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Editorial: Hot topic of cancer survivorship and the ‘seven deadly sins’

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Cancer survivorship has become a hot topic as overall mortality for most cancer patients continues to decrease, the worldwide population continues to age and as patients become more information savvy [1-3]. Gavin et al. [4] provide a data-rich population-based patient survey of seven of the most common physical symptoms after prostate cancer treatment. While we, as urologists and prostate cancer providers, may not be able to recount the seven deadly sins or the seven dwarfs, we do know these seven symptoms: impotence; incontinence; bowel problems; fatigue; hot flushes; loss of libido; and breast symptoms. Urological surgeons and radiation oncologists talk to patients every day about the ‘big three’ of these: impotence, incontinence and bowel problems. Gavin et al. provide the striking statistic that ~1.6% of the male population over the age of 45 years is a prostate cancer survivor currently living with one of the seven.

The paper describes mailed survey results from a population-based cohort of 3 348 prostate cancer survivors 2–15 years after diagnosis with a response rate of 54%. The average age of respondents was 64.9 years, 64% had localized disease at presentation, 65% had Gleason 5–7 disease, and 48, 32 and 20% were surveyed 2–4.9, 5–9.9 and >10 years after diagnosis, respectively. The paper is chock full of descriptive statistics about rates of past and ongoing side effects of the various treatments and essentially has ‘something for everyone’. For example, at baseline before treatment, 51.2% of respondents reported urinary frequency, 18.8% reported impotence and 14.7% reported loss of libido. These data may be useful for estimating population-based general men’s health disease. After treatment, radical prostatectomy (RP) had the highest rates of impotence (76% current) and incontinence (current 28%; ever 70%); however, the authors examined radiation plus hormonal therapy and found impotence rates of 64% and rates of hot flushes, breast changes and bowel problems in the 20–27% range. Table 3 and Figs 3 and 4 in the paper are particularly useful to further examine the seven side effects with treatment.

On the one hand, these data could be useful in educating patients about treatment options for prostate cancer and what they might expect should they choose one treatment over another. Ideally, this education would occur in the multidisciplinary clinic setting [5]. On the other hand, these data could also be used in the wrong way. For example, an aggressive surgeon could selectively present the ‘deadly downsides’ of radiation while downplaying the ‘surgical sins’, whereas a radiation oncologist could do just the opposite to try to influence his or her patients. This highlights the limitations of the present study. While the authors are to be congratulated for a wonderful population-based survey, no control group was surveyed and, more importantly, the authors do not address satisfaction and regret. In other words, the seven side effects must be placed into the patient’s overall satisfaction regarding cancer control and the patient’s ‘trade-offs individualized internal assessment’. For example, our group examined satisfaction and regret after open and robot-assisted RP, finding an ~80–85% satisfaction rate despite levels of impotence and incontinence slightly lower but similar to those in the present population-based survey [6]. While patients who underwent open RP enjoyed more satisfaction and less regret, we attributed much of this to the ‘used car salesman’ approach to ‘selling’ robot-assisted RP in the last decade [7]. In other words, we hypothesized that patients undergoing robot-assisted RP were misled into believing the robot would lessen or eliminate the surgical sins while those undergoing open RP were counselled more realistically. Also, we found that in multivariable analysis, African-American patients exhibited more regret [6]. These data point to the fact that the present study from Ireland may not be applicable to other populations, particularly those with a mixed or different ethnic make-up. Another limitation to population-based data is the impact of centres of excellence and highly experienced treatment providers. The impact of high-volume surgeons/providers on treatment outcomes is now being recognized as a critical variable that is rarely accounted for in case series, multicentre studies or population data as seen here.

Overall, Gavin et al. are to be commended for a very rich source of side effect data for a large population-based cohort of prostate cancer survivors. The ‘seven deadly sins’ of possible side effects/complications of prostate cancer treatment should be shared openly and honestly with our patients. Furthermore, physicians and healthcare systems must be encouraged to collect provider and system-specific data to better fine-tune our pre-treatment counselling that will ultimately improve the satisfaction of our cancer survivors.

