Oncology lead at Eastern Health. Shomik has particular interests in prostate cancer, including open and robotic prostatectomy, as well as bladder cancer, including cystectomy with neobladder diversion. Shomik is the current leader of the UroOncology SAG within USANZ, and the past chair of Victorian urology training.  Shomik is a Board member and scientific advisory member of the ANZUP Cancer trials group and is heavily involved in numerous clinical trials in GU oncology.

Twitter: @shomik_s 


Article of the week: Management of patients with advanced prostate cancer in the Asia Pacific region: ‘real‐world’ consideration of results from the Advanced Prostate Cancer Consensus Conference 2017

Every week, the Editor-in-Chief selects an Article of the Week 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 the article itself, there is an editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. There is also a video produced by the authors describing the ‘real-world’ findings.

If you only have time to read one article this week, it should be this one.

Management of patients with advanced prostate cancer in the Asia Pacific region: ‘real‐world’ consideration of results from the Advanced Prostate Cancer Consensus Conference 2017

Edmund Chionga, Declan G. Murphyb,c, Hideyuki Akazad, Nicholas C. Buchane,f, Byung Ha Chungg, Ravindran Kanesvaranh, Makarand Khochikari, Jason LetranjBannakij Lojanapiwatk, Chi-fai Ngl, Teng Ongm, Yeong-Shiau Pun, Marniza Saado, Kathryn Schubachq, Levent rkeris, Rainy Umbast, Vu Le Chuyenu, Scott Williamsv,r, Ding-Wei Yew, ANZUP Cancer Trials Groupx and Ian D. Davisy,z,r

 

aDepartment of Urology, National University Hospital, National University Health System Singapore, hDivision of Medical Oncology, National Cancer Centre Singapore, Singapore City, Singapore, bDivision of Cancer Surgery, vDivision of Radiation Oncology, Peter MacCallum Cancer Centre Melbourne, yMonash University, zEastern Health, Melbourne, cSir Peter MacCallum Department of Oncology, University Melbourne, Parkville, qAustralian New Zealand Urology Nurses (ANZUNS), Melbourne, VIC, Australia, rANZUP Cancer Trials Group, xLifehouse, Camperdown, Sydney, NSW, Australia, dStrategic Investigation on Comprehensive Cancer Network, The University of Tokyo, Tokyo, Japan, eCanterbury Urology Research Trust, fCanterbury District Health Board, Christchurch, New Zealand, gDepartment of Urology, Yonsei University College of Medicine, Seoul, Korea, iSiddhi Vinayak Ganapati Cancer Hospital, Miraj, India, jSection of Urology, Department of Surgery, University of Santo Tomas, Manila, Philippines, kDivision of Urology, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand, lDepartment of Surgery, SH Ho Urology Centre, The Chinese University of Hong Kong, Hong Kong, wDepartment of Urology, Fudan University Shanghai Cancer Center, Shanghai, China, mDivision of Urology, Department of Surgery, oDepartment of Clinical Oncology, Faculty of Medicine, University of Malaya, Kuala Lumpur,Malaysia, nDepartment of Urology, National Taiwan University Hospital, Taipei, Taiwan, sDepartment of Urology, Acibadem University, Istanbul, Turkey, tDepartment of Urology, University of Indonesia, Jakarta, Indonesia, and uDepartment of Urology, Binh dan Hospital, Ho Chi Minh City, Vietnam

 

Abstract

Objective

The Asia Pacific Advanced Prostate Cancer Consensus Conference (APAC APCCC 2018) brought together 20 experts from 15 APAC countries to discuss the real‐world application of consensus statements from the second APCCC held in St Gallen in 2017 (APCCC 2017).

