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ABSTRACT: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Even after a negative set of prostate biopsies, the risk of undetected prostate cancer remains clinically significant. Predictive markers of such a risk are undefined. In addition to PSA and PSAD, low prostate volume and %fPSA are interesting time-varying risk factors and are relevant in biopsy decision-making. OBJECTIVE: To assess prospectively the time-varying risk of rebiopsy and of prostate cancer (PCa) detection after an initial negative biopsy protocol. PATIENTS AND METHODS: Over a period of 10 years, 1995 consecutive patients with initially negative biopsies were followed. Rebiopsies were performed in patients who had a persistent suspicion of PCa. Predictive factors for rebiopsy and for PCa detection were tested using univariate, multivariate and time-dependent models. RESULTS: A total of 617 men (31%) underwent at least one rebiopsy after a mean follow-up of 19 months. PCa detection rates during second, third, and fourth sets of biopsies were 16.7, 16.9 and 12.5%, respectively. The overall rate of detected PCa was 7.0%. The 5-year rebiopsy-free and PCa-free survival rates were 65.9 and 92.5%, respectively. Indications for rebiopsy were more frequently reported in patients having a high prostate-specific antigen (PSA) level (P = 0.006) or a high PSA density (PSAD; P < 0.001) and in younger patients (P = 0.008). The risk of PCa on rebiopsies was not correlated with age, but significantly increased more than twofold in cases of PSA >6 ng/mL, PSAD >0.15 ng/mL/g, free-to-total PSA ratio (%fPSA) <15, and/or prostate volume <50 mL. Time-dependent analyses were in line with these findings. The main study limitation was the lack of control of the absence of PCa and PSA kinetics in men not rebiopsied. CONCLUSIONS: The overall risk of detected PCa after an initial negative biopsy was low. In addition to PSA and PSAD, which are well-used in rebiopsy indications, low prostate volume and %fPSA are interesting time-varying risk factors for PCa on rebiopsy and could be relevant in biopsy decision-making.
BJU International 03/2013; · 2.84 Impact Factor
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Yann Neuzillet,
Michel Soulie,
Stéphane Larre,
Morgan Roupret,
Guillaume Defortescu,
Thibaut Murez,
Géraldine Pignot,
Aurélien Descazeaud,
Jean-Jacques Patard,
Pierre Bigot, Laurent Salomon,
Pierre Colin,
Jérôme Rigaud,
Cyrille Bastide,
Xavier Durand,
Antoine Valeri,
François Kleinclauss,
Franck Bruyere,
Christian Pfister
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ABSTRACT: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Positive surgical margin (PSM) frequency after radical cystectomy has been estimated to be 4-15%. Studies that have not distinguished between the different sites of PSM have failed to show that they are an independent prognostic factor for disease-free survival. Only perivesical soft tissue PSMs have been associated with an increased risk of cancer recurrence and cancer-specific death. This is the first comprehensive published analysis of PSMs occurring during radical cystectomy for pTx pN0 M0 bladder cancer according to their location, comparing their cancer-specific survival (CSS) and other outcomes with those of a control group paired according to TNM status, age, sex and urinary diversion method. Local recurrence-free survival rates were found to be lower in patients with both soft tissue and urethral PSMs. Moreover, soft-tissue PSMs were associated with lower metastatic recurrence-free and CSS rates. OBJECTIVE: To compare the prognoses associated with positive surgical margins (PSMs) according to their urethral, ureteric and/or soft tissue locations in patients with pN0 M0 bladder cancer who have not undergone neoadjuvant chemotherapy. PATIENTS AND METHODS: A retrospective, case-control study was conducted between 1991 and 2011 using data from 17 academic centres in France. A total of 154 patients (cases) with PSMs met the eligibility criteria and were matched according to centre, pT stage, gender, age and urinary diversion method with a population-based sample of 154 patients (controls) from 3651 patients who had undergone cystectomies. The median follow-up period was 23.9 months. Multivariable Cox regression analysis was used to test the effects of PSMs on local recurrence (LR)-free survival, metastatic recurrence (MR)-free survival and cancer-specific survival (CSS). RESULTS: The 5-year LR-free survival and CSS rates of patients with urethral and soft tissue PSMs were lower than those in the control group. A significant decrease in CSS was associated with soft tissue PSMs (P = 0.003, odds ratio = 0.425, 95% confidence interval 0.283-0.647). The prognosis was not affected in cases of ureteric PSMs. CONCLUSIONS: Soft tissue PSMs were associated with poor CSS rates in patients with pN0 M0 bladder cancer. A correlation between urethrectomy and a reduction of the risk of LR in a urethral PSM setting was observed.