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Judd W. Moul
Duke Cancer Institute, Durham, NC, USA

 

References

1 Resnick MJ, Lacchetti C, Bergman J et al. Prostate cancer survivorship care guideline: American society of clinical oncology clinical practice guideline endorsement. J Clin Oncol 2015; 33: 1078–85

2 Skolarus TA, Wolf AM, Erb NL et al. American Cancer Society prostate cancer survivorship care guidelines. CA Cancer J Clin 2014; 64: 225–49; Erratum in: CA Cancer J Clin. 2014; 64: 445

3 Gupta S, Peterson AC. Stress urinary incontinence in the prostate cancer survivor. Curr Opin Urol 2014; 24: 395–400

4 Gavin A, Drummond F, Donnelly C, O’Leary E, Sharp L, Kinnear H. Patient reported ‘ever had’ and ‘current’ long-term physical symptoms following prostate cancer treatments. BJU Int 2015.

5 Stewart SB, Ba~nez LL, Robertson CN et al. Utilization trends at a multidisciplinary prostate cancer clinic: initial 5-year experience from the Duke Prostate Center. J Urol 2012; 187: 103–8

6 Schroeck FR, Krupski TL, Sun L et al. Satisfaction and regret after open retropubic or robot-assisted laparoscopic radical prostatectomy. Eur Urol 2008; 54: 785–93

7 Schroeck FR, Krupski TL, Stewart SB et al. Pretreatment expectations of patients undergoing robotic assisted laparoscopic or open retropubic radical prostatectomy. J Urol 2012; 187: 894–8

 

Video: Patient-reported long-term physical symptoms after prostate cancer treatments

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Patient reported “ever had” and “current” long term physical symptoms following prostate cancer treatments.

To investigate the prevalence of physical symptoms that were ‘ever’ and ‘currently’ experienced by survivors of prostate cancer at a population level, to assess burden and thus inform policy to support survivors. The study included 3 348 men surviving prostate cancer for 2-18 years after diagnosis. A cross-sectional, postal survey of 6 559 survivors diagnosed 2-18 years ago with primary, invasive prostate cancer (ICD10-C61) identified via national, population-based cancer registries in Northern Ireland and Republic of Ireland. Questions included symptoms at diagnosis, primary treatments and physical symptoms (erectile dysfunction [ED]/urinary incontinence [UI]/bowel problems/breast changes/loss of libido/hot flashes/fatigue) experienced ‘ever’ and at questionnaire completion (‘current’). Symptom proportions were weighted by age, country and time since diagnosis. Bonferroni corrections were applied for multiple comparisons.

Adjusted response rate 54%; 75% reported at least one ‘current’ physical symptom (‘ever’ 90%), with 29% reporting at least three. Prevalence varied by the diverse treatments found at https://www.ukmeds.co.uk/finasteride. Overall, 57% reported current ED and this was highest after radical prostatectomy (RP, 76%) followed by external beam radiotherapy with concurrent hormone therapy (HT, 64%). UI (overall ‘current’ 16%) was highest after RP (‘current’ 28%; ‘ever’ 70%). While 42% of brachytherapy patients reported no ‘current’ symptoms, 43% reported ‘current’ ED and 8% ‘current’ UI. ‘Current’ hot flashes (41%), breast changes (18%) and fatigue (28%) were reported more often by patients on HT.

Anna T. Gavin, Frances J. Drummond*, Conan Donnelly, Eamonn O’Leary*, Linda Sharp† and Heather R. Kinnear

Northern Ireland Cancer Registry, Centre for Public Health, Queen’s University Belfast, Mulhouse Building, Belfast Northern Ireland, UK, *National Cancer Registry Ireland, Building 6800, Airport Business Park Cork, Ireland, and †Institute of Health and Society, Newcastle University, Richardson Road, Newcastle upon Tyne, NE2 4AX, England, UK

 

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OBJECTIVE

To investigate the prevalence of physical symptoms that were ‘ever’ and ‘currently’ experienced by survivors of prostate cancer at a population level, to assess burden and thus inform policy to support survivors.

