Mansour Alnazari

Standardized 4-step technique of bladder neck dissection during robot-assisted radical prostatectomy

Bladder neck (BN) dissection is considered one of the most challenging steps during robot-assisted radical prostatectomy. Better understanding of the BN anatomy, coupled with a standardized approach may facilitate dissection while minimizing complications. We describe in this article the 4 anatomic spaces during standardized BN dissection, as well other technical maneuvers of managing difficult scenarios including treatment of a large median lobe or patients with previous transurethral resection of the prostate. The first step involves the proper identification of the BN followed by slow horizontal dissection of the first layer (the dorsal venous complex and perivesicle fat). The second step proceeds with reconfirming the location of the BN followed by midline dissection of the second anatomical layer (the anterior bladder muscle and mucosa) using the tip of the monopolar scissor until the catheter is identified. The deflated catheter is then grasped by the assistant to apply upward traction on the prostate from 2 directions along with downward traction on the posterior bladder wall by the tip of the suction instrument. This triangulation allows easier, and safer visual, layer by layer, dissection of the third BN layer (the posterior bladder mucosa and muscle wall). The forth step is next performed by blunt puncture of the fourth layer (the retrotrigonal fascia) aiming to enter into the previously dissected seminal vesical space. Finally, both vas deferens and seminal vesicles are pulled through the open BN and handed to the assistant for upper traction to initiate Denovilliers dissection and prostate pedicle/neurovascular bundle control.

Perioperative predictors for post-prostatectomy urinary incontinence in prostate cancer patients following robotic-assisted radical prostatectomy: Long-term results of a Canadian prospective cohort

INTRODUCTION We aimed to report the impact of perioperative factors that have not been well-studied on continence recovery following robotic-assisted radical prostatectomy (RARP). METHODS We analyzed data of 322 men with localized prostate cancer who underwent RARP between October 2006 and May 2015 in a single Canadian centre. All patients were assessed at one, three, six, 12, and 24 months after surgery. We evaluated risk factors for post-prostatectomy urinary incontinence from a prospectively collected database in multivariate Cox regression analysis. The primary endpoint was continence, defined as 0 pad usage per day. RESULTS 0-pad continence rates were 126/322 (39%), 187/321 (58%), 222/312 (71%), 238/294 (80%), and 233/257 (91%) at one, three, six, 12, and 24 months, respectively. Bladder neck preservation (hazard ratio [HR] 0.71; 95% confidence interval [CI] 0.5-0.99; p=0.04), and prostate size (HR 0.99; 95% CI 0.98-0.99; p=0.02) were independent predictors of continence recovery after RARP. Smoking at time of surgery predicted delayed continence recovery on multivariate analysis (HR 1.42; 95% CI 1.01-1.99; p=0.04). Neurovascular bundles preservation was associated with continence recovery after 24 months. No statistically significant correlation was found with other variables, such as age, body mass index, Charlson comorbidity index, preoperative oncological baseline parameters, presence of median lobe, or thermal energy use. CONCLUSIONS Our results confirmed known predictors of postprostatectomy incontinence (PPI), namely bladder neck resection and large prostate volume. Noteworthy, cigarette smoking at the time of RARP was found to be a possible independent risk factor for PPI. This study is hypothesis-generating.

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

INTRODUCTION Transurethral 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. METHODS A 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. RESULTS Mean 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. CONCLUSIONS This 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

AIM Utility of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in predicting biochemical recurrence (BCR) in patients with localized prostate cancer. MATERIALS & METHODS Retrospective 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. RESULTS Out 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. CONCLUSION Neither elevated NLR nor PLR predicted an increased risk of BCR.