Findings

Differences in genetics, environment, lifestyle, diet and culture are all likely to influence the management of advanced prostate cancer in the APAC region when compared with the rest of the world. When considering the strong APCCC 2017 recommendation for the use of upfront docetaxel in metastatic castration‐naïve prostate cancer, the panel noted possible increased toxicity in Asian men receiving docetaxel, which would affect this recommendation in the APAC region. Although androgen receptor‐targeting agents appear to be well tolerated in Asian men with metastatic castration‐resistant prostate cancer, access to these drugs is very limited for financial reasons across the region. The meeting highlighted that cost and access to contemporary treatments and technologies are key factors influencing therapeutic decision‐making in the APAC region. Whilst lower cost/older treatments and technologies may be an option, issues of culture and patient or physician preference mean, these may not always be acceptable. Although generic products can reduce cost in some countries, costs may still be prohibitive for lower‐income patients or communities. The panellists noted the opportunity for a coordinated approach across the APAC region to address issues of access and cost. Developments in technologies and treatments are presenting new opportunities for the diagnosis and treatment of advanced prostate cancer. Differences in genetics and epidemiology affect the side‐effect profiles of some drugs and influence prescribing.

Box 1: Management of advanced prostate cancer in the APAC region: real‐world challenges in implementing the St Gallen APCCC recommendations.

  1. Differences in toxicity: safety data for docetaxel are not fully established in Asian men and concerns about the toxicity profile and risk of neutropaenia may influence prescribing.
  2. Disparities in access to imaging technology: variable access to imaging technology may limit prescribing according to precise definitions.
  3. Disparities in access and cost of treatment: availability and cost of treatments are the most significant factor influencing prescribing decisions in the region; lower‐cost alternatives are not always culturally acceptable, and informed choice is important.
  4. Variability in MDT approaches: the importance of multidisciplinary input to treatment recommendations is understood but MDTs are a challenge in some APAC countries; virtual MDT participation should be encouraged.
  5. Variability in demographics: genetics and epidemiology in Asian men with prostate cancer may result in different treatment responses; collaborative registry studies and trials in APAC populations are likely to be valuable.

Conclusions

As the field continues to evolve, collaboration across the APAC region will be important to facilitate relevant research and collection and appraisal of data relevant to APAC populations. In the meantime, the APAC APCCC 2018 meeting highlighted the critical importance of a multidisciplinary team‐based approach to treatment planning and care, delivery of best‐practice care by clinicians with appropriate expertise, and the importance of patient information and support for informed patient choice.

 

Article of the week: RS‐RARP vs standard RARP: it’s time for critical appraisal

Every week, the Editor-in-Chief selects an Article of the Week 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 the article itself, there are two accompanying editorials written by prominent members of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. There is also a podcast by one of our Resident Podcasters describing the article.

If you only have time to read one article this week, it should be this one.

Retzius‐sparing robot‐assisted radical prostatectomy (RS‐RARP) vs standard RARP: it’s time for critical appraisal

Thomas Stonier*, Nick Simson*, John Davisand Ben Challacombe

 

*Department of Urology, Princess Alexandra Hospital, Harlow, Urology Centre, Guy s Hospital, London, UK and Department of Urology, MD Anderson Cancer Center, Houston, TX, USA

 

Since robot‐assisted radical prostatectomy (RARP) started to be regularly performed in 2001, the procedure has typically followed the original retropubic approach, with incremental technical improvements in an attempt to improve outcomes. These include the running Van‐Velthoven anastomosis, posterior reconstruction or ‘Rocco stitch’, and cold ligation of the Santorini plexus/dorsal vein to maximise urethral length. In 2010, Bocciardi’s team in Milan proposed a novel posterior or ‘Retzius‐sparing’ RARP (RS‐RARP), mirroring the classic open perineal approach. This allows avoidance of supporting structures, such as the puboprostatic ligaments, endopelvic fascia, and Santorini plexus, preserving the normal anatomy as much as possible and limiting damage that may contribute to improved postoperative continence and erectile function. There has been much heralding of the excellent functional outcomes in both the medical and the lay press, but as yet no focus or real mention of any potential downsides of this new technique.

 

Editorial: Retzius‐sparing robot‐assisted radical prostatectomy

In their commentary in the current issue of BJUI, Stonier et al. [1] examine the potential technical pitfalls and published results of the Retzius‐sparing technique of robotic radical prostatectomy. The authors reviewed three studies from three different groups [2,3], including a study by our group [4], and raised three specific concerns: the oncological efficacy of the procedure; the long learning curve; and the generalizability of the technique to challenging surgical scenarios. We offer a few clarifications and comments.

