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Editorial: sLND – if yes, Robotics?

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The manuscript in this issue of the BJUI by de Castro Abreu et al. [1] reports the results of the first series of patients to undergo robotic-assisted salvage lymph node dissection (sLND) for nodal recurrence of prostate cancer. Despite the absence of a high level of evidence, sLND has been gaining attention in recent years. Indeed, several series have shown promising results of such an approach, especially in terms of PSA response to surgery and delay in clinical recurrence [2-4]. However, sLND is a complex surgery and is not devoid of complications, as in up to 13.8% of patients Clavien–Dindo ≥IIIa complications occur [5]. When analysing the results of the current manuscript [1], it is impressive to read that the mean number of LNs removed was 83, ranging from 41 to 132, which is significantly higher than the reported figures of open sLND series. Moreover, despite the long median operative time (4.8 h), complication rates and postoperative course were excellent as compared to previously published series, although a direct comparison between the open and robot-assisted approach should be only addressed in prospective studies. The authors should be congratulated on the superb results obtained during the learning curve of such complex surgery, but some issues need to be discussed.

First, it is difficult to understand whether such results apply only to very expert surgeons. In other words, is it possible to translate such surgery to less experienced robotic surgeons? Second, is it necessary to extend the LND to a similar extent in all cases? Previous reports have shown that patients with retroperitoneal involvement may not benefit from sLND as much as their counterparts with only pelvic involvement [2]. The authors [1] show no significant impact of such an extended approach on complications and postoperative course, but the invasiveness of such an extended approach needs to be justified in each case. Third, the introduction of new tracer methods, such as prostate-specific membrane antigen (PSMA) positron emission tomography/CT, with higher specificity for prostate cancer may reduce the need for such extended templates, without compromising the oncological results [6]. Fourth, is the robotic approach feasible and safe in patients previously submitted to radical prostatectomy independently from the approach (open vs laparoscopic/robotic), from the extent of the previous LND, as well as from the previous administration of adjuvant/salvage radiotherapy? All these answers will need to be addressed in future studies on subgroups of patients undergoing sLND. Most importantly, until a high level of evidence is available, sLND should still be considered experimental and should be performed by highly experienced surgeons.

Nazareno Suardi and Francesco Montorsi
Department of Urology, Urological Research Institute, Vita –Salute San Raffaele University, Milan, Italy

 

References
1 Abreu A, Fay C, Park D et al. Robotic salvage retroperitoneal and pelvic lymph node dissection for ‘node-only’ recurrent prostate cancer: technique and initial series. BJU Int 2017; 120: 401–8

 

2 Suardi N, Gandaglia G, Gallina A et al. Long-term outcomes of salvage lymph node dissection for clinically recurrent prostate cancer: results of a single-institution series with a minimum follow-up of 5 years. Eur Urol 2015; 67: 299–309

 

3 Ost P, Bossi A, Decaestecker K et al. Metastasis-directed therapy of regional and distant recurrences after curative treatment of prostate cancer: a systematic review of the literature. Eur Urol 2015; 67: 852-63

 

4 Ploussard G, Almeras C, Briganti A et al. Management of node only recurrence after primary local treatment for prostate cancer: a systematic review of the literature. J Urol 2015; 194: 983–8

 

5 Abdollah F, Briganti A, Montorsi F et al. Contemporary role of salvage lymphadenectomy in patients with recurrence following radical prostatectomy. Eur Urol 2015; 67: 839–49

 

6 van Leeuwen PJ, Stricker P, Hruby G et al. (68) Ga-PSMA has a high detection rate of prostate cancer recurrence outside the prostatic fossa in patients being considered for salvage radiation treatment. BJU Int 2016;117:732–9

 

Infographic: Long-term sexual health outcomes in men with classic bladder exstrophy

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Infographic: Long-term sexual health outcomes in men with classic bladder exstrophy

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Article of the Month: Long-term sexual health outcomes in men with classic bladder exstrophy

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Every Month the Editor-in-Chief selects an Article of the Month 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.

Long-term sexual health outcomes in men with classic bladder exstrophy

Timothy S. Baumgartner, Kathy M. Lue, Pokket Sirisreetreerux, Sarita Metzger, Ross G. Everett, Sunil S. Reddy, Ezekiel Young, Uzoma A. Anele, Cameron E. Alexander, Nilay M. Gandhi, Heather N. Di Carlo and John P. Gearhart

 

Division of Pediatric Urology, James Buchanan Brady Urological Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA

 

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Abstract

Objectives

To identify the long-term sexual health outcomes and relationships in men born with classic bladder exstrophy (CBE).