PATIENTS AND METHODS

The study included 3 348 men surviving prostate cancer for 2–18 years after diagnosis. A cross-sectional, postal survey of 6 559 survivors diagnosed 2–18 years ago with primary, invasive prostate cancer (ICD10-C61) identified via national, population-based cancer registries in Northern Ireland and Republic of Ireland. Questions included symptoms at diagnosis, primary treatments and physical symptoms (erectile dysfunction [ED]/urinary incontinence [UI]/bowel problems/breast changes/loss of libido/hot flashes/fatigue) experienced ‘ever’ and at questionnaire completion (‘current’). Symptom proportions were weighted by age, country and time since diagnosis. Bonferroni corrections were applied for multiple comparisons.

RESULTS

Adjusted response rate 54%; 75% reported at least one ‘current’ physical symptom (‘ever’ 90%), with 29% reporting at least three. Prevalence varied by treatment. Overall, 57% reported current ED and this was highest after radical prostatectomy (RP, 76%) followed by external beam radiotherapy with concurrent hormone therapy (HT, 64%). UI (overall ‘current’ 16%) was highest after RP (‘current’ 28%; ‘ever’ 70%). While 42% of brachytherapy patients reported no ‘current’ symptoms, 43% reported ‘current’ ED and 8% ‘current’ UI. ‘Current’ hot flashes (41%), breast changes (18%) and fatigue (28%) were reported more often by patients on HT.

CONCLUSION

Symptoms after prostate cancer treatment are common, often multiple, persist long-term and vary by treatment method. They represent a significant health burden. An estimated 1.6% of men aged >45 years are survivors of prostate cancer and currently experiencing an adverse physical symptom. Recognition and treatment of physical symptoms should be prioritised in patient follow-up. This information should facilitate men and clinicians when deciding about treatment as differences in survival between radical treatments is minimal.

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Article of the Week: A prospective study of erectile function after transrectal ultrasonography-guided prostate biopsy

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Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Katie Murray discussing her paper. 

If you only have time to read one article this week, it should be this one.

A prospective study of erectile function after transrectal ultrasonography-guided prostate biopsy

 

Murray KS1, Bailey J2, Zuk K3, Lopez-Corona E4, Thrasher JB1,4.

 

Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA.

Kansas City University of Medicine and Biosciences, Kansas City, KS, USA.

University of Kansas School of Medicine, Kansas City, KS, USA.

Kansas City Veterans Administration Medical Center, Kansas City, KS, USA.

 

Read the full article
OBJECTIVE

To prospectively evaluate the effect of transrectal ultrasonography (TRUS)-guided prostate biopsy on erectile and voiding function at multiple time-points after biopsy.

PATIENTS AND METHODS

All men who underwent TRUS-guided prostate biopsy completed a five-item version of the International Index of Erectile Function (IIEF-5) and the International Prostate Symptom Score (IPSS) before and at 1, 4 and 12 weeks after TRUS-guided biopsy. Statistical analyses used were a general descriptive analysis, continuous variables using a t-test and categorical data using chi-square analysis. A paired t-test was used to compare each patient’s baseline score to their own follow-up survey scores.

RESULTS

In all, 220 patients were enrolled with a mean age of 64.1 years and PSA level of 6.7 ng/dL. At initial presentation, 38.6% reported no erectile dysfunction (ED), 22.3% mild ED, 15.5% mild-to-moderate ED, 10% moderate ED, and 13.6% severe ED. On paired t-test there was a statistically significant reduction in IIEF-5 score at 1 week after biopsy compared with before biopsy (18.2 vs 15.5; P < 0.001). This remained significantly reduced at 4 (18.4 vs 17.3; P = 0.008) and 12 weeks (18.4 vs 16.9, P = 0.004) after biopsy.

CONCLUSIONS

The effects of TRUS-guided prostate biopsy on erectile function have probably been underestimated. It is important to be aware of these transient effects so patients can be appropriately counselled. The exact cause of this effect is yet to be determined.

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Editorial: Temporary Erectile Dysfunction Following Prostate Biopsy

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TRUS-guided prostate needle biopsy (PB) is considered to be the ‘gold standard’ for the diagnosis of prostate cancer. While serious side-effects (e.g. infection, sepsis and urinary retention) can occur after PB, they are relatively rare. Minor side-effects, including haematuria, haematospermia, rectal discomfort and bleeding, are more common but are usually self-limiting. As such, men undergoing biopsy are usually counselled about these risks, which generally occur at an acceptably low frequency and are outweighed by the potential benefits of PB.

