Assessing Decision Regret in Patients with Same-Day Discharge Pathway After Robot-Assisted Radical Prostatectomy.

Introduction: After the introduction of same-day discharge (SDD) pathways for various surgeries, these pathways have demonstrated comparable complication rates and a reduced overall cost of care. Outpatient robot-assisted radical prostatectomy (RARP) is introduced in high-volume centers; however, patients' perspectives on the SDD RARP protocol are not well understood. Materials and Methods: A questionnaire consisting of 24 questions, including the Likert Decisional Regret Scale, was distributed to patients who underwent RARP at our center. The overall decision regret score was calculated as described in the literature. We used 15 as a cutoff point for differentiating between high- and low-regret rates. Median and interquartile range were determined for non-normally distributed variables, while mean ± standard deviation was calculated for continuous data. Results: Of the 72 patients who completed the questionnaire, 65.7% (n = 44) of patients felt no regret about their decision of choosing the SDD RARP protocol and 90.3% (n = 65) of men stated that they would have made the same decision. At the same time, 97.1% (n = 68) of patients would also recommend this procedure to others. The median decisional regret score of the cohort (n = 67) was 0 (0-10). Fifty-four of 67 (80.6%) patients were in the low-regret score group, while 13 (19.4%) were in the high-regret group. Patients in the high-regret group were more likely to have low household income (<$30,000 a year) and they experienced postoperative pain more frequently compared with patients in the lower regret group (7.7% vs 1.9%, p = 0.626, and 61.5% vs 38.9%, p = 0.212, respectively). Conclusions: Most patients expressed low regret about choosing the SDD pathway for RARP, underscoring the importance of thorough explanation of the procedure and discharge process to enhance patient experience. However, a subset of patients did express regret, possibly due to an interplay of patient- and procedure-related factors.

Multi-Institutional Development and Validation of a Radiomic Model to Predict Prostate Cancer Recurrence Following Radical Prostatectomy.

The use of multiparametric magnetic resonance imaging (mpMRI)-derived radiomics has the potential to offer noninvasive, imaging-based biomarkers for the identification of subvisual characteristics indicative of a poor oncologic outcome. The present study, therefore, seeks to develop, validate, and assess the performance of an MRI-derived radiomic model for the prediction of prostate cancer (PC) recurrence following radical prostatectomy (RP) with curative intent. mpMRI imaging was obtained from 251 patients who had undergone an RP for the treatment of localized prostate cancer across two institutions and three surgeons. All patients had a minimum of 2 years follow-up via prostate-specific antigen serum testing. Each prostate mpMRI was individually reviewed, and the prostate was delineated as a single slice (ROI) on axial T2 high-resolution image sets. A total of 924 radiomic features were extracted and tested for stability via intraclass correlation coefficient (ICC) following image normalization via histogram matching. Fourteen important and nonredundant features were found to be predictors of PC recurrence at a mean ± SD of 3.2 ± 2.2 years post-RP. Five-fold, ten-run cross-validation of the model containing these fourteen features yielded an area under the curve (AUC) of 0.89 ± 0.04 in the training set (n = 225). In comparison, the University of California San Fransisco Cancer of the Prostate Risk Assessment score (UCSF-CAPRA) and Memorial Sloan Kettering Cancer Center (MSKCC) Pre-Radical prostatectomy nomograms yielded AUC of 0.66 ± 0.05 and 0.67 ± 0.05, respectively (p < 0.01). When the radiomic model was applied to the test set (n = 26), AUC was 0.78; sensitivity, specificity, positive predictive value, and negative predictive value were 60%, 86%, 52%, and 89%, respectively. Accuracy in predicting PC recurrence was 81%.

Assessing the Impact of Positive Surgical Margins on Mortality in Patients Who Underwent Robotic Radical Prostatectomy: 20 Years' Report from the EAU Robotic Urology Section Scientific Working Group.

