Philippa J. Cheetham

Penile rehabilitation protocol after robot‐assisted radical prostatectomy: assessment of compliance with phosphodiesterase type 5 inhibitor therapy and effect on early potency

Study Type – Therapy (case series)
Level of Evidence 4

Testosterone in prostate cancer: the Bethesda consensus.

Whats known on the subject? and What does the study add?

Gleason score concordance on biopsy-confirmed prostate cancer: is pathological re-evaluation necessary prior to radical prostatectomy?

Study Type – Diagnosis (case series)

Diet and Prostate Cancer: A Holistic Approach to Management

There is now increasing evidence from epidemiologic surveys and from laboratory, intervention, and case-control studies that diet and lifestyle plays a crucial role in prostate cancer biology and tumorigenesis. This applies to both the development and progression of prostate cancer, although in many cases the specific initiating factors in the diet are poorly understood. Conversely, many nutrients and herbs also show significant promise in helping to treat prostate cancer by slowing progression and reducing recurrence, ultimately reducing the risk of morbidity and mortality from the disease. Furthermore for all grades of prostate cancer, nutritional interventions complement conventional treatment to improve response and quality of life. Slowing or even reversing the progression of, high-grade prostate intraepithelial neoplasia [HGPIN]). with chemo-preventative agents could be the best primary defense against prostate cancer, preventing it from occurring in the first place. The information given in this review about prostate cancer chemoprevention summarizes the key evidence for the role of different dietary components and their effect on prostate cancer prevention and progression. Most nutritional chemoprevention agents also have the added benefit of being beneficial for the cardiovascular system, bone health and for the prevention of other cancers.

Use of a flexible carbon dioxide laser fiber for precise dissection of the neurovascular bundle during robot-assisted laparoscopic prostatectomy.

INTRODUCTION Carbon dioxide (CO(2)) lasers deliver energy with minimal thermal spread to tissues during dissection. Excess thermal spread during dissection of the neurovascular bundle (NVB) can affect potency in men after robot-assisted radical prostatectomy (RARP). We report on a novel delivery mechanism for CO(2) laser energy through a flexible fiber to enhance accuracy of NVB dissection during RARP. MATERIALS A feasibility study of the OmniGuide BeamPath URO-LG CO(2) laser fiber for NVB dissection was performed on 10 patients with primary Gleason 3 T1c prostate cancer during RARP. Bilateral lateral fascial antegrade nerve sparing was performed. We evaluated fiber performance, safety, and efficacy. RESULTS The fiber was inserted through the 12-mm assistants port and easily manipulated by robotic instruments. Once pedicles were clipped and dissected, the laser fiber was effective in establishing planes of dissection between prostatic capsule and NVB. The endoscopically discernable thermal laser footprint was small, with minimal thermal spread during nerve sparing, meticulous dissection of NVB, and fascial layer identification. Although the laser did provide extremely accurate dissection, it was unable to serve as an adequate means of larger vessel coagulation. CONCLUSIONS The flexible CO(2) laser fiber was easily manipulated. Identification of fascial layers during nerve sparing was facilitated with the fiber. Long-term follow-up is necessary to determine efficacy of this technology versus conventional techniques on the NVB. Larger studies are currently in progress to determine if use of the flexible CO(2) laser fiber results in improvements in functional outcomes with regard to return of sexual potency after RARP.

Standard versus saturation biopsy before primary focal cryosurgery of the prostate: Does it matter?

123 Background: Primary focal cryosurgery (PFC) has emerged as a viable option for local therapy in prostate cancer (PCa), most suitable for patients with clinical stage T1c-T3 disease of any tumor grade in whom potency is not of primary concern and who are not suitable for radical prostatectomy or radiation therapy. Success of 5-year biochemical recurrence (BCR)-free survival, depending on criteria, ranges from 60% to 90% in the literature. We hypothesize that saturation biopsy before PFC leads to lower rates of BCR compared to standard 12-core biopsy. Methods: We compiled a consecutive series of patients who underwent PFC at our institution for localized PCa. Parameters including demographics, PSA levels, and Gleason scores before primary treatment and at time of recurrence were assessed. Biochemical failure was defined by both Phoenix (PD) and Stuttgart (SD) definitions. Chi-square analysis was performed to compare outcomes. Results: One hundred and forty-seven patients underwent PFC at our institution...