BJU International 01/2013; · 2.84 Impact Factor
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ABSTRACT: PURPOSE: The aim of this study was to determine the impact of increasing the number of cores from 12 to 20 at initial prostatic biopsy (PB) in men suspicious of prostate cancer (PCa). MATERIAL AND METHODS: From December 2009 to November 2011, patients in 7 centers scheduled for a first PB, with a PSA < 20 ng/mL and no nodule on digital rectal examination, were invited to participate in this superiority trial. Patients were randomized to a 12-core (PB12 group) or a 20-core (PB20 group) protocol. The primary end point was cancer detection rate (CDR). Secondary end points were cancer characteristics, rate of complications and patient's tolerance assessed by a self-completed booklet before PB and at day 5 and day 15. RESULTS: A total of 339 patients were randomized. Preoperative variables were similar in both groups. Cancer was detected in 71 patients (42.0%) in PB12 group and in 81 patients (48.8%) in PB20 group: the difference was not significant (p>0.2). Gleason score and cancer length measured on PB cores were not significantly different between groups. Although CDR rate was linked to prostate volume, this was not affected by the number of extracted cores (p> 0.4). Complications number and seriousness were comparable in both arms. No significant difference was noted regarding side-effects and tolerance as self-assessed by the patient at day 5 and day 15 following PB. CONCLUSIONS: Our findings suggest that there is no significant advantage in using a 20-core biopsy protocol vs 12-core protocol during an initial PB.
The Journal of urology 01/2013; · 4.02 Impact Factor
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ABSTRACT: Objective: We aimed to build a nomogram allowing to predict the probability of prostate cancer (PC) after an initial 21-core biopsy and with readily available clinical data. Methods: 1,490 screened men who underwent an initial 21-core biopsy protocol were included. A multivariate logistic regression was realized including age, prostate volume, prostate-specific antigen (PSA) level, digital rectal examination (DRE) and transrectal ultrasonography (TRUS). Receiver-operating characteristic estimates were used to quantify accuracy of each model. Results: PC was detected in 41.3% of the patients. Median PSA, age and prostate volume were 6.2 ng/ml (range 0.2-50), 64.6 years (range 33-87) and 40 ml (range 10-270), respectively. Abnormal TRUS findings were detected in 14.7% of patients. Age, PSA level, prostate volume, DRE and TRUS were significantly associated with PC (all p ≤ 0.004) in univariable logistic regression analysis. In multivariate logistic regression analysis, significant associations were found for age, PSA level, prostate volume and DRE. Predictive accuracy estimate of this model was equal to 0.70. TRUS was not an independent predictor of PC. Conclusions: We constructed the first prebiopsy predictive nomogram based on an extended 21-core biopsy procedure with age, PSA level, DRE and prostate volume which are readily available clinical data to urologists.
Urologia Internationalis 01/2013; · 0.99 Impact Factor
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ABSTRACT: OBJECTIVES: To report our surgical technique and outcomes after extraperitoneal robot-assisted laparoscopic radical prostatectomy (RALRP). MATERIALS AND METHODS: At Henri Mondor's Hospital, we performed the first RALRP in 2001 and started to perform routinely RALRP since 2006. Preoperative characteristics, perioperative parameters, functional and oncological outcomes were collected in a prospective database and studied. All parameters were tested in patients undergoing RALRP beyond the learning curve of each surgeon. The overall cohort included 792 patients. RESULTS: RALRP offers interesting results in terms of hospital stay, operative time, and blood loss. The overall rate of complications was low, especially concerning the rates of anastomosis' complications. An extraprostatic extension was seen in 42.8 % of specimens. The overall rate of positive margins was 30.7 % of specimens. In our cohort, after a mean follow-up of 19 months, 8.7 % of PSA failure has been reported. The rate of continence was 77.4 % at 6 months and 96.8 % at 2 years. The rate of potency was 17 % at 3 months and 60.9 % at 2 years. The 2-year rate was 86.7 % in case of intrafascial dissection. A trifecta outcome was achieved in 44 and 53 % of men at 12 and 24 months, respectively. CONCLUSIONS: The extraperitoneal approach confers interesting results in terms of perioperative parameters as previously described in series using a transperitoneal approach. Functional outcomes in terms of continence and potency recovery after extraperitoneal seem equivalent to those reported after transperitoneal RALRP. Longer follow-up is warranted to confirm our favorable mid-term oncologic outcomes.
