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Objective: To assess rates of treatment-related hospitalizations following surgery and radiotherapy in the treatment of clinically localized prostate cancer, given the importance of hospitalizations in healthcare resource utilization., Methods: We conducted a population-based retrospective cohort study of patients aged 65-79 years receiving radical prostatectomy (open or minimally invasive) or radiotherapy (brachytherapy or external beam) from 2001 to 2008 in the Surveillance, Epidemiology & End Results-Medicare linked databases. We assessed treatment-related hospitalizations. We analyzed the role of primary treatment on the number of complications per patient in each category using negative binomial regression., Results: Among 60,476 men, 14,492 underwent primary surgery and 45,984 underwent primary radiotherapy. Over a median follow-up of 5.6 years, the surgery group had significantly lower rates of hospital admissions (8.9 vs 20.3/1000 person-years) than the radiation group. For both groups, admissions peaked within 2 years of treatment, but continued at a steady rate for 10 years. After adjustment for confounders, patients treated with radiation had higher incidence of hospital admissions (relative rate [RR] = 1.8, 95% confidence interval [CI]: 1.8-1.9, P < .0001), compared to those having surgery. Stratified analysis showed an increased rate of hospitalizations of 1 day and 2 or more days (RR 3.1, 95% CI: 2.7-3.7 and RR 1.6, 95% CI 1.4-1.8, respectively) for patients treated with radiotherapy. The use of adjuvant/salvage therapies significantly increased rates of hospitalization. The results were robust to analysis using propensity-score matching., Conclusion: Treatment-related hospitalizations are more common following radiotherapy than surgery in the treatment of clinically localized prostate cancer. Limitations include a lack of treatment detail and residual confounding due to observational study design., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: We assessed survival after radical prostatectomy, intensity modulated radiation therapy or conformal radiation therapy vs no local therapy for metastatic prostate cancer adjusting for patient comorbidity, androgen deprivation therapy and other factors., Materials and Methods: We identified men 66 years old or older with metastatic prostate cancer treated with radical prostatectomy, intensity modulated radiation therapy, conformal radiation therapy or no local therapy in the SEER-Medicare linked database from 2004 to 2009. Multivariable Cox proportional hazards models before and after inverse propensity score weighting were used to assess all cause and prostate cancer specific mortality. Competing risk regression analysis was done to assess prostate cancer specific mortality., Results: Of 4,069 men with metastatic prostate cancer radical prostatectomy in 47, intensity modulated radiation therapy in 88 and conformal radiation therapy in 107 were selected as local therapy vs no local therapy in 3,827. Radical prostatectomy was associated with a 52% decrease (HR 0.48, 95% CI 0.27-0.85) in the risk of prostate cancer specific mortality after adjusting for sociodemographics, primary tumor characteristics, comorbidity, androgen deprivation therapy and bone radiation within 6 months of diagnosis. Intensity modulated radiation therapy was associated with a 62% decrease (HR 0.38, 95% CI 0.24-0.61) in the risk of prostate specific cancer specific mortality. Conformal radiation therapy was not associated with improved survival compared to no local therapy. Propensity score weighting yielded comparable results. Competing risk analysis revealed a 42% and 57% decrease (SHR 0.58, 95% CI 0.35-0.95 and SHR 0.43, 95% CI 0.27-0.68, respectively) in the risk of prostate cancer specific mortality for radical prostatectomy and intensity modulated radiation therapy., Conclusions: Local therapy with radical prostatectomy and intensity modulated radiation therapy but not with conformal radiation therapy was associated with a survival benefit in men with metastatic prostate cancer. This finding warrants prospective evaluation in clinical trials., (Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We examined prostatectomy pathology, and oncologic and functional outcomes of men progressing from active surveillance to radical prostatectomy., Materials and Methods: We identified patients on active surveillance treated with radical prostatectomy. We compared patients on active surveillance ultimately treated with radical prostatectomy to age and prostate specific antigen matched men undergoing immediate radical prostatectomy after a diagnosis of low risk disease who were candidates for active surveillance (group 1). We also compared patients on active surveillance with progression to Gleason 7 disease to men treated who had similar de novo disease (group 2) to determine whether patients on active surveillance have potentially adverse outcomes., Results: Of 289 patients on active surveillance 41 (14.2%) underwent radical