Khaled Ajib

Does surgical delay for radical prostatectomy affect biochemical recurrence? A retrospective analysis from a Canadian cohort

AimWe sought to explore the impact of surgical wait time (SWT) to robot-assisted radical prostatectomy (RARP) on biochemical recurrence (BCR).MethodRetrospective review of a prospectively collected database between 2006 and 2015 was conducted on all RARP cases. SWT was defined as period from prostate biopsy to surgery. Primary outcome was the impact on BCR, which was defined as two consecutive PSA ≥xa00.2xa0ng/dl, or salvage external beam radiation therapy and/or salvage androgen deprivation therapy. Patients were stratified according to D’Amico risk categories. Univariable analysis (UVA) and multivariable analyses (MVA) with a Cox proportional hazards regression model were used to evaluate the effect of SWT and other predictive factors on BCR, in each D’Amico risk group and on the overall collective sample.ResultsPatients eligible for analysis were 619. Mean SWT was 153, 169, 150, and 125xa0days, for overall, low-, intermediate-, and high-risk patients, respectively. Multivariate analysis on the overall cohort did not show a significant relation between SWT and BCR. On subgroup analysis of D’Amico risk group, SWT was positively correlated to BCR for high-risk group (pxa0=xa00.001). On threshold analysis, cut-off was found to be 90xa0days. SWT did not significantly affect BCR on UVA and MVA in the low- and intermediate-risk groups.ConclusionIncreased delay to surgery could affect the BCR, as there was a positive association in high-risk group. Further studies with longer follow-up are necessary to assess the impact of wait time on BCR, cancer specific survival and overall survival.

Multicentre international experience of 532-nm laser photoselective vaporization with GreenLight XPS in men with very large prostates

To describe peri‐operative results, functional outcomes and complications of laser photoselective vaporization, using the GreenLight system, of prostate glands ≥200 mL in volume.

Functional outcomes of robot-assisted radical prostatectomy in patients eligible for active surveillance

ObjectiveTo assess the outcome of low risk prostate cancer (PCa) patients who were candidates for active surveillance (AS) but had undergone robot-assisted radical prostatectomy (RARP).MethodWe reviewed our prospectively collected database of patients operated by RARP between 2006 and 2014. Low D’Amico risk patients were selected. Oncological outcomes were reported based on pathology results and biochemical failure. Functional outcomes on continence and potency were reported at 12 and 24xa0months. Continence was assessed by the number of pads per day. With respect to potency, it was assessed using the Sexual Health Inventory for Men (SHIM) and Erectile Hardness Scale (EHS).ResultsOut of 812 patients, 237 (29.2%) patients were D’Amico low risk and were eligible for analysis. 44 men fit Epstein’s criteria. 134 (56.5%) men had pathological upgrading. Age and clinical stage were predictors of upgrading on multivariate analysis. 220 (92.8%) patients had available follow-up for biochemical recurrence, potency, and continence for 2xa0years. The mean and median follow-up was 34.8 and 31.4xa0months, respectively. Only 5 (2.3%) men developed BCR, all of whom had pathological upgrading. Extra capsular extension and positive surgical margins were observed in 14.8 and 19.1%, respectively. 0 pad was achieved in 86.7 and 88.9% at 1 and 2xa0years, respectively. Proportion of patients with SHIMu2009>u200921 at 1 and 2xa0years was 24.8 and 30.6%, respectively. Moreover, patients having erections adequate for intercourse (EHSu2009≥u20093) were seen in 69.6 and 83.1% at 1 and 2xa0years, respectively. Functional outcomes of patients fitting Epstein’s criteria (nu2009=u200944) and patients with no upgrading on final pathology (nu2009=u2009103) were not significantly different compared to the overall low risk study group.ConclusionThis retrospective study showed that RARP is not without harm even in patients with low risk disease. On the other hand, considerable rate of upgrading was noted.

Monopolar Transurethral Enucleo-Resection of the Prostate (TUERP) versus HoLEP: A Canadian Novel Experience

OBJECTIVEnTo study the functional outcome of patients undergoing transurethral enucleation and resection of the prostate (TUERP) vs patients undergoing holmium laser enucleation of the prostate (HoLEP) in men with bladder outlet obstruction.nnnMATERIALS AND METHODSnWe retrospectively analyzed our prospectively collected database of two groups of patients. Twenty-four patients underwent TUERP (group 1), and 27 underwent HoLEP (group 2). Preoperative characteristics, intervention parameters, postoperative functional outcomes, uroflowmetry, and complications were collected.nnnRESULTSnMean prostate size in groups 1 and 2 were 87.2 and 93.5 cc, respectively. The mean duration of surgery was 110 minutes in group 1 and 136 minutes in group 2. In group 1, prostate-specific antigen (PSA) dropped from 4.4 to 1.2u2009ng/cc after 12 months. International Prostate Symptom Score (IPSS) was 3.75 at 12 months with a preoperative value of 20.9. With respect to maximum urinary flow rate (Qmax), it increased to 21.8u2009mL/s from a preoperative value of 6.4u2009mL/s. In group 2, the PSA dropped from 7.6 to 1.3u2009ng/cc. IPSS dropped from 22.3 to 3.8, Qmax increased from 7.7 to 22.5u2009mL/s. Hemoglobin, complications, and all studied parameters were not statistically significant between both groups.nnnCONCLUSIONnIn this study, TUERP was safe and efficacious in benign prostatic hyperplasia patients with large glands. Modifications can be implemented on the standard transurethral resection of the prostate technique to treat patients with prostate sizes >70 cc.

