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Prasanna Sooriakumaran - One of the best experts on this subject based on the ideXlab platform.
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erectile function and oncologic outcomes following open retropubic and robot assisted radical Prostatectomy results from the laparoscopic Prostatectomy robot open trial
European Urology, 2017Co-Authors: Prasanna Sooriakumaran, Giovannalberto Pini, Tommy Nyberg, Maryam Derogar, Stefan Carlsson, Johan Stranne, Anders Bjartell, Jonas Hugosson, Gunnar SteineckAbstract:Abstract Background Whether surgeons perform better utilising a robot-assisted laparoscopic technique compared with an open approach during Prostate Cancer Surgery is debatable. Objective To report erectile function and early oncologic outcomes for both surgical modalities, stratified by Prostate Cancer risk grouping. Design, setting, and participants In a prospective nonrandomised trial, we recruited 2545 men with Prostate Cancer from seven open ( n =753) and seven robot-assisted ( n =1792) Swedish centres (2008–2011). Outcome measurements and statistical analysis Clinometrically-validated questionnaire-based patient-reported erectile function was collected before, 3 mo, 12 mo, and 24 mo after Surgery. Surgeon-reported degree of neurovascular-bundle preservation, pathologist-reported positive surgical margin (PSM) rates, and 2-yr Prostate-specific antigen-relapse rates were measured. Results and limitations Among 1702 preoperatively potent men, we found enhanced erectile function recovery for low/intermediate-risk patients in the robot-assisted group at 3 mo. For patients with high-risk tumours, point estimates for erectile function recovery at 24 mo favoured the open Surgery group. The degree of neurovascular bundle preservation and erectile function recovery were greater correlated for robot-assisted Surgery. In pT2 tumours, 10% versus 17% PSM rates were observed for open and robot-assisted Surgery, respectively; corresponding rates for pT3 tumours were 48% and 33%. These differences were associated with biochemical recurrence in pT3 but not pT2 disease. The study is limited by its nonrandomised design and relatively short follow-up. Conclusions Earlier recovery of erectile function in the robot-assisted Surgery group in lower-risk patients is counterbalanced by lower PSM rates for open surgeons in organ-confined disease; thus, both open and robotic surgeons need to consider this trade-off when determining the plane of surgical dissection. Robot-assisted Surgery also facilitates easier identification of nerve preservation planes during radical Prostatectomy as well as wider dissection for pT3 cases. Patient summary For Prostate Cancer Surgery, an open operation reduces erection problems in high-risk Cancers but has higher relapse rates than robotic Surgery. Relapse rates appear similar in low/intermediate-risk Cancers and the robot appears better at preserving erections in these cases.
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trends in radical Prostatectomy risk group distribution in a european multicenter analysis of 28 572 patients towards tailored treatment
European urology focus, 2017Co-Authors: Roderick C N Van Den Bergh, Prasanna Sooriakumaran, Giorgio Gandaglia, H Borgmann, Derya Tilki, Christian I Surcel, Massimo Valerio, L Salomon, Alberto Briganti, Markus GraefenAbstract:Abstract Background Active surveillance (AS) has been increasingly proposed as the preferential initial management strategy for low-risk Prostate Cancer (PC), while in high-risk PC the indication for Surgery has widened. Objective To evaluate the development of risk group distribution of patients undergoing radical Prostatectomy (RP). Design, setting, and participants Retrospective database review of combined RP databases (2000–2015) of four large European centers (Creteil, Paris; San Rafaele, Milan; Martini Klinik, Hamburg; NKI, AvL, Amsterdam). Outcome measurements and statistical analysis Clinical and pathological characteristics per year of Surgery. Eligibility for AS was defined according to Prostate Cancer Research International Active Surveillance criteria: cT≤2c, cN0/X, cM0/X, PSA ≤10ng/ml, Prostate-specific antigen density 20ng/ml, and/or Gleason ≥8. Results and limitations In total, 28572 patients had complete clinical and 24790 complete pathological data available. The absolute number of RPs increased: 401, 975, 2344, and 2504 in 2000, 2005, 2010, and 2015, respectively. The proportion of cases considered suitable for AS decreased: 31%, 32%, 18%, and 5%, while the cases considered high risk increased: 10%, 8%, 16%, and 30%. The percentage of patients having only localized Gleason 6 disease after RP decreased: 46%, 34%, 14%, and 8% for all patients ( p 0.01), as well as for AS-suitable patients: 70%, 54%, 41%, and 38% ( p Conclusions This European analysis confirmed the risk profile of patients undergoing RP shifting away of the most favorable disease spectrum. Patients with PC clinically considered suitable for AS and men having only localized Gleason 6 disease pathologically comprised a decreasing share of all RP performed. High-risk disease comprised an increasing share of all RPs. Patient summary The databases of four large European centers of Prostate Cancer Surgery were analyzed. In recent years, the risk profile of patients shifted away of low-risk Cancer, while high-risk Cancer comprised a larger part of cases. This confirms the introduction of active surveillance for low-risk Prostate Cancer and increase in potentially curative options for high-risk disease.