BACKGROUND: Positive surgical margins (PSMs) are frequent in patients undergoing radical prostatectomy (RP). The impact of PSMs on cancer-specific (CSM) and overall (OM) mortality has not yet been proved definitively. OBJECTIVE: To evaluate whether the presence and the features of PSMs were associated with CSM and OM in patients who underwent robotic-assisted RP. DESIGN, SETTING, AND PARTICIPANTS: A cohort of 8141 patients underwent robotic-assisted RP with >10 yr of follow-up. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Cox multivariable analyses assessed the impact of margin status (positive vs negative) and PSM features (negative vs <3 mm vs >3 mm vs multifocal) on the risk of CSM, OM, and biochemical recurrence (BCR) after adjusting for potential confounders. We repeated our analyses after stratifying patients according to clinical (Cancer of the Prostate Risk Assessment [CAPRA] categories) and pathological characteristics (adverse: pT 3-4 and/or grade group [GG] 4-5 and/or pN1 and/or prostate-specific antigen [PSA] persistence). RESULTS AND LIMITATIONS: PSMs were found in 1348 patients (16%). Among these, 48 (3.6%) patients had multifocal PSMs. Overall, 1550 men experienced BCR and 898 men died, including 130 for prostate cancer. At Cox multivariable analyses, PSMs were associated with CSM in patients with adverse clinical (Intermediate risk: hazard ratio [HR]: 1.71, p = 0.048; high risk: HR: 2.20, p = 0.009) and pathological (HR: 1.79, p = 0.005) characteristics. Only multifocal PSMs were associated with CSM and OM in the whole population (HR for CSM: 4.68, p < 0.001; HR for OM: 1.82, p = 0.037) and in patients with adverse clinical (intermediate risk: HR for CSM: 7.26, p = 0.006; high risk: HR for CSM: 9.26, p < 0.001; HR for OM: 2.97, p = 0.006) and pathological (HR for CSM: 9.50, p < 0.001; HR for OM: 2.59, p = 0.001) characteristics. Potential limitations include a selection bias and a lack of information on the Gleason score at PSM location. CONCLUSIONS: We did not find an association between unifocal PSMs and mortality. Conversely, our results underscore the importance of avoiding multifocal PSMs in patients with adverse clinical (intermediate- and high-risk CAPRA score) and pathological (GG ≥4, pT ≥3, pN1, or PSA persistence) characteristics, to enhance overall survival and reduce CSM. PATIENT SUMMARY: In this study, we evaluated whether the presence and the characteristics of positive surgical margins were associated with mortality in patients who underwent robotic-assisted radical prostatectomy. We found that the presence of positive surgical margins, particularly multifocal margins, was associated with mortality only in patients with adverse clinical and pathological characteristics.

Prostate Cancer-specific and All-cause Mortality After Robot-assisted Radical Prostatectomy: 20 Years' Report from the European Association of Urology Robotic Urology Section Scientific Working Group.

BACKGROUND: Evidence on long-term oncological efficacy is available only for open radical prostatectomy but remains scarce for robot-assisted radical prostatectomy (RARP). OBJECTIVE: To validate the long-term survival rates after RARP and provide stratified outcomes based on contemporary prostate cancer (PCa) risk-stratification tools. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of the European Association of Urology (EAU) Robotic Urology Section Scientific Working Group international multicenter database for RARP was performed. Patients who underwent RARP at seven pioneer robotic urology programs in Europe and the USA between 2002 and 2012 were included. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcomes were PCa-specific mortality and all-cause mortality. The probability of cancer-specific survival (CSS) was estimated with the competing risks method, and the probability of overall survival (OS) was estimated with the Kaplan-Meier method. RESULTS AND LIMITATIONS: A total of 9876 patients who underwent RARP between 2002 and 2012 were included. Within follow-up, 1071 deaths occurred and 159 were due to PCa. At 15 yr of follow-up, CSS and OS were 97.6% (97.2%, 98.0%) and 85.5% (84.6%, 86.4%), respectively. Stratified analyses based on EAU risk groups at diagnosis and pT stage showed favorable survival rates, with low-risk (n = 4601, 46.6%), intermediate-risk (n = 4056, 41.1%), and high-risk (n = 1219, 12.3%) patients demonstrating CSS rates of 99%, 98%, and 90% at 15 yr, respectively. Notably, patients with pT3a disease had similar survival outcomes to those with pT2 disease, with worse CSS in patients with pT3b PCa (98.9% vs 97.4% vs 86.5%). Multivariable analyses identified age, prostate-specific antigen, biopsy Gleason grade group, clinical T stage, and treatment year as independent predictors of worse oncological outcomes. CONCLUSIONS: Our multicenter study with long-term follow-up confirms favorable survival outcomes after RARP for localized PCa. Patients with low- and intermediate-risk disease face a higher risk of mortality from causes other than PCa. On the contrary, high-risk patients have a significantly higher risk of PCa-specific mortality. PATIENT SUMMARY: In the present study, we reported the outcomes of patients with prostate cancer (PCa) who underwent robot-assisted radical prostatectomy between 10 and 20 yr ago, and we found a very low probability of dying from PCa in patients with low- and intermediate-risk PCa.

