Morlacco, Alessandro

Radical prostatectomy is widely used as the primary modality of treatment for clinically localised prostate cancer. A considerable proportion of men will have adverse histopathologic features and could benefit from adjunctive treatments: mainly adjuvant or salvage radiation. This review focusses on the still unanswered questions: How to manage the patient after radical prostatectomy? Which patients need further treatment and which ones will not progress if not treated? How to refine patients selection for further treatments? What is the role for clinical nomograms and biomarkers and which ones are validated? When is it wise to propose adjuvant radiation therapy (RT) instead of observation with or without salvage RT? What is the optimal timing for the use of salvage RT and how to choose patients for each approach? This article discusses the evidence available in the current literature, providing a critical analysis of the controversies of each strategy.

Purpose: Pelvic lymph node dissection is an important step during robotic radical prostatectomy. The collection of lymphatic fluid (lymphocele) is the most common complication with potentially severe impact; therefore, different strategies have been proposed to reduce its incidence. Materials and Methods: In this systematic review, EMBASE, MEDLINE, Cochrane Library, and NIH Registry of Clinical Trials were searched for articles including the following interventions: transperitoneal vs extraperitoneal approach, any reconfiguration of the peritoneum, the use of pelvic drains, and the use of different sealing techniques and sealing agents. The outcome evaluated was the incidence of symptomatic lymphocele. Randomized, nonrandomized, and/or retrospective studies were included. Results: Twelve studies were included (including one ongoing randomized clinical trial). Because of heterogeneity of included studies, no meta-analysis was performed. No significant impact was reported by different sealing techniques and agents or by surgical approach. Three retrospective, nonrandomized studies showed a potential benefit of peritoneal reconfiguration to maximize the peritoneal surface of reabsorption. Conclusion: Lymphocele formation is a multistep and multifactorial event; high-quality literature analyzing risk factors and preventive measures is rather scarce. Peritoneal reconfiguration could represent a reasonable option that deserves further evaluation; no other preventive measure is supported by current evidence.

AbstractBackgroundMetabolic syndrome (MetS) has a negative impact on functional recovery and complications after many surgical procedures.AimTo assess the role of Mets on functional outcomes and complications after radical prostatectomy (RP) for prostate cancer.Patients and MethodsComplete data were collected from 5758 patients, undergoing RP at a single referral centers in a 10‐year period and the presence of MetS before surgery was ascertained in 17.7% of them using a modified version of the IDF‐AHA/NHLBI criteria. Outcomes included 1‐year continence and potency rates, early (≤90 days) and late (>90 days) complications.ResultsPostoperative continence (no pads) was significantly less likely in MetS patients (75.4% vs 82.6%, P < .01), despite no difference in preoperative continence. Erections with or without therapy were reached in 55.8% of non‐MetS and 41.8% of MetS patients (P < .01), in this case a significant difference in preoperative function was seen. No differences in early and late complications, except for wound infections (5.8% vs 3.9%, P < .01) were observed.ConclusionsIn the present study RP was safe from the complications standpoint in MetS patients, but the presence of the syndrome was a significant risk factor for post‐RP incontinence and impotence.

Objectives To identify which patients with macroscopic bladder‐infiltrating T4 prostate cancer ( PC a) might have favourable outcomes when treated with radical cystectomy ( RC ). Materials and Methods We evaluated 62 patients with cT 4cN0–1 cM0 PC a treated with RC and pelvic lymph node dissection between 1972 and 2011. In addition to descriptive statistics, the Kaplan–Meier method and log‐rank tests were used to depict survival rates. Univariate and multivariate Cox regression analysis tested the association between predictors and progression‐free, PC a‐specific and overall survival. Results Of the 62 patients, 19 (30.6%) did not have clinical progression during follow‐up, two (3.2%) had local recurrence, and 32 (51.6%) had haematogenous and nine (14.5%) combined pelvic and distant metastasis. Forty patients (64.5%) died, 34 (54.8%) from PC a and six (9.7%) from other causes. The median (range) survival time of the 19 patients who were metastasis‐free at last follow‐up was 86 (1–314) months, 8/19 patients had a follow‐up of >5 years, and five patients survived metastasis‐free for >15 years. Patients without seminal vesicle invasion ( SVI ) had the best outcomes, with an estimated 10‐year PC a‐specific survival of 75% compared with 24% for patients with SVI . Conclusion For cT 4 PC a RC can be an appropriate treatment for local control and part of a multimodality‐treatment approach. Although recurrences are probable, these do not necessarily translate into cancer‐specific death. Men without SVI had a 75% 10‐year PC a‐specific survival. Although outcomes for patients with SVI are not as favourable, there can be good local control; however, these patients are at higher risk of progression and may need more aggressive systemic treatment.