World Journal of Urology 12/2012; · 2.41 Impact Factor
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ABSTRACT: BACKGROUND: Prognostic factors in pathologic node-positive patients after radical cystectomy are debated. Extranodal extension (ENE) and lymph node density (LND) are strong predictors of survival. The aim of this study was to assess factors predictive of survival and to evaluate the prognostic significance of the tumor, node, metastasis staging system (TNM) nodal classification in a retrospective cohort of node-positive bladder cancers after radical cystectomy. METHODS: We retrospectively reviewed the data of 75 patients with node-positive bladder cancer after radical cystectomy. Node pathological examination was performed by two experienced uropathologists. Cox regression analysis was performed to identify factors predictive of progression. RESULTS: The median number of removed lymph node was 18 (range 3-49). The median number of positive lymph nodes was 3 (range 1-35). Overall progression-free and cancer-specific survival were 5 and 12 %. In multivariate analysis, ENE, LND with a 20 % cutoff, and adjuvant chemotherapy were independent predictors of progression-free survival (p = 0.007, 0.006, <0.0001). Neither the 2002 nor the 2009 TNM nodal classification was associated with recurrence. CONCLUSIONS: ENE and LND are strong predictors of clinical outcome in patients with node-positive bladder cancer treated by cystectomy. The actual TNM classification could probably be improved using these criteria, allowing better prognostic classification of node-positive bladder cancer after radical cystectomy.
Annals of Surgical Oncology 12/2012; · 4.17 Impact Factor
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ABSTRACT: BACKGROUND: In spite of the increasing use of robot-assisted radical prostatectomy (RALP) worldwide, no level 1 evidence-based benefit favouring RALP versus pure laparoscopic approaches has been demonstrated in extraperitoneal laparoscopic procedures. OBJECTIVE: To compare the operative, functional, and oncologic outcomes between pure laparoscopic radical prostatectomy (LRP) and RALP. DESIGN, SETTING, AND PARTICIPANTS: From 2001 to 2011, 2386 extraperitoneal LRPs were performed consecutively in cases of localised prostate cancers. INTERVENTION: A total of 1377 LRPs and 1009 RALPs were performed using an extraperitoneal approach. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Patient demographics, surgical parameters, pathologic features, and functional outcomes were collected into a prospective database and compared between LRP and RALP. Biochemical recurrence-free survival was tested using the Kaplan-Meier method. Mean follow-up was 39 and 15.4 mo in the LRP and RALP groups, respectively. RESULTS AND LIMITATIONS: Shorter durations of operative time and of hospital stay were reported in the RALP group compared with the LRP group (p<0.001) even beyond the 100 first cases. Mean blood loss was significantly lower in the RALP group (p<0.001). The overall rate and the severity of the complications did not differ between the two groups. In pT2 disease, lower rates of positive margins were reported in the RALP group (p=0.030; odds ratio [OR]: 0.396) in multivariable analyses. The surgical approach did not affect the continence recovery. Robot assistance was independently predictive for potency recovery (p=0.045; OR: 5.9). Survival analyses showed an equal oncologic control between the two groups. Limitations were the lack of randomisation and the short-term follow-up. CONCLUSIONS: Robotic assistance using an extraperitoneal approach offers better results than pure laparoscopy in terms of operative time, blood loss, and hospital stay. The robotic approach independently improves the potency recovery but not the continence recovery. When strict indications of nerve-sparing techniques are respected, RALP gives better results than LRP in terms of surgical margins in pathologically organ-confined disease. Longer follow-up is justified to reach conclusions on oncologic outcomes.
European urology 12/2012; · 7.67 Impact Factor
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ABSTRACT: To evaluate the impact of obesity on the outcomes of laparoscopic radical prostatectomy.
In a prospective urologic cancer database, 765 patients underwent extraperitoneal laparoscopic radical prostatectomy for localized prostate cancer. The patients were categorized into 3 groups of body mass index (kg/m(2)): <25.0 (n = 276, 30%, "normal weight"), 25.0 to 30.0 (n = 365, 48%, "overweight") and >30.0 (n = 124, 16%, "obese"). We assessed the perioperative, oncological, and functional outcomes in this cohort of patients. Preoperative and postoperative evaluation of continence and erectile function were performed using validated questionnaires.
Mean operative time was significantly longer in obese patients (P < .001) and blood loss was also more important (P < .01). The obese patients had the highest likelihood of having aggressive tumors: nonorgan confined prostate cancer (49%, P = .002) and Gleason score ≥ 7 (80%, P = .005). The obese group had the higher positive surgical margins rate (overall: 27%, P = .012; pT2: 20%, P = .02). With a mean follow-up of 38 months, obesity was not an independent predictive factor of biochemical recurrence. At the 12-month follow-up, 85%, 74%, and 72% of normal, overweight, and obese men, respectively, were continent (no pad) (P = .04). At the 12-month follow-up, 57%, 58%, and 40% of normal, overweight, and obese men, respectively, reported an erection sufficient for intercourse (P = .01).