Penile erection is a complex physiological process that occurs through a coordinated cascade of neurological, vascular, humoral and psychological events. Therefore, there are a multitude of factors that could ultimately influence or disrupt normal erectile function after PB, including type of anaesthetic, age, psychological stress and damage to the neurovascular bundles. Erectile dysfunction (ED) and worsening LUTS have been reported to occur after PB, but the true incidence and possible pathophysiology remain subject to debate. For example, in their manuscript entitled, ‘A prospective study of erectile function after transrectal ultrasound and prostate biopsy’, Murray et al. [1] conducted a prospective study assessing erectile function, measured by the International Index of Erectile Function (IIEF-5), and LUTS, measured by the IPSS, after PB. The results suggest that there is a significant decrease in erectile function that persists up to 3 months after PB. By contrast, worsening LUTS were not documented at this time after PB.

The present prospectively conducted trial [1] supports the findings of some other retrospective studies [2], but contradicts others [3–5]. For example, Helfand et al. [6] previously documented that a diagnosis of prostate cancer can influence a man’s erectile function after PB. Similarly, Murray et al. [1] found that patients without a diagnosis of prostate cancer reported lower IIEF scores up to 3 weeks, whereas those diagnosed with the disease had significantly lower IIEF scores up to 3 months after PB. Taken together, these results support other studies [2,6] showing that the psychological stress associated with a cancer diagnosis might contribute to ED.

Other recent studies have supported the notion that PB does not influence the frequency of ED [3–5]. These data have been mainly obtained from studies of men undergoing repeated PB as part of an active surveillance protocol. Some of these discrepancies might be related to the timing of evaluation after PB (e.g. 3 vs 12 months). Nonetheless, other studies found that age may be a better predictor of changes in erectile function. For example, data obtained from Braun et al. [3] support that men who undergo multiple biopsies (a median of five PB) fail to report substantially decreased erectile function over time. Similarly, Hilton et al. [4] found that erectile function scores were strongly associated with age and sexual activity, and not number of PBs. In support of this age relationship, the present study found that men aged <60 years had lower IIEF scores only at 1 week, compared with those patients aged >60 years who continued to report sexual side-effects up to 3 months after PB [1].

When the results of Murray et al. [1] are considered in light of previous studies on this topic, it appears that patients should be counselled on the possibility of relatively short-term (‘acute’) changes in erectile function. However, it should also be emphasised that long-term ED might not be related to the PB procedure itself, but rather to other factors, including advanced age, psychological stress and/or prostate cancer diagnosis.

 

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Brian Helfand

North Shore University Health System, Division of Urology, John and Carol Walter Center for Urological Health, Evanston, IL, USA.

University of Chicago, Chicago, IL, USA.

 

References

1 Murray KS, Bailey J, Zuk K, Lopez-Corona E, Thrasher JB. A prospective study of erectile function after transrectal ultrasound and prostate biopsy. BJU Int 2015; 116: 190–5

2 Zisman A, Leibovici D, Kleinmann J, Cooper A, Siegel Y, Lindner A. The impact of prostate biopsy on patient well-being: a prospective study of voiding impairment. J Urol 2001; 166: 2242–6

3 Braun K, Ahallal Y, Sjoberg DD et al. Effect of repeated prostate biopsies on erectile function in men on active surveillance for prostate cancer. J Urol 2014; 191: 744–9

4 Hilton JF, Blaschko SD, Whitson JM, Cowan JE, Carroll PR. The impact of serial prostate biopsies on sexual function in men on active surveillance for prostate cancer. J Urol 2012; 188: 1252–8

5 Chrisofos M, Papatsoris AG, Dellis A, Varkarakis IM, Skolarikos A, Deliveliotis C. Can prostate biopsies affect erectile function? Andrologia 2006; 38: 79–83

6 Helfand BT, Glaser AP, Rimar K et al. Prostate cancer diagnosis is associated with an increased risk of erectile dysfunction after prostate biopsy. BJU Int 2013; 111: 38–43

Video: A prospective study of erectile function after transrectal ultrasonography-guided prostate biopsy

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A prospective study of erectile function after transrectal ultrasonography-guided prostate biopsy

 

Murray KS1, Bailey J2, Zuk K3, Lopez-Corona E4, Thrasher JB1,4.

