Robot-assisted radical prostatectomy: Advancements in surgical technique and perioperative care

We reviewed the evolving strategies, practice patterns, and recent advancements aimed at improving the perioperative and surgical outcomes in patients undergoing robot-assisted radical prostatectomy for the management of localized prostate cancer

Rare Histological Variants of Prostate Adenocarcinoma (PCa): NCDB Analysis

Introduction and Objective: American Joint Committee on Cancer (AJCC) recognizes five rare histological variants of prostate adenocarcinoma (PCa). Our aim was to describe the contemporary presentation and overall survival (OS) of these rare variants. Methods: From 2004-2015, we selected cases of mucinous, ductal, signet ring cell (SRC), Adenosquamous, and neuroendocrine (NEC) variants of PCa from the National Cancer Database. Characteristics at presentation for each variant were compared with nonvariant PCa. Cox regression was used to study the effect of histological subtype on overall mortality. Results: Less than 1 percent (5062/1345561; 0.38%) patients presented with rare-variant PCa. All variants had a higher clinical T stage at presentation than nonvariant PCa (all p\u3c0.001; Table 1). Metastatic disease was most common with NEC (62.9%), followed by adenosquamous (31.1%), SRC (10.3%), and ductal (9.8%) variants, compared to 4.2% in nonvariant PCa (all p\u3c0.001). Metastatic disease in mucinous (3.3%) was similar to nonvariant PCa (p = 0.15). SRC, mucinous, and ductal variants presented with a significantly higher PSA (Median 9.0, 6.7, and 6.6, respectively vs. 6.2 ng/ml in nonvariant PCa; all p \u3c 0.001), and higher biopsy grade (Grade group ≥ 4 (34.7%, 11.2%, and 27%, respectively vs. 8.6% in nonvariant PCa; all p \u3c 0.001). Estimated 5-year OS was highest in mucinous variant (89.3%), followed by nonvariant (87.2%), ductal (76.4%), SRC (67.0%), adenosquamous (20.5%), and NEC PCa (13.4%). After adjusting for covariates—compared to nonvariant PCa—mortality was significantly higher in ductal, SRC, adenosquamous, and NEC variants (Table 2) Conclusions: There are differences in the presentation and OS among rare variants of PCa. NEC, adenosquamous, signet ring cell, and ductal variants more commonly present with metastatic disease. All variants present with a higher local stage than nonvariant PCa. NEC variant is associated with the worst, and mucinous variant with the best OS.https://scholarlycommons.henryford.com/merf2019basicsci/1004/thumbnail.jp

Understanding the Use of Prostate Biopsy Among Men with Limited Life Expectancy in a Statewide Quality Improvement Collaborative

BACKGROUND: The potential harms of a prostate cancer (PCa) diagnosis may outweigh its benefits in elderly men. OBJECTIVE: To assess the use of prostate biopsy in men with limited life expectancy (LE) within the practices comprising the Michigan Urological Surgery Improvement Collaborative (MUSIC). DESIGN, SETTING, AND PARTICIPANTS: MUSIC is a consortium of 42 practices and nearly 85% of the urologists in Michigan. From July 2013 to October 2014, clinical data were collected prospectively for all men undergoing prostate biopsy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We calculated comorbidity-adjusted LE in men aged ≥66 yr and identified men with(limited LE) undergoing a first biopsy. Our LE calculator was not designed for men agedyr; thus these men were excluded. Multivariable models estimated the proportion of all biopsies performed for men with limited LE in each MUSIC practice, adjusting for differences in patient characteristics. We also evaluated what treatments, if any, these patients received. RESULTS AND LIMITATIONS: Among 3035 men aged ≥66 yr undergoing initial prostate biopsy, 60% had none of the measured comorbidities. Overall, 547 men (18%) had limited LE. Compared with men with a longer LE, these men had significantly higher prostate-specific antigen levels and abnormal digital rectal examination findings. The adjusted proportion of biopsies performed for men with limited LE ranged from 3.8% to 39% across MUSIC practices (p \u3c 0.001). PCa was diagnosed in 69% of men with limited LE; among this group, 74% received any active treatment. Of these men, 46% had high-grade cancer (Gleason score 8-10). CONCLUSIONS: Among a large and diverse group of urology practices, nearly 20% of prostate biopsies are performed in men with limited LE. These data provide useful context for quality improvement efforts aimed at optimizing patient selection for prostate biopsy. PATIENT SUMMARY: In this report, nearly 2 of every 10 men undergoing prostate biopsy had a life expectancy (LE)biopsy

Genomic Classifier Augments the Role of Pathological Features in Identifying Optimal Candidates for Adjuvant Radiation Therapy in Patients With Prostate Cancer: Development and Internal Validation of a Multivariable Prognostic Model.

