Yosuke Hirasawa

Impact of Surgeon and Hospital Volume on the Safety of Robot-Assisted Radical Prostatectomy: A Multi-Institutional Study Based on a National Database

Introduction: We aimed to perform a multi-institutional study using a national database led by the Japanese Society of Endourology to investigate the effect of surgeon or hospital volume on the safety of robot-assisted radical prostatectomy (RARP). Materials and Methods: Clinical data of 3,214 patients who underwent RARP for the treatment of clinically localized prostate cancer between April 2012 and March 2013 in Japan were evaluated. Surgical outcomes and all intra- and perioperative complications were collected. Results: The intraoperative complication rate was 0.56%. In a total number of 241 patients, 261 perioperative complications were observed. The following percentages of patients presented the Clavien-graded complications: 7.2%, grades 1-2; 0.84%, grade 3; and 0.093%, grade 4a. No cases of multiple organ dysfunction or death (grades 4b and 5) were found. Multivariable logistic regression analysis showed that the hospital volume (OR 3.6; p = 0.010) for intraoperative complications and surgeon volume (OR 0.19; p < 0.0001) and extended lymph node discectomy (OR 3.9; p < 0.0001) for perioperative complications were significant independent risk factors. Conclusions: Hospital volume for intraoperative complications and surgeon volume and extended lymph node dissection for perioperative complications were significantly associated with increased risk of each complication in RARP.

Prostate-specific antigen screening impacts on biochemical recurrence in patients with clinically localized prostate cancer

To clarify the impact of prostate‐specific antigen screening on surgical outcomes of prostate cancer.

A Case of Primary Small-Cell Carcinoma of the Bladder.

Primary small-cell carcinoma arising from the bladder (SmCCB) is uncommon. It differs from urothelial carcinoma (UC), the most common type of bladder cancer, with respect to its cell of origin, biology, and prognosis. Biologically, prostatic SmCCB is much more aggressive than UC, and the prognosis for cases with distant metastasis is especially poor. We report here a case of primary SmCCB (cT3bN1M0) treated with radical cystectomy.

Age and prostate volume are risk factors for transient urinary incontinence after transurethral enucleation with bipolar for benign prostatic hyperplasia

To investigate the predictive factors for transient urinary incontinence after transurethral enucleation with bipolar.

MP97-20 PREDICTION OF NON-BIOCHEMICAL RECURRENCE RATE AFTER ROBOT ASSISTED RADICAL PROSTATECTOMY (RARP) IN A JAPANESE COHORT: DEVELOPMENT OF A POSTOPERATIVE NOMOGRAM

calculated by number of RPs reported from the treatment facility with high volume centers considered to be ones in the top third of reported RPs. Multivariable logistic regression was conducted to determine factors independently associated with quality surgical outcomes using the SOAP score. RESULTS: We identified 72,864 patients with high risk disease, of whom 42.5% (n1⁄431,008) were treated with RP. Overall, 34.1% of patients had a quality surgical outcome with a SOAP score 6. On multivariable logistical regression, factors associated with a quality surgical outcome included surgery at a high volumecenter (OR1.8: CI 1.6-1.9; p1⁄4 <0.01), surgery at an academic hospital (OR 1.8: CI 1.7-1.9: p1⁄4 <0.01), cN1 stage (OR 1.6: CI 1.2-2.0; p1⁄4 <0.01), and omission of neoadjuvent hormonal therapy (OR1.4:CI 1.3-1.5; p1⁄4<0.01). Factorsassociatedwith a poor surgical outcome include robotic approach (OR0.81: CI 0.76-0.87; p1⁄4 <0.01), PSA > 30 (OR 0.59: CI 0.55-0.64; p1⁄4 <0.01), and African American ethnicity (OR 0.89: CI 0.82-0.96; p1⁄4 <0.01). CONCLUSIONS: For patients with high risk prostate cancer, treatment at high volume centers and at academic centers appear to be associated with a high quality surgical outcomes. Given the increased use of this management strategy, optimizing surgical quality is needed in order to achieve the best outcomes for this aggressive malignancy.