 

Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA.

Kansas City University of Medicine and Biosciences, Kansas City, KS, USA.

University of Kansas School of Medicine, Kansas City, KS, USA.

Kansas City Veterans Administration Medical Center, Kansas City, KS, USA.

 

Read the full article
OBJECTIVE

To prospectively evaluate the effect of transrectal ultrasonography (TRUS)-guided prostate biopsy on erectile and voiding function at multiple time-points after biopsy.

PATIENTS AND METHODS

All men who underwent TRUS-guided prostate biopsy completed a five-item version of the International Index of Erectile Function (IIEF-5) and the International Prostate Symptom Score (IPSS) before and at 1, 4 and 12 weeks after TRUS-guided biopsy. Statistical analyses used were a general descriptive analysis, continuous variables using a t-test and categorical data using chi-square analysis. A paired t-test was used to compare each patient’s baseline score to their own follow-up survey scores.

RESULTS

In all, 220 patients were enrolled with a mean age of 64.1 years and PSA level of 6.7 ng/dL. At initial presentation, 38.6% reported no erectile dysfunction (ED), 22.3% mild ED, 15.5% mild-to-moderate ED, 10% moderate ED, and 13.6% severe ED. On paired t-test there was a statistically significant reduction in IIEF-5 score at 1 week after biopsy compared with before biopsy (18.2 vs 15.5; P < 0.001). This remained significantly reduced at 4 (18.4 vs 17.3; P = 0.008) and 12 weeks (18.4 vs 16.9, P = 0.004) after biopsy.

CONCLUSIONS

The effects of TRUS-guided prostate biopsy on erectile function have probably been underestimated. It is important to be aware of these transient effects so patients can be appropriately counselled. The exact cause of this effect is yet to be determined.

Read more articles of the week

Article of the Week: Central obesity is predictive of persistent storage LUTS after surgery for BPE

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Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

Finally, the third post under the Article of the Week heading on the homepage will consist of additional material or media. This week we feature a video from Dr. Mauro Gacci discussing his paper. 

If you only have time to read one article this week, it should be this one.

Central obesity is predictive of persistent storage LUTS after surgery for Benign Prostatic Enlargement: results of a multicenter prospective study

Mauro Gacci, Arcangelo Sebastianelli, Matteo Salvi, Cosimo De Nunzio*, Andrea
Tubaro*, Linda Vignozzi†, Giovanni Corona‡, Kevin T. McVary§, Steven A. Kaplan¶, Mario Maggi†, Marco Carini and Sergio Serni

 

Department of Urology, Careggi Hospital, University of Florence, Florence, *Department of Urology, Sant’Andrea Hospital, University ‘La Sapienza’, Rome, †Department of Clinical Physiopathology, University of Florence, Florence , ‡Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Bologna, Italy, §Department of Urology, Southern Illinois University School of Medicine, Springfield, IL , and Department of Urology, Weill Cornell Medical College, Cornell University, New York, NY, USA

 

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OBJECTIVE

To evaluate the impact of components of metabolic syndrome (MetS) on urinary outcomes after surgery for severe lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE), as central obesity can be associated with the development of BPE and with the worsening of LUTS.

PATIENTS AND METHODS

A multicentre prospective study was conducted including 378 consecutive men surgically treated for large BPE with simple open prostatectomy (OP) or transurethral resection of the prostate (TURP), between January 2012 and October 2013. LUTS were measured by the International Prostate Symptom Score (IPSS), immediately before surgery and at 6–12 months postoperatively. MetS was defined according the USA National Cholesterol Education Program-Adult Treatment Panel III.

RESULTS

The improvement of total and storage IPSS postoperatively was related to diastolic blood pressure and waist circumference (WC). A WC of >102 cm was associated with a higher risk of an incomplete recovery of both total IPSS (odds ratio [OR] 0.343, P = 0.001) and storage IPSS (OR 0.208, P < 0.001), as compared with a WC of <102 cm. The main limitations were: (i) population selected from a tertiary centre, (ii) Use exclusively of IPSS questionnaire, and (iii) No inclusion of further data.

