Nerve Sparing during Robot-Assisted Radical Prostatectomy Increases the Risk of Ipsilateral Positive Surgical Margins.


  • 影响因子:1.46
  • DOI:10.1097/JU.0000000000000760
  • 作者列表:"Soeterik TFW","van Melick HHE","Dijksman LM","Stomps S","Witjes JA","van Basten JPA
  • 发表时间:2020-07-01

PURPOSE:Available published studies evaluating the association between nerve sparing robot-assisted radical prostatectomy and risk of ipsilateral positive surgical margins were subject to selection bias. In this study we overcome these limitations by using multivariable regression analysis. MATERIALS AND METHODS:Patients undergoing robot-assisted radical prostatectomy for prostate cancer at 4 institutions from 2013 to 2018 were included in the study. A multilevel logistic random intercept model, including covariates on patient level and side specific factors on prostate lobe level, was used to evaluate the association between nerve sparing and risk of ipsilateral positive margins. RESULTS:A total of 5,148 prostate lobes derived from 2,574 patients who underwent robot-assisted radical prostatectomy were analyzed. Multivariable analysis showed nerve sparing was an independent predictor for ipsilateral positive margins (OR 1.42, 95% CI 1.14-1.82). Other significant predictors for positive margins were prostate specific antigen density (OR 3.64, 95% CI 2.36-5.90) and side specific covariates including highest preoperative ISUP (International Society of Urological Pathology) biopsy grade (OR 1.58, 95% CI 1.13-2.53; OR 1.62, 95% CI 1.13-2.69; OR 2.11, 95% CI 1.39-3.59 and OR 4.43, 95% CI 3.17-10.12 for ISUP grade 2, 3, 4 and 5, respectively), presence of extraprostatic extension on magnetic resonance imaging (OR 1.42, 95% CI 1.03-1.91) and percentage of positive cores on systematic biopsy (OR 3.82, 95% CI 2.50-5.86). CONCLUSIONS:Nerve sparing was associated with an increased risk of ipsilateral positive surgical margins. The increased risk of positive margins should be considered when counseling patients who opt for nerve sparing robot-assisted radical prostatectomy.


目的: 现有已发表的评估保留神经的机器人辅助根治性前列腺切除术与同侧阳性手术切缘风险之间相关性的研究受到选择偏倚的影响。在这项研究中,我们通过使用多变量回归分析克服了这些限制。 材料和方法: 研究纳入2013年至2018年在4家机构接受机器人辅助前列腺癌根治术的患者。采用多水平logistic随机截距模型,包括患者水平的协变量和前列腺叶水平的侧面特定因素,评估神经保留与同侧阳性边缘风险之间的关联。 结果: 共分析了5,148例机器人辅助根治性前列腺切除术患者的2,574个前列腺叶。多变量分析显示,神经保留是同侧切缘阳性的独立预测因子 (OR 1.42,95% CI 1.14-1.82)。阳性切缘的其他重要预测因子是前列腺特异性抗原密度 (OR 3.64,95% CI 2.36-5.90) 和侧面特异性协变量,包括最高的术前ISUP (国际泌尿病理学会) 活检分级 (OR 1.58,95% CI 1.13-2.53; OR 1.62,95% CI 1.13-2.69; OR 2.11,95% CI 1.39-3.59和OR 4.43,95% CI 3.17-10.12分别为ISUP 2级、3级、4级和5级),在磁共振成像中存在前列腺外延伸 (OR 1.42,95% CI 1.03-1.91) 和系统活检中阳性核心的百分比 (OR 3.82,95% CI 2.50-5.86)。 结论: 保留神经与同侧阳性手术切缘的风险增加相关。在咨询选择保留神经的机器人辅助根治性前列腺切除术的患者时,应考虑阳性切缘的风险增加。



作者列表:["Hunt JA","Heydenburg M","Kelly CK","Anderson SL","Dascanio JJ"]

METHODS::Veterinary educators use models to allow repetitive practice of surgical skills leading to clinical competence. Canine castration is a commonly performed procedure that is considered a Day One competency for a veterinarian. In this study, we sought to create and evaluate a canine pre-scrotal closed castration model and grading rubric using a validation framework of content evidence, internal structure evidence, and relationship with other variables. Veterinarians (n = 8) and students (n = 32) were recorded while they performed a castration on the model and provided survey feedback. A subset of the students (n = 7) then performed a live canine castration, and their scores were compared with their model scores. One hundred percent of the veterinarians and 91% of the students reported that the model was helpful in training for canine castration. They highlighted several areas for continued improvement. Veterinarians' model performance scores were significantly higher than students', indicating that the model had adequate features to differentiate expert from novice performance. Students' performance on the model strongly correlated with their performance of live castration (r = .82). Surgical time was also strongly correlated (r = .70). The internal consistency of model and live rubric scores were good at .85 and .94, respectively. The framework supported validation of the model and rubric. The canine castration model facilitated cost-efficient practice in a safe environment in which students received instructor feedback and learned through experience without the risk of negatively affecting a patient's well-being. The strong correlation between model and live animal performance scores suggests that the model could be useful for mastery learning.