Gunnar Steineck - One of the best experts on this subject based on the ideXlab platform.
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erectile function and oncologic outcomes following open retropubic and robot assisted radical Prostatectomy results from the laparoscopic Prostatectomy robot open trial
European Urology, 2017Co-Authors: Prasanna Sooriakumaran, Giovannalberto Pini, Tommy Nyberg, Maryam Derogar, Stefan Carlsson, Johan Stranne, Anders Bjartell, Jonas Hugosson, Gunnar SteineckAbstract:Abstract Background Whether surgeons perform better utilising a robot-assisted laparoscopic technique compared with an open approach during Prostate Cancer Surgery is debatable. Objective To report erectile function and early oncologic outcomes for both surgical modalities, stratified by Prostate Cancer risk grouping. Design, setting, and participants In a prospective nonrandomised trial, we recruited 2545 men with Prostate Cancer from seven open ( n =753) and seven robot-assisted ( n =1792) Swedish centres (2008–2011). Outcome measurements and statistical analysis Clinometrically-validated questionnaire-based patient-reported erectile function was collected before, 3 mo, 12 mo, and 24 mo after Surgery. Surgeon-reported degree of neurovascular-bundle preservation, pathologist-reported positive surgical margin (PSM) rates, and 2-yr Prostate-specific antigen-relapse rates were measured. Results and limitations Among 1702 preoperatively potent men, we found enhanced erectile function recovery for low/intermediate-risk patients in the robot-assisted group at 3 mo. For patients with high-risk tumours, point estimates for erectile function recovery at 24 mo favoured the open Surgery group. The degree of neurovascular bundle preservation and erectile function recovery were greater correlated for robot-assisted Surgery. In pT2 tumours, 10% versus 17% PSM rates were observed for open and robot-assisted Surgery, respectively; corresponding rates for pT3 tumours were 48% and 33%. These differences were associated with biochemical recurrence in pT3 but not pT2 disease. The study is limited by its nonrandomised design and relatively short follow-up. Conclusions Earlier recovery of erectile function in the robot-assisted Surgery group in lower-risk patients is counterbalanced by lower PSM rates for open surgeons in organ-confined disease; thus, both open and robotic surgeons need to consider this trade-off when determining the plane of surgical dissection. Robot-assisted Surgery also facilitates easier identification of nerve preservation planes during radical Prostatectomy as well as wider dissection for pT3 cases. Patient summary For Prostate Cancer Surgery, an open operation reduces erection problems in high-risk Cancers but has higher relapse rates than robotic Surgery. Relapse rates appear similar in low/intermediate-risk Cancers and the robot appears better at preserving erections in these cases.