CONCLUSIONS

Increased WC is associated with persistent postoperative urinary symptoms after surgical treatment of BPE. Obese men have a higher risk of persistent storage LUTS after TURP or OP.

 

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Editorial: Exercise, diet and weight loss before therapy for LUTS/BPH?

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In recent decades we have had access to an increasing body of evidence evoking a strong relationship between metabolic syndrome and the development of LUTS/BPH. This relationship suggests that metabolic syndrome might be responsible not only for putting patients at higher risk of developing LUTS/BPH but also for influencing the response and outcome of therapy. In a study in the present issue of BJUI [1] it has been observed that patients with a greater waist circumference, a sign of metabolic syndrome, are at a higher risk of experiencing persistent LUTS after either TURP or open prostatectomy for BPH. Likewise, in a recent systematic review and meta-analysis, a strong relationship between metabolic syndrome and prostatic enlargement was observed, underlining the exacerbating role of this syndrome in inducing the development of benign prostate enlargement as obese, dyslipidaemic and aged men have a higher risk of metabolic syndrome being a determinant factor of their prostate enlargement [2].

Metabolic syndrome is a constellation of clinical findings characterizing patients affected by a combination of abdominal obesity, elevated serum triglyceride levels, lowered HDL cholesterol levels, increased blood pressure or a high level of plasma glucose. It has also been considered an important risk factor for the eventual development of a number of diseases including type 2 diabetes, coronary vascular disease, fatty liver disease, chronic kidney disease and hyperuricaemia [3]. Furthermore metabolic syndrome has been recently associated with an increased risk of clinical progression of LUTS/BPH in men with moderate to severe LUTS, reinforcing this syndrome as a factor for progression in addition to IPSS score, prostate volume, PSA, maximum urinary flow rate and post-void residual urine volume [4]. Several studies have recently shown that patients with LUTS/BPH and metabolic syndrome have a higher prostate volume than those without, and express a worse response to pharmacological therapy, suggesting the need to consider this at the time of selecting patients with LUTS/BPH for drug therapy [5, 6]. Check these leptitox reviews for harmless and natural weight loss treatment.

Several factors in the development of metabolic syndrome have been elucidated, including hyperinsulinaemia and autonomic hyperactivity, increased adiposity, ischaemia and hypoxia, chronic proinflamatory state and abnormal androgen levels. These factors are probably inter-related. A lack of exercise, together with obesity, may lead to insulin resistance, exerting a detrimental effect on lipid ratios decreasing blood levels of HDL cholesterol and increasing blood levels of triglycerides and LDL cholesterol. These undesirable levels of cholesterol may lead to deposits of atheromatous plaques in artery walls, increasing the risk of cardiovascular disease. In addition, hyperinsulinaemia may lead to sodium retention, causing hypertension.

The implications for clinical practice are that, if metabolic syndrome is related to the development of BPH/LUTS, lifestyle interventions including weight loss (you can check resurge reviews and find how this supplement heal you losing weight), a healthy diet, and physical activity would have a positive effect in both symptom relief and disease progression. As a consequence we should develop management strategies to address both the symptoms and the underlying processes, not only because men with LUTS/BPH and metabolic syndrome respond worse than those without metabolic syndrome, but also because lifestyle change, a healthy diet and exercise might be enough to achieve symptom improvement and decrease the risk of cardiovascular disease, prevent most obesity related conditions just by reading these meticore reviews.

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David Castro-Diaz
Department of Urology, University Hospital of the Canary Islands, University of La Laguna, Tenerife, Spain

Video: Central obesity is predictive of persistent storage LUTS after surgery for BPE

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Central obesity is predictive of persistent storage LUTS after surgery for Benign Prostatic Enlargement: results of a multicenter prospective study

Mauro Gacci, Arcangelo Sebastianelli, Matteo Salvi, Cosimo De Nunzio*, Andrea
Tubaro*, Linda Vignozzi†, Giovanni Corona‡, Kevin T. McVary§, Steven A. Kaplan¶, Mario Maggi†, Marco Carini and Sergio Serni

 

Department of Urology, Careggi Hospital, University of Florence, Florence, *Department of Urology, Sant’Andrea Hospital, University ‘La Sapienza’, Rome, †Department of Clinical Physiopathology, University of Florence, Florence , ‡Endocrinology Unit, Medical Department, Maggiore-Bellaria Hospital, Bologna, Italy, §Department of Urology, Southern Illinois University School of Medicine, Springfield, IL , and Department of Urology, Weill Cornell Medical College, Cornell University, New York, NY, USA

 

Read the full article
OBJECTIVE

To evaluate the impact of components of metabolic syndrome (MetS) on urinary outcomes after surgery for severe lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE), as central obesity can be associated with the development of BPE and with the worsening of LUTS.