Men’s reproductive health issues is often ignored and not prioritized in modern society. Male individuals sometimes resort to finding alternative solutions to their own problems and one in particular has helped them achieve sexual fulfillment. Prostate stimulation has helped in the prevention of such diseases using unconventional tools and methods. Lovehoney UK coupons have helped many to try out and explore other forms of expression and treatment using sex toys that stimulate the prostate. Here you will get a best penis extender device by Maleedge, visit once.  For those interested, check out their website and you can also find many of their discounts and coupons with a quick search online. There are many places to buy sex toys, but if one or both persons are nervous about it, buying them online is a fantastic option. Buying sex toys online allows you to see detailed colour, vivid photographs of all the Sex Toys you could ever want without having to go into an adult store!

Materials and Methods

A prospectively maintained institutional database comprising 1248 patients with exstrophy-epispadias was used. Men aged ≥18 years with CBE were included in the study. A 42-question survey was designed using a combination of demographic information and previously validated questionnaires.

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Results

A total of 215 men met the inclusion criteria, of whom 113 (53%) completed the questionnaire. The mean age of the respondents was 32 years. Ninety-six (85%) of the respondents had been sexually active in their lifetime, and 66 of these (58%) were moderately to very satisfied with their sex life. The average Sexual Health Inventory for Men score was 19.8. All aspects of assessment using the Penile Perception Score questionnaire were on average between ‘very dissatisfied’ and ‘satisfied’. Thirty-two respondents (28%) had attempted to conceive with their partner. Twenty-three (20%) were successful in conceiving, while 31 (27%) reported a confirmed fertility problem. A total of 31 respondents (27%) reported undergoing a semen analysis or post-ejaculatory urine analysis. Of these, only four respondents reported azoospermia.

Conclusion

Patients with CBE have many of the same sexual and relationship successes and concerns as the general population. This is invaluable information to give to both the parents of boys with CBE, and to the boys themselves as they transition to adulthood. See article from PlugLust and learn one way to prevention.

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Editorial: Sexuality in men with exstrophy

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It is always exciting to get new data on exstrophy from Johns Hopkins, but especially when sexual development is the subject [1]. It is the only unit with enough patients on continuous follow-up to overcome the difficulties of researching such a rare condition.

In the last 40 years, patients born with exstrophy have achieved a near normal life-expectancy. Reconstructive techniques for the bladder are now such that incontinence is rare, although often bladder emptying depends on clean intermittent self-catheterisation [2]. As with all fit young men, their minds turn frequently to sex and, occasionally, its natural consequence – pregnancy.

Current data have established that the men have a normal libido, orgasms, and erections. It is probable that the testes are normal at birth but often are damaged by recurrent infections. The penis is short, broad and has a characteristic chordee. Other erectile deformities are probably the result of corporeal damage during reconstruction in infancy. Most of these are surgically correctable. Ejaculation is poor or absent [3, 4].

Data on the men’s own satisfaction are contradictory and there are none on the partner’s opinions. Masturbation is almost universal. The incidence of erectile dysfunction is more than double that of controls (58% vs 23%) [3]. Much the commonest cause is fear of rejection by a partner because of the obvious penile anomalies. Most series show that men like to establish a good partnership before starting intercourse, although at least one group report that random and short-term relationships are common [5]. Unfortunately the published series are small and few of them address sexuality in a structured manner.

At Johns Hopkins the exstrophy database now has >1 200 patients and there is a programme for close and indefinite review. This is good for the patients and good for outcomes research. Sexual function has been investigated in 113 adult men (53% of those eligible) using a 42-question survey, which incorporated four validated instruments and additional questions related to sexuality [1].

In all, 85% had been sexually active at some time and 62% were currently in a relationship; three were homosexual and three bisexual. The divorce rate was lower than the norm in the USA! Amongst much other data, it was found that only 58% were moderately-to-very satisfied with their sex life. The mean penile perception score (PPS) was 6.2 (maximum possible 12) and most men were dissatisfied with their penile appearance to some degree. However, there was no relationship between the PPS and sexual activity or satisfaction. In all, 32 of 113 men had tried to achieve a pregnancy, of whom 72% were successful, with half of them requiring reproductive technology. Another 27% had a confirmed fertility problem.