Climacturia and Penile Length Shortening: Adverse Outcomes following Robot-Assisted Radical Prostatectomy.

Purpose: While erectile dysfunction and urinary incontinence are commonly cited side effects following radical prostatectomy (RP), climacturia and penile length shortening are less explored. The present study seeks to explore the incidence, risk factors, and predictors of recovery associated with climacturia and penile length shortening following robot-assisted radical prostatectomy (RARP). Patients and Methods: From September 2018 to January 2020, 800 patients underwent RARP for primary treatment of localized prostate cancer. A survey was sent to patients following 1-year follow-up assessing outcomes of continence, erectile dysfunction, climacturia, and penile length shortening. Descriptive statistics were utilized to describe incidence and risk factors and logistic regression modeling was used to identify predictors associated with recovery. Results: Of the 800 patients surveyed, 339 (42%) and 369 (46%) patients responded, with 127/339 (37.5%) and 216/369 (58.5%) endorsing climacturia and penile length shortening. In univariate analysis, a lack of bilateral nerve sparing was associated with climacturia; high body mass index (BMI), high prostate weight, lack of nerve-sparing, and high pathologic stage was associated with penile length shortening. In logistic regression modeling, BMI, prostate weight, and p-stage were all significantly correlated with penile length shortening. Recovery from climacturia was associated with a preoperative International Index of Erectile Function-5 score >21. When patients were asked to rank the importance of these outcomes compared to erectile dysfunction and incontinence, <5% of patients ranked either climacturia or penile length shortening as a high priority following RP. Conclusion: While incidence of climacturia and penile length shortening following RP is significant, impact on patient- and partner-related quality of life are low in comparison to risks of erectile dysfunction and urinary incontinence.

Active Observation of Biochemical Recurrence without Treatment following Radical Prostatectomy: Long-Term Analysis of Outcomes.

Biochemical recurrence (BCR) following radical prostatectomy (RP) is an unreliable predictor of prostate cancer (PC) progression. This study was a retrospective cohort analysis of prospectively collected data (407/1895) of men with BCR at a tertiary referral center. Patients were assessed for active observation (AO) compared with a treatment group (TG) utilizing doubling time (DT) kinetics. Risk assessment was based on the initial DT (>12 vs. <12 months), then based on the DT pattern (changed over time). Those with unstable, rapidly decreasing DTs received treatment. Those with increasing and slowly decreasing DTs prompted observation. The primary outcome was PC mortality, safety, and efficacy of observations based on DT kinetics. The secondary outcome was BCR patients managed with or without treatment. The median follow-up was 7.5 years (IQR 3.9−10.7). The PCSM in TG and AO was 10.7% and 0%, respectively (p < 0.001). The initial DT was >12 months in 73.6% of AO versus 22.6% of TG (p < 0.001). An increasing DT pattern was observed in 71.5% of AO versus 32.7% of TG (p < 0.001). Utilizing the Cleveland Clinic's PCSM nomogram, at 10 years, predicted and observed PCSM was 8.6% and 9.5% (p = 0.78), respectively. In conclusion, one-third of patients with BCR post-RP were managed without treatment using DT kinetics, avoiding treatment-related complications, quality-of-life issues, and expenses.