PATIENTS AND METHODS

A multicentre prospective study was conducted including 378 consecutive men surgically treated for large BPE with simple open prostatectomy (OP) or transurethral resection of the prostate (TURP), between January 2012 and October 2013. LUTS were measured by the International Prostate Symptom Score (IPSS), immediately before surgery and at 6–12 months postoperatively. MetS was defined according the USA National Cholesterol Education Program-Adult Treatment Panel III.

RESULTS

The improvement of total and storage IPSS postoperatively was related to diastolic blood pressure and waist circumference (WC). A WC of >102 cm was associated with a higher risk of an incomplete recovery of both total IPSS (odds ratio [OR] 0.343, P = 0.001) and storage IPSS (OR 0.208, P < 0.001), as compared with a WC of <102 cm. The main limitations were: (i) population selected from a tertiary centre, (ii) Use exclusively of IPSS questionnaire, and (iii) No inclusion of further data.

CONCLUSIONS

Increased WC is associated with persistent postoperative urinary symptoms after surgical treatment of BPE. Obese men have a higher risk of persistent storage LUTS after TURP or OP.

 

Read more articles of the week

Article of the Week: A Novel Interface for the Telementoring of Robotic Surgery

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Every Week the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

A Novel Interface for the Telementoring of Robotic Surgery

Daniel H. Shin, Leonard Dalag, Raed A. Azhar, Michael Santomauro, Raj Satkunasivam, Charles Metcalfe, Matthew Dunn, Andre Berger, Hooman Djaladat, Mike Nguyen, Mihir M. Desai, Monish Aron, Inderbir S. Gill and Andrew J. Hung

 

University of Southern California Institute of Urology, Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

 

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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.

CONCLUSIONS

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.

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Editorial: Robotic Networks – delivering empowerment through integration

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Intuitive’s latest version of Connect™ for the Da Vinci Si model allows surgeons to communicate remotely via a laptop or personal computer, direct to the surgeon’s console. It has one-way video from the console to the remote mentor and bi-directional audio and telestration (drawing), replicating the successful strategy employed in many industries to develop networks, to share expertise and knowledge. The study published by Shin et al. [1] in this issue of BJUI is a technical proof of concept study and is an important first step to realising the potential of robotic networks. The study describes the application of Connect on a local area network (LAN), which is a network that interconnects computers in a limited geographical area such as a hospital, whereas a wide access network (WAN) is a computer network spanning regions, countries or even the world. The next logical advance for Connect is to study connections between different institutions, states and even internationally between countries. Connections between two UK NHS trusts have been successfully trialled, with plans for formal connections between hospitals in Sweden and the UK underway.

Minimally invasive surgery using video technologies has greatly improved opportunities for surgical learning. Telementoring has existed in various forms for >20 years and has been shown to have a positive impact on outcomes [2]. In a study by Påhlsson et al. [3], telementoring delivered by a high-volume surgeon at a tertiary hospital to a low-volume rural hospital, increased their cannulation rate in endoscopic retrograde cholangiopancreatography from 85% (one of the lowest in the country) to 99% (highest success rate).

While robotic surgery continues to evolve quickly, it remains an expensive service with required investment in surgeons’ learning curves in both established and new techniques. Maximum value is realised once the team is experienced, efficient and outcomes are optimised. Even between tertiary centres of excellence there are different skill sets. Successful collaborative approaches to training have potential to steepen learning curves. With Connect robotic trainers will have the additional option to disseminate their knowledge from a distance, without the need for mentor or mentee to travel.