With these new data, we can say that men born with exstrophy have a normal ambition for their sexual activity and form solid partnerships. Their overall level of satisfaction is lower than normal and the appearance of the penis is a major contributory cause. The fertility rate is significantly lower than normal. We still know nothing about the feelings of the partners.

Can anything be done to improve this situation? On the positive side, correction of the penile deformities, prompt management of urinary infections (to avoid epididymo-orchitis), and reproductive technology are helpful. It is most important not to damage the penis or its nerve supply during reconstructive surgery. At present, there are inadequate data to say whether the formation of a new phallus incorporating the native penis (similar to female–male gender reassignment) would generally be beneficial [6]. Psycho-sexual support is often recommended but the techniques used and outcomes rarely reported. However, paediatric and adolescent urologists have a vital role in discussing sexual function with their patients, encouraging ‘normality’ and providing practical help when possible.

Christopher R.J. Woodhouse

 

Emeritus Professor of Adolescent Urology, University College London, UK

 

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References

 

1 Baumgartner TS, Lue KM, Sirisreetreerux P et al. Long-term sexual health outcomes in men with classic bladder exstrophy. BJU Int 2 017; 120: 422– 7

 

2 Woodhouse CR, North A, Gearhart J. Standing the test of time: a long term outcome of reconstruction of the exstrophy bladder. World J Urol 2006; 24: 244–9

 

3 Castagnetti M, Tocco A, Rigamonti W, Artibani W. Sexual function in men born with classic bladder exstrophy: a norm related study. J Urol 2010; 183: 1118–22

 

4 Woodhouse CR. Exstrophy and epispadias. In Adolescent Urology and Long-Term Outcomes, Oxford: Wiley Blackwell: 2015, pp 128–53

 

5 Ben-Chaim J, Jeffs RD, Reiner WG, Gearhart JP. The outcome of patients with classic exstrophy in adult life. J Urol 1996; 155: 1251–2

 

6 Massanyi EZ, Gupta A, Goel S et al. Radial forearm free flap phalloplasty for penile inadequacy in patients with exstrophy. J Urol 2013; 190(Suppl.): 1577–82

 

Article of the Week: Sentinel node biopsy for prostate cancer: report from a consensus panel meeting

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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.

Sentinel node biopsy for prostate cancer: report from a consensus panel meeting

Henk G. van der Poel* , Esther M. Wit*, Cenk Acar†, Nynke S. van den Berg‡,Fijs W. B. van Leeuwen‡, Renato A. Valdes Olmos‡, Alexander Winter§,Friedhelm Wawroschek§, Fredrik Liedberg**, Steven Maclennan††and Thomas Lam†† On behalf of the Sentinel Node Prostate Cancer Consensus Panel Group members 

 

*Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands, †Department of Urology, Eryaman Hospital, Ankara, Turkey, ‡Department of Radiology, University of Leiden Medical Centre, Leiden, The Netherlands, §Klinikum Oldenburg, School of Medicine and Health Sciences, University Hospital for Urology, Oldenburg, Germany, Department of Urology, Skane University Hospital, Malmo, **Department of Translational Medicine Lund University, Lund, Sweden, and ††Academic Urology Unit, University of Aberdeen, Aberdeen, UK

 

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Abstract

Objective

To explore the evidence and knowledge gaps in sentinel node biopsy (SNB) in prostate cancer through a consensus panel of experts.

Methods

A two-round Delphi survey among experts was followed by a consensus panel meeting of 16 experts in February 2016. Agreement voting was performed using the research and development project/University of California, Los Angeles Appropriateness Methodology on 150 statements in nine domains. The disagreement index based on the interpercentile range, adjusted for symmetry score, was used to assess consensus and non-consensus among panel members.

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Results

Consensus was obtained on 91 of 150 statements (61%). The main outcomes were: (1) the results from an extended lymph node dissection (eLND) are still considered the ‘gold standard’, and sentinel node (SN) detection should be combined with eLND, at least in patients with intermediate- and high-risk prostate cancer; (2) the role of SN detection in low-risk prostate cancer is unclear; and (3) future studies should contain oncological endpoints as number of positive nodes outside the eLND template, false-negative and false-positive SN procedures, and recurrence-free survival. A high rate of consensus was obtained regarding outcome measures of future clinical trials on SNB (89%). Consensus on tracer technology was only obtained in 47% of statements, reflecting a need for further research and standardization in this area. The low-level evidence in the available literature and the composition of mainly SNB users in the panel constitute the major limitations of the study.