Retrospective Concomitant Nonrandomized Comparison of "Touch" Cautery Versus Athermal Dissection of the Prostatic Vascular Pedicles and Neurovascular Bundles During Robot-assisted Radical Prostatectomy.

BACKGROUND: During robotic-assisted radical prostatectomy (RARP), the use of electrocautery near the neurovascular bundles (NVBs) frequently results in thermal injury to the cavernous nerves. The cut and "touch" monopolar cautery technique has been suggested to reduce desiccating thermal injury caused by bipolar energy when vessels are sealed. OBJECTIVE: To compare potency outcomes between an athermal technique (AT) and touch cautery (TC) to transect the prostatic vascular pedicles (PVPs) and dissect the NVBs. DESIGN, SETTING, AND PARTICIPANTS: A retrospective concomitant nonrandomized study of AT versus TC was performed in 733 men. A total of 323 undergoing AT had "thin" pedicles, easily suitable for suture ligation. TC was based on "thick" pedicles (n = 230) difficult to suture ligate. Men were excluded for an International Index of Erectile Function (IIEF-5) score of <15 or adjuvant therapies (n = 180). SURGICAL PROCEDURE: Single-surgeon RARP. MEASUREMENTS: Patient-reported outcomes with erectile function (EF) recovery defined as two affirmative answers to erections sufficient for intercourse (ESI; "are erections firm enough for penetration?" and "are the erections satisfactory?"), IIEF-5 scores 15-25, and a novel percent fullness score comparing pre- versus postoperative erection fullness. Logistic regression models assessed the correlation between cautery technique, covariates, and EF recovery. RESULTS AND LIMITATIONS: In an unadjusted analysis, preoperative IIEF-5, age, body mass index (BMI), and prostate weight were significant predictors of potency recovery. Follow-up was similar (AT 52.7 mo vs TC 54.6 mo, p = 0.534). In logistic regression, preoperative IIEF-5, age, and BMI were significant predictors of EF recovery, defined as IIEF-5 scores 15-25, ESI, and percent fullness >75%. Results were similar when IIEF-5 and percent fullness were assessed continuously. CONCLUSIONS: During transection of the PVPs and dissection of the NVBs, TC did not impact EF recovery significantly, compared with an AT. PATIENT SUMMARY: Electrocautery can be applied safely, with similar outcomes to those of an athermal technique.

How Does Geographic Region Affect the Total and Individual Costs for Medical Students Applying to the Competitive Surgical Residencies?

OBJECTIVE: Studies have individually assessed the expenses for medical students desiring a surgical residency in neurosurgery, orthopaedic surgery, otolaryngology, plastic surgery, and urology. A detailed comparison of expenses by geographic region have not been reported. The aim was to geographically compare the expenses of United States medical students applying to the 5 most competitive surgical residencies. SETTING/PARTICIPANTS: Anonymous nationwide survey of plastic surgery, orthopaedic surgery, otolaryngology, urology, and neurological surgery residency applicants. DESIGN: A cross sectional, retrospective analysis of the 2019-2020 Texas STAR Dashboard database, an online tool generated from a nationwide survey of students. Individual (application, away rotation, interview) and total costs for medical school seniors were recorded in addition to applicant characteristics. Mean and median costs were reported for each specialty with percentile distributions and geographic comparisons. A Kruskal-Wallis H test was performed to compare differences in costs between surgical specialties and medical school region. RESULTS: In total, 1136 applicants to surgical residency were included. The number of applicants to orthopaedic surgery (OS) (n = 459), neurological surgery (NS) (n = 121), urology (UR) (n = 191), plastic surgery (PS) (n = 117), and otolaryngology (OTO) (n = 248) were reported. Mean total costs were (OS; $8,205), (NS; $11,882), (UR; $8,207), (PS; $10,845), and (OTO; $7,516) (p ≤ 0.029). Application fees were only significantly different in the northeast and southern applicants between the different specialties, notably orthopaedic surgery applicants spent the most. In all geographic regions excluding the west, neurosurgery and plastic surgery applicants spent significantly more than other specialties for interview costs and away rotation costs. In all geographic regions neurosurgery and plastic surgery applicants spent significantly more than other specialties in total costs. CONCLUSIONS: Orthopaedic surgery applicants spend the most on application fees in select geographic regions. Neurosurgery and plastic surgery applicants spend more on interviews, away rotations, and total costs in nearly all geographic regions.

