Thierry Quackels

Laparoscopic radical prostatectomy: The learning curve

Purpose of review Laparoscopic radical prostatectomy is now an accepted treatment option for the management of localized prostate cancer. Numerous studies have demonstrated the feasibility and the reproducibility of this procedure. Expert teams in high-volume centres routinely carry out laparoscopic radical prostatectomy but for the novice the obstacle to success is how to learn and gain proficiency in this procedure. In this review, we will present our views on how this can be done. Recent findings A learning curve includes the necessity for continuous self-evaluation in terms of cancer control, continence and potency. Many different methods can be used to acquire the technique: dry lab, animal live lab, cadaveric laparoscopic dissection or mentoring with an expert. All of these steps may not be essential as laparoscopic radical prostatectomy is not too dissimilar to open prostatectomy. However, one must understand that the physiological consequences of anaesthesia during laparoscopy and basic laparoscopic suturing technique should be perfected prior to taking on laparoscopic radical prostatectomy. The training then must continue under the supervision of a mentor. The opportunity for discussion with an expert allows the novice to learn the pitfalls and the tips and tricks of laparoscopic radical prostatectomy, thus reducing the length of the learning curve and negating the need to reinvent the wheel. Summary Laparoscopic radical prostatectomy is similar to any other new surgical procedure and as with open surgery we learn and gain experience with each procedure; the learning curve is never completely finished.

Bacillus Calmette-Guerin therapy in non-muscle-invasive bladder carcinoma after renal transplantation for end-stage aristolochic acid nephropathy.

Intravesical instillation of bacillus Calmette‐Guerin (BCG) is the treatment of choice for non‐muscle‐invasive bladder cancer (NMIBC) of high grade and/or carcinoma in situ. This study evaluated the feasibility, efficacy, and tolerance of BCG instillations in eight kidney recipients for end‐stage aristolochic acid nephropathy (AAN), a condition at high risk of urothelial carcinoma, and diagnosed for NMIBC. Five of them had relapsed after mitomycin C treatment. Tolerance to BCG was evaluated clinically and regular follow‐up with fluorescence cystoscopy was performed along with renal graft function monitoring. Immunosuppression doses were adjusted and prophylactic anti‐tuberculous treatment given to reduce risks of graft rejection and infection. After a mean follow‐up period of 50 months, seven of the eight patients are free of relapse and kidney graft function remained unchanged. Tolerance was good, except for one episode of fever and one early discontinuation because of subjective discomfort. No systemic tuberculous infection was observed. This is the first clinical observation of successful BCG therapy for NMIBC in patients given transplant for end‐stage AAN. Under standardized conditions, immunotherapy based on intravesical BCG is feasible, effective, and well tolerated in renal transplantation.

Risk factor assessment in high-risk, bacillus Calmette–Guérin-treated, non-muscle-invasive bladder cancer

Objective To assess the risk factors associated with recurrence, progression and survival in high-risk non-muscle-invasive bladder cancer (NMIBC) patients treated with bacillus Calmette–Guérin (BCG) and validate the European Organization for Research and Treatment of Cancer (EORTC) and Spanish Urological Club for Oncological Treatment (CUETO) scores. Patients and methods We retrospectively analyzed all BCG-treated NMIBC patients from 1998 to 2012. Multiple variables were tested as risk factors for recurrence-free survival and progression-free survival (PFS). Variables included age, sex, grade, stage, tumor size, number of tumors, carcinoma in situ (CIS), recurrence status, BCG strain used, smoking status, use of re-staging transurethral resection and use of single immediate postoperative instillation. We also tested the accuracy of EORTC and CUETO scores in predicting recurrence and progression. Results Overall, 123 patients were analyzed. Median (interquartile range) follow-up was 49 months. The 5-year overall survival, cancer-specific survival, recurrence-free survival and PFS were 75.0%, 89.3%, 59.4% and 79.2%, respectively. On univariate analysis, multiple tumors (≥3), concomitant CIS and smoking influenced recurrence. Regarding progression, multiple tumors, concomitant CIS and Connaught strain (vs Tice) negatively influenced PFS on univariate and multivariate analyses were independent prognostic factors. CUETO scores were accurate, with a slight overestimation, while EORTC score was not predictive of recurrence or progression. Conclusion In this study, CIS and tumor multiplicity were unfavorable predictors of recurrence and progression in patients with NMIBC receiving BCG. CUETO model was superior to EORTC risk tables in predicting recurrence and progression in our BCG-treated patient population. Nonetheless, both scores overestimated recurrence and progression rates. Prospective trials are needed to validate our findings.

