Is the Complication Rate of Radical Cystectomy Predictive of the Complication Rate of Other Urological Procedures?

Source: UroToday

A higher hospital radical cystectomy volume appears to lead to a lower risk of complications only after other common urological oncological procedures, namely radical prostatectomy and nephrectomy, but not after nononcological urology procedures.

This abstract found that hospitals that performed radical cystectomy (removal of the bladder and surrounding tissue for bladder cancer) had less complcations for kidney and prostate cancer surgery as well.

I have been perfoming radical cystecomies my whole career and started perfoming these robotically 3 1/2 years ago. Although I thought performing the more complex surgery helpe me in other surgeries, I didnt realize that a study would show less complications for these other procedures.

Medical News: ASTRO: Proton Radiation Fails to Impress in Prostate Cancer Study – in Meeting Coverage, ASTRO

Source: Med page today

Proton radiation for early prostate cancer had an acceptable tolerability profile but produced little evidence of a “gee whiz” impact to support its cost, according to preliminary results from a phase I/II clinical trial.
Two-thirds of patients had acute genitourinary or gastrointestinal toxicity, and a third had late GU/GI toxicity, Anthony Zietman, M.D., of Harvard and Massachusetts General Hospital, reported at the American Society for Therapeutic Radiology and Oncology meeting.
Although most of the toxicity was grade 2 in severity, the overall profile provided little reason for enthusiasm.
“The bottom line is that the treatment was safe, it was reasonably well tolerated, but probably no better tolerated than any other form of radiation that we give,” Dr. Zietman said.

According to this study, the less available and much more expensive proton radiation therapy for prostate cancer is not much different than traditional radiation.

Regrets After Prostate Surgery

Source: Tara Parker-Pope – Health – New York Times Blog

One in five men who undergoes prostate surgery to treat cancer later regrets the decision, a new study shows. And surprisingly, regret is highest among men who opt for robotic prostatectomy, a minimally invasive surgery that is growing in popularity as a treatment.

The research, published in the medical journal European Urology, is the latest to suggest that technological advances in prostate surgery haven’t necessarily translated to better results for the men on which it is performed. It also adds to growing concerns that men are being misled about the real risks and benefits of robotic surgical procedures used to treat prostate cancer.

This was an interesting article about prostate cancer satisfaction rates. The important point was that patients who underwent robotic prostatectomy were not as satisfied as patients that underwent conventionally surgery. It is interesting to read the comments as well.

The important things that I have done that I believe give me a higher satisfaction rate is to better explain how the procedure is still a major surgery. I know that my patients expect less problems and I believe they do have less problems. The important thing is to have them understand it is still a major surgery that is similar to open surgery in what we are trying to accomplish.

That being said, once expectations are realistic, most patienst are satisfied. I do notice that the satisfaction rate is often higher in patients that have worse than expected incontinence. After several weeks to months, once the urinary control is back to normal people have a much higher satisfaction rate.

Best of AUA Orlando 2008 for Prostate Cancer

Source: Urology Times
Robotic Surgery
Presented by Ashutosh K. Tewari, MD,
Weill-Cornell Medical College, New York.

* Robot-assisted laparoscopic partial nephrectomy is associated with shorter hospital stay and less bleeding, but the warm ischemia time is still around 30 minutes.

* Studies comparing robot-assisted laparoscopic cystectomy and open radical cystectomy show similar oncologic outcomes. At a high-volume tertiary care center, the robotic technique was more cost-efficient, but that finding needs to be confirmed at other centers. Other remaining issues regarding the robotic procedure include the need to define how the reconstruction should be performed, the extent of the lymphadenectomy, and ensuring clear margins at lateral areas.

* A study of almost 4,000 patients reaffirms the safety of robotic-assisted laparoscopic prostatectomy (RALP). Rates of major surgical, major medical, and minor medical complications were all ≤0.7%, and the rate of minor surgical complications was 3.3%.

* Studies comparing open and RALP show the surgeon is the most important variable in determining outcome.

* Extended lymph node dissection should be performed in high-risk prostate cancer patients, and can be done with RALP.