Conclusions

Consensus on a majority of elementary statements on SN detection in prostate cancer was obtained.; therefore, the results from this consensus report will provide a basis for the design of further studies in the field. A group of experts identified evidence and knowledge gaps on SN detection in prostate cancer and its application in daily practice. Information from the consensus statements can be used to direct further studies.

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Editorial: Sentinel nodes in prostate cancer– are we chasing a ghost?

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Van der Poel et al. [1] report the findings of a consensus panel meeting on sentinel node (SN) biopsy at the time of radical prostatectomy. The consensus process was based on a two-round Delphi survey on the current evidence and knowledge gaps on SN detection. Then, a number of experts among those who answered the survey were invited to further discuss these issues during a consensus meeting.

The authors are to be complimented on their effort to establish standard definitions, techniques, and reporting of outcomes of SN detection. Their results push the field forward and will make it possible to compare future data between institutions, individual surgeons, and techniques of SN detection. Nevertheless, although the authors admittedly represented a group of potentially biased experts, current limitations of SN detection were fairly acknowledged.

One thorny issue remains, the definition of SN and whether a true SN exists or not. The SN concept implies that one should reliably find tumour in the first echelon of drainage when tumour is present. The SN concept further assumes that if the SN is free of tumour, then so are the next drainage stations. Does that really happen in prostate cancer? We know from previous mapping studies that primary lymphatic landing sites of the prostate are heterogeneously localised, that drainage varies from site to site of tracer injection (and thus tumour location), and that drainage varies from patient to patient [2, 3]. Thus, prostate cancer does not fit the Halstedian paradigm of a pre-defined, stepwise, uniform pathway of metastatic spread. An additional setback of SN detection is that lymph nodes that contain a large tumour burden often fail to take up the tracer [2, 4]. One might critically argue that this limitation may be dependent on the tracer used. The consensus group could not conclusively agree on which tracer technology to use. Looking forward, imaging probes that target tumour-specific molecules may improve tumour detection during pelvic lymph node dissection (PLND). The prostate-specific membrane antigen (PSMA) represents a particularly promising marker in prostate cancer imaging. However, using 68Ga-PSMA-positron emission tomography/CT for the detection of lymph node metastases before radical prostatectomy, one group failed to observe the expected improvement and reported only 33% sensitivity [5]. Future studies will determine whether these advances in prostate cancer detection will translate into more precise targeted dissection of lymph node metastases.

Altogether, the consensus group concluded that extended PLND should remain the standard of care, at least in patients with intermediate- and high-risk prostate cancer. This conclusion is laudable, but to be fair, we have no level 1 evidence for this either. However, every oncology-oriented surgeon would agree that each potential positive lymph node should be found and removed during surgery with curative intent. In case of true low-risk prostate cancer, this is probably less of an issue, but it should be mentioned that this population is at very low risk of dying from prostate cancer, even if left untreated, and the indication for radical prostatectomy should be questioned rather than that for PLND. Furthermore, pathological Gleason score is underestimated in preoperative biopsies in ~30% of all cases [6], making the decision to perform PLND or not in low-risk disease difficult.

Again, the authors should be complimented for their thorough work. We still do not know whether the SN exists, but performing surgery with image-guidance provides quality control for completeness of resection and might help detect (positive?) lymph nodes outside of the extended PLND template. Indeed, up to 35% of prostate lymphatic drainage sites may remain outside the extended anatomical template [3]. SN detection might also teach us when and where to stop dissection to decrease potential morbidity of PLND without leaving tumour behind. Thus, chasing the ghost of the SN has made and makes us better and more meticulous cancer surgeons. At the same time, it is humbling that we have been chasing a ghost for so long without bringing up level 1 evidence.