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long term quality of life outcomes after radical Prostatectomy or watchful waiting the scandinavian Prostate Cancer group 4 randomised trial
Lancet Oncology, 2011Co-Authors: Eva Johansson, Tommy Nyberg, Gunnar Steineck, Lars Holmberg, Janerik Johansson, Mirja Ruutu, Anna BillaxelsonAbstract:Summary Background For men with localised Prostate Cancer, Surgery provides a survival benefit compared with watchful waiting. Treatments are associated with morbidity. Results for functional outcome and quality of life are rarely reported beyond 10 years and are lacking from randomised settings. We report results for quality of life for men in the Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) after a median follow-up of more than 12 years. Methods All living Swedish and Finnish men (400 of 695) randomly assigned to radical Prostatectomy or watchful waiting in SPCG-4 from 1989 to 1999 were included in our analysis. An additional 281 men were included in a population-based control group matched for region and age. Physical symptoms, symptom-induced stress, and self-assessed quality of life were evaluated with a study-specific questionnaire. Longitudinal data were available for 166 Swedish men who had answered quality-of-life questionnaires at an earlier timepoint. Findings 182 (88%) of 208 men in the radical Prostatectomy group, 167 (87%) of 192 men in the watchful-waiting group, and 214 (76%) of 281 men in the population-based control group answered the questionnaire. Men in SPCG-4 had a median follow-up of 12·2 years (range 7–17) and a median age of 77·0 years (range 61–88). High self-assessed quality of life was reported by 62 (35%) of 179 men allocated radical Prostatectomy, 55 (34%) of 160 men assigned to watchful waiting, and 93 (45%) of 208 men in the control group. Anxiety was higher in the SPCG-4 groups (77 [43%] of 178 and 69 [43%] of 161 men) than in the control group (68 [33%] of 208 men; relative risk 1·42, 95% CI 1·07–1·88). Prevalence of erectile dysfunction was 84% (146 of 173 men) in the radical Prostatectomy group, 80% (122 of 153) in the watchful-waiting group, and 46% (95 of 208) in the control group and prevalence of urinary leakage was 41% (71 of 173), 11% (18 of 164), and 3% (six of 209), respectively. Distress caused by these symptoms was reported significantly more often by men allocated radical Prostatectomy than by men assigned to watchful waiting. In a longitudinal analysis of men in SPCG-4 who provided information at two follow-up points 9 years apart, 38 (45%) of 85 men allocated radical Prostatectomy and 48 (60%) of 80 men allocated watchful waiting reported an increase in number of physical symptoms; 50 (61%) of 82 and 47 (64%) of 74 men, respectively, reported a reduction in quality of life. Interpretation For men in SPCG-4, negative side-effects were common and added more stress than was reported in the control population. In the radical Prostatectomy group, erectile dysfunction and urinary leakage were often consequences of Surgery. In the watchful-waiting group, side-effects can be caused by tumour progression. The number and severity of side-effects changes over time at a higher rate than is caused by normal ageing and a loss of sexual ability is a persistent psychological problem for both interventions. An understanding of the patterns of side-effects and time dimension of their occurrence for each treatment is important for full patient information. Funding US National Institutes of Health; Swedish Cancer Society; Foundation in Memory of Johanna Hagstrand and Sigfrid Linner.
Giorgio Gandaglia - One of the best experts on this subject based on the ideXlab platform.