* A total reconstruction procedure including anterior and posterior restoration of the vesicourethral junction is associated with early return to continence and improvement in overall continence rates.

Some of the highlights from the AUA
Of interest is the growing application of robotic surgery for smaller kidney cancers (partial nephrectomy) and bladder cancer, which I have been performing since 2005 myself.

The other very important adaption is the posterior and anterior reconstruction of the urinary tract during robotic prostatectomy, which I have performing for over a year after attending Dr Tewari’s conference.

Prostate Cancer-Specific Survival Following Salvage Radiotherapy vs Observation in Men With Biochemical Recurrence After Radical Prostatectomy: Abstract

Source: JAMA
Prostate Cancer-Specific Survival Following Salvage Radiotherapy vs Observation in Men With Biochemical Recurrence After Radical Prostatectomy
Bruce J. Trock, PhD; Misop Han, MD; Stephen J. Freedland, MD; Elizabeth B. Humphreys, MS; Theodore L. DeWeese, MD; Alan W. Partin, MD, PhD; Patrick C. Walsh, MD
JAMA. 2008;299(23):2760-2769.

Context Biochemical disease recurrence after radical prostatectomy often prompts salvage radiotherapy, but no studies to date have had sufficient numbers of patients or follow-up to determine whether radiotherapy improves survival, and if so, the subgroup of men most likely to benefit.
Objectives To quantify the relative improvement in prostate cancer-specific survival of salvage radiotherapy vs no therapy after biochemical recurrence following prostatectomy, and to identify subgroups for whom salvage treatment is most beneficial.
Design, Setting, and Patients Retrospective analysis of a cohort of 635 US men undergoing prostatectomy from 1982-2004, followed up through December 28, 2007, who experienced biochemical and/or local recurrence and received no salvage treatment (n = 397), salvage radiotherapy alone (n = 160), or salvage radiotherapy combined with hormonal therapy (n = 78).
Main Outcome Measure Prostate cancer-specific survival defined from time of recurrence until death from disease.
Results With a median follow-up of 6 years after recurrence and 9 years after prostatectomy, 116 men (18%) died from prostate cancer, including 89 (22%) who received no salvage treatment, 18 (11%) who received salvage radiotherapy alone, and 9 (12%) who received salvage radiotherapy and hormonal therapy. Salvage radiotherapy alone was associated with a significant 3-fold increase in prostate cancer-specific survival relative to those who received no salvage treatment (hazard ratio [HR], 0.32 [95% confidence interval {CI}, 0.19-0.54]; P<.001). Addition of hormonal therapy to salvage radiotherapy was not associated with any additional increase in prostate cancer-specific survival (HR, 0.34 [95% CI, 0.17-0.69]; P = .003). The increase in prostate cancer-specific survival associated with salvage radiotherapy was limited to men with a prostate-specific antigen doubling time of less than 6 months and remained after adjustment for pathological stage and other established prognostic factors. Salvage radiotherapy initiated more than 2 years after recurrence provided no significant increase in prostate cancer-specific survival. Men whose prostate-specific antigen level never became undetectable after salvage radiotherapy did not experience a significant increase in prostate cancer-specific survival. Salvage radiotherapy also was associated with a significant increase in overall survival.
Conclusions Salvage radiotherapy administered within 2 years of biochemical recurrence was associated with a significant increase in prostate cancer-specific survival among men with a prostate-specific antigen doubling time of less than 6 months, independent of other prognostic features such as pathological stage or Gleason score. These preliminary findings should be validated in other settings, and ultimately, in a randomized controlled trial.

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Prostate cancer tied to inactivity

Source: UPI

Men who work at desk jobs are more likely to develop prostate cancer than manual workers, a study indicates.
Researchers found low levels of physical activity in the workplace can significantly raise the risk of cancer, the Daily Mail reported Saturday.
The study determined men who worked as teachers or in office jobs were much more likely to get cancer than those who spend much of their day on their feet, such as laborers, bakers and barbers.
Specifically, men who spend their day working at a desk are 30 percent more likely to develop prostate cancer than manual workers, the study found.