prostatectomy after a median of 35.2 months (IQR 22.8-46.6) on active surveillance. Compared to group 1, the radical prostatectomy after active surveillance group had expectedly worse pathological outcomes, whereas the pathological outcomes of patients undergoing radical prostatectomy after active surveillance with progression to Gleason 7 disease were similar to those of group 2. At a median of 3.5 years from radical prostatectomy (IQR 2.6-4.7), biochemical recurrence was low and comparable between the radical prostatectomy after active surveillance group and group 1 (2.6% vs 5.4%, p = 0.47), while erectile function was 29.0% and continence 89.7%, comparable to both groups., Conclusions: Radical prostatectomy after a period of active surveillance does not appear to result in adverse pathological outcomes compared to patients with a similar preoperative pathology., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: The use of cavernous nerve interposition grafting to preserve erectile function in men who require neurovascular bundle resection for cancer control is controversial. We report outcomes and predictors of cavernous nerve interposition grafting in men undergoing unilateral grafting during radical prostatectomy or bilateral grafting during radical cystectomy and prostatectomy with autologous nerve grafts., Materials and Methods: We retrospectively reviewed the electronic records of 36 patients who underwent cavernous nerve interposition grafting between 2003 and 2006. Postoperatively erectile function was assessed with the International Index of Erectile Function 15-item questionnaire. Predictors of potency, including age at surgery, time since surgery and prostate specific antigen at surgery, were assessed by univariate analysis., Results: A total of 33 patients (92% response rate) were followed for a median of 32, 25 and 11 months after bilateral grafting during radical cystectomy (10), unilateral grafting during radical prostatectomy (20), and bilateral grafting during radical cystectomy and prostatectomy (3), respectively. The rate of potency, defined as the ability to attain and maintain erection sufficient for penetration at least 50% of the time with or without phosphodiesterase-5 inhibitors, was 31% (5 of 13 men) for unilateral grafts, 38% (5 of 16) for bilateral grafts and 30% (3 of 10) for bilateral grafts during radical cystectomy. Age at surgery was the only significant determinant of potency and it showed an inverse relationship in the bilateral nerve graft group (p = 0.02)., Conclusions: Cavernous nerve interposition grafting appears to have a role in the recovery of erectile function. To our knowledge this study represents the largest series of cavernous nerve interposition grafting during cystectomy and it suggests that this should be considered during bilateral neurovascular bundle resection.

Introduction: We sought to determine whether patients undergoing radical prostatectomy (RP) in the context of disseminated cancer have higher 30-day complications. Methods: We conducted a retrospective cohort study of the National Surgical Quality Improvement Program (NSQIP) database. Men undergoing RP (from January 1, 2005 to December 31, 2014) for prostate cancer were identified and stratified by presence (n=97) or absence (n=27 868) of disseminated cancer. The primary outcome was major complications (death, re-operation, cardiac or neurologic events) within 30 days of surgery. Secondary outcomes included pulmonary, infectious, venous thromboembolic, and bleeding complications; prolonged length of stay; and concomitant procedures (bowel-related, cystectomy, urinary diversion, and major ureteric reconstruction). Odds ratios (OR) for each complication were calculated using univariable logistic regression. Results: We did not identify a difference in major complication rates (OR 2.26, 95% confidence interval [Cl] 0.71-7.1 6). Patients with disseminated cancer had increased risk of venous thromboembolic events (OR 3.30, 95% Cl 1.04-10.48) and transfusion (OR 2.45, 95% 0 1.18-5.05), but similar odds of pulmonary and infectious complications and length of stay. Bowel procedures were rare, however, a significantly higher proportion of patients with disseminated cancer required bowel procedures (2.1% vs. 0.3%; p=0.03). Patients with disseminated cancer undergoing RP had greater comorbidities and higher predicted probability of morbidity and mortality. This study is limited by its retrospective design, lack of cancer-specific variables, and prostatectomyspecific complications. Conclusions: RP in the context of disseminated cancer may be associated with increased perioperative complications. Caution should be exercised in embarking on this practice outside of clinical trials. [ABSTRACT FROM AUTHOR]