George N. Thalmann and Daniel P. Nguyen

 

Department of Urology, University Hospital Bern, Bern, Switzerland

 

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References

1 van der Poel HG, Wit EM, Acar C et al. Sentinel node biopsy for prostate cancer: report from a consensus panel meeting. BJU Int 2017; 120: 204–11

2 Nguyen DP, Huber PM, Metzger TA, Genitsch V, Schudel HH, Thalmann GN. A specific mapping study using fluorescence sentinel lymph node detection in patients with intermediate- and high-risk prostate cancer undergoing extended pelvic lymph node dissection. Eur Urol 2016; 70: 734–7

 

3 Mattei A, Fuechsel FG, Bhatta Dhar N et al. The template of the primary lymphatic landing sites of the prostate should be revisited: results of a multimodality mapping study. Eur Urol 2008; 53: 118–25

 

4 Weckermann D, Dorn R, Holl G, Wagner T, Harzmann R. Limitations of radioguided surgery in high-risk prostate cancer. Eur Urol 2007; 51: 1549–58

 

5 Budaus L, Leyh-Bannurah SR, Salomon G et al. Initial experience of 68Ga-PSMA PET/CT imaging in high-risk prostate cancer patients prior to radical prostatectomy. Eur Urol 2015; 69: 4–7

 

6 Moussa AS, Kattan MW, Berglund R, Yu C, Fareed K, Jones JS.A nomogram for predicting upgrading in patients with low- and intermediate-grade prostate cancer in the era of extended prostate sampling. BJU Int 2010; 105: 352–8

 

Article of the Week: Impact of 68Ga-PSMA PET/CT in PCa with rising PSA

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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.

Clinical impact of 68Ga-prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) in patients with prostate cancer with rising prostate-specific antigen after treatment with curative intent: preliminary analysis of a multidisciplinary approach

 

Simone Albisinni*, Carlos Artigas†, Fouad Aoun*, Ibrahim Biaou*, Julien Grosman*, Thierry Gil‡, Eric Hawaux*, Ksenija Limani*, Francois-Xavier Otte§, Alexandre Peltier*, Spyridon Sideris‡, Nicolas Sirtaine, Patrick Flamen† and Roland van Velthoven*

 

Departments of *Urology, †Nuclear Medicine, ‡Oncology, §Radiation Oncology, and Pathology, Institut Jules Bordet, Universite Libre de Bruxelles, Brussels, Belgium

 

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How to Cite

Albisinni, S., Artigas, C., Aoun, F., Biaou, I., Grosman, J., Gil, T., Hawaux, E., Limani, K., Otte, F.-X., Peltier, A., Sideris, S., Sirtaine, N., Flamen, P. and van Velthoven, R. (2017), Clinical impact of 68Ga-prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) in patients with prostate cancer with rising prostate-specific antigen after treatment with curative intent: preliminary analysis of a multidisciplinary approach. BJU International, 120: 197–203. doi: 10.1111/bju.13739

Abstract

Objective

To assess the impact of a novel molecular imaging technique, 68Ga-(HBED-CC)-prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT), in the clinical management of patients with prostate cancer with rising prostate-specific antigen (PSA) after treatment with curative intent.

Patients and Methods

In all, 131 consecutive patients were referred to our centre for a 68Ga-PSMA PET/CT in the setting of recurring prostate cancer. Of these patients, 11/131(8%) presented with persistent PSA after radical prostatectomy, while 120/131 (92%) were referred for biochemical recurrence after surgery, radiotherapy or both. The images where taken 1 h after injection of 2 MBq/kg of the 68Ga-(HBED-CC)-PSMA ligand. All examinations were interpreted by two experienced nuclear medicine specialists. Using the results of the examination, a multidisciplinary oncology committee (MOC) reported on the treatment strategy. A positive impact on clinical management was considered if the examination determined a modification in the treatment strategy compared to the MOC decision before PSMA imaging.

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Results

All patients completed the examination with no adverse reactions. The median (interquartile range) PSA level at the time of the examination was 2.2 (0.72–6.7) ng/mL. Overall, 68Ga-PSMA PET/CT detected at least one lesion suspicious for prostate cancer in 98/131 (75%) patients. There was an impact on subsequent management in 99/131 patients (76%). The main modifications included continuing surveillance (withholding hormonal therapy), hormonal manipulations, stereotaxic radiotherapy, salvage radiotherapy, salvage node dissection or salvage local treatment (prostatectomy, high-intensity focussed ultrasound).

Conclusion

Our preliminary experience suggests that performing 68Ga-PSMA PET/CT in patients with prostate cancer with rising PSA after treatment with curative intent can be clinically useful as it changes the treatment strategy in a significant proportion of patients. However, larger prospective trials are needed to validate our present findings.