PD51-07 IMPACT OF THE TIME INTERVAL BETWEEN BIOPSY AND ROBOTIC-ASSISTED RADICAL PROSTATECTOMY ON BIOCHEMICAL RECURRENCE: A PROPENSITY SCORE MATCHING ANALYSIS

RESULTS: On IVA adjusting for socio-demographic, facilityand tumor-specific covariates, RP was associated with lower overall mortality compared to RT+ADT (hazard ratio (HR) 0.52; 95% CI, 0.470.57; p<0.001) in the overall analysis, in patients with age 1⁄465 years with CCI 0 (HR 0.48; p<0.001), in patients >65 years with CCI 0 (0.53; p<0.001), those receiving RT with neoadjuvant (HR 0.52; p<0.001) or adjuvant ADT (HR 0.47; p<0.001), or treated with high dose (1⁄475.6 Gy) RT (HR 0.54; p<0.001). While the survival outcomes for patients treated with RT (+/-ADT) in the RCTs were not statistically different from similarly treated and appropriately selected patients within the NCDB, RP was associated with greater overall mortality-free survival than any of the arms represented in the RCTs. CONCLUSIONS: Our results suggest that in patients with clinically high-risk PCa, primary RP is associated with greater overall mortality-free survival than primary RT+ADT in patients with clinically high-risk PCa, regardless of baseline characteristics. These findings, in lieu of a randomized trial, can guide the clinicians to carefully choose the primary modality of treatment for patients with high-risk PCa.

PD23-02 TRANSURETHRAL ENUCLEATION WITH BIPOLAR FOR BENIGN PROSTATIC HYPERPLASIA: 2-YEAR OUTCOME AND LEARNING CURVE BASED ON A SINGLE SURGEON'S EXPERIENCE WITH 584 CONSECUTIVE PATIENTS

INTRODUCTION AND OBJECTIVES: Compare the different impact of monopolar and bipolar TURP (Trans-urethral resection of the prostate) on the sexual function of male patients with LUTS (Lower urinary tract symptoms) by the use of IIEF ( International index of erectile function ) and to identify statistical risk factors associated with development of post-operative ED (Erectile dysfunction). METHODS: This study was a comparative prospective study between monopolar and bipolar TURP regarding their effect on the sexual function of male patients with LUTS by the use of IIEF. It was taken into consideration age, associated comorbidities, preoperative medications, smoking, assisted methods to obtain erection, duration of the operation, weight of the specimen and intraoperative complications (e.g. perforation (.The IIEF scores were compared one day before the surgery and 3 and 6 months after the surgery in the two limbs of the study monopolar vs. bipolar. The study design is a nonrandomized clinical trial that was carried out on a total number of 98 consecutive Egyptian patients who underwent TURP, 58 patients by the monopolar technique, 40 patients by the bipolar technique for the treatment of symptomatic benign prostatic hyperplasia. The study was done at the Department of Urology, Cairo University, between April 2014 and April 2015. An informed consent was obtained from all patients prior to enrollment in the study. Patients had to have stable sexual partners for 6 months before surgery and for 6 months postoperatively until follow-up. RESULTS: Patients were classified into two groups: patients experienced change in the EF score by less than 4 and patients experienced change in the EF score by 1⁄4 4. Change in the EF score by 1⁄4 4 was defined as the minimal clinically importance difference that is clinically perceived by the patient as a change in his erection. The incidence of ED after monopolar TURP was 22.4%, the incidence of ED after bipolar TURP was 30% and the overall incidence of postoperative ED was 25.5%. There was no statistically reported difference between monopolar and bipolar TURP on developing postoperative ED (p value 0.33 at the 3rd month and 0.397 at the 6th month). The risk factors that have been statistically associated with high incidence of post-operative ED in the whole population of study were DM (P value 0.001), intraoperative capsular perforation (P value 0.0001) and preoperative use of PDE5I (P value 0.004). In the monopolar group DM (P value 0.002) and Intra-operative capsular perforation (P value 0.00001) were the statistically significant factors associated with high incidence of post-operative ED. In the bipolar group there were no significant risk factors associated with high incidence of post-operative ED, and that were explained by the smaller sample size in the bipolar arm of the study. Other factors which were the age, the operative time, the weight of the specimen, preoperative EF score, preoperative IIEF score, smoking, COPD, cardiovascular disorders, preoperative use of alpha blocker and intraoperative or postoperative bleeding which were studied in our study showed no statistically significant impact on developing postoperative ED either in the monopolar or the bipolar arm. CONCLUSIONS: TURP carries a risk of post-operative ED around 25.5% and the patient should be aware of this degree of ED. The most commonly affected domain of the 5 IIEF domains by TURP is the orgasmic domain (retrograde ejaculation) and the patient should be consented on this before the operation. Generally there is no difference between the monopolar TURP and the bipolar TURP in developing post-operative ED. DM, intraoperative capsular perforation and preoperative use of PDE5I are important risk factors for developing postoperative ED. Larger number of patients should be included in future studies to validate these results.