Purpose: To describe our approach for port placement and robot docking for pelvic and kidney surgery (KS). Patients and Methods: We use a four-arm robotic approach and a 5 to 6 port placement consisting of: One 12-mm camera port, three 8-mm robotic ports, and one to two assistant ports. For radical prostatectomy, the working robotic ports run parallel below the level of the umbilicus. Radical cystectomy ports are more cephalad and above the level of the umbilicus. For transperitoneal KS, two bariatric robotic ports are used, aiming for an equilateral triangle configuration. With retroperitoneal (RN) KS, a balloon dilator and balloon port create the RN space; bariatric ports comprise the most anterior and posterior ports. Results: This technique has been used since 2010 on more than 2370 robotic urologic cases. To date, no procedure has needed patient or robot positioning while maintaining fourth arm functionality with minimal robotic arm clashing. Conclusions: Our approach of port placement and robot docking is reproducible and feasible for pelvic surgical procedures and KS. [ABSTRACT FROM AUTHOR]

Objective To prospectively evaluate the feasibility and safety of a novel, second-generation telementoring interface ( Connect™; Intuitive Surgical Inc., Sunnyvale, CA, USA) for the da Vinci robot. Materials and Methods Robotic surgery trainees were mentored during portions of robot-assisted prostatectomy and renal surgery cases. Cases were assigned as traditional in-room mentoring or remote mentoring using Connect. While viewing two-dimensional, real-time video of the surgical field, remote mentors delivered verbal and visual counsel, using two-way audio and telestration (drawing) capabilities. Perioperative and technical data were recorded. Trainee robotic performance was rated using a validated assessment tool by both mentors and trainees. The mentoring interface was rated using a multi-factorial Likert-based survey. The Mann- Whitney and t-tests were used to determine statistical differences. Results We enrolled 55 mentored surgical cases (29 in-room, 26 remote). Perioperative variables of operative time and blood loss were similar between in-room and remote mentored cases. Robotic skills assessment showed no significant difference ( P > 0.05). Mentors preferred remote over in-room telestration ( P = 0.05); otherwise no significant difference existed in evaluation of the interfaces. Remote cases using wired (vs wireless) connections had lower latency and better data transfer ( P = 0.005). Three of 18 (17%) wireless sessions were disrupted; one was converted to wired, one continued after restarting Connect, and the third was aborted. A bipolar injury to the colon occurred during one (3%) in-room mentored case; no intraoperative injuries were reported during remote sessions. Conclusion In a tightly controlled environment, the Connect interface allows trainee robotic surgeons to be telementored in a safe and effective manner while performing basic surgical techniques. Significant steps remain prior to widespread use of this technology. [ABSTRACT FROM AUTHOR]

Background Androgen-deprivation therapy (ADT) has been associated with cardiovascular risk factors and the development of cardiovascular disease in men with metastatic prostate cancer. We sought to examine the effect of ADT on nonprostate cancer mortality among patients with nonmetastatic prostate cancer. Methods We performed a population-based, retrospective cohort study of men aged 66 years and older treated with surgery or radiotherapy for nonmetastatic prostate cancer in Ontario, Canada from 2002 to 2009 using administrative datasets (including the Ontario Cancer Registry, Ontario Drug Benefit, and Ontario Health Insurance Plan). Analysis was performed between September 2016 and April 2017. ADT exposure was operationalized as a time-varying binary and cumulative dose exposure. Primary and secondary outcomes were nonprostate cancer mortality and cardiovascular mortality, respectively. The Fine and Gray subdistribution method with generalized estimating equations was used to calculate subdistribution hazard ratios (sdHR), while accounting for competing risks. Results We examined 20,651 men treated for nonmetastatic prostate cancer. Median follow-up was 7.4 years and median ADT exposure was 6.4 months. ADT was not significantly associated with nonprostate cancer mortality (sdHR = 0.75, 95% CI: 0.37–1.50) or cardiovascular mortality (sdHR = 1.16, 95% CI: 0.37–3.63) when operationalized as a binary time-varying exposure. Similar results were obtained when we examined ADT cumulative dose exposure. Conclusions ADT is not associated with nonprostate cancer mortality or cardiovascular mortality in a large, population-based cohort of older men with localized prostate cancer treated by surgery or radiation therapy. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of androgen deprivation therapy (ADT) and primary treatment modality on cardiovascular and skeletal-related events and to investigate potential effect modification in a contemporary cohort of patients treated for clinically localized prostate cancer.Subjects and Methods: We conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results-Medicare linked databases for men aged 65-79 years who underwent radical prostatectomy or radiotherapy for cT1 or cT2 prostate cancer from 2000 to 2008. We categorized treatment according to primary therapy and receipt of ADT. We described the cumulative incidence of cardiovascular and skeletal-related events.Results: Among 60,156 men, 14,403 underwent surgery and 45,753 underwent radiotherapy. Median follow-up was 6.0 years. After adjusting for baseline differences, treatments with radiotherapy (adjusted hazard ratios [aHR] 1.16-1.28, P <.0001-.04) and ADT (aHR 1.18-1.32, P <.0001-.008) were each independently associated with increased risk of coronary heart disease, sudden cardiac death, fracture, and fracture requiring hospitalization. Radiotherapy was associated with an increased risk of myocardial infarction (aHR 1.20, P = .02), whereas ADT was not (P = .5). We did not identify a significant statistical interaction between primary and hormonal treatment.Conclusion: Care for cardiovascular and skeletal-related events is an important part of the survivorship phase for a significant proportion of patients with localized prostate cancer. Increasing use of ADT for patients with localized disease undergoing radiotherapy and the observed higher prevalence of these events in these patients should be considered when discussing the risks and benefits of treatment for localized prostate cancer and when formulating a survivorship plan. [ABSTRACT FROM AUTHOR]

Peripheral nerve injury (PNI) is a rare but preventable complication of surgery. We sought to assess whether the use of minimally invasive surgery (MIS) affects the occurrence of PNI. Using the American College of Surgeons National Surgical Quality Improvement Program database, we examined rates of PNI among patients undergoing appendectomy, hysterectomy, colectomy, or radical prostatectomy between 2005 and 2012. We assessed the effect of MIS, as compared with open surgery, on PNI occurrence using logistic regression. Among 297,532 patients, of whom 175,884 (59.1%) underwent MIS, the rate of PNI was 0.03 per cent. Forty-four patients treated using MIS had PNI (0.03%) as compared with 63 who underwent open surgery (0.05%; P = 0.0002). There was a significant decrease in the proportion of surgeries resulting in PNI (P < 0.0001) over time. In univariate analysis, MIS was associated with a decreased occurrence of PNI (odds ratio 0.48, 95% confidence interval 0.33-0.71), but this became nonsignificant on multivariable analysis (odds ratio 0.71, 95% confidence interval 0.47-1.09). Increased operative time and smoking status were the only factors independently associated with an increased risk of PNI on multivariable analysis. MIS techniques during common abdominal-pelvic surgeries do not appear to increase the risk of PNI. Prolonged operative time and smoking are independently associated with an increased risk of PNI. Quality improvement initiatives to increase awareness of PNI and identify patients at increased risk of this preventable complication should be considered. [ABSTRACT FROM AUTHOR]

Context To date, there is no Level 1 evidence comparing the efficacy of radical prostatectomy and radiotherapy for patients with clinically-localized prostate cancer. Objective To conduct a meta-analysis assessing the overall and prostate cancer-specific mortality among patients treated with radical prostatectomy or radiotherapy for clinically-localized prostate cancer. Evidence acquisition We searched Medline, EMBASE, and the Cochrane Library through June 2015 without year or language restriction, supplemented with hand search, using Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. We used multivariable adjusted hazard ratios (aHRs) to assess each endpoint. Risk of bias was assessed using the Newcastle-Ottawa scale. Evidence synthesis Nineteen studies of low to moderate risk of bias were selected and up to 118 830 patients were pooled. Inclusion criteria and follow-up length varied between studies. Most studies assessed patients treated with external beam radiotherapy, although some included those treated with brachytherapy separately or with the external beam radiation therapy group. The risk of overall (10 studies, aHR 1.63, 95% confidence interval 1.54–1.73, p < 0.00001; I 2 = 0%) and prostate cancer-specific (15 studies, aHR 2.08, 95% confidence interval 1.76–2.47, p < 0.00001; I 2 = 48%) mortality were higher for patients treated with radiotherapy compared with those treated with surgery. Subgroup analyses by risk group, radiation regimen, time period, and follow-up length did not alter the direction of results. Conclusions Radiotherapy for prostate cancer is associated with an increased risk of overall and prostate cancer-specific mortality compared with surgery based on observational data with low to moderate risk of bias. These data, combined with the forthcoming randomized data, may aid clinical decision making. Patient summary We reviewed available studies assessing mortality after prostate cancer treatment with surgery or radiotherapy. While the studies used have a potential for bias due to their observational design, we demonstrated consistently higher mortality for patients treated with radiotherapy rather than surgery. [ABSTRACT FROM AUTHOR]