The first study on Retzius‐sparing robot‐assisted radical prostatectomy came from the Bocciardi group [2]. This was a prospective, single‐arm study of 200 patients. The authors reported a 14‐day continence rate of 90–92%, a 1‐year potency rate of 71–81% (in preoperatively potent patients undergoing bilateral intrafascial nerve‐sparing) and a positive surgical margin rate of 25.5%. The positive surgical margin rate improved in patients with pT2 disease, from 22% to 9% (P = 0.04) over the course of the study (initial 100 vs subsequent 100 patients), while in patients with pT3 disease, it remained stable at ~45%. Lim et al. [3] also noted an improvement in their overall positive surgical margin rate from 20% to 8% when comparing the initial 25 patients with the subsequent 25 patients. In that study, a standard robot‐assisted radical prostatectomy comparator arm was included and there were no differences in overall positive surgical margin rates (14% in both arms), while continence was better with the Retzius‐sparing approach.

Recognizing the potentially technically challenging nature of the Bocciardi approach, we performed a randomized controlled trial to objectively evaluate the technique. Randomized controlled trials are typically designed to answer a single question. Our trial was designed to determine whether there were differences in the rate of return of urinary continence, the primary benefit that previous non‐controlled studies had reported. This our study clearly showed [4].

Once the trial was completed, post hoc analysis of secondary outcomes was performed [5]. One of these outcomes was the positive surgical margin rate. In our trial, we noted an overall positive surgical margin rate of 25% in the Retzius‐sparing arm vs 13% in the control arm, a difference that did not achieve statistical significance (P = 0.11). Stonier et al. [1] suggested that if the sample size of our trial were doubled, then the positive surgical margin rate in each group would be doubled as well, leading to significance. This conclusion is problematic. The likelihood that doubling the sample size would result in the exact doubling of numbers in all four cells of a 2 × 2 contingency table is estimated at <5% using Fisher’s exact test (this calculation is different from the P value). Furthermore, the surgical margins depend as much on the pathological stage as on surgical approach. In our trial, patients were matched preoperatively for risk in the best manner possible for a pragmatic randomized trial. However, it is impossible to predict and control for the final pathological characteristics. Pathological analysis showed that patients undergoing Retzius‐sparing surgery did have significantly more aggressive disease: ≥pT3 disease in 45% vs 23.3% of patients (P = 0.04) [4, 5]. This, by itself, could account for a substantial difference in surgical margin rates.

In writing our paper, we made no judgements as to whether the Bocciardi or posterior technique is fundamentally superior to an anterior or Menon approach, whether it is easier to perform, how generalizable it is [6], or what the learning curve may be. That is best left to the individual surgeon’s training and judgement. We do suggest, however, that surgical margins be interpreted as a function of pathological variables, and not in isolation, and that it is simplistic to assume that identical results will be obtained by doubling sample size. We suggest that such conclusions are hypothesis‐generating, and should best be explored through a separate, purpose‐designed randomized trial.

Authors: Akshay Sood, Firas Abdollah and Mani Menon

References

  1. Stonier T, Simson N, Davis J, Challacombe B. Retzius‐sparing robot‐assisted radical prostatectomy (RS‐RARP) vs standard RARP: it’s time for critical appraisal. BJU Int 2019; 123: 5–10
  2. Galfano A, Di Trapani D, Sozzi F et al. Beyond the learning curve of the Retzius‐sparing approach for robot‐assisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with >/= 1 year of follow‐up. Eur Urol 2013; 64: 974–80
  3. Lim SK, Kim KH, Shin TY et al. Retzius‐sparing robot‐assisted laparoscopic radical prostatectomy: combining the best of retropubic and perineal approaches. BJU Int 2014; 114: 236–44
  4. Dalela D, Jeong W, Prasad MA et al. A pragmatic randomized controlled trial examining the impact of the Retzius‐sparing approach on early urinary continence recovery after robot‐assisted radical prostatectomy. Eur Urol 2017; 72: 677–85
  5. Menon M, Dalela D, Jamil M et al. Functional recovery, oncologic outcomes and postoperative complications after robot‐assisted radical prostatectomy: an evidence‐based analysis comparing the Retzius sparing and standard approaches. J Urol 2018; 199: 1210–7
  6. Galfano A, Secco S, Bocciardi AM. Will Retzius‐sparing prostatectomy be the future of prostate cancer surgery? Eur Urol 2017; 72: 686–8

 

Editorial: Reply: RS-RARP vs standard RARP

Since the introduction of robotic surgery in the treatment of patients with prostate cancer (PCa), different surgical innovations have been implemented in order to preserve postoperative functional outcomes while maintaining oncological safety. Sparing the Retzius space during robot‐assisted radical prostatectomy (RARP) was introduced early this decade by Galfano et al [1]. Interestingly, 90% and 96% of patients treated with Retzius‐sparing RARP (RS‐RARP) were continent (no pad/safety pad) at 1 week and 1 year, respectively. Similarly, our group reported a 70% continence rate (no pad) at 1 month after RS‐RARP [2].