Exploring positive surgical margins after minimally invasive radical prostatectomy: Does body habitus really make a difference ?

BACKGROUND Positive surgical margins (PSMs) at radical prostatectomy (RP) are generally recognized as a surrogate of poor or difficult dissection of the prostatic gland. In open RP cohorts, obesity seems to be associated to an increased risk of PSMs, probably due to the technical challenge that obese men pose to surgical access. Minimally invasive RP has been claimed to possibly reduce PSM rate. Aim of the study was to explore the impact of obesity and body habitus on PSM risk and their localisation during laparoscopic and robotic-assisted RP. MATERIALS AND METHODS We reviewed 539 prospectively enrolled patients undergoing laparoscopic and robotic-assisted RP with pT2 prostate cancer. The outcome measured was rate of PSM according to the BMI and surgical approach (laparoscopic vs robotic-assisted). Patients were categorized in BMI<25kg/m2, BMI 25-29.9kg/m2 and BMI >30kg/m2 groups respectively and compared using Kruskall-Wallis or χ2 test, as appropriate. Uni- and multivariate logistic regression models were constructed to assess the impact of BMI and surgical technique on PSM risk. RESULTS Overall, 127 (24%) of men had PSMs detected at final specimen evaluation. Mean PSM length was 3.9±3.4mm, and 30 (6%) men presented significant margins ≥4mm. Analysing the rate of PSMs across BMI categories, no significant association between increased BMI and PSM was detected (all P>0.48). On uni- and multivariate logistic regression BMI was not a statistically significant risk factor for PSM (P=0.14), nor was the minimally invasive technique (laparoscopic vs robotic-assisted) (P=0.54). CONCLUSIONS In this study obese men do not appear to have a significant increase in risk of PSMs at RP compared to lean and overweight men when operated by a minimally invasive approach. The magnified vision and increased access to the pelvis allowed by a laparoscopic and robotic-assisted approach may be accountable for our findings. Larger studies are needed to validate our results. LEVEL OF PROOF 4.

MP93-13 EXPLORING POSITIVE SURGICAL MARGINS AFTER MINIMALLY INVASIVE RADICAL PROSTATECTOMY: DOES BODY HABITUS REALLY MAKE A DIFFERENCE?

return of urinary continence, and recovery of sexual function that constitute the RARP 00trifecta00. A method to quantifying RARP outcome was developed in Europe that classifies survival (S), continence (C), and potency (P). The SCP mimics the TNM system used for staging. We sought to validate SCP in a large cohort of Americans followed for more than 5 years after RARP. METHODS: A retrospective review of prospectively collected data from 800 men who underwent RARP from Jan 2006 to Dec 2011 was performed. Total of 637 men were used for analysis after applying inclusion and exclusion criteria. NCCN biochemical failure was used as a proxy for oncologic outcome (S). The UCLA-Prostate Cancer Index Urinary Function and Sexual Function Questionnaires were used to evaluate continence (C) and potency (P), respectively. Continence was refined further by querying medical records for use of a security pad. RESULTS: The 5and 10-year biochemical progression-free survival rates were 93% (95% CI: 0.90-0.95) and 73% (95% CI: 0.67-0.79), respectively. At last follow up, 502 (79%) patients used no pads (C0), 70 (11%) patients used one security pad (C1), 63 (9.8%) patients used one or more pads routinely (C2), and 2 (0.2%) patients were incontinent before RARP (Cx). Of the 522 (82%) patients who had bilateral nerve-sparing RARP, 128 (24.5%) patients were fully potent without use of aids (P0), 74 (14.2%) patients were potent with PDE-5 inhibitor (P1), 320 (61.3%) patients experienced erectile dysfunction (P2). 115 (18%) patients were impotent preoperatively or did not undergo bilateral nerve sparing (Px). In patients preoperatively continent and potent who underwent bilateral nerve preservation and did not require adjuvant radiation therapy, oncologic and functional perfection (S0C0P0) was achieved in 58 (45%) patients. Oncologic and continence perfection (S0C0) was achieved in 92 (80%) of patients for whom potency was not recoverable (Px). CONCLUSIONS: SCP classification offers a tool for objective assessment of oncologic and functional outcome after RARP.