Current healthcare WANs between hospitals can enable secure, quality assured connections over national and international networks. Connect will have a role in LANs [1]; however, studying telementoring across larger networks will probably define its beneficial effects on the learning curve. Connections between centres with the largest difference in skill sets are likely to show the greatest impacts.

Robotic networks are likely to exist in various forms and telementoring could be complemented by supplementary services delivered over both local and wide access networks. Future potential services over a LAN include real-time multi-disciplinary teams with direct communication from the console to the radiologists and histopathologists.

Simulators have been used in industries outside healthcare, such as the aviation industry, to measure both proficiency and technical skill learning. Although robotic surgical simulation has not yet reached a stage where it replicates all aspects of robotic surgical procedures, it currently has potential to accelerate trainees along their learning curve outside the operating room and thus contribute to patient safety. Simulators greatest future value may be aligned with the data and feedback that robotic networks will provide, replicating the roles of airport control centres and flight simulators. With better understanding of surgical learning curves and the ability to score and differentiate between performance levels [4], data collected via networks may also have a future role in regulation of surgery (Fig. 1).

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Figure 1. Potential effect of robotic networks on identifying suboptimal technique and improving patient outcomes. (*Connect and Simulation diagrams by Intuitive Surgical™).

International robotic networks will help achieve balance between the continual cycle of optimisation and standardisation of robotic surgical techniques. Standardised live surgery broadcast from home institutions [5] could support and promote both telementoring and the benefits of standardised surgical techniques [5, 6]. Standardisation is critical to developing cohesive networks with better understanding between mentors and mentees. It also aids identification of the ‘hazard’ steps in complex multistep procedures, enabling strategies to avoid the associated complications [6].

Sharing of expertise requires shared goals. In highly competitive healthcare systems where hospitals compete in attracting patients, there is inherent resistance to sharing. Connect enables interaction between mentor and mentee and once hard endpoints are identified and the beneficial effects of sharing are studied, new thinking in robotic surgery is likely. If benefits to surgical outcomes and improved safety using Connect are confirmed, both legal and reimbursement issues will probably be resolved.

In conclusion, change is driven on varying scales from local discussion, to national and international opinion and debate. While Connect will undoubtedly enhance communication between surgeons, it is the development of WANs, connecting the centres with the biggest differences in skill sets, which may deliver the greatest improvements. Collaboration via robotic networks has the potential to not only enable but to drive advancement in multiple areas of robotic surgery through the sharing of knowledge, innovations and expertise, resulting in continuous incremental improvement.

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Justin Collins, Consultant Urologists, Olof Akre, Consultant Urologists, Benjamin Challacombe*, Consultant Urologists, Omer Karim†, Consultant Urologists and Peter Wiklund, Professor
Department of Urology, Karolinska University Hospital, Stockholm, Sweden, *Department of Surgery and Cancer, Kings College, Guy’s Hospital, London, and †Department of Urology, Wexham Park Hospital, Slough, UK

 

References

 

1 Shin DH, Dalag L, Azhar Raed A et al. A novel interface for the telementoring of robotic surgery. BJU Int 2014; [Epub ahead of print]. DOI: 10.1111/bju.12985.

 

2 Challacombe B, Kandaswamy R, Dasgupta P, Mamode N. Telementoring facilitates independent hand-assisted laparoscopic living donor nephrectomy. Transplant Proc 2005;37:613–6. 

 

3Pahlsson HI, Groth K, Permert J et al. Telemedicine: an important aid to perform high-quality endoscopic retrograde cholangiopancreatography in low-volume centers. Endoscopy 2013;45:357–61.

 

4 Bonrath EM, Zevin B, Dedy NJ, Grantcharov TP. Error rating tool to identify and analyse technical errors and events in laparoscopic surgery. Br J Surg 2013;100:1080–8.

 

5 Collins JW, Akre O, Wiklund PN. Re: Walter Artibani, Vincenzo Ficarra, Ben J. Challacombe et al. EAU Policy on Live Surgery Events. Eur Urol 2014; 66: 87–97. Eur Urol 2014; 66: e121–2.

 

6 Collins JW, Tyritzis S, Nyberg T et al. Robot-assisted radical cystectomy – description of an evolved approach to radical cystectomy. Eur Urol 2013;64:654–63.

 

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