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salvage lymph node dissection for nodal recurrent Prostate Cancer a systematic review
European Urology, 2019Co-Authors: G Ploussard, Giorgio Gandaglia, H Borgmann, Pieter De Visschere, Isabel Heidegger, Alexander Kretschmer, R Mathieu, C Surcel, Derya Tilki, Igor TsaurAbstract:Abstract Context Identification of early nodal recurrence after primary Prostate Cancer (PCa) treatment by functional imaging may guide metastasis-directed therapy such as salvage lymph node dissection (SLND). Objective The aim of this systematic review was to assess the oncological role and the safety of SLND in the era of modern imaging in case of exclusive nodal recurrence after primary PCa treatment with curative intent. Evidence acquisition A systematic literature search in the PubMed and Cochrane databases was performed up to August 2018 according to Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Overall, 27 SLND series have been selected for synthesis. Evidence synthesis Prostate-specific membrane antigen or choline positron emission tomography/computed tomography was the reference detection technique. SLND was performed by open or laparoscopic approach with Conclusions A growing body of accumulated data suggests that SLND is a safe metastasis-directed therapy option in nodal recurrence after primary treatment. However, to date, high level of evidence is still missing to draw any clinically meaningful conclusion about the oncological impact of SLND on long-term endpoints. Patient summary When imaging identifies exclusive nodal recurrent Prostate Cancer, Surgery directed to the positive lesions is safe and can offer at least a temporary biochemical response. The oncological role assessed by strong clinical endpoints remains uncertain.
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trends in radical Prostatectomy risk group distribution in a european multicenter analysis of 28 572 patients towards tailored treatment
European urology focus, 2017Co-Authors: Roderick C N Van Den Bergh, Prasanna Sooriakumaran, Giorgio Gandaglia, H Borgmann, Derya Tilki, Christian I Surcel, Massimo Valerio, L Salomon, Alberto Briganti, Markus GraefenAbstract:Abstract Background Active surveillance (AS) has been increasingly proposed as the preferential initial management strategy for low-risk Prostate Cancer (PC), while in high-risk PC the indication for Surgery has widened. Objective To evaluate the development of risk group distribution of patients undergoing radical Prostatectomy (RP). Design, setting, and participants Retrospective database review of combined RP databases (2000–2015) of four large European centers (Creteil, Paris; San Rafaele, Milan; Martini Klinik, Hamburg; NKI, AvL, Amsterdam). Outcome measurements and statistical analysis Clinical and pathological characteristics per year of Surgery. Eligibility for AS was defined according to Prostate Cancer Research International Active Surveillance criteria: cT≤2c, cN0/X, cM0/X, PSA ≤10ng/ml, Prostate-specific antigen density 20ng/ml, and/or Gleason ≥8. Results and limitations In total, 28572 patients had complete clinical and 24790 complete pathological data available. The absolute number of RPs increased: 401, 975, 2344, and 2504 in 2000, 2005, 2010, and 2015, respectively. The proportion of cases considered suitable for AS decreased: 31%, 32%, 18%, and 5%, while the cases considered high risk increased: 10%, 8%, 16%, and 30%. The percentage of patients having only localized Gleason 6 disease after RP decreased: 46%, 34%, 14%, and 8% for all patients ( p 0.01), as well as for AS-suitable patients: 70%, 54%, 41%, and 38% ( p Conclusions This European analysis confirmed the risk profile of patients undergoing RP shifting away of the most favorable disease spectrum. Patients with PC clinically considered suitable for AS and men having only localized Gleason 6 disease pathologically comprised a decreasing share of all RP performed. High-risk disease comprised an increasing share of all RPs. Patient summary The databases of four large European centers of Prostate Cancer Surgery were analyzed. In recent years, the risk profile of patients shifted away of low-risk Cancer, while high-risk Cancer comprised a larger part of cases. This confirms the introduction of active surveillance for low-risk Prostate Cancer and increase in potentially curative options for high-risk disease.