Monopolar Transurethral Enucleo-Resection of the Prostate Versus Holmium Laser Enucleation of the Prostate: A Canadian Novel Experience

OBJECTIVEnTo study the functional outcome of patients undergoing transurethral enucleation and resection of the prostate (TUERP) vs patients undergoing holmium laser enucleation of the prostate (HoLEP) in men with bladder outlet obstruction.nnnMATERIALS AND METHODSnWe retrospectively analyzed our prospectively collected database of two groups of patients. Twenty-four patients underwent TUERP (group 1), and 27 underwent HoLEP (group 2). Preoperative characteristics, intervention parameters, postoperative functional outcomes, uroflowmetry, and complications were collected.nnnRESULTSnMean prostate size in groups 1 and 2 were 87.2 and 93.5 cc, respectively. The mean duration of surgery was 110 minutes in group 1 and 136 minutes in group 2. In group 1, prostate-specific antigen (PSA) dropped from 4.4 to 1.2u2009ng/cc after 12 months. International Prostate Symptom Score (IPSS) was 3.75 at 12 months with a preoperative value of 20.9. With respect to maximum urinary flow rate (Qmax), it increased to 21.8u2009mL/s from a preoperative value of 6.4u2009mL/s. In group 2, the PSA dropped from 7.6 to 1.3u2009ng/cc. IPSS dropped from 22.3 to 3.8, Qmax increased from 7.7 to 22.5u2009mL/s. Hemoglobin, complications, and all studied parameters were not statistically significant between both groups.nnnCONCLUSIONnIn this study, TUERP was safe and efficacious in benign prostatic hyperplasia patients with large glands. Modifications can be implemented on the standard transurethral resection of the prostate technique to treat patients with prostate sizes >70 cc.

Photoselective vaporization of the prostate with the 180-W XPSGreenlight laser: Five-year experience of safety, efficiency, and functional outcomes

INTRODUCTIONnTransurethral resection of the prostate (TURP) is still considered the gold standard surgical treatment for symptomatic benign prostatic hyperplasia (BPH). However, photoselective vaporization of the prostate (PVP) has gained widespread global acceptance in national guidelines as a safe and effective alternative option. Nevertheless, further evidence is required to assess the durability of Greenlight PVP. Herein, we report our five years of PVP experience with the Greenlight 180W XPS laser system.nnnMETHODSnA retrospective analysis was conducted on a prospectively gathered database of 370 consecutively included patients who underwent PVP using Greenlight XPS-180 W laser system (Boston Scientific, Boston, MA, U.S.) performed by a single experienced laser surgeon between 2011 and 2016. Preoperative characteristics, intervention parameters, postoperative functional, uroflowmetry outcomes, and complications were collected. Outcomes are reported over a period of five years.nnnRESULTSnMean age was 68 years, with a mean prostate volume of 78.8 cc (95% confidence interval [CI] 70.9-78.7]). The mean followup was 59.4 months (55.4-63.5). Mean energy, operative time, and energy/cc were 270.2 kJ (255.2-285.2), 62.7 minutes (59.6-65.7), and 3.7 kJ/cc (3.6-3.9), respectively. Compared to preoperative values, International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and post-void residual (PVR) parameters were significantly improved and sustained over the five postoperative years. Of note, only 66 patients (out of 370) had a complete five-year followup. Prostate-specific antigen (PSA) reached nadir at one year, with a drop of 67% from the mean preoperative value of 6.2 ng/mL. Mean IPSS nadir was reached at three years, with a drop of 80.4% (-21.1 points). Similarly, mean quality of life (QoL) score dropped by 82.8% after three years (preoperative mean of 4.7). With respect to mean Qmax, there was an increase by 72.7% (+14.7 mL/s) at one year, reaching the value of 19.9 mL/s. Moreover, mean PVR was 32.8 mL at four years compared to 345 mL preoperatively. At five years followup, PSA, IPSS, QoL, and PVR dropped by 59.7% (3.7 ng/mL), 75.2% (19.7 points), 78.72% (3.7 points), and 84.4% (291.3 mL), respectively. Qmax increased by 12.9 mL/s. Clavien complication rates were low, with bladder neck stenosis observed in seven (1.6%) men. During the five-year followup, only four patients (1%) required BPH surgical re-intervention.nnnCONCLUSIONSnThis is the first long-term reporting of Greenlight XPS-180W laser system. In experienced hands, the observed outcomes appear to demonstrate that Greenlight XPS-180 W laser system is safe, efficacious, and durable for the treatment of bladder outlet obstruction (BOO) secondary to BPH.