Primary focal cryosurgery of the prostate: Long-term clinical and biochemical outcomes in a large cohort at a tertiary referral center.

114 Background: Modern primary focal cryosurgery (PFC) has emerged as a primary therapy option for localized and minimal low-risk prostate cancer (PCa), achieving good local cancer control and survival outcome. The aim of this analysis was to report on the experience of PFC in our tertiary referral center in the management of localized PCa. Methods: We identified a consecutive series of patients that underwent PFC for localized PCa at our institution between 8/2000 and 1/2014. Demographics, PSA levels and Gleason scores before primary treatment and at time of recurrence were assessed; BDFS, OS, and DSS were assessed. BCR was defined by the Phoenix (PD) and Stuttgart Definitions (SD). Results: A total of 126 patients were included in the analysis, with a median follow-up of 40.3 (0.8-116, IQR 41) months. Median age was 73.5 (range 45-92, IQR 9) years. Median initial serum PSA level was 6.0 (1-44.5, IQR 3) ng/ml. Median primary and secondary Gleason score on initial biopsy was 3 (3-5, IQR 1) with a median s...

Re: Abiraterone and Increased Survival in Metastatic Prostate Cancer

Experts’ summary: This paper reports results on the use of the oral agent abiraterone acetate (an androgen biosynthesis inhibitor that selectively inhibits the enzyme 17a-hydroxylase expressed in and required for androgen biosynthesis from extragonadal sites) for the treatment of patients with metastatic castration-resistant prostate cancer (mCRPC) who have received prior docetaxelbased chemotherapy. The authors reported that in a placebo-controlled, phase 3 clinical trial, abiraterone acetate (Zytiga) plus prednisone resulted in improved median overall survival by 4.6 mo (15.8 mo vs 11.2 mo in the placebo-plus-prednisone arm), a 13% reduction in the absolute risk of death, a 33% reduction in risk of radiographic progression (median time to radiographic progression: 5.6 mo vs 3.6 mo), and significant improvement in pain palliation compared with placebo plus prednisone for the treatment of men with mCRPC who have received prior docetaxel-based chemotherapy.

AGE AND INTERNATIONAL PROSTATE SYMPTOM SCORE AS PREDICTORS OF EARLY URINARY CONTINENCE AFTER ROBOTIC PROSTATECTOMY

OBJECTIVE We sought to identify predictors of early urinary continence after robot-assisted prostatectomy (RARP) in men who underwent a posterior rhabdosphincter reconstruction. MATERIALS AND METHODS A prospective analysis was performed in 107 consecutive men who underwent RARP by a single surgeon in an academic center. Men were excluded if they received adjuvant radiation therapy (7 men), were lost to follow up (4), or did not have a posterior rhabdosphincter reconstruction (8 men). Eighty-eight men received a posterior rhabdosphincter reconstruction and were followed in this study. Patient demographic and postoperative urinary control was recorded at interval follow up visits by the physician and research staff. Level of comorbidity was measured with the Charlson Comorbidity Index (CACI). Preoperative urinary function was measured using the International Prostate Symptom Score (IPSS). Continence was defined as men using zero pads per day. RESULTS Eighty-eight men with a mean age of 59.2 years (43.1-77.6) were followed for a median of 7.6 (range 1.5-16.7) months. The median preoperative PSA and IPSS was 5.0 ng/mL (range 0.95 ng/mL-23 ng/mL) and 8 (range 0-30), respectively. Overall, 91% of the men achieved continence with a median time to continence of 2.3 months. Of those, 50% achieved continence by 6 weeks. Men continent at 6 weeks were significantly younger, had lower IPSS scores, and less comorbidities (p = 0.01). Age (OR = 0.91, p < 0.01) and higher IPSS scores (OR = 0.28, p = 0.03) were associated with decreased odds of achieving continence at 6 weeks. The presence of coexisting disease was not predictive of continence return. After adjusting for comorbidity, body mass index (BMI), nerve sparing, and IPSS score, only age remained as an independent predictor of early continence (OR = 0.90, p = 0.04). CONCLUSIONS In conclusion, we found that increased age and increased lower urinary tract symptom (LUTS) severity are associated with decreased odds of achieving continence 6 weeks after RARP. Patient age remains the strongest predictor of early return of continence in a multivariate model. These factors should be used in counseling prior to surgery to meet realistic patient expectations.