作者列表:["Renninger M","Fahmy O","Schubert T","Schmid MA","Hassan F","Stenzl A","Gakis G"]

METHODS:PURPOSE:To investigate whether hexaminolevulinate-based (HAL) bladder tumor resection (TURBT) impacts on outcomes of patients with primary non-muscle-invasive bladder cancer (NMIBC) who were eventually treated with radical cystectomy (RC). METHODS:A total of 131 consecutive patients exhibiting NMIBC at primary diagnosis were retrospectively investigated whether they had undergone any HAL-guided TURBT prior to RC. Uni- and multivariable analyses were used to evaluate the impact of HAL-TURBT on cancer-specific (CSS) and overall survival (OS). The median follow-up was 38 months (IQR 13-56). RESULTS:Of the 131 patients, 69 (52.7%) were managed with HAL- and 62 (47.3%) with white light (WL)-TURBT only prior to RC. HAL-TURBT was associated with a higher number of TURBTs prior to RC (p = 0.002) and administration of intravesical chemotherapy (p = 0.043). A trend towards a higher rate of tumor-associated immune cell infiltrates in RC specimens (p = 0.07) and a lower utilization rate of post-operative systemic chemotherapy (p = 0.10) was noted for patients who were treated with HAL-TURBT. The 5-year CSS/OS was 90.9%/74.5% for the HAL-group and 73.8%/55.8% for the WL-group (p = 0.042/0.038). In multivariable analysis, lymph node tumor involvement (p = 0.007), positive surgical margins (p = 0.001) and performance of WL-TURBT only (p = 0.040) were independent predictors for cancer-specific death. CONCLUSIONS:The present data suggest that the resection of NMIBC under HAL exerts a beneficial impact on outcomes of patients who will need to undergo RC during their course of disease. This finding may be due to improved risk stratification as the resection under HAL may allow more patients to be treated timely and adequately.

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来源期刊:The Journal of urology
作者列表:["Alder R","Zetner D","Rosenberg J"]

METHODS:PURPOSE:To investigate the incidence of inguinal hernia following radical prostatectomy we compared the incidence after open retropubic radical prostatectomy with the incidence after the laparoscopic and robot-assisted radical prostatectomies, and using control groups. MATERIALS AND METHODS:We included all original articles on studies providing data on inguinal hernia incidence in patients treated with radical prostatectomy for localized prostate cancer. PubMed® and EMBASE® were searched on February 28, 2018. A meta-analysis was done as a weighted and pooled estimate of the incidence of inguinal hernia. The bias risk was assessed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane Collaboration tool for randomized clinical trials. RESULTS:We included 54 studies with a total of 101,687 patients. The estimated incidence of inguinal hernia was 13.7% (95% CI 12.0-15.4) after open retropubic radical prostatectomy, 7.5% (95% CI 5.2-9.8) after laparoscopic radical prostatectomy and 7.9% (95% CI 5.0-10.9) after robot-assisted laparoscopic radical prostatectomy. In studies comparing the incidence of inguinal hernia after open prostatectomy vs no treatment the incidence was significantly higher in the radical prostatectomy group (11.7%, 95% CI 9.2-14.2 vs 3.3%, 95% CI 2.0-4.6). Two of 3 studies showed a significantly higher incidence after laparoscopic and robot-assisted radical prostatectomies compared with a control group. Most studies of intraoperative inguinal hernia prevention techniques demonstrated a significantly lower inguinal hernia incidence in the experimental group. Inguinal hernias that developed after radical prostatectomy were primarily indirect (81.9%, 95% CI 75.3-88.4). CONCLUSIONS:We found a high incidence of inguinal hernia following radical prostatectomy and hernias were primarily of the indirect type. The highest incidence of inguinal hernia was noted after open radical prostatectomy, followed by laparoscopic and robot-assisted radical prostatectomies. There was no significant difference between the laparoscopic and robot-assisted groups. The incidence of inguinal hernia was significantly higher after open radical prostatectomy than in control groups with some evidence to support the same finding for the laparoscopic and robot-assisted approaches. Promising results have been reported in studies of intraoperative prophylactic surgical techniques to reduce the postoperative incidence of inguinal hernia.

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