Morbidity of RALP for PCa with seminal vesicle invasion : results from the Be-RALP project

Overall, pelvic lymph-node dissection (PLND) was performed in 69% of patients. Five hundred twenty-seven patients had high-risk localized or locally advanced PCa. Eighty-five% of patients with high-risk locally advanced PCa received PLND. The use of robot-assisted laparoscopic prostatectomy (RALP) in high-risk prostate cancer (PCa) and even locally advanced disease is gaining more and more adherents. The objective is to evaluate the early postoperative outcome of RALP in patients with confirmed seminal vesicle invasion on pathology (pT3b).

Current trends in patient enrollment for robotic-assisted laparoscopic prostatectomy in Belgium

During the last decade, an inverse stage migration has been observed in radical prostatectomy series at tertiary centers. However, it remains unclear whether similar trends can also be observed in solely robotic practices, including nonreferral centers. The aim of this study was to investigate the clinical and pathological trends in robotic‐assisted laparoscopic prostatectomy (RALP) enrollment in Belgium over a period of 6 years through an analysis of a prospective registry.

MP27-19 QUALITY OF LIFE AND FUNCTIONAL RESULTS AFTER ROBOTIC ASSISTED LAPAROSCOPIC RADICAL PROSTATECTOMY (RALP): A PROSPECTIVE POPULATION-BASED SERIES

INTRODUCTION AND OBJECTIVES: Bladder outlet obstruction (BOO) after prostate cancer treatment (PCT) includes urethral strictures, bladder neck contractures and stenosis of the prostatic urethra. We have shown that by 10 years post-PCT, BOO occurs in 20-38% of men, varying by PCT type. BOO recurrence is common and the need for retreatment may burden the cancer survivor. We sought to describe the burden of BOO in a population-based cohort by detailing the types and numbers of BOO procedures performed per patient. METHODS: From a SEER-Medicare cohort of men aged 66 years diagnosed with non-metastatic prostate cancer (1992-2007), we identified 12,676 men who underwent at least one surgery for BOO after radical prostatectomy (RP), external beam radiation therapy (EBRT), brachytherapy (BT), EBRTþBT, RPþEBRT or cryotherapy. To describe the risk of multiple treatments, we report the incidence rate per personyear and incidence rate ratios of BOO treatment. Cox proportional hazards regression with repeated events analysis was used to adjust for demographic, clinical and cancer characteristics. RESULTS: Median follow-up was 8.8 years. 45% underwent more than one treatment; mean number of treatments was 2.5 (range 1 to 7). Men who received EBRTþBT were most likely to receive seven or more treatments (9.2%), and those receiving RP were least likely (4.5%). Incidence rate ratio and Cox proportional hazards of BOO for each treatment group are shown in the Table. Direct vision internal urethrotomy or transurethral incision of bladder neck contracture was the most common type of stricture treatment across all cancer treatment groups (43.0-51.1%). In RP (35.0%) and RPþEBRT (34.7%), dilation was the second most common treatment of BOO. In EBRT (41.2%), BT (37.0%) and BTþEBRT (28.9%), transurethral resection was the second most common surgery treatment. CONCLUSIONS: When BOO occurs after PCT, nearly half of patients undergo multiple treatments. Men with BOO after radiation or cryotherapy undergo treatments that are more invasive and they have a higher retreatment rate than men with BOO after RP. The need for BOO retreatment and the burden it creates for the cancer survivor deserves more investigation.