Prognostic utility of neutrophil-to-lymphocyte and platelets-to-lymphocyte ratio in predicting biochemical recurrence post robotic prostatectomy

AIMnUtility of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting biochemical recurrence (BCR) in patients with localized prostate cancer.nnnMATERIALS & METHODSnRetrospective analysis of patients operated by robot-assisted radical prostatectomy. Variables included were: NLR, PLR pre-operative prostate specific antigen, pathological Gleason score, surgical margins status, extracapsular extension, seminal vesical invasion, and lymph node status.nnnRESULTSnOut of 321 patients, no association between NLR or PLR and BCR was detected. Predictors of BCR were pathological Gleason score, extracapsular extension and positive surgical margins. On multivariate analysis, the Gleason Score, extracapsular extension and positive surgical margins remained the only predictors of BCR.nnnCONCLUSIONnNeither elevated NLR nor PLR predicted an increased risk of BCR.

Functional and oncological outcomes of salvage external beam radiotherapy following robot-assisted radical prostatectomy in a Canadian cohort

INTRODUCTIONnWe sought to determine the impact of salvage radio-therapy (SRT) on oncological and functional outcomes of patients with prostate cancer after biochemical recurrence (BCR) following robot-assisted radical prostatectomy (RARP).nnnMETHODSnData of 70 patients with prostate cancer treated with SRT after developing BCR were retrospectively analyzed from a prospectively collected RARP database of 740 men. Oncological (prostate-specific antigen [PSA]) and functional (pads/day, International Prostate Symptom Score [IPSS], and Sexual Health Inventory for Men [SHIM]) outcomes were reported at six, 12, and 24 months after RT and adjusted for pre-SRT status.nnnRESULTSnMen who underwent SRT had a mean age, PSA, and time from radical prostatectomy (RP) to RT of 61.8 years (60.1-63.6), 0.5 ng/ml (0.2-0.8), and 458 days (307-747), respectively. Freedom from biochemical failure (FFBF) post-SRT, defined as a PSA nadir <0.2 ng/mL, was observed in 89%, 93%, and 81%, at six, 12, and 24 months, respectively. Undetectable PSA was observed in 14%, 35%, and 40% at the same time points, respectively. There was no significant difference in urinary continence post-SRT (p=0.56). Rate of strict continence (0 pads/day) was 71% at 24 months compared to 78% pre-SRT. Mean IPSS at six, 12, and 24 months was 3.4, 3.6, and 3.6, respectively compared to pre-RT score of 3.3 (p=0.61). The mean SHIM score pre-SRT was comparable at all time points following treatment (p=0.86).nnnCONCLUSIONSnIn this unique Canadian experience, it appears that early SRT is highly effective for the treatment of BCR following RARP with little impact on urinary continence and potency outcomes.

The risk of urinary retention following robot-assisted radical prostatectomy and its impact on early continence outcomes

INTRODUCTIONnWe aimed to evaluate the risk factors of acute urinary retention (AUR) following robot-assisted radical prostatectomy (RARP), as well as the relationship of AUR with early continence outcomes.nnnMETHODSnThe records of 740 consecutive patients who underwent RARP by two experienced surgeons at our institution were retrospectively reviewed from a prospectively collected database. Multiple factors, including age, body mass index (BMI), international prostate symptom score (IPSS), prostate volume, presence of median lobe, nerve preservation status, anastomosis time, and catheter removal time (Day 4 vs. 7), were evaluated as risk factors for AUR using univariate and multivariate analysis. The relation between AUR and early return of continence (one and three months) post-RARP was also evaluated.nnnRESULTSnThe incidence of clinically significant vesico-urethral anastomotic (VUA) leak and AUR following catheter removal were 0.9% and 2.2% (17/740), respectively. In men who developed AUR, there was no significant relationship with regards to age, BMI, IPSS, prostatic volume, median lobe, nerve preservation, or anastomosis time; however, the incidence of AUR was significantly higher for men with catheter removal at Day 4 (4.5% [16/351]) vs. Day 7 (0.2% [1/389]) (p=0.004). Moreover, patients with early removal of the catheter (Day 4) who developed AUR had an earlier one-month return of 0-pad continence 87.5% (14/16) compared to patients without AUR 45.6% (153/335), with no significant difference at three months.nnnCONCLUSIONSnWhile AUR is an uncommon complication of RARP, its incidence is much higher than VUA leakage. Further, it is often not well-discussed during patient counselling preoperatively. Moreover, earlier return of urinary continence was observed in patients experiencing AUR following RARP exclusively with catheter removal at Day 4. Future studies are warranted to validate the long-term impact of AUR on continence outcomes.