This study shows that men with sedentery jobs are at increased risk or prostate cancer. I wouldn’t advise changing careers, but adding exercise to your daily regimen should help prevent illnesses and probably helps prevent recurrences and delays progression in men who have cancer.

UroToday – Percent Tumor Involvement and Risk of Biochemical Progression After Radical Prostatectomy

From UroToday:

We examined the association between percent tumor involvement in the radical prostatectomy specimen and the outcome measures of pathological stage and biochemical progression using multivariate logistic regression and Cox proportional hazards analysis, respectively, in 2,220 patients from the Duke Prostate Center radical prostatectomy database.

This was a study that showed that if you had more cancer in the prostate, you had a higher risk of the cancer coming back after surgery. Although this is obvious, it is important to show these type of things with studies.

Would I would like to see is if patients with the same gleason score and stage (meaning the extent of cancer spread) have different rates of recurrences.

For example, 2 men with organ confined prostate cancer that both have gleason 6 cancers. If 1 man has 1% of tumor volume in his prostate and the other 30%, I would imagine the man with 30% would be more likely to have a recurrence. I am not aware of any studies that have looked at this.

Determinants of Long-Term Retention of Prostate Cancer Patients in Active Surveillance Management Programs

From Urotoday and the AUA

Of the 2134 PCa cases, 169 (7.9%) had AS as their initial management. Of the 169 AS cases, 89 (53%) remained untreated throughout follow-up (mean 7.1 years) and the remaining 47% received treatment an average of 3.1 years post-diagnosis. Significant predictors of eventual active treatment in multivariate models included younger age at diagnosis (60-69 vs. 70+ years), higher Gleason score (>6 vs. <6), and higher prostate cancer aggressiveness/risk. The researchers observed similar rates for development of clinical metastases and PCa death in both AS and immediate treatment groups, respectively (metastases: N=8 and N=92, 6.5 vs. 6.7 events per 1,000 person-years, p=1.0; PCa death: N=4 and N=51, 2.4 vs. 2.7 deaths per 1,000 person-yrs, p=1.0).

This one study shows that men that did active surveillance, needed therapy about half of the time. The results seemed similar for both groups. My main concern is that we do not know the cancer characteristics of the patients. It is possible that the active surveillance patients had less cancer than the treated patients and should have done better.
I also think that waiting 3 years to treat someone may later the treatment approach and possibly lead to more side effects after therapy.

Vitamin D doesn’t cut prostate cancer risk

Source Reuters

U.S. National Cancer Institute researchers set out to see if vitamin D might protect against prostate cancer, the second most frequently diagnosed cancer in men worldwide. They tracked vitamin D concentrations in the blood of 749 men diagnosed with prostate cancer and 781 men who did not have the disease.
They found no association between higher levels of the vitamin and a reduced prostate cancer risk. The findings hinted at a possible increased risk for aggressive prostate cancer in men with higher blood concentration of vitamin D, but this link was not statistically significant, the researchers said.

This one study did not reveal any benefit from Vitamin D. There have been others that do show a benefit. This is why it is important to continue to do studies and use scientific method to assess things.

I ask patients to take a multivitamin a day, but not extra Vitamin D.

Surgical experience affects prostate cancer control ‘regardless of risk’

From MedWire News – Oncology –

Prostate cancer control after radical prostatectomy improves with increasing surgeon experience, regardless of patients’ risk, say US scientists who suggest that the primary reason for recurrence in low-risk patients is inadequate surgical technique.
The team, led by Eric Klein from the Cleveland Clinic in Ohio, previously discovered that open radical prostatectomy has a learning curve, and other studies have indicated that patients treated by higher-volume surgeons have shorter hospital stays, fewer peri-operative complications, and better urinary continence than those treated by lower-volume surgeons.

This study was done for open radical prostatectomy patients.
My guess is that we will have similar results for robotic surgeons, but I think novice robotic surgeons that have vast experience with laparoscopic or open prostate cancer surgery will have better results than those who do not.

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