Risk of complications and urinary incontinence following cytoreductive prostatectomy: a multi-institutional study.

Emerging evidence has suggested that cytoreductive prostatectomy (CRP) allows superior oncologic control when compared to current standard of care androgen deprivation therapy alone. However, the safety and benefit of cytoreduction in metastatic prostate cancer (mPCa) has not been proven. Therefore, we evaluated the incidence of complications following CRP in men newly diagnosed with mPCa. A total of 68 patients who underwent CRP from 2006 to 2014 at four tertiary surgical centers were compared to 598 men who underwent radical prostatectomy for clinically localized prostate cancer (PCa). Urinary incontinence was defined as the use of any pad. CRP had longer operative times (200 min vs 140 min, P < 0.0001) and higher estimated blood loss (250 ml vs 125 ml, P < 0.0001) compared to the control group. However, both overall (8.82% vs 5.85%) and major complication rates (4.41% vs 2.17%) were comparable between the two groups. Importantly, urinary incontinence rate at 1-year after surgery was significantly higher in the CRP group (57.4% vs 90.8%, P < 0.0001). Univariate logistic analysis showed that the estimated blood loss was the only independent predictor of perioperative complications both in the unadjusted model (OR: 1.18; 95% CI: 1.02-1.37; P = 0.025) and surgery type-adjusted model (OR: 1.17; 95% CI: 1.01-1.36; P = 0.034). In conclusion, CRP is more challenging than radical prostatectomy and associated with a notably higher incidence of urinary incontinence. Nevertheless, CRP is a technically feasible and safe surgery for selecting PCa patients who present with node-positive or bony metastasis when performed by experienced surgeons. A prospective, multi-institutional clinical trial is currently underway to verify this concept.

Bladder neck contracture-incidence and management following contemporary robot assisted radical prostatectomy technique.

PURPOSE: Bladder neck contracture (BNC) is a well-recognized complication following robot-assisted radical prostatectomy (RARP) for treatment of localized prostate cancer with a reported incidence of up to 1.4%. In this series, we report our institutional experience and management results. METHODS: A prospectively collected database of patients who underwent RARP by a single surgeon from 2006 to 2012 was reviewed. Watertight bladder neck to urethral anastomosis was performed over 18-French foley catheter. BNC was diagnosed by flexible cystoscopy in patients who developed symptoms of bladder outlet obstruction. Subsequently, these patients underwent cold knife bladder neck incisions. Patients then followed a strict self regimen of clean intermittent catheterization (CIC). We identify the patient demographics, incidence of BNC, associated risk factors and success of subsequent management. RESULTS: Total of 930 patients who underwent RARP for localized prostate cancer was identified. BNC was identified in 15 patients, 1.6% incidence. Mean patient age and preoperative prostate-specific antigen was 58.8 years old and 7.83 ng/mL (range, 2.5-14.55 ng/mL) respectively. Mean estimated blood loss was 361±193 mL (range, 50-650 mL). Follow-up was mean of 23.4 months. Average time to BNC diagnosis was 5.5 months. In three patients, a foreign body was identified at bladder neck. On multivariate analysis, estimated blood loss was significantly associated with development of BNC. All patients underwent cystoscopy and bladder neck incision with a 3-month CIC regimen. Out of 15 index patients, none had a BNC recurrence over the follow-up period. CONCLUSIONS: BNC was identified in 1.6% of patients in our series following RARP. Intraoperative blood loss was a significant risk factor for BNC. In 20% of BNC patients a migrated foreign body was noted at vesicourethral anastomosis. Primary management of patients with BNC following RARP should be bladder neck incision and self CIC regimen.

Active surveillance in men with low-risk prostate cancer: current and future challenges.

INTRODUCTION: The implementation of prostate-specific antigen (PSA) screening has coincided with a decrease in mortality rate from prostate cancer at the cost of overtreatment. Active surveillance has thus emerged to address the concern for over-treatment in men with low-risk prostate cancer. METHODS: A contemporary review of literature with respect to low-risk prostate cancer and active surveillance was conducted. The premise of active surveillance, ideal candidates, follow-up practices, treatment triggers, and the observed outcomes of delayed interventions are reviewed. Various institutional protocols are compared and contrasted. RESULTS: Eligibility criteria from various institutions share similar principles. Candidates are followed with PSA kinetics and/or repeat biopsies to identify those who require intervention. Various triggers for intervention have been recognized achieving overall and cancer-specific survival rates > 90% in most protocols. New biomarkers, imaging modalities and genetic tests are also currently being investigated to enhance the efficacy of active surveillance programs. CONCLUSION: Active surveillance has been shown to be safe and effective in managing men with low-risk prostate cancer. Although as high as 30% of men on surveillance will eventually need intervention, survival rates with delayed intervention remain reassuring. Long-term studies are needed for further validation of current active surveillance protocols.