Laparoscopic radical prostatectomy is a safe and effective procedure in obese men with midterm cancer control. However, obese patients are at higher risk of aggressive disease. Recovery of continence and potency in these patients are significantly lower compared to nonobese men.
Urology 09/2012; 80(3):576-84. · 2.43 Impact Factor
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Jean-Baptiste Beauval,
Guillaume Ploussard,
Michel Soulié,
Christian Pfister,
Simon Van Agt,
Sébastien Vincendeau,
Sébastien Larue,
Jérome Rigaud,
Nicolas Gaschignard,
Morgan Rouprêt,
Sarah Drouin,
Mickael Peyromaure,
Jean Alexandre Long,
Francois Iborra,
Guy Vallancien,
Francois Rozet, Laurent Salomon
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ABSTRACT: To evaluate the pathologic features of surgical specimens after radical prostatectomy in patients with low-risk prostate cancer fulfilling the strictest pathologic selection criteria for active surveillance.
Retrospective analysis of 10 785 consecutive radical prostatectomy performed in 10 university hospitals (January 2003 through December 2008). A total of 919 patients fulfilled the following unique and very stringent criteria: T1c, prostate-specific antigen (PSA) <10 ng/mL, a single positive biopsy, tumor length <3 mm, and Gleason score <7. Clinico-biologic and pathologic data at diagnosis and after radical prostatectomy, prostatic and tumor volume, pathologic Gleason score and stage, positive surgical margins, insignificant prostate cancer, and PSA outcomes were recorded.
Median age was 63 years. Mean prebiopsy PSA level was 6.2 ng/mL. At radical prostatectomy, Gleason score was upgraded in 34% of patients, including 1.2% Gleason score 8-9. Pathologic stages were pT2 in 87.3%, pT3 in 11.1%, and pT4 in 1.4% of cases. Extraprostatic extension was found in 12.5%. Only 26% of patients had "insignificant" tumors. Biochemical recurrence-free survival at 5 years was 92.3%. There was no significant difference in survival between patients with "significant" and "insignificant" tumors (90.1% vs 93.4%; P = .06).
Despite of a stringent selection of patients with low-risk prostate cancer, active surveillance definition included a significant proportion of patients with upstaged (about 12%) and upgraded (about one-third) disease at diagnosis. Only a quarter of active surveillance patients have a pathologically confirmed "insignificant" cancer.
Urology 07/2012; 80(3):656-60. · 2.43 Impact Factor
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ABSTRACT: Study Type - Prognosis (inception cohort) Level of Evidence 2 What's known on the subject? and What does the study add? Several criteria have been described to select patients with prostate cancer in active surveillance (AS) protocols; however, the risk of missing unfavourable disease remains. We report the risk of misclassification using the Prostate Cancer Research International: Active Surveillance (PRIAS) study in an analysis of pathological results after radical prostatectomy. We also define predictors of favourable disease that can be used to better select patients eligible for AS, as well as risk factors associated with disease progression. OBJECTIVE: • To identify the risk of failure of active surveillance (AS) in men who had the Prostate Cancer Research International: Active Surveillance (PRIAS) criteria and had undergone radical prostatectomy (RP), by studying as primary endpoints the risk of unfavourable disease in RP specimens (stage > T2 and/or Gleason score > 6) and of biochemical progression after RP. PATIENTS AND METHODS: • We assessed 626 patients who had the PRIAS criteria for AS defined as T1c/T2, PSA level of ≤10 ng/mL, PSA density (PSAD) of <0.2 ng/mL per mL, Gleason score of <7, and one or two positive biopsies. All patients underwent immediate RP at our department between January 1991 and December 2010. • Multivariate logistic regression was used to test factors correlated with the risk of unfavourable prostate cancer. • The risk of progression was tested using multivariate Cox regression models. • Biochemical recurrence-free survival (BFS) was established using the Kaplan-Meier method RESULTS: • Pathological study of RP specimens showed upstaging (>T2) in 129 patients (20.6%), upgrading (Gleason score > 6) in 281 (44.9%) and unfavourable disease in 312 patients (50%). • There was a statistically non-significant trend for BFS at P= 0.06. • Predictors of favourable tumours were age < 65 years (P= 0.005), one vs two positive biopsies (P= 0.01) and a biopsy core number >12 (P= 0.005). • Preoperative factors predicting disease progression were a PSAD of >0.15 ng/mL(2) (P= 0.008) and biopsy core number of ≤12 (P= 0.017). CONCLUSIONS: • Even with stringent AS criteria, the rate of unfavourable disease remains high. • Predictive factors of unfavourable disease and biochemical progression should be considered when including patients in AS protocols.
BJU International 06/2012; · 2.84 Impact Factor
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ABSTRACT: BACKGROUND: The debate on the optimal number of prostate biopsy core samples that should be taken as an initial strategy is open. OBJECTIVE: To prospectively evaluate the diagnostic yield of a 21-core biopsy protocol as an initial strategy for prostate cancer (PCa) detection. DESIGN, SETTING, AND PARTICIPANTS: During 10 yr, 2753 consecutive patients underwent a 21-core biopsy scheme for their first set of biopsy specimens. INTERVENTION: All patients underwent a standardized 21-core protocol with cores mapped for location. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The PCa detection rate of each biopsy scheme (6, 12, or 21 cores) was compared using a McNemar test. Predictive factors of the diagnostic yield achieved by a 21-core scheme were studied using logistic regression analyses. RESULTS AND LIMITATIONS: PCa detection rates using 6 sextant biopsies, 12 cores, and 21 cores were 32.5%, 40.4%, and 43.3%, respectively. The 12-core procedure improved the cancer detection rate by 19.4% (p=0.004), and the 21-biopsy scheme improved the rate by 6.7% overall (p<0.001). The six far lateral cores were the most efficient in terms of detection rate. The diagnostic yield of the 21-core protocol was >10% in prostates with volume >70ml, in men with a prostate-specific antigen level<4 ng/ml, with a prostate-specific antigen density (PSAD) <0.20 ng/ml per gram. A PSAD <0.20 ng/ml per gram was the strongest independent predictive factor of the diagnostic yield offered by the 21-core scheme (p<0.001). The 21-core protocol significantly increased the rate of PCa eligible for active surveillance (62.5% vs 48.4%; p=0.036) than those detected by a 12-core scheme without statistically increasing the rate of insignificant PCa (p=0.503). CONCLUSIONS: A 21-core biopsy scheme improves significantly the PCa detection rate compared with a 12-core protocol. We identified a cut-off PSAD (0.20 ng/ml per gram) below which an extended 21-core scheme might be systematically proposed to significantly improve the overall detection rate without increasing the rate of detected insignificant PCa.
European urology 06/2012; · 7.67 Impact Factor
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ABSTRACT: Introduction. Radical prostatectomy (RP) can lead to erectile dysfunction due to surgical injury of the cavernous nerves. However, there is no simple, objective test to evaluate cavernous nerve damage caused by RP in clinical practice. Aim. To assess the value of the measurement of penile thermal and vibratory sensory thresholds to reflect cavernous nerve damage caused by RP. Methods. We included 42 consecutive patients who underwent RP with cavernous nerve sparing (laparoscopic approach, N = 12) or without cavernous nerve sparing (laparoscopic, N = 13; retropubic, N = 11; or transperineal, N = 6). Penile thermal (warm and cold) and vibratory sensory thresholds were measured twice, together with the Erectile Dysfunction Symptom Score (EDSS), 1 month before and 2 months after RP. Main Outcome Measures. Penile sensory thresholds for warm, cold, and vibration sensations. Results. Penile sensory thresholds for warm (P < 0.0001) and cold (P < 0.0001) sensations significantly increased after non-nerve-sparing RP, but not after nerve-sparing RP. Vibration threshold only increased after transperineal non-nerve-sparing RP (P = 0.031). EDSS values were significantly increased in all groups of patients 2 months after surgery. Conclusions. Sensory nerve fibers carrying penile skin sensations travel with the cavernous nerves in the pelvis. Therefore, testing these sensations may help to evaluate the extent of cavernous nerve damage caused by RP. In this series, post-operative changes in penile sensory thresholds differed with the surgical technique of RP, as the cavernous nerves were preserved or not. The present results support the value of quantitative penile sensory threshold measurement to indicate RP-induced cavernous nerve injury. Yiou R, De Laet K, Hisano M, Salomon L, Abbou C-C, and Lefaucheur J-P. Neurophysiological testing to assess penile sensory nerve damage after radical prostatectomy. J Sex Med 2012;9:2457-2466.
Journal of Sexual Medicine 05/2012; 9(9):2457-66. · 3.55 Impact Factor
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Alexandra Masson-Lecomte,
Laurent Guy,
Philippe Pedron,
Franck Bruyere,
Morgan Rouprêt,
Bonaventure Nsabimbona,
Mickael Dahan,
Patrice Hoffman, Laurent Salomon,
Dimitri Vordos,
Andras Hoznek,
Philippe Le Corvoisier,
Pierrick Morel,
Claude Abbou,
Alexandre de la Taille
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ABSTRACT: PURPOSE: At the time of castration resistance, it is recommended to realize hormonal manipulations before chemotherapy. We evaluated the impact of a switch from GnRH agonist to antagonist in patients with castration-resistant prostate cancer on PSA and testosterone levels at 3 months. METHODS: Retrospectively, 17 patients from 5 different centers undergoing androgen deprivation therapy and presenting rising PSA confirmed on 3 blood samples 2 weeks apart and despite a castrate testosterone level (<0.5 ng/ml) were reviewed. Antiandrogen withdrawal syndrome had been tested before the switch. Degarelix was administered as followed: 240 mg for the first injection and then 80 mg every month, subcutaneously. We evaluated the PSA and testosterone level variation 3 months after the switch. Patients who experienced a variation in PSA of less than 10% compared to the baseline or who had a more than 10% PSA decrease were defined as responders. RESULTS: Mean PSA level at the switch was 34.3 ± 50.3 ng/ml, with a mean testosterone level of 0.21 ± 0.13 ng/ml. Three months after the switch, mean PSA level was 59.9 ± 81.6 ng/ml (P = 0.061), with a mean testosterone level of 0.19 ± 0.08 ng/ml (P = 0.086). At 3 months, 4 patients (23%) responded to therapy. Thirteen patients (77%) experienced a rise in PSA of more than 10% compared to baseline; 41% of patients decreased their testosterone level. The limitations of this study are its retrospective nature and the limited number of patients. CONCLUSION: Switch from an agonist to an antagonist of GnRH has a limited impact on PSA at 3 months in castration-resistant prostate cancer patients.
World Journal of Urology 04/2012; · 2.41 Impact Factor
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ABSTRACT: Patients with localized prostate cancer (PCa) who are treated by radical prostatectomy (RP) have a good overall survival rate. Their quality of life, however, can deteriorate because of the incidence of bladder neck contracture (BNC). Our aim was to evaluate the incidence and the risk factors of BNC after minimally invasive radical prostatectomy (MIRP) with a single-knot running suture also known as the Van Velthoven technique (VVT).
From 2003 to 2010, 2115 patients underwent extraperitoneal, transperitoneal, or robot-assisted RP for localized PCa. A single-knot running suture according to the VVT was performed for the vesicourethral anastomosis. Follow-up was scheduled and standardized for all patients and recorded into a prospective database. BNC was defined by a reduction of the lumen that does not allow the passage of an 18F fibroscope.
Mean follow-up of the patients was 43 (6-144) months. Of all, 1342, 241, and 532 had extraperitoneal, transperitoneal, and robot-assisted prostatectomy, respectively. BNC was diagnosed in 30 (1.4%) patients. Among them, 78% had the diagnosis within the first year of follow-up. Previous transurethral resection of the prostate (TURP) and external beam radiotherapy were independent risk factors of BNC.
BNC incidence after MIRP using the single-knot running suture for the vesicourethral anastomosis is low. Previous TURP and external beam radiotherapy are identified as risk factors. This technique showed satisfying results regardless of the classic laparoscopic or robot-assisted approach.
Journal of endourology / Endourological Society 04/2012; 26(8):1020-5. · 1.75 Impact Factor
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ABSTRACT: OBJECTIVE: To evaluate the impact of detailed biopsy characteristics such as positive cores location or multifocality on the risk of initial reclassification in prostate cancer (CaP) patients eligible for active surveillance (AS). MATERIALS AND METHODS: We reviewed data from 300 consecutive men eligible for AS (PSA ≤ 10 ng/ml, clinical stage T1c, Gleason score ≤6, <3 positive cores, extent of cancer in any core < 50%) who have undergone a radical prostatectomy (RP). Reclassification was defined as upstaged disease and/or upgraded disease in RP specimens. RESULTS: Biopsy features showed 36% of CaP involving 2 cores and a mean total tumor length of 2.63 mm. The 2 most frequently positive sites were base and apex. Mean total tumor length was significantly associated with upgraded disease (P = 0.025). In a multivariate model taking into account PSA, PSAD, number of positive cores and total tumor length, a total tumor length > 5 mm were independently predictor for a upgraded disease (OR 1.93, P = 0.046). The number, the multifocality and the bilaterality of positive cores were not associated with reclassification. Upgraded disease was significantly less reported in case of positivity at midline zone compared with positivity at base, apex, or transition zone (P = 0.013). CONCLUSIONS: Detailed biopsy data provide additional information on the initial risk of reclassification in AS patients. Patients having a total tumor length < 5 mm and positive cores at midline zone are more likely to have favorable pathologic characteristics at diagnosis. These variables can be used for selection and monitoring improvement in AS programs.
Urologic Oncology 01/2012; · 3.22 Impact Factor
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ABSTRACT: Objective. The objective of this study was to compare perioperative, oncologic, and functional outcomes of TLPN (transperitoneal laparoscopic partial nephrectomy) versus RLPN (retroperitoneal). Patients and Methods. From 1997 to 2009, a retrospective study of 153 consecutive patients who underwent TLPN or RLPN for suspicious renal masses was performed. Complications, functional and oncological outcomes were compared between the 2 groups. Results. With a mean followup of 39 and 32 months, respectively, 66 and 87 patients had TLPN and RLPN, respectively. Tumor location was more often posterior in the RLPN and more often anterior in the TLPN. Mean operative time and mean hospital stay were longer in the TLPN group with 190 ± 85 min versus 154 ± 47 (P = 0.001) and 9.2 ± 6.4 days versus 6.2 ± 4.5 days (P < 0.05), respectively. Transfusion and urinary fistulas rates were similar in the 2 groups. After 3-year followup, chronic kidney failure occurred in 6 and and 4% (P = 0.67) in after TLPN and RLPN, respectively. After 3-year followup, recurrence free survival was 96.7% and 96.6% (P = 0.91) in the TLPN and RLPN groups, respectively. Conclusion. Our study confirmed that TLPN had longer operative time and hospital stay than RLPN. The complication rates were similar. Furthermore, mid-term oncological and functional outcomes were similar.
Advances in Urology 01/2012; 2012:473457.
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ABSTRACT: PURPOSE: To assess the pathological and the oncologic outcomes of the prostate cancer (PCa) missed by 6- and 12-core biopsy protocols by using a reference 21-core scheme. MATERIALS AND METHODS: Between 2001 and 2009, all patients who had PCa detected in an initial 21-core TRUS biopsy scheme and were treated by a radical prostatectomy (RP) were included. Patients were sorted in 3 groups according to the diagnosis site: sextant (6 first cores; group 1), peripheral zone (12 first cores; group 2) or midline/transitional zone (after 21 cores; group 3). Demographics, pathological features in biopsy and RP specimens and follow-up after RP were analyzed. The 5-year progression-free survival (PFS) was studied in the 3 groups. RESULTS: During the study period, 443 patients were included. Among them, 67, 23.7 and 9.2% were, respectively, diagnosed in groups 1, 2 and 3. Among PCa diagnosed in midline/transition zone cores, 42% were intermediate or high risk. Unfavorable disease was more frequently reported in group 1 in terms of extraprostatic extension (P = 0.001), high Gleason score (P = 0.001) and progression (P = 0.001). No significant difference was observed between groups 2 and 3 in terms of pathological features in RP specimens and oncologic outcome. The 5-year PFS was 89.7% and not significantly different in patients diagnosed with a 12-core scheme compared to those diagnosed only with 21-core scheme (P = 0.332). CONCLUSIONS: Our findings emphasize that PCa diagnosed only in a 21-core protocol is at least as aggressive as PCa detected in a 12-core scheme. This study invalidates the widespread idea sustaining that cancers diagnosed by more than 12 biopsies are less aggressive.
World Journal of Urology 11/2011; · 2.41 Impact Factor
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Guillaume Ploussard,
Alexandra Masson-Lecomte,
Jean-Baptiste Beauval,
Adil Ouzzane,
Romain Bonniol,
François Buge,
Saad Fadli,
Morgan Rouprêt,
Xavier Rebillard,
Nicolas Gaschignard,
Christian Pfister,
Arnauld Villers,
Michel Soulié, Laurent Salomon
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ABSTRACT: To estimate the effect of predictive factors for oncologic outcomes after radical prostatectomy (RP) for high-risk prostate cancer (PCa).
A total of 813 patients underwent RP for high-risk PCa in a national retrospective multi-institutional study. High-risk PCa was defined as follows: prostate-specific antigen (PSA) level>20 ng/mL, Gleason score 8-10, and/or clinical Stage T2c-T4 disease. The preoperative criteria of high-risk PCa were studied in a logistic regression model to assess the correlations with the pathologic findings in the RP specimens. The predictive factors isolated or combined in scores were assessed by Cox multivariate and Kaplan-Meier analyses in predicting PSA failure (recurrence-free survival [RFS]) and overall survival (OS).
The median follow-up was 64 months. Organ-confined disease was reported in 36.5%. The 5-year RFS, metastasis-free survival, and OS rate was 74.1%, 96.1%, and 98.6%, respectively. Each preoperative criteria of high-risk PCa was an independent predictor of PSA failure. The PSA failure risk was increased by 1.5- and 2.8-fold in men with 2 and 3 criteria, respectively. The RFS, but not the OS, was significantly different according to the preoperative score (P<.001). The postoperative score was significantly predictive for RFS and OS (P<.001 and P<.035, respectively). The risk of PSA failure was significantly increased with an increasing postoperative score (2-4.6-fold).
National data support evidence that RP can result in encouraging midterm oncologic outcomes for the management of high-risk PCa. At 5 years after surgery, 75% of patients remain disease free. Our easy-to-use risk stratification might help clinicians to better predict the clinical and PSA outcomes of high-risk patients after surgery.
Urology 07/2011; 78(3):607-13. · 2.43 Impact Factor
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ABSTRACT: Obese patients have a greater risk of adverse pathologic features and biochemical recurrence after radical prostatectomy (RP). The impact of body mass index (BMI) on the risk of reclassification and deferred treatment in active surveillance (AS) programs has not been thoroughly assessed.
To evaluate the impact of BMI on the risk of reclassification for AS eligibility.
We assessed 230 men who underwent an immediate RP and were eligible for AS according to the following criteria: prostate-specific antigen (PSA) ≤ 10 ng/ml, clinical stage T1c, Gleason score ≤ 6, fewer than three positive cores, extent of cancer in any core <50%, and life expectancy >10 yr.
All patients underwent a standardised 21-core biopsy and RP at our department between January 2001 and December 2010.
Reclassification was defined as upstaged disease (pathologic stage >pT2) and/or upgraded disease (Gleason score ≥ 7; primary Gleason pattern 4) in RP specimens. PSA outcomes were also recorded.
Mean BMI was 26.4 kg/m(2), and 13% of patients were obese (BMI >30). Mean BMI was the only preoperative factor significantly associated with the risk of upstaged disease. In multivariate analysis, BMI >30 remained an independent predictive factor for upstaged disease (p=0.003; odds ratio: 4.2). The risk of upgraded disease (primary Gleason pattern 4) was significantly decreased 4.5-fold in large prostate glands (>50 ml; p=0.008). The biochemical recurrence-free survival curves were not significantly different between men who were or were not overweight (p=0.950).
Obese men are at higher risk of upstaged disease, with a proportion of 30% of pT3 disease in RP specimens. BMI should be taken into account for inclusion of low-risk prostate cancer patients in AS programs, and our results may help urologists better inform their obese patients eligible for AS about this risk of reclassification and improve treatment decision making.
European urology 07/2011; 61(2):356-62. · 7.67 Impact Factor
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ABSTRACT: OBJECTIVES:: Outcomes of continence, erectile function, and oncologic control are well-described in isolation especially for the retropubic open approach. However, only few series have yet reported combined results after radical prostatectomy. To determine the proportion of men who are continent, potent, and cancer-free (trifecta rate) 2 years after robot-assisted laparoscopic radical prostatectomy (RALRP). MATERIALS AND METHODS:: We included patients who underwent a RALRP at our department and who were followed during at least 2 years. Men who were impotent or incontinent before the surgery were excluded from the analysis. Overall, 500 men were included. All patients prospectively completed validated questionnaires (IIEF-5, ICS) before the medical visit and concerning their voiding and sexual disorders, preoperatively, 3, 6, 12, 18, and 24 months after RALRP. Biochemical recurrence was defined as any detectable serum PSA (≥0.2 ng/ml). The study end point was the trifecta rate (cancer control, continence, and potency) at 2 years of the surgery. Predictive factors of the trifecta outcome were assessed in univariate and multivariate analyses. RESULTS:: Median age and PSA level were 62.2 years and 9.7 ng/mL. A trifecta outcome was achieved in 44% and 53% of men at 12 and 24 months, respectively. The 2-year trifecta rate reached 62% in men undergoing bilateral nerve-sparing surgery and 71% in men < 60 years. Age < 60 years, PSA level < 10 ng/ml, organ-confined disease, and bilateral nerve-sparing procedure were significantly associated with the 2-year trifecta outcome. CONCLUSION:: Two years after RALRP, the trifecta outcome is achieved in 53% of preoperatively potent and continent men.
Urologic Oncology 06/2011; · 3.22 Impact Factor