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more extensive pelvic lymph node dissection improves survival in patients with node positive Prostate Cancer
European Urology, 2015Co-Authors: Firas Abdollah, Giorgio Gandaglia, Nazareno Suardi, Umberto Capitanio, Andrea Salonia, Alessandro Nini, Marco Moschini, Pierre I Karakiewicz, Sharhokh F Shariat, Francesco MontorsiAbstract:Background: The role of extended pelvic lymph node dissection (ePLND) in treating Prostate Cancer (PCa) patients with lymph node invasion (LNI) remains controversial. Objective: The relationship between the number of removed lymph nodes (RLNs) and Cancer-specific mortality (CSM) was tested in patients with LNI. Design, setting, and participants: We examined data of 315 pN1 PCa patients treated with radical Prostatectomy (RP) and anatomically ePLND between 2000 and 2012 at one tertiary care centre. All patients received adjuvant hormonal therapy with or without adjuvant radiotherapy (aRT). Outcome measurements and statistical analysis: Univariable and multivariable Cox regression analyses tested the relationship between RLN number and CSM rate, after adjusting to all available covariates. Survival estimates were based on the multivariable model; patients were stratified according to RLN number using points of maximum separation. Results and limitations: The average number of RLNs was 20.8 (median: 19; interquartile range: 14–25). Mean and median follow-up were 63.1 and 54 mo, respectively. At 10-yr, the CSM-free survival rate was 74.7%, 85.9%, 92.4%, 96.0%, and 97.9% for patients with 8, 17, 26, 36, and 45 RLNs, respectively. By multivariable analyses, the number of RLNs independently predicted lower CSM rate (hazard ratio [HR]: 0.93; p = 0.02). Other predictors of CSM were Gleason score 8–10 (HR: 3.3), number of positive nodes (HR: 1.2), and aRT treatment (HR: 0.26; all p 0.006). The study is limited by its retrospective nature. Conclusions: In PCa patients with LNI, the removal of a higher number of LNs during RP was associated with improvement in Cancer-specific survival rate. This implies that ePLND should be considered in all patients with a significant preoperative risk of harbouring LNI. Patient summary: We found that removing more lymph nodes during Prostate Cancer Surgery can significantly improve Cancer-specific survival in patients with lymph node invasion.
Francesco Montorsi - One of the best experts on this subject based on the ideXlab platform.
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more extensive pelvic lymph node dissection improves survival in patients with node positive Prostate Cancer
European Urology, 2015Co-Authors: Firas Abdollah, Giorgio Gandaglia, Nazareno Suardi, Umberto Capitanio, Andrea Salonia, Alessandro Nini, Marco Moschini, Pierre I Karakiewicz, Sharhokh F Shariat, Francesco MontorsiAbstract:Background: The role of extended pelvic lymph node dissection (ePLND) in treating Prostate Cancer (PCa) patients with lymph node invasion (LNI) remains controversial. Objective: The relationship between the number of removed lymph nodes (RLNs) and Cancer-specific mortality (CSM) was tested in patients with LNI. Design, setting, and participants: We examined data of 315 pN1 PCa patients treated with radical Prostatectomy (RP) and anatomically ePLND between 2000 and 2012 at one tertiary care centre. All patients received adjuvant hormonal therapy with or without adjuvant radiotherapy (aRT). Outcome measurements and statistical analysis: Univariable and multivariable Cox regression analyses tested the relationship between RLN number and CSM rate, after adjusting to all available covariates. Survival estimates were based on the multivariable model; patients were stratified according to RLN number using points of maximum separation. Results and limitations: The average number of RLNs was 20.8 (median: 19; interquartile range: 14–25). Mean and median follow-up were 63.1 and 54 mo, respectively. At 10-yr, the CSM-free survival rate was 74.7%, 85.9%, 92.4%, 96.0%, and 97.9% for patients with 8, 17, 26, 36, and 45 RLNs, respectively. By multivariable analyses, the number of RLNs independently predicted lower CSM rate (hazard ratio [HR]: 0.93; p = 0.02). Other predictors of CSM were Gleason score 8–10 (HR: 3.3), number of positive nodes (HR: 1.2), and aRT treatment (HR: 0.26; all p 0.006). The study is limited by its retrospective nature. Conclusions: In PCa patients with LNI, the removal of a higher number of LNs during RP was associated with improvement in Cancer-specific survival rate. This implies that ePLND should be considered in all patients with a significant preoperative risk of harbouring LNI. Patient summary: We found that removing more lymph nodes during Prostate Cancer Surgery can significantly improve Cancer-specific survival in patients with lymph node invasion.
Ajay Aggarwal - One of the best experts on this subject based on the ideXlab platform.