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Editorial: Defining the clinical utility of PSMA-targeted PET imaging of prostate cancer

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In the field of oncology, positron emission tomography (PET) is most commonly performed using 2-deoxy-2-[18F]fluoro-d-glucose (18F-FDG), a radiofluorinated glucose analogue that accumulates in cells undergoing aerobic glycolysis. Unfortunately, because of the low glycolytic activity of hormone-naïve prostate cancer cells, 18F-FDG PET has been of little value in imaging men with this malignancy [1]. Instead, clinicians have been left to rely mostly on 99mTc-methylene diphosphonate bone scan, CT, and MRI to stage and follow patients. Recently, however, the development of multiple urea-based small molecules targeting the type II transmembrane glycoprotein prostate-specific membrane antigen (PSMA) has allowed for the highly sensitive and specific detection of prostate cancer using PET imaging [2]. To date, the majority of clinical data with PSMA-targeted PET have been generated with the 68Ga-PSMA-11 radiotracer (also known as 68Ga-PSMA-HBED-CC). Notably, studies evaluating PSMA-targeted PET have mostly focused on establishing the diagnostic performance characteristics of the various radiotracers (e.g. sensitivity and specificity), with relatively few reports exploring the clinical impact or utility of this form of molecular imaging.

In this month’s edition of BJUI, Albisinni et al. [3] aimed to look beyond the performance characteristics of 68Ga-PSMA-11 PET/CT and retrospectively analysed the impact of this imaging test on the management of 131 men with a persistently elevated PSA level or biochemical recurrence after local treatment of their prostate cancer with curative intent. Of these patients, 106 (81%) had undergone a previous radical prostatectomy. The authors defined clinical utility as any imaging finding (or lack thereof) leading to a change in a patient’s pre-PET treatment plan. In total, 68Ga-PSMA-11 PET/CT demonstrated clinical utility in 76% of imaged patients. Most commonly, the results of this imaging test led to avoidance of androgen deprivation therapy (44% of all patients imaged) in place of an alternative management strategy, such as surveillance or salvage radiation therapy. Another notable finding was that among men who had planned to undergo salvage radiation therapy prior to 68Ga-PSMA-11 PET/CT, the majority (19 of 32 [59%]) were managed with an alternative approach after undergoing imaging.

Albisinni et al. [3] are not alone in their observations regarding the high clinical utility of 68Ga-PSMA-11 PET. For example, van Leeuwen et al. [4] previously reported that nearly 30% of men who were felt to be candidates for post-prostatectomy salvage radiation therapy had findings on 68Ga-PSMA-11 PET/CT that led to a major change in management. Additionally, Sterzing et al. [5] found that approximately 50% of patients undergoing radiation therapy planning for primary or recurrent prostate cancer experienced a change to their treatment concept after imaging with 68Ga-PSMA-11 PET/CT. Combined, these data suggest that a substantial proportion of men with prostate cancer stand to have their management altered by undergoing PSMA-targeted PET imaging.

While encouraging, the study by Albisinni et al. is somewhat limited by its retrospective design [3]. An outstanding example of how data on the clinical utility of an imaging test can be prospectively collected comes to us from the National Oncology PET Registry (NOPR) in the USA. Working in collaboration with the Centers for Medicare and Medicaid Services (CMS), NOPR was established to assess the question of clinical utility related to 18F-FDG PET/CT. To measure clinical utility, NOPR required physicians to complete questionnaires assessing the indication for imaging as well as pre- and post-PET treatment plans. In a 2008 study from NOPR incorporating data from 40 863 18F-FDG studies performed at 1368 centres, it was reported that 38% of patients experienced a change in intended management as a result of this imaging test [6]. In light of these and other data from NOPR, 18F-FDG PET/CT is now widely used across a range of tumour histologies. Moreover, this imaging study is readily reimbursed by both the CMS and private insurers.

In summary, we are delighted by the results of Albisinni et al. [3] and look forward to other prospective studies (for example ClinicalTrials.gov identifier NCT02825875) that aim to define the clinical utility of PSMA-targeted PET imaging of prostate cancer.