The fast urinary continence recovery after RS‐RARP is related to several anatomical factors: the anterior Retzius space is kept intact; the urinary bladder is not dropped; the endopelvic fascia and puboprostatic ligaments are preserved; and there is minimal distortion of the supporting urethral tissues. A recent study reported [3] that less bladder neck descent was observed during postoperative cystogram in patients treated with RS‐RARP than in those treated with standard RARP.

In a recent randomized controlled study, the postoperative continence rate at 1 week was 48% in standard RARP compared with 71% in RS‐RARP (P = 0.01), and this difference was maintained at 3 months (86% standard RARP vs 95% RS‐RARP; P = 0.02). At 1 year, however, the effect on urinary continence difference was muted (93.3% standard RARP vs 98.3% RS‐RARP; P = 0.09) [4]. Similarly, Chang et al. [3] found that the higher continence rate at 1 week (73.3% RS‐RARP vs 26.7% standard RARP; P = 0.000) had vanished at 1 year (100% vs 93.3%; P = 0.15). By contrast, a large recent prospective series showed that the superiority of RS‐RARP in terms of higher early urinary continence was maintained at 1 year (97.5% RS‐RARP vs 68.5% standard RARP) [5].

In addition to a higher early continence rate, RS‐RARP has a lower incidence of postoperative inguinal hernia occurrence compared with standard RARP [6]. Theoretically, RS‐RARP may provide several other potential advantages. It may be advantageous if patients require future surgery necessitating access to the Retzius space and dropping of the bladder, such as an artificial urinary sphincter implantation, an inflatable penile prosthesis insertion, or kidney transplantation. In addition, in patients with previous inguinal hernia repair using mesh, it enables the avoidance of anterior adhesions by accessing the prostate directly from the Douglas pouch. Notably, large‐size glands and/or middle‐lobe, advanced/high‐risk PCa, and patients with previous prostatic surgeries can be managed safely with RS‐RARP in experienced hands.

Undoubtedly, oncological safety is our main concern in treating cancer. To determine the effectiveness of new treatment methods, long‐term follow‐up is warranted. Biochemical recurrence (BCR) is widely used as a primary oncological outcome to assess PCa treatment success. To our knowledge, after radical prostatectomy, ~35% of patients are at risk of developing BCR in the next 10 years. Currently, there are insufficient data regarding the oncological outcomes of RS‐RARP. Only four articles have compared early oncological outcomes between RS‐RARP and standard RARP, and there was no significant difference (Table 1).

More recently, we reported on the mid‐term oncological outcomes of 359 patients who underwent RS‐RARP. The median follow‐up was 26 months. Although this period is not long enough to reach a meaningful conclusion on the oncological safety of RS‐RARP, it is the longest follow‐up period reported in literature. Overall, the positive surgical margin (PSM) rate was 30.6% (14.6% in pT2 and 40.8% in pT3a disease) and the BCR rate was 14.8%. In terms of functional outcomes, the urinary continence rate at 1 year was 93.9% [7]. Interestingly, 164 patients (45.7%) of our cohort had high‐risk PCa. In these patients, the PSM rate was 41.2%, the BCR rate was 22%, and the 3‐year BCR‐free survival (BCRFS) rate was 72%. We compared our results with those in patients with high‐risk PCa treated with standard RARP in the literature. In studies that used the D’Amico criteria the median follow‐up ranged from 12.5 to 37.3 months, the PSM rates were 20.5% to 53.3%, the BCR rates were 17.4% to 31% and the 3‐year BCRFS rates were 41.4% to 86%. In studies that used the National Comprehensive Cancer Network criteria, the median follow‐up ranged from 23.6 to 27 months, the PSM rates were 29% to 38%, the BCR rates were 9.4% to 33%, and the 3‐year BCRFS rates were 55% to 66% [7].

In summary, RS‐RARP is a novel surgical approach which is associated with better urinary continence recovery in the first few months compared with standard RARP [2,3,4,5]. This superiority might be maintained [5] or equalized at 1 year [3,4]. A few studies have compared the early oncological results between RS‐RARP and standard RARP and no significant difference was found [2,3,4,5]. Recently, our group reported the mid‐term oncological outcomes of patients with high‐risk PCa treated with RS‐RARP and these were similar to those of large studies of conventional RARP. This confirms effective and safe mid‐term BCR control after RS‐RARP, while the long‐term oncological results are awaited [7]. Currently, >4 000 cases of RS‐RARP are performed worldwide and more centres are beginning to use and converting to Retzius‐sparing surgery. All centres are experiencing faster recovery of continence. Thanks are due to Drs Galfano and Bocciardi for exploring and sharing this surgical frontier.

 

References

  1. Galfano A, Di Trapani D, Sozzi F, et al. Beyond the learning curve of the Retzius‐sparing approach for robotassisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with ? 1 year of follow‐up. Eur Urol 2013; 64: 974‐80
  2. Lim SK, Kim KH, Shin TY et al. Retzius‐sparing robot‐assisted laparoscopic radical prostatectomy: combining the best of retropubic and perineal approaches. BJU Int 2014; 114: 236–44
  3. Chang LW, Hung SC, Hu JC et al. Retzius‐sparing robotic‐assisted radical prostatectomy associated with less bladder neck descent and better early continence outcome. Anticancer Res 2018; 38: 345–51
  4. Menon M, Dalela D, Jamil M et al. Functional recovery, oncologic outcomes and postoperative complications after robot‐assisted radical prostatectomy: an evidence‐based analysis comparing the Retzius sparing and standard approaches. J Urol 2018; 199: 1210–7
  5. Sayyid RK, Simpson WG, Lu C et al. Retzius sparing robotic assisted laparoscopic radical prostatectomy: a safe surgical technique with superior continence outcomes. J Endourol 2017; 31: 1244–50
  6. Chang KD, Abdel Raheem A, Santok GDR et al. Anatomical Retzius‐space preservation is associated with lower incidence of postoperative inguinal hernia development after robot‐assisted radical prostatectomy. Hernia 2017; 21: 555–61
  7. Abdel Raheem A, Kidon C, Alenzi M et al. Predictors of biochemical recurrence after retzius‐sparing robot‐assisted radical prostatectomy: analysis of 359 cases with a median follow‐up of 26 months. Int J Urol 2018; 25: 1006–14

 

Resident’s podcast: Retzius‐sparing robot‐assisted radical prostatectomy

Maria Uloko is a Urology Resident at the University of Minnesota Hospital. In this podcast she discusses the following BJUI Article of the Week:

Retzius‐sparing robot‐assisted radical prostatectomy (RS‐RARP) vs standard RARP: it’s time for critical appraisal

Thomas Stonier*, Nick Simson*, John Davisand Ben Challacombe

 

*Department of Urology, Princess Alexandra Hospital, Harlow, Urology Centre, Guy s Hospital, London, UK and Department of Urology, MD Anderson Cancer Center, Houston, TX, USA

 

Abstract

Since robot‐assisted radical prostatectomy (RARP) started to be regularly performed in 2001, the procedure has typically followed the original retropubic approach, with incremental technical improvements in an attempt to improve outcomes. These include the running Van‐Velthoven anastomosis, posterior reconstruction or ‘Rocco stitch’, and cold ligation of the Santorini plexus/dorsal vein to maximise urethral length. In 2010, Bocciardi’s team in Milan proposed a novel posterior or ‘Retzius‐sparing’ RARP (RS‐RARP), mirroring the classic open perineal approach. This allows avoidance of supporting structures, such as the puboprostatic ligaments, endopelvic fascia, and Santorini plexus, preserving the normal anatomy as much as possible and limiting damage that may contribute to improved postoperative continence and erectile function. There has been much heralding of the excellent functional outcomes in both the medical and the lay press, but as yet no focus or real mention of any potential downsides of this new technique.

 

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