Should obesity be associated with worse urinary continence outcomes after robotic-assisted radical prostatectomy? a propensity score matching analysis

ABSTRACT Purpose: To analyze the association between obesity and urinary incontinence rate in men submitted to robot-assisted radical prostatectomy (RARP) in a high-volume cancer center. Materials and Methods: We reported 1.077 men who underwent RARP as the primary treatment for localized prostate cancer from 2013 to 2017. Patients were classified as non-obese (normal BMI or overweight) or obese men (BMI ≥30kg/m2). They were grouped according to the age, PSA level, D'Amico risk group, Gleason score, ASA classification, pathological stage, prostate volume, salvage/adjuvant radiotherapy, perioperative complications, and follow-up time. Urinary continence was defined as the use of no pads. For the analysis of long-term urinary continence recovery, we conducted a 1:1 propensity-score matching to control confounders. Results: Among the obese patients, mean BMI was 32.8kg/m2, ranging 30 - 45.7kg/m2. Only 2% was morbidly obese. Obese presented more comorbidities and larger prostates. Median follow-up time was 15 months for the obese. Complications classified as Clavien ≥3 were reported in 5.6% of the obese and in 4.4% of the non-obese men (p=0.423). Median time for continence recovery was 4 months in both groups. In this analysis, HR was 0.989 for urinary continence recovery in obese (95%CI=0.789 - 1.240; p=0.927). Conclusions: Obese can safely undergo RARP with similar continence outcomes comparing to the non-obese men when performed by surgeons with a standardized operative technique. Future studies should perform a subgroup analysis regarding the association of obesity with other comorbidities, intending to optimize patient counseling.

Prostate Cancer Screening in Brazil: a single center experience in the public health system

ABSTRACT Purpose: Incidence and mortality of prostate cancer (PCa) are still increasing in developing countries. Limited access to the health system or more aggressive disease are potential reasons for this. Ethnic and social differences in developed countries seem to make inappropriate to extrapolate data from other centers. We aim to report the epidemiological profile of a PSA-screened population from a cancer center in Brazil. Materials and Methods: We retrospectively selected 9.692 men enrolled in a PCa prevention program, comprising total PSA level and digital rectal examination at the first appointment, associated with complementary tests when necessary. Men aged over 40 years-old were included after shared decision-making process. Prostate biopsy (TRUS) was performed when clinically suspected for PCa. After the diagnosis, patients underwent appropriate treatment. Results: TRUS was performed in 5.5% of men and PCa incidence was 2.6%. Overall ratio between number of patients who needed to be screened in order to diagnose one cancer was 38.9 patients, with 2.1 biopsies performed to diagnose a cancer. Positive predictive value (PPV) of TRUS biopsy in this strategy was 47.2%, varying from 38.5% (<50 years-old) to 60% (>80 years-old). We evidenced 70 patients (27.9%) classified as low risk tumors, 74 (29.5%) as intermediate risk, and 107 (42.6%) as high-risk disease. Conclusions: PSA-screening remains controversial in literature. In front of a huge miscegenated people and considering the big proportion of high-risk PCa, even in young men diagnosed with the disease, it is imperative to inform patients and health providers about these data particularities in Brazil.

Análise da custo-efetividade do rastreamento e das modalidades terapêuticas do câncer de próstata / Cost-effectiveness analysis of prostate cancer screening and therapeutic modalities

O câncer de próstata é a segunda neoplasia maligna mais comum no mundo. Apesar do emprego do rastreamento populacional com o uso do PSA (Prostate specific antigen) ter proporcionado diminuição na mortalidade pela doença, sua validade tem sido questionada em alguns grandes estudos. A da falta de políticas de prevenção efetivas e de dados brasileiros sobre o comportamento do câncer de próstata desfavorecem a análise sobre a realidade dessa população. As opções terapêuticas curativas para o câncer de próstata em seus estágios iniciais incluem a prostatectomia radical, radioterapia, ablação prostática com ultrassom de alta frequência (HIFU), todas elas relacionadas a complicações e sequelas funcionais, as quais podem ser diminuídas com o uso de técnicas minimamente invasivas, porém acarretando impacto no aumento de custos das fontes pagadoras. O presente estudo analisa a relação custoefetividade de um programa de rastreamento populacional de câncer de próstata na cidade de São Paulo (SP ­ Brasil), bem como custo-efetividade das cirurgias (aberta e robótica); a relação de custo minimização entre radioterapia e terapia ablativa (HIFU), e os custos de hormonioterapia, quimioterapia e outras terapias sistêmicas paliativas realizadas no A.C.Camargo Cancer Center entre os anos de 2013 e 2018. A análise dos resultados demonstrou que o rastreamento populacional e a prostatectomia radical robótica são custo-efetivas em relação ao não rastreamento e à prostatectomia aberta, segundo os padrões de cálculo estabelecidos pela OMS (AU)

Prostate cancer is the second most common malignancy in the world. Despite of prostate specific antigen (PSA) based population screening had shown mortality reduction, its validity has been questioned in some large studies. The lack of effective Brazilian prevention policies and data on prostate cancer behavior undermine a population's reality analysis. Curative treatment options for initial prostate cancer include radical prostatectomy, radiotherapy and high frequency ultrasound prostate ablation (HIFU), all of them related to complications and functional sequelae, which can be diminished by using minimally invasive techniques, however, affecting the rising costs of paying sources. This study analyzes the cost-effectiveness of a prostate cancer population screening program in the city of São Paulo (SP - Brazil), as well as the cost-effectiveness of surgeries (open and robotic approaches); a minimized-cost relationship between radiotherapy and ablative therapy (HIFU), and general costs of hormone therapy, chemotherapy and other palliative systemic therapies performed at the A.C.Camargo Cancer Center between 2013 and 2018. Results demonstrated that PSA based population screening and Robotic radical prostatectomy are cost-effective compared to not-screening population and open prostatectomy, according to WHO calculation standards (AU)