Evidence for the integration of total and free testosterone levels in the management of prostate cancer.

OBJECTIVE: To comprehensively assess total and calculated free testosterone levels in a consecutive group of patients with prostate cancer (PCa) and any potential impact on disease aggressiveness and recurrence outcomes. PARTICIPANTS AND METHODS: The study included a single-centre prospective cohort of 882 patients presenting for radical prostatectomy from 2009 to 2018. Data on total testosterone (TT), sex hormone-binding globulin (SHBG), and calculated free testosterone (cFT) were prospectively collected. Stepwise logistic regression models were used to assess correlations of TT and cFT with pathological Gleason Grade Group (GGG), extraprostatic extension (EPE), seminal vesicle invasion (SVI) and biochemical recurrence (BCR). RESULTS: Total testosterone remained nearly constant across decades (40s-80s): 0.09 decrease/year (R = 0.02), while SHBG increased 0.87/year (R = 0.32) and cFT decreased 0.08/year (R = -0.02). Low cFT of <5.5 independently predicted: very-high-risk GGG (odds ratio [OR] 0.435, 95% confidence interval [CI] 0.846-0.994; P = 0.036), EPE (OR 0.557, 95% CI 0.810-0.987; P = 0.011), SVI (OR 0.396, 95% CI 0.798-1.038; P = 0.059), and BCR within 1 year after robot-assisted radical prostatectomy (OR 0.638, 95% CI 0.971-3.512, P = 0.046). TT was not a predictor. CONCLUSION: In contrast to popular belief, testosterone remained stable in men aged 40-80 years, whereas free testosterone decreased by 2-3%/year. Low cFT was an independent predictor of very-high-risk PCa and BCR.

Impact of statin use on overall and time to biochemical failure following radical prostatectomy or radiation therapy.

OBJECTIVES: To assess the impact of statin use on overall and time to biochemical failure following primary treatment of localized prostate cancer (PCa). SUBJECTS/PATIENTS AND METHODS: 1581 patients undergoing radical prostatectomy (RP) or radiation therapy (RT) for primary treatment of PCa between July 2007 and January 2020 were evaluated for statin use, demographic/oncologic characteristics, and biochemical outcomes. Rate of biochemical failure (BF) was assessed overall and at 1, 3, and 5 years; time to BF was estimated with Kaplan-Meier. Logistic and linear regression were used to control for treatment modality and disease characteristics. RESULTS: The average age was 63.0 ± 7.5 years and median pre-treatment PSA was 6.55 (IQR 4.94). 1473 (93.2%) and 108 (6.8%) underwent RP and RT, respectively. RP patients were younger, had lower pre-PSA, lower BMI, and lower risk disease. At 3.4 ± 2.7 years follow-up, 323 (20.4%) experienced BF. When stratified by statin use, BF overall and within 1, 3, and 5 years were not different. Time to BF, was lower in patients using statins (1.8 ± 1.9 years vs. 2.4 ± 2.6 years; p = 0.016). These results persisted in multivariate analysis, wherein statin use was not associated with BF but was associated with a shorter time to BF. CONCLUSION: Overall, statin use was not associated with a reduced risk of BF in RP or RT patients. However, for patients with BF, statin use was associated with a decreased time to BF. Future investigations are warranted to further elucidate the impact of statin use on PCa recurrence.

Protective Effects of Metformin Against Biochemical Failure Following Radical Prostatectomy or Radiation Therapy in Localized Prostate Cancer.

OBJECTIVE: To assess the impact of metformin on biochemical failure (BF) in localized prostate cancers (PC) treated with radical prostatectomy or radiation therapy. MATERIALS AND METHODS: About 1449 patients undergoing radical prostatectomy (n = 1338, 92.3%) or radiation therapy (n = 108, 7.5%) for localized PC between July 2007 and January 2020 were evaluated for metformin use, demographic/oncologic characteristics, and biochemical outcomes. Androgen deprivation therapy was utilized per NCCN guidelines. BF rates were assessed overall and at 1, 3, and 5 years. Time to BF was estimated via Kaplan-Meier; logistic regression and Cox proportionate hazards models were generated to adjust for significant differences. RESULTS: Of 1449 patients, 148 (10.2%) utilized metformin at time of diagnosis, while 1,301 (89.8%) did not. Patients on metformin were significantly older, had higher body mass indexes, and more aggressive disease (Gleason score >7). At a mean ± SD follow-up of 3.6 ± 2.6 years, patients on metformin were less likely to experience BF at later timepoints; however, univariate analysis showed no differences at 1, 3, and 5 years. In multivariate analysis, patients on metformin were significantly less likely to experience BF at 5 years and overall in both treatment groups. In Cox regression, metformin was independently associated with a 40% relative risk reduction in BF. CONCLUSION: In multivariate analysis, metformin use was associated with a significant risk reduction in BF overall and at 5 years following primary treatment; this trend was not witnessed in univariate analysis. This suggests the need for future investigations of metformin's role in disease-free survival in men with localized PC.

Validation of "patient-reported outcomes via online questionnaire" as a urinary continence assessment and quality improvement tool following radical prostatectomy.

BACKGROUND: Securing reliable data on functional outcomes following radical prostatectomy (RP) is paramount to patient follow-up and management. OBJECTIVE: To validate an email-based patient-reported outcomes tracking system in assessing pad-free continence rates and time-to continence recovery following RP. PATIENTS AND METHODS: 483 men undergoing RP by a single surgeon from November 2013 to March 2019 were prospectively assigned to 1 of 3 tracking systems: 1) a preaddressed paper packet containing a pad-free card and daily urinary pad log, (N = 249); 2) an automated email questionnaire, (N = 234) or 3) both (N = 51). Patients tracked electronically received electronic Research Electronic Data Capture surveys 30 days after catheter removal, with up to 3 reminders sent automatically if no response was received within 2 days. Response rates and continence rates were compared in group 1 vs. group 2 via student t-tests; time-to pad-free status was assessed for concordance among men in group 3 via linear regression. RESULTS: Thirty-day response rates in group 1 (paper) vs. group 2 (electronic) were 80.7% (201/249) and 94.0% (220/234), (P < 0.0001); pad-free rates were 64.2% (129/201) and 64.1% (141/220), (P = 0.9847), respectively. Similarly, 1-year response rates in group 1 and 2 were 87.6% (218/249) vs. 94.0% (220/234), (P = 0.0146); pad-free rates were 91.7% (200/218) vs. 96.4% (212/220), (P = 0.0411), respectively. In group 3, time to pad-free continence recovery assessed via Patient Reported Outcomes via Online Questionnaire (PROVOQ) was highly concordant in 89.6% (43/48) of patients ± 5 days (Figure 1, R2 = 0.9893). No significant bias was found for subsequent reporting in either group. CONCLUSION: The use of automated email survey questionnaires via PROVOQ for the assessment of patient-reported post-RP continence recovery facilitates increased response rates, timeliness of response, and accuracy. PROVOQ significantly reduce the labor of tracking continence outcomes, improve quality improvement efforts, and enables surgeons to more clearly differentiates risk of long-term incontinence.

Perioperative and Functional Outcomes of Robot-Assisted Radical Prostatectomy in Octogenarian Men.

Background: The functional and oncologic outcomes of robot-assisted radical prostatectomy (RARP) in octogenarians are not well studied. We sought to study the perioperative, functional, and oncologic outcomes of RARP in octogenarian men. Methods: Between January 2009 and 2019, 46 patients ≥80 years with localized prostate cancer (PCa) underwent RARP in three high-volume robotic urologic practices in the United States. Clinical and pathologic features, and perioperative and postoperative complications were retrospectively evaluated. Functional outcomes for urinary and sexual function were collected via patient-reported questionnaires. Continence was defined as the use of zero or one safety pad per day. Results: The median (interquartile range) age was 81 (80-82), the mean (standard deviation [SD]) operative time was 116.5 (36.4) minutes, and the mean (SD) blood loss was 132 (35.6) mL. All cases were completed robotically, no intraoperative complications were encountered, and the mean length of stay was 1.21 (0.78) days. Regarding 30- and 90-day complication, nine patients had postoperative complications; seven were Clavien-Dindo grade I-II, and two were Clavien-Dindo grade ≥III. Post-RARP continence rates at 3 and 12 months were 68.4% and 84.8%, respectively. Conclusions: RARP represents a feasible option to treat PCa in well-selected octogenarian men. Careful patient selection and counseling are critical before offering surgical treatment for these men.

Impact of surgically maximized versus native membranous urethral length on 30-day and long-term pad-free continence after robot-assisted radical prostatectomy.

BACKGROUND: Pelvic multiparametric magnetic resonance imaging (mpMRI)-determined membranous urethral length (MUL) and its surgical maximization have been reported to impact early- and long-term pad-free urinary continence after robot-assisted radical prostatectomy (RARP). OBJECTIVE: The objective of this study was to present evidence (data and video) of important effects on post-RARP continence recovery from both innate mpMRI-assessed and surgical preservation of MUL. DESIGN SETTING AND PARTICIPANTS: Of 605 men undergoing RARP, 580 with complete follow-up were included: Group 1, prior (N = 355), and Group 2, subsequent (N = 225) to technique change of MUL maximization. Effect of innate, mpMRI-assessed MUL on postoperative continence was assessed. SURGICAL PROCEDURE: Before technique change, the dorsal venous complex was stapled before transection of the membranous urethra. After the change, the final step of extirpation was transection of the dorsal venous complex and periurethral attachments, thus facilitating surgical maximization of MUL. MEASUREMENTS: Primary and secondary outcomes for technique change and mpMRI-assessed MUL were both patient-reported 30-day and 1-year pad-free continence after RARP, respectively. RESULTS: Preoperative prostate-specific antigen, age, and disease aggressiveness were significantly higher in Group 2. After technique change and surgical maximization of MUL, 30-day and 1-year pad-free continence were both significantly improved (p < 0.05). In multivariate analysis, maximization of MUL significantly increased the likelihood of both early- and long-term continence recovery. For men undergoing MUL preservation, mpMRI-assessed MUL>1.4 cm also independently predicted higher 30-day (odds ratio: 4.85, 95% confidence interval: 1.24-18.9) and 1-year continence recovery (odds ratio: 11.26, 95% confidence interval: 1.07-118). CONCLUSIONS: Prostatic rotation and circumferential release of apical attachments and maximization of MUL improves continence after RARP. Separately, innate MUL>1.4 cm independently increased 30-day and 1-year continence recovery. PATIENT SUMMARY: Surgeon efforts to maximize MUL during radical prostatectomy are highly encouraged, as maximally preserved MUL likely improves post-RARP continence recovery. In addition, individual patients' mpMRI-assessed MUL (approximately >1.4 cm) independently limits continence recovery.

Testosterone replacement therapy reduces biochemical recurrence after radical prostatectomy.

OBJECTIVE: To evaluate risk of prostate cancer biochemical recurrence (BCR) after radical prostatectomy (RP) in men receiving vs not receiving testosterone replacement therapy (TRT). PATIENTS AND METHODS: A total of 850 patients underwent RP by a single surgeon. All patients had preoperative testosterone and sex hormone-binding globulin levels determined; free testosterone was calculated prospectively. In all, 152 (18%) patients with low preoperative calculated free testosterone (cFT) levels and delayed postoperative sexual function recovery were placed on TRT and proportionately matched to 419 control patients by pathological Gleason Grade Group (GGG) and stage. Rates and time to BCR [two consecutive prostate-specific antigen (PSA) levels of ≥0.2 ng/mL] were compared in univariate and multivariate regression; Cox regression was used to generate a survival function at the mean of covariates. RESULTS: The median follow-up was 3.5 years. There were no statistically significant differences in demographics or general health complications between groups. BCR occurred in 11/152 (7.2%) and 53/419 (12.6%) patients in the TRT and control groups, respectively. In adjusted time-to-event analysis, TRT was an independent predictor of recurrence-free survival. After accounting for GGG, pathological stage, preoperative PSA level, and cFT, patients on TRT were ~54% less likely to recur (hazard ratio 0.54, 95% confidence interval 0.292-0.997). In men destined to recur, TRT delayed time to recurrence by an average of 1.5 years. CONCLUSION: In our experience, TRT after RP significantly reduced BCR and delayed time to BCR. There was no identifiable general health complications associated with TRT. These findings are hypothesis-generating and require confirmation with multi-centred, prospective randomised controlled trials.

Internal and External Validation of a 90-Day Percentage Erection Fullness Score Model Predicting Potency Recovery Following Robot-assisted Radical Prostatectomy.

BACKGROUND: We previously reported a new post-radical prostatectomy (RP) prediction model for men with normal baseline erectile function (EF) using 90-d postoperative erection fullness to identify men who might benefit from early EF rehabilitation. OBJECTIVE: To prospectively internally and externally validate the use of this risk assessment model in predicting 1- and 2-yr post-RP EF recovery. DESIGN, SETTING, AND PARTICIPANTS: We randomly assigned 297 patients with a preoperative International Index of Erectile Function 5 score of 22-25 undergoing robot-assisted RP by a single surgeon to a training set and internal validation set at a ratio of 2:1. A prospective external validation set included 91 patients treated by five high-volume surgeons. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Potency was defined as erections sufficient for intercourse. To predict 1- and 2-yr potency recovery, logistic regression models were developed in the training set based on 90-d erection fullness of 0-24% or 25-100%. The resultant models were applied to the internal and external validation sets to calculate risk scores for 1- and 2-yr potency for each patient. Predictive validity was assessed using receiver operating characteristic (ROC) curves. RESULTS AND LIMITATIONS: Percentage erection fullness was an independent predictor of 1- and 2-yr potency recovery in all data sets. Internal validation confirmed strong reliability in predicting 2-yr potency outcomes (area under the ROC curve [AUC] 0.87) and external validation illustrated similar reliability in predicting 1-yr potency outcomes (AUC 0.80). In the external validation, the model predicted a mean 1-yr potency recovery rate of 39.7% (standard deviation 3.2%), compared to the actual rate of 36.26%. Limitations include the short follow-up for this cohort. CONCLUSIONS: We present internal and external validation of a 90-d percentage erection fullness score, confirming that this metric is a robust predictor of post-RP EF recovery. PATIENT SUMMARY: Percentage erection fullness at 3 mo after radical prostatectomy discriminates patients with a low or a high probability of recovery of erectile function (EF), which can facilitate identification of a need for early EF rehabilitation.

Results of Phase 1 study on cytoreductive radical prostatectomy in men with newly diagnosed metastatic prostate cancer.

BACKGROUND: Preclinical and retrospective data suggest that cytoreductive radical prostatectomy may benefit a subset of men who present with metastatic prostate cancer (mPCa). Herein, we report the results of the first planned Phase 1 study on cytoreductive surgery. METHODS: From four institutions, 36 patients consented to the study. However, four did not complete surgery because of rapid disease progression (n = 3) and another because of an intraoperatively discovered pericolonic abscess. Men with newly diagnosed clinical mPCa to lymph nodes or bones were eligible. The primary endpoint was the rate of major perioperative complications (Clavien-Dindo Grade 3 or higher) occurring within 90 days of surgery. RESULTS: The mean age at surgery was 64.0 years. The 90-day overall complication rate was 31.2% (n = 10), of which two (6.25%) were considered major complications: one acute tubular necrosis requiring temporary dialysis and one death. In men with more than 6 months of follow-up, 67.9% had prostate specific antigen nadir ≤0.2 ng/mL, while one patient experienced a rapid rise in prostate specific antigen and another a widely disseminated disease that resulted in death 5 months after surgery. Altogether, these results demonstrate that cytoreductive radical prostatectomy is safe and surgically feasible in selected patients who present with mPCa . Yet, there may be a small subset of patients in whom surgery may cause a significant harm. CONCLUSION: Therefore, cytoreductive surgery in men with mPCa should be limited to clinical trials until robust data are available.