MP64-11 ZONAL DISTRIBUTION OF PROSTATE CANCER IS IMPORTANT PROGNOSTIC FACTOR IN PATIENTS WITH CLINICALLY LOCALIZED PROSTATE CANCER TREATED ROBOT ASSISTED RADICAL PROSTATECTOMY(RARP)

INTRODUCTION AND OBJECTIVES: Available recommendations for extended lymph node dissection [eLND] at radical prostatectomy [RP] do not consider patient age, but rely on cancer characteristics only. However, for patients with limited life-expectancy, eLND might be an overtreatment. We hypothesized that limited life-expectancy of older RP candidates might dilute any beneficial effect of eLND in terms of cancer staging and outcomes. Therefore, we aimed at assessing the differential effect of age on the risk of lymph node invasion [LNI] and mortality due to cause other than prostate cancer [OCM] in order to define an age limit above which eLND might be avoided. METHODS: We included 3,906 patients diagnosed with prostate cancer and treated with RP and an anatomically defined eLND at a single Institution. Logistic and Cox regression analyses were used to compute the risk of LNI at eLND and the risk of OCM 10 years after RP. Predictors of LNI were chosen in compliance with guidelines-recommended models and were PSA, primary and secondary biopsy Gleason score and clinical stage. Predictors of OCM were age at surgery, Charlson comorbidity index [CCI] and year of surgery. Locally weighted scatterplot smoothing method was used to graphically examine the differential effect of age on the risk of LNI and OCM. RESULTS: Median age was 65 years. LNI rate was 12%. 10year OCM rate was 5%. PSA (odd ratio [OR] 1.06; p<0.001), primary (OR 5.32; p<0.001) and secondary (OR 2.27; p<0.001) biopsy Gleason score 4 as well as clinical stage cT2 (OR 2.4; p<0.001) and cT3 (OR 3.24; p<0.001) were associated with higher LNI risk. Age (hazard ratio [HR] 1.11; p<0.001) and CCI (HR 1.28; p1⁄40.03) were associated with higher OCM risk. Year of surgery (HR 0.92; p<0.001) was associated with lower OCM risk. For patients aged 75 or younger, the risk of LNI (811%) was higher than the risk of OCM (<1-10%; Figure 1). Conversely, for patients aged 76 or older the risk of LNI (11-17%) was equal or lower than the risk of OCM (11-26%). CONCLUSIONS: For RP candidates older than 75 years, the risk of OCM equals or exceeds the risk of LNI. Such relatively high risk of OCM compared to the relatively low risk of LNI casts relevant doubts on any potential benefit related to eLND at RP. These findings argue against the routine use of eLND for older patients in clinical practice.

No clinical significance of the time interval between biopsy and robotic-assisted radical prostatectomy for patients with clinically localized prostate cancer on biochemical recurrence: a propensity score matching analysis

Purpose To investigate the impact of the time interval (TI) between prostate biopsy and robot-assisted radical prostatectomy (RARP) on the risk of biochemical recurrence (BCR). Methods We retrospectively reviewed the medical records of 793 consecutive patients who were treated with RARP at our institution. Patients were divided into three groups, according to TI, to compare BCR-free survival (BCRFS) rates: Group 1 (n = 196), TI < 3 months; Group 2 (n = 513), 3 ≤ TI < 6 months; Group 3 (n = 84), TI ≥ 6 months. Eighty-three patients with TI ≥ 6 months were matched with an equal number of patients with TI < 6 months based on propensity scores by using four preoperative factors: prostate-specific antigen (PSA), primary (pGS) and secondary (sGS) Gleason score and positive prostate biopsy. Results The 5-year BCRFS rates for TI Groups 1, 2, and 3 were 76%, 80.7% and 82.6% (P = 0.99), respectively. The multivariate analysis revealed that PSA, pGS, sGS and a positive prostate biopsy were independent preoperative risk factors for BCR. The propensity adjusted 5-year BCRFS for patients with TI ≥ 6 months was 84.0%. This was not worse than that of patients with TI < 6 months (71.0%, P = 0.18). Conclusions In our cohorts, a delay in the time from biopsy to RARP did not significantly affect recurrence. Therefore, hasty treatment decisions are unnecessary for at least 6 months after diagnosis of early prostate cancer.

Clinical significance of preoperative renal function and gross hematuria for intravesical recurrence after radical nephroureterectomy for upper tract urothelial carcinoma

To investigate the predictive values of perioperative factors and to develop a nomogram for intravesical recurrence after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma.