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Robotic-assisted laparoscopic radical prostatectomy (RALP) has become the most widespread treatment for organ-confined prostate cancer. Here, we describe a fast specimen retrieval technique for RALP to obtain high-quality tissue specimen with minimal warm ischemia time for next-generation biobanking. Here, we show that using fast retrieval technique, short warm ischemia times can be achieved while not increasing the surgical time. Patients undergoing RALP with written informed consent participated in Helsinki Urological Bank study. Previously operated RALP patients and those, who were not willing to participate in the study, served as a control group. The study consisted of 1685 patients, 684 in fast retrieval and 1001 in control group. We developed a novel fast retrieval technique in which fascia is opened for camera port according to the prostate size and a running suture is placed and tightened against the camera port in the beginning of the operation. Immediately after prostate is freed from attachments, suture is loosened and the prostate is extirpated inside the endoscopic bag through the camera port fascial opening, then the fascial suture is again tightened against the camera port and the RALP procedure is completed. The mean warm ischemia times in fast retrieval group were 20 min 18 s and 22 min 30 s, respectively, in patients without and with lymphadenectomy. The mean console and surgery times with and without lymphadenectomy were similar in both groups. There were no technique-related complications associated with Fast Retrieval procedure. Tissue integrity test results for the RNA and DNA quality showed good quality for the specimen. Fast retrieval technique can easily and safely be utilized to maximize usefulness of RALP tissue specimen in downstream biobank applications.

Background: Improved prostate cancer (PCa) survival by statin use has been reported among PCa patients managed with radiation or androgen deprivation therapy (ADT), while results are controversial for men managed surgically. We evaluate the association between cholesterol-lowering medication with initiation of ADT and disease-specific death among PCa cases who underwent radical prostatectomy in Finland between 1995 and 2013., Methods: The study cohort included 14 424 men with PCa who underwent radical prostatectomy in Finland between 1995 and 2013. Cases were identified from national hospital discharge registry. Clinical data were amended from patient files of the treating hospitals. Information on co-morbidities, additional radiation- or chemotherapy, and causes of deaths were collected from national registries. Personal-level data on medication use during 1995-2014 were gathered from national prescription database. Registry linkages were carried out using personal identification number. Lipid-lowering drugs were categorized into statins and non-statin drugs. Risk of PCa death and initiation of ADT was analyzed using Cox-regression model with adjustment for age, radiation therapy, chemotherapy, co-morbidities and other drug use. Statin use was analyzed as time-dependent variable. Delayed risk associations were evaluated in lag-time analysis., Results: Compared to non-users the risk of PCa death was significantly lower among statin users before PCa diagnosis (HR 0.70, 95%CIs 0.52-0.95). For statin use after PCa diagnosis the risk was lowered in age-adjusted analysis (HR 0.76 95%CIs 0.62-0.93) but not after multivariable-adjustment. Post-diagnostic statin use was associated with improved PCa-specific survival in 1, 3 and 5 years lag-time analyses. The risk reduction was clearest for statin use initiated 5 years earlier (HR 0.71 95%CIs 0.55-0.92). Use of statins both before and after PCa diagnosis was associated with reduced risk of ADT use (HR 0.72 95%CIs 0.65-0.80 and HR 0.73, 95%CI 0.67-0.80, respectively). The risk of ADT decreased by increasing intensity of statin use before diagnosis., Conclusion: Statin use among surgically treated PCa patients has significant association with decreased risk of starting ADT and PCa death. The risk is lowered especially among men with statin use before PCa diagnosis and in men who used statins at high-dose. Our results are hypothesis generating due to retrospective study design., (© 2019 Wiley Periodicals, Inc.)

Background: The Prostate Cancer Research International Active Surveillance (PRIAS) study was initiated a decade ago to study the most optimal selection and follow-up of men on active surveillance (AS)., Objective: We report on 10 yr of follow-up of men on AS in the PRIAS study and evaluate if criteria used to recommend a switch to active treatment truly predict unfavorable outcome on subsequent radical prostatectomy (RP)., Design, Setting, and Participants: Men with low-risk prostate cancer were included and followed prospectively on AS. Follow-up consisted of regular prostate-specific antigen (PSA) tests, digital rectal examinations, and biopsies. Men with Gleason >3+3, more than two positive biopsy cores, or stage higher than cT2 were advised to switch to active treatment (until 2014, a PSA doubling time [PSA DT] of 0-3 yr was also used)., Outcome Measurements and Statistical Analysis: Reclassification rates, treatment after discontinuation, and outcome on RP after discontinuing AS were reported. Regression analysis on the outcome of RP was used to evaluate the predictive value of criteria currently used to recommend a switch to active treatment. Kaplan-Meier and competing risk analysis were used to report discontinuation rates over time and long-term oncologic end points., Results and Limitations: A total of 5302 men were included in PRIAS across 18 countries. Reclassification rates remained stable on all subsequent biopsies, with 22-33% of men having either Gleason >3+3 or more than two positive cores on any repeat biopsy. At 5 and 10 yr of follow-up, 52% and 73% of men, respectively, had discontinued AS, most of them because of protocol-based reclassification. A third of men undergoing subsequent RP had favorable pathologic tumor features (Gleason 3+3 and pT2). Of the criteria used to recommend a switch to active treatment, more than two positive cores and a PSA DT of 0-3 yr were not predictive of unfavorable pathologic outcome on RP., Conclusions: A substantial group of men discontinued AS without subsequent unfavorable tumor features on RP; therefore, we propose Gleason upgrading and cT3 as the only indicators for an immediate switch to active treatment. Surrogate indicators (eg, more than two positive cores and a fast-rising PSA) should not trigger immediate active treatment but rather further investigation to confirm the suspicion of higher risk disease., Patient Summary: We confirmed the safety of active surveillance as a treatment option for men with low-risk prostate cancer; however, some changes could be made to the follow-up protocol to safely increase the number of men who remain on active surveillance., (Copyright © 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective The aim of this study was to analyze the impact of introduction of robot-assisted prostate surgery and its quality measures in Finland from 2008 to 2012. Materials and methods Registry data were collected for time trends and national distribution of prostate cancer surgery in Finland, while preoperative, operative and follow-up data were collected for quality measures. Results The number and proportion of robot-assisted laparoscopic radical prostatectomies (RALPs) increased rapidly and they accounted for 68% of all radical prostatectomies in 2012. The number of centers performing prostatectomies diminished from 25 to 20 at the expense of low-volume centers. In total, 1996 patients were operated on in the four RALP centers in 2008-2012. As anticipated, the learning curve was uniform between the centers, as were mean blood loss (212 ml), hospitalization (1.8 days) and catheterization times (10.6 days). At 3 and 12 months, 49.4% and 71.2% of patients, respectively, were totally continent (no pads). After unilateral nerve-sparing surgery, 9.9% and 5.1% had partial or normal erection at 3 months postoperatively and 14.8% and 20.4% at 12 months, respectively. If bilateral nerve sparing was done, the figures were 13.0% and 13.5% at 3 months and 14.6% and 34.9% at 12 months. Clavien-Dindo grade 3, 4 or 5 complications were seen in 0.3%, 0.3% and 0.1% of patients, respectively. Limitations of the study include non-standardized collection of outcome parameters. Conclusions This report shows that the main impact of adoption of RALP on a national level was rapid spontaneous centralization of prostate cancer surgery. The main advantages of minimally invasive prostatectomy, i.e. low blood loss and short hospitalization, are easily achieved, while continuous effort is necessary for improvements in surgical outcomes.

Objective: The aim of this study was to investigate the performance of transrectal biopsies in predicting pathological outcomes after radical prostatectomy (RP) and in estimating possible candidates for focal therapies., Material and Methods: The study was a retrospective analysis of 96 prostate cancer patients treated by robot-assisted laparoscopic RP at Helsinki University Central Hospital in 2009-2010. Data from diagnostic biopsies were compared with data from reassessment of RP slides. At reanalysis, an index tumour was chosen for all patients and was determined as being the most dedifferentiated tumour or the largest tumour with Gleason pattern 3 in case Gleason patterns 4 or 5 were absent. The performance of prostate biopsies in predicting cancer laterality, tumour size and tumour location was analysed. Statistical methods included Spearman's correlation, linear regression analysis and Pearson's chi-squared test. Suitability for focal therapies was assessed based on tumour morphology and laterality., Results: The extent of cancer in biopsies correlated with tumour size in the apex and middle of the prostate [standard coefficients in linear regression for the apex 2.479-2.553, 95% confidence interval (CI) 1.952-3.056, p < 0.001-0.007; and for the middle 1.936-2.388, 95% CI 1.504-2.861, p < 0.001]. Prostate biopsies performed moderately in predicting tumour location in RP slides (positive predictive value 34.1-90.9%). Thirty-six patients (37.5%) would possibly have been candidates for focal therapy and thirty-nine (40.6%) patients for hemiablation., Conclusions: Contemporary transrectal prostate biopsies are a suboptimal tool for predicting pathological findings at RP. Approximately 40% of patients would possibly have been suitable candidates for focal or hemiablative therapies.

Objective: The aims of this study were to analyse the efficacy and safety of orally administered dabigatran in prostate cancer patients who have undergone robotic assisted laparoscopic prostatectomy (RALP) and to analyse the effects of RALP on selected markers of coagulation activity., Material and Methods: Data were collected prospectively on the first 400 patients who underwent RALP at Helsinki University Central Hospital between 2009 and 2011. As thromboprophylaxis, intermittent compression devices were used in association with anaesthesia. Dalteparin sodium at 2500 IU was administered on the preoperative evening and at 5000 IU daily until discharge. Then patients were prescribed 220 mg dabigatran etexilate once daily for the next 15 days. Bleeding and thromboembolic complications were recorded. A set of routine coagulation analyses was undertaken in 61 patients preoperatively, on the first, second and eight postoperative days., Results: One patient with obesity- and cancer-related risk factors developed venous thromboembolism 18 days after the operation. Nine patients (2.3%) had postoperative blood loss or bleeds, eight patients required blood transfusions and three underwent reoperation before dabigatran administration. Increased fibrinogen, factor VIII, d-dimer and thrombocytosis were observed postoperatively, reflecting coagulation activity., Conclusions: RALP activates coagulation, and thromboprophylaxis for high-risk patients even after minimally invasive surgery may be beneficial. Orally administered dabigatran after discharge from hospital appears safe for venous thromboembolism prophylaxis after RALP.

Background: Little is known about the outcome of radical prostatectomy (RP) in men initially followed on active surveillance (AS) for low-risk prostate cancer (PCa)., Objective: Evaluate pathology findings after RP in our prospective AS cohort., Design, Setting, and Participants: All men participated in the Prostate Cancer Research International: Active Surveillance (PRIAS) study. Eligible men were initially diagnosed with low-risk PCa (clinical stage ≤ T2, prostate-specific antigen [PSA] ≤ 10 ng/ml, PSA density <0.2 ng/ml per ml, one or two positive biopsy cores, and Gleason score ≤ 6) and underwent RP between December 2006 and July 2011. The study protocol recommends RP in case of risk reclassification on repeat biopsy (Gleason score >6 and/or more than two positive cores) or a PSA doubling time ≤ 3 yr., Measurements: Descriptive statistics were used to report on pathology findings for staging and grading., Results and Limitations: Pathology results were available in 167 out of 189 RP cases (88.4%). Median time to RP was 1.3 yr (range: 1.1-1.9). Protocol-based recommendations led to deferred RP in 143 men (75.7%); 24 men (12.7%) switched because of anxiety, and 22 (11.6%) had other reasons. Pathology results showed 134 (80.8%) organ-confined cases and 32 (19.2%) cases with extracapsular extension. Gleason scores ≤ 6, 3+4, 4+3, and 8 were found in 79 (47.3%), 64 (38.3%), 21 (12.6%), and 3 (1.8%) cases, respectively. Unfavourable RP results (pT3-4 and/or Gleason score ≥ 4+3) were found in 49 patients (29%), of whom 33 (67%) had a biopsy-related reason for deferred RP., Conclusions: RP results in men initially followed on AS show organ-confined disease and favourable Gleason grading in a majority of cases. Most men in our cohort had a protocol-based reason to switch to deferred RP. A main focus for AS protocols should be to improve the selection of patients at the time of inclusion to minimise reclassification of risk and preserve the chance for curative treatment, if indicated., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Robotic laparoscopic radical prostatectomy is an established method in the treatment of localized prostatic cancer. The equipment comprises a separate control console that makes ergonomic working possible. The optics creates a three-dimensional view and 10 to 15-fold magnification, thus enabling accurate operation. Recovery from the procedure is quicker and the number of blood transfusions lower than in open radical prostatectomy. The methods do not differ in regard to oncological results. Regardless of technique, radical prostatectomy is a demanding operation, in which the surgeon's skills and experience are decisive for the final result.

The beta subunit of human chorionic gonadotropin (hCGβ) is encoded by six genes (CGB) classified as type I and type II. CGB mRNA is produced in large amounts by trophoblastic tissues and in small amounts by several cancerous tissues including prostate cancer and by a few benign tissues, including the prostate. Quantitative reverse-transcription polymerase chain reaction (RT-qPCR) was used to study the expression levels of all CGB mRNAs together (total CGB mRNA) and the two types of CGB mRNA separately in non-cancerous (n = 74) and cancerous prostatic tissue obtained by radical prostatectomy (n = 193). RNA was isolated from formalin-fixed paraffin-embedded (FFPE) samples and mRNA levels of CGB were correlated with disease-specific survival. Total CGB mRNA concentrations were significantly lower (p < .0001) in cancerous than non-cancerous prostatic tissue. Separate analysis of type I CGB and type II CGB mRNA showed that both type I CGB (p < .0001) and type II CGB mRNA (p = .007) are lower in cancerous tissue than in non-cancerous tissue. Low type II CGB mRNA level in cancerous tissue was associated with shorter cancer-specific survival (p = .001) of prostate cancer patients treated by radical prostatectomy. [ABSTRACT FROM AUTHOR]

Objective:Although many studies have dealt with adverse effects (AEs) and quality of life (QoL) in prostate cancer (PCa) patients, the quantification of the patients’ perspective on AE-related reduction in QoL has been less studied. This study describes the impact of self-reported local (erectile, bowel, urinary dysfunction) or systemic (mental distress, fatigue, virility loss) AEs on QoL reduction. Materials and methods:Nordic PCa patients completed a questionnaire containing 84 multiple-choice questions. The main outcome variable of the survey was patient-reported PCa-induced QoL reduction, assessed by descriptive and regression analyses. The level of significance wasp < 0.05. Results:Among 6200 patients, 39% described their QoL as reduced owing to the PCa trajectory: radical prostatectomy group (RPGroup): 42%, radiotherapy without hormones (RADGroup): 27%, hormones (HormGroup): 47% and no treatment (NoTrtGroup): 19%. Except for the NoTrtGroup, urinary leakage and fatigue doubled the risk of QoL reduction, while virility loss and erectile dysfunction tripled the risk. Significant intergroup differences emerged for the age-adjusted odds of QoL reduction: RPGroup (0.66), RADGroup (0.40), HormGroup (0.95) and NoTrtGroup (0.22). Conclusions:After RP, RAD or hormone treatment of PCa, systemic AEs, in particular loss of virility, significantly reduce PCa patients’ QoL similarly to or more than local AEs. The probability of reduced QoL is highest during hormone treatment and lowest in patients without anticancer therapy, and seems lower in patients treated with RAD without hormones than after RP. The treatment-related risk of reduced QoL due to systemic AEs should become a part of the pretreatment counselling of patients. [ABSTRACT FROM PUBLISHER]

Purpose: To evaluate the utility of percentage of free serum PSA (%fPSA) as a predictor of adverse rebiopsy findings, treatment change and radical prostatectomy (RP) findings in a prospective active surveillance (AS) trial. Methods: Patients enrolled in the global PRIAS study with baseline %fPSA available were included. Putative baseline predictors (e.g. PSA, %fPSA) of adverse rebiopsy findings were explored using logistic regression analysis. Association of variables with treatment change and RP findings over time were evaluated with Cox regression analysis. Active treatment-free survival was assessed with a Kaplan-Meier method. Results: Of 3701 patients recruited to PRIAS, 939 had %fPSA measured at study entry. Four hundred and thirty-eight of them had %fPSA available after 1 year. Median follow-up was 17.2 months. First rebiopsy results were available for 595 patients and of those, 144 (24.2 %) had adverse findings. A total of 283 (30.1 %) patients discontinued surveillance, of those 181 (64.0 %) due to protocol-based reasons. Although median %fPSA values were significantly lower in patients who changed treatment, according to the multivariate regression analysis, initial %fPSA value was not predictive for treatment change or adverse rebiopsy findings. However, the probability of discontinuing AS was significantly lower in patients with 'favourable' initial %fPSA characteristics and %fPSA during follow-up (initial %fPSA ≥15 and positive %fPSA velocity) compared to those with 'adverse' %fPSA characteristics (initial %fPSA <15 and negative %fPSA velocity). Conclusions: Diagnostic %fPSA provides no additional prognostic value when compared to other predictors already in use in AS protocols. However, %fPSA velocity during surveillance may aid in predicting the probability for future treatment change. [ABSTRACT FROM AUTHOR]

Study Type – Therapy (prospective cohort) Level of Evidence 2b OBJECTIVE To evaluate the short-term outcomes of the prospective international Prostate Cancer Research International: Active Surveillance (‘PRIAS’) study (Dutch Trial Register NTR1718), as active surveillance (AS) for early prostate cancer might provide a partial solution to the current overtreatment dilemma in this disease. PATIENTS AND METHODS The first 500 (of >950) participants with asymptomatic T1c/T2 prostate cancer, with a prostate-specific antigen (PSA) level of ≤10.0 ng/mL, a PSA density of <0.2 ng/mL/mL, a Gleason score of ≤3 + 3 = 6, and one or two positive biopsy cores, were analysed. The follow-up protocol consisted of frequent PSA measurements, digital rectal examinations, and standard repeat biopsies (the first after 1 year). The primary outcome is survival free of active therapy; the secondary endpoints are reasons for stopping AS, findings in 1-year repeat biopsies, and outcomes after radical prostatectomy (RP). RESULTS Patients were included between December 2006 and July 2008. The median (25–75th percentile) follow-up after diagnosis was 1.02 (0.6–1.5) years. The 2-year survival rate free from active therapy was 73%. Of the 82 men who changed to active therapy during the follow-up, 68 (83%) did so based on the protocol. Of the 261 repeat biopsies available for analysis, 90 (34%) showed no cancer, while 57 (22%) showed a Gleason score of >6 or more than two positive biopsy cores. There was a relatively unfavourable PSA doubling time of 0–10 years in 53% (102/194) and 62% (33/53) of men with favourable and unfavourable re-biopsy results, respectively. After RP, four of 24 (17%) men had T3 disease and 12 (50%) had a Gleason score of >6. CONCLUSION AS seems feasible, but mortality outcomes are unknown. A strict follow-up protocol including standard 1-year repeat biopsies resulted in a quarter of men stopping AS after 2 years. [ABSTRACT FROM AUTHOR]

The article presents the author's comments on a study conducted on the effectiveness of radical prostatectomy (RP) for the treatment of local prostate cancer, as compared to the use of prostate-specific antigen PSA for early diagnostics. According to the author, clinical trials comparing different treatments for prostate cancer are very difficult to execute. The author says that a randomized trial has found that comparing RP against surveillance suggested no benefit in local prostate cancer.

Context There is great interest in using magnetic resonance imaging (MRI) for men on active surveillance for prostate cancer. Objective To systematically review evidence regarding the use of MRI in men with low- or intermediate-risk prostate cancer suitable for active surveillance. Evidence acquisition Ovid Medline and Embase databases were searched for active surveillance, prostate cancer, and MRI from inception until April 25, 2014 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses process. Identified reports were critically appraised according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) criteria. Evidence synthesis A lesion on MRI suspicious for prostate cancer (positive MRI) is seen in two-thirds of men otherwise suitable for active surveillance. A positive MRI makes the identification of clinically significant disease at repeat biopsy more likely, especially when biopsies are targeted to suspicious MRI lesions. Radical prostatectomy data show that positive MRI is more likely to be associated with upgrading (Gleason score >3 + 3) than a negative MRI (43% vs 27%). A positive MRI is not significantly more likely to be associated with upstaging at radical prostatectomy (>T2) than a negative MRI (10% vs 8%). Although MRI is of interest in the monitoring of men on active surveillance, robust data on the use of repeat MRI in active surveillance are lacking. Prospective studies with clear definitions of radiological significance and progression are needed before this approach can be adopted. Conclusions MRI is useful for detection of clinically significant disease at initial assessment of men considering active surveillance. To use MRI as a monitoring tool in surveillance, it will be necessary to define both radiological significance and radiological progression. Patient summary This review assesses evidence for the use of magnetic resonance imaging (MRI) in men on active surveillance for prostate cancer. MRI at the start of surveillance can detect clinically significant disease in one-third to half of men. There are few data to assess the use of MRI as a monitoring tool during surveillance, so there is a need to define significant disease on MRI and significant changes over time. [ABSTRACT FROM AUTHOR]