Michael A. Gorin,* Martin G. Pomper, †Kenneth J. Pienta* and Steven P. Rowe†

 

*The James Buchanan Brady Urological Institute and Department of Urology, and †Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA

 

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References

 

1 Gorin MA, Rowe SP, Denmeade SR. Clinical applications of molecular imaging in the management of prostate cancer. PET Clin 2017; doi: 10.1016/j.cpet.2016.11.001
2 Rowe SP, Gorin MA, Allaf ME et al. PET imaging of prostate-specific membrane antigen in prostate cancer: current state of the art and future challenges. Prostate Cancer Prostatic Dis 2016; 19: 223–30

 

3 Albisinni S, Artigas C, Aoun F et al. Clinical impact of 68Ga-prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) in patients with prostate cancer with rising prostate-specific antigen after treatment with curative intent:preliminary analysis of a multidisciplinary approach. BJU Int 2017; 120: 197–203

 

4 van Leeuwen PJ, Stricker P, Hruby G et al. 68Ga-PSMA has a high detection rate of prostate cancer recurrence outside the prostatic fossa in patients being considered for salvage radiation treatment. BJU Int 2016; 117: 732–9

 

5 Sterzing F, Kratochwil C, Fiedler H et al. 68Ga-PSMA-11 PET/CT: a new technique with high potential for the radiotherapeutic management of prostate cancer patients. Eur J Nucl Med Mol Imaging 2016; 43: 34–41

 

6 Hillner BE, Siegel BA, Shields AF et al. Relationship between cancer type and impact of PET and PET/CT on intended management: findings of the national oncologic PET registry. J Nucl Med 2008; 49: 1928–35

 

Article of the Week: Introduction of RARC within an established enhanced recovery programme

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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.

Introduction of robot-assisted radical cystectomy within an established enhanced recovery programme

Catherine Miller*,†, Nicholas J. Campain†, Rachel Dbeis†, Mark Daugherty†, Nicholas Batchelor†, Elizabeth Waine† and John S. McGrath†

 

*Urology Department, Torbay Hospital, Torquay, and †Exeter Surgical Health Services Research Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK

 

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How to Cite

Miller, C., Campain, N. J., Dbeis, R., Daugherty, M., Batchelor, N., Waine, E. and McGrath, J. S. (2017), Introduction of robot-assisted radical cystectomy within an established enhanced recovery programme. BJU International, 120: 265–272. doi: 10.1111/bju.13702

Abstract

Objectives

To describe the implementation phase of a robot-assisted radical cystectomy (RARC) programme including side-effect profiles and impact on length of stay (LOS).

Patients and Methods

In all, 114 consecutive patients (82% male) underwent RARC and urinary diversion between April 2013 and December 2015 [ileal conduit (97 patients) and orthotopic neobladder (17)]. Surgery was performed by two surgeons within a designated regional cancer centre. No exclusion criteria were applied. All patients were managed on the Exeter Enhanced Recovery Pathway (ERP) in a unit where embedded enhanced recovery practice was already established. Data were collected prospectively on the national cystectomy registry – the British Association of Urological Surgeons (BAUS) Complex Operations Dataset.

aotw-aug-2017-2

Results

RARC was technically feasible in all but one case. The mean operating time was 3–5 h with an overall transfusion rate of 8.8%. There were higher-grade complications (Clavien–Dindo grade III–IV) in 18.4% of patients, with a 30-day mortality rate of 0.9%. The median (range) LOS after RARC was 7 (3–68) days, with a re-admission rate of 18.4%.

Conclusions

The present series shows that RARC can be safely implemented in a unit experienced in robot-assisted surgery (RAS). Case-selection in this setting is not deemed necessary. There are benefits in terms of lower transfusion rates and reduced LOS. The side-effect profile appears to differ from that of open RC, and despite the fact that complication rate is equivalent; ‘technical’ complications are over-represented in the RAS group. As such, they should improve with experience, recognition, and modification of surgical technique. ERPs can be safely applied to all patients undergoing RARC to maximise the benefits of minimally invasive surgery.

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Editorial: Speeding up recovery from radical cystectomy: how low can we go?

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Radical cystectomy (RC) is the ‘gold standard’ treatment for muscle-invasive bladder cancer (BCa) [1]. It offers the best chance of cure in patients with curable disease and excellent palliation in those with local symptoms from advanced disease. Longitudinal reports suggest many patients accept and adapt to the impact of RC, leading to minimal overall impact on their quality of life [2]. As such, RC also offers a viable alternative to BCG for patients with high-risk non-muscle-invasive BCa. Whilst I recognize the vital role that chemotherapy and radiotherapy play in treating this disease, and that radiotherapy may be a better choice for some patients than RC, it is the morbidity from RC that hinders its wider use and encourages alternatives [3]. For example, studies in the USA show that up to one-third of patients with muscle-invasive cancers do not receive radical treatment [4], and implementation of centralized cancer services in the UK has only now shown survival improvements, as morbidity from RC comes down [5]. The lowering of peri-operative morbidity and mortality from RC is changing the face of the operation and increasing its use.

In this month’s issue of BJUI, Miller et al. [6] combine robot-assisted minimal access surgery with enhanced recovery to report outcomes in a consecutive series of ‘state-of-the-art’ RCs in their study from Exeter, UK. The authors show consistent improvements in outcome, such that length of stay halved over the duration of study recruitment. Importantly, recovery becomes more predictable (as shown by the converging mean and median length of stay figures), although it is unclear as to how many patients had prolonged stays. Whilst the authors should be congratulated for their efforts in delivering this service and for charting its implementation so meticulously, some key descriptive findings are missing. For example, what is the extent of the variation in their outcomes (range and quartiles) and do the data differ among surgeons? What happened to the 25% of patients who stayed longer than 10 days? Did all patients receive all components of their enhanced recovery programme, and if not, which were the most impactful? How did length of stay and complication rates differ by reconstructive choice and reconstructive location (intra- or extracorporeal)? Did patient selection stay the same over time, or did improved outcomes lower the ‘fit for cystectomy’ bar? Many of these answers will be missing, given that the primary source of information was the BAUS major operations registry. This self-completed dataset is extremely valuable for comparisons between units and trends over times, but has limited data complexity and granularity. Finally, whilst the field is moving towards total intracorporeal surgery, the reported complication rates appear similar for extra- and intracorporeal reconstruction, questioning the need for the added complexity of intracorporeal surgery.

Economists, commissioners and patients will want to know the importance of the forces driving these improved outcomes. Do the better outcomes reflect centralization of services, the team’s learning curve, the meticulous use of enhanced recovery or minimally invasive surgery through robotics? The latter has vastly different cost implications from the others. My guess is that, whilst all of these aspects were important, it was volume of service (from centralization) and enhanced recovery that were the main contributors. I speak having had a similar experience in my unit, although we started robotic surgery at a later date than did the present authors, and in the knowledge that this group previously published the dramatic impact of enhanced recovery on their length of stays after open RC [7].

Regardless of these concerns, the outcomes are to be welcomed by urologists and patients, and the team should be congratulated. As length of hospital stay becomes shorter, our next scientific focus should be on out-of-hospital recovery. We rarely see data on time taken to return to normal activity and on how patients adjust after surgery. Whilst return to work is important for younger patients, many patients with bladder cancer are retired so for these patients it is return to quality of life that matters most. This question becomes even more important in an era of centralized care, where many patients recover away from their surgical teams and, conversely, surgical teams are less aware of problems and outcomes. Perhaps it will be out of the hospital that the effort and cost of minimally invasive surgery are justified.

James W.F. Catto
Academic Urology Unit, University of Sheffield, Sheffield, UK

 

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References

 

1 Witjes JA, Comperat E, Cowan NC et al. EAU guidelines on muscle- invasive and metastatic bladder cancer: summary of the 2013 guidelines. Eur Urol 2014; 65: 778–92

 

2 Hardt J, Filipas D, Hohenfellner R, Egle UT. Quality of life in patients with bladder carcinoma after cystectomy: first results of a prospective study. Qual Life Res 2000; 9: 1–12

 

3 Shabsigh A, Korets R, Vora KC et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009; 55: 164–74

 

4 Gore JL, Litwin MS, Lai J et al. Use of radical cystectomy for patients with invasive bladder cancer. J Natl Cancer Inst 2010; 102: 802–11

 

5 Hounsome LS, Verne J, McGrath JS, Gillatt DA. Trends in operative caseload and mortality rates after radical cystectomy for bladder cancer in England for 1998–2010. Eur Urol 2015; 67: 1056–62

 

6 Miller C, Campain NJ, Dbeis R et al. Introduction of robot-assisted radical cystectomy within an established enhanced recovery programme. BJU Int 2017; 120: 265–72

 

7 Smith J, Pruthi RS, McGrath J. Enhanced recovery programmes for patients undergoing radical cystectomy. Nat Rev Urol 2014; 11: 437–4

 

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