Purpose Despite documented oncologic benefit, use of postoperative adjuvant radiotherapy (aRT) in patients with prostate cancer is still limited in the United States. We aimed to develop and internally validate a risk-stratification tool incorporating the Decipher score, along with routinely available clinicopathologic features, to identify patients who would benefit the most from aRT. Patient and Methods Our cohort included 512 patients with prostate cancer treated with radical prostatectomy at one of four US academic centers between 1990 and 2010. All patients had ≥ pT3a disease, positive surgical margins, and/or pathologic lymph node invasion. Multivariable Cox regression analysis tested the relationship between available predictors (including Decipher score) and clinical recurrence (CR), which were then used to develop a novel risk-stratification tool. Our study adhered to the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis guidelines for development of prognostic models. Results Overall, 21.9% of patients received aRT. Median follow-up in censored patients was 8.3 years. The 10-year CR rate was 4.9% vs. 17.4% in patients treated with aRT versus initial observation ( P \u3c .001). Pathologic T3b/T4 stage, Gleason score 8-10, lymph node invasion, and Decipher score \u3e 0.6 were independent predictors of CR (all P \u3c .01). The cumulative number of risk factors was 0, 1, 2, and 3 to 4 in 46.5%, 28.9%, 17.2%, and 7.4% of patients, respectively. aRT was associated with decreased CR rate in patients with two or more risk factors (10-year CR rate 10.1% in aRT v 42.1% in initial observation; P = .012), but not in those with fewer than two risk factors ( P = .18). Conclusion Using the new model to indicate aRT might reduce overtreatment, decrease unnecessary adverse effects, and reduce risk of CR in the subset of patients (approximately 25% of all patients with aggressive pathologic disease in our cohort) who benefit from this therapy

Evaluating the Role of LVI as an Indicator for Adverse Outcomes in Patients with Upper Tract Urothelial Carcinoma and its Histological Subtypes

Lymphvascular invasion (LVI) is recognized as an adverse prognostic factor in many cancers. Our aim is to assess the prognostic ability of LVI in UTUC urothelial carcinoma (UC) and micropapillary urothelial carcinoma (MPUC) subtypes as a predictor of overall survival (OS) using a large North American cohort. Our cohort included 9750 cM0 UTUC patients who underwent a radical nephroureterectomy (RNU), between 2004 and 2015, within the National Cancer Database (NCDB). The main variable of interest was LVI status, and its interaction with pathological nodal (pN) status. Kaplan-Meier curves were used to estimate the OS. Cox regression analysis tested the impact of LVI status on OS after accounting for covariates. In patients with UC at 5-years post-RNU, the OS rates were 60.2%, 29.9%, 28.9%, and 20.8% in patient with pN0 without LVI, pN0 with LVI, pN+ without LVI, and pN+ with LVI, respectively (p Our report is the first to examine the impact of LVI on OS in a large North American nationwide cohort. It indicates that LVI is associated with reduced OS in patients with UTUC treated surgically

Impact of Hospital Teaching Status on Healthcare Utilization, Length of Stay (LOS), and Cost of Hospitalization of Radiation Cystitis (RC) in the United States

Background: Limited data exist regarding in-hospital use of resources, LOS, and cost of RC-associated admissions in teaching hospital (TH) versus nonteaching hospital (NTH) settings. The goal of this study was to address the above void in literature. Methods:We focused on 13,272 admissions for RC between 2008-2014 within the National Inpatient Sample. Patients with concurrent diagnosis of other bladder conditions (n=914) were excluded. ICD-9 diagnosis and procedure codes were used to study inpatient procedures performed during admission. Type of admissions, receipt of a procedure, type of procedures performed, LOS, and total inflation-adjusted cost were then compared between TH and NTH. Complex survey chi-squared test and analysis of variance procedures were used to account for the NIS sampling design. Results: Of the 12,358 assessable records, 49% were at THs. Patients were more commonly admitted to emergency department at NTH (85%) compared to TH (80%; p\u3c0.001). Weekend admissions were more common at NTH (24%) compared to TH (21%) (p=0.004). Receipt of a procedure during admission was higher in TH (65%) compared to NTH (60%; p\u3c0.001). Number of procedure codes recorded was higher in TH (\u3e= 2 codes; 28.9% in TH vs 24.5% in NTH; p \u3c0.001. More complex procedures like cystectomy were almost exclusively performed at TH (cystectomy 2.4% in TH vs 0.4% in NTH admissions; p \u3c0.001), whereas there was no difference in procedures like blood transfusion (TH 34%; NTH 33%; p=0.3), suprapubic cystostomy (TH 1.3%; NTH 1.4%; p=0.8), and transurethral procedures (TH 14%; NTH 16%; p=0.06). Despite statistically significant difference in LOS between the two groups (Median days (IQR): TH 5 (3-9); NTH 5 (3-8); p\u3c0.001) the difference was not clinically significant. Cost of admission was higher in TH (10,377$TH; 8504$ NTH; p\u3c0.001). Conclusions: In the United States, patients with RC are more frequently admitted to the emergency department in NTH. Patients admitted to TH receive a procedure more often, receive a higher number of procedures, and more complex procedures, compared to NTH. This explains higher cost of admission in TH. Further research is needed to study the readmission rates and outcomes of patients treated in both types of health systems to know the best practices that can reduce morbidity and readmissions.https://scholarlycommons.henryford.com/merf2019qi/1021/thumbnail.jp