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effect of patient choice and hospital competition on service configuration and technology adoption within Cancer Surgery a national population based study
Lancet Oncology, 2017Co-Authors: Ajay Aggarwal, Daniel Lewis, Malcolm David Mason, Richard Sullivan, Arnie Purushotham, Jan Van Der MeulenAbstract:Summary Background There is a scarcity of evidence about the role of patient choice and hospital competition policies on surgical Cancer services. Previous evidence has shown that patients are prepared to bypass their nearest Cancer centre to receive Surgery at more distant centres that better meet their needs. In this national, population-based study we investigated the effect of patient mobility and hospital competition on service configuration and technology adoption in the National Health Service (NHS) in England, using Prostate Cancer Surgery as a model. Methods We mapped all patients in England who underwent radical Prostatectomy between Jan 1, 2010, and Dec 31, 2014, according to place of residence and treatment location. For each radical Prostatectomy centre we analysed the effect of hospital competition (measured by use of a spatial competition index [SCI], with a score of 0 indicating weakest competition and 1 indicating strongest competition) and the effect of being an established robotic radical Prostatectomy centre at the start of 2010 on net gains or losses of patients (difference between number of patients treated in a centre and number expected based on their residence), and the likelihood of closing their radical Prostatectomy service. Findings Between Jan 1, 2010, and Dec 31, 2014, 19 256 patients underwent radical Prostatectomy at an NHS provider in England. Of the 65 radical Prostatectomy centres open at the start of the study period, 23 (35%) had a statistically significant net gain of patients during 2010–14. Ten (40%) of these 23 were established robotic centres. 37 (57%) of the 65 centres had a significant net loss of patients, of which two (5%) were established robotic centres and ten (27%) closed their radical Prostatectomy service during the study period. Radical Prostatectomy centres that closed were more likely to be located in areas with stronger competition (highest SCI quartile [0·87–0·92]; p=0·0081) than in areas with weaker competition. No robotic Surgery centre closed irrespective of the size of net losses of patients. The number of centres performing robotic Surgery increased from 12 (18%) of the 65 centres at the beginning of 2010 to 39 (71%) of 55 centres open at the end of 2014. Interpretation Competitive factors, in addition to policies advocating centralisation and the requirement to do minimum numbers of surgical procedures, have contributed to large-scale investment in equipment for robotic Surgery without evidence of superior outcomes and contributed to the closure of Cancer Surgery units. If quality performance and outcome indicators are not available to guide patient choice, these policies could threaten health services' ability to deliver equitable and affordable Cancer care. Funding National Institute for Health Research.
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determinants of patient mobility for Prostate Cancer Surgery a population based study of choice and competition
European Urology, 2017Co-Authors: Ajay Aggarwal, Daniel Lewis, Malcolm David Mason, Richard Sullivan, Jan Van Der Meulen, Susan C Charman, Noel W ClarkeAbstract:Many countries have introduced policies that enable patients to select a health care provider of their choice with the aim of improving the quality of care. However, there is little information about the drivers or the impact of patient mobility. Using administrative hospital data (n = 19 256) we analysed the mobility of Prostate Cancer patients who had radical Surgery in England between 2010 and 2014. Our analysis, using geographic information systems and multivariable choice modelling, found that 33·5% (n = 6465) of men bypassed their nearest Prostate Cancer surgical centre. Travel time had a strong impact on where patients moved to but was less of a factor for men who were younger, fitter, and more affluent (p always < 0.001). Men were more likely to move to hospitals that provided robotic Prostate Cancer Surgery (odds ratio: 1.42, p < 0.001) and to hospitals that employed surgeons with a strong media reputation (odds ratio: 2.18, p < 0.001). Patient mobility occurred in the absence of validated measures of the quality of care, instead influenced by the adoption of robotic Surgery and the reputation of individual clinicians. National policy based on patient choice and provider competition may have had a negative impact on equality of access, service capacity, and health system efficiency.