MP93-04 THE RISK OF URINARY RETENTION FOLLOWING ROBOT-ASSISTED RADICAL PROSTATECTOMY AND ITS IMPACT ON EARLY CONTINENCE OUTCOMES

INTRODUCTION AND OBJECTIVES: Radical prostatectomy (RP), external-beam radiotherapy (EBRT), and brachytherapy are standard treatments for localized prostate cancer but each may negatively impact bowel function. We sought to develop a nomogram predicting the probability of treatment-related bowel problems using prospective, patient-reported data. METHODS: Patient-reported data on treatment-related bowel problems was obtained from four prospective, longitudinal, healthrelated quality-of-life (HRQOL) protocols comprising 2,668 patients treated between 1999 and 2011 in the United States and Spain. A single HRQOL instrument was not uniformly used for each study, though a similar 5-point scale was used in each protocol to assess bother related to bowel problems. Bowel dysfunction was defined as bowel symptoms identified as a moderate-to-big problem by patients on survey responses before treatment and 2 years post-treatment. Multivariable logistic regression analysis was used to model the clinical information and follow-up data. Internal validation was performed using bootstrapping. RESULTS: Overall, 43 patients (2%) with complete data had bowel dysfunction prior to treatment. The rate of bowel dysfunction at 2 years in patients with no bowel dysfunction pretreatment was 2%, 10%, and 4% for patients treated by RP, EBRT, and brachytherapy, respectively (p<0.001). A nomogram based on pretreatment bowel bother, treatment modality, and race had a concordance index of 0.725 and predictions were well-calibrated with observed outcome on cross-validation. The predictive accuracy was not increased by the inclusion of additional demographic, tumor-related, or treatmentrelated variables, or by the creation of separate treatment-specific models. CONCLUSIONS: A validated nomogram that predicts 2-year probability of bowel dysfunction after treatment for localized prostate cancer has been developed. The nomogram is anticipated to be useful for patient counseling regarding treatment options for localized prostate cancer.

MP20-13 VALIDATION OF A MODIFIED GLEASON GRADING SYSTEM IN A CANADIAN COHORT

INTRODUCTION AND OBJECTIVES: Commonly used Gleason score grading of prostate cancer presents various deficiencies. Recently a new 5 Grade Group system has been developed sub-stratifying standard Biopsy Gleason scores 6, 3+4, 4+3, 8 and 9-10 into 5 distinct, prognostic Groups 1-5. We sought to replicate this new grading system for surgical Gleason score on a large contemporary Canadian cohort. METHODS: Analysis was realized on pathologic specimens of a prospectively maintained Canadian database of men who underwent robot-assisted radical prostatectomy (RARP) between 2006 and 2016 at two major academic centers in Montreal. Outcome was based on biochemical recurrence (BCR) defined as a rising PSA>0.2ng/mL. The log-rank test assessed univariable differences in BCR by the novel Gleason score groups from prostate biopsy. Separate univariable and multivariable Cox proportional hazards used four possible categorizations of Gleason scores. RESULTS: Of the 617 patients eligible for analysis, 102, 398, 57, 34, 26 were classified as group 1,2,3,4,5 respectively. With a mean followup of 28 months, significant differences in BCR rates between both Gleason 3 + 4 versus 4 + 3 (p<0.001) were observed. There were no statistical difference in BCR rates between Gleason 8 versus 9-10 (p1⁄4 0.342). The hazard ratios relative to Gleason score 6 were 1.531 95% CI (0.588; 3.987), 5.146 (1.754; 15.098), 8.157 (2.783; 23.911), and 11.7 (3.585; 30.804) for Gleason scores 3 + 4, 4 + 3, 8, and 9e10, respectively. CONCLUSIONS: The present study demonstrates the importance of the separation of the two Gleason categories 3+4 versus 4+3 in the new system. Further studies are warranted to implement the updated system for more accurate prognostications, and to improve patient counseling of cancer grading.

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

INTRODUCTION We 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). METHODS Data 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. RESULTS Men 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). CONCLUSIONS In 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

INTRODUCTION We 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. METHODS The 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. RESULTS The 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. CONCLUSIONS While 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.