1. New perioperative risk factors for biochemical recurrence after robotic assisted radical prostatectomy: A single surgeon experience in high volume Canadian center
Emad Rajih1,2, Malek Meskawi1, Abdullah M. Alenizi1, Kevin C. Zorn1, Assaad El-Hakim1
1Division of Robotic Urology, Hôpital du Sacré Cœur de Montréal, University of Montreal, Montreal, Quebec, Canada.
2Urology department, Taibah University, Madinah, Saudi Arabia
All authors confirm no conflicts of interest
RESULTS
INTRODUCTION
Covariates
No BCR
n=273
+ve BCR
n=53
p-value
Multivariate analysis
RR (CI 95%; p-value)
Mean (median) or number of patients (%)
Age (year)
60.8 (61)
60.1 (61)
0.65 -
BMI
28 (26.8)
28.1 (26.2)
0.97
Prostate size
49.5 (47)
48 (44)
0.17
PSA (ng/ml)
6.54 (5.5)
8.9 (6.9)
0.003
1.16 ( ); 0.17
PSAD
0.14 (0.11)
0.2 (0.14)
0.006
0.008(0-19.1); 0.17
Grade 6
3+4
4+3
 8
46 (90.2%)
183 (89.7%)
17 (60.7%)
27 (62.8%)
5 (9.8%)
21 (10.3%)
11 (39.3%)
16 (37.2%)
0.0001
Reference
0.5 ( ); 0.30
3.1 ( ); 0.12
1.76 ( ); 0.49
Pathological stage
T2a-b
T2c
T3a
T3b-T4
65 (89%)
151 (88.3%)
48 (76.2%)
9 (47.4%)
8 (11%)
20 (11.7%)
15 (23.8%)
10 (52.6%)
0.7( ); 0.64
1.59 ( ); 0.48
1.15 ( ); 0.87
Prop Positive cores
3.9 (4)
4.4 (4)
0.96( ); 0.78
Surgical margin
-ve SM
+ve SM
222 (90.2%)
51 (63.7%)
24 (9.8%)
29 (36.3%)
5.1 ( );
% Biopsy tumor volume
34.3 (33.3)
40.1 (41.6)
0.06
1.01( );0.38
Statin use No
Yes
180 (90.2%)
93 (84.5%)
36 (16.7%)
17 (15.5%)
0.77
Covariates
No BCR
n=273
+ve BCR
n=53
p-value
Multivariate analysis
RR (CI 95%; p-value)
Mean (median) or number of patients (%)
Year of Surgery
2006 – 2010
2011 – 2015
118 (78.1%)
155 (88.6%)
33 (21,9%)
20 (11.4%)
0.01
1 ( ); 0.01
Operative time (min)
208.2 (200)
249 (226)
0.0001
1 (1-1.02); 0.04
Blood loss (ml)
326 (300)
340 (300)
0.61
0.9 ( ); 0.29
NVB release time (min)
43 (41)
52 (50)
0.001 -
Apical resection time (min)
10 (0.11)
14 (0.14)
0.006
0.9 ( ); 0.71
NVB preservation No
Unilateral
Bilateral
49 (80.3%)
95 (84.1%)
129 (84.9%)
12 (19.7%)
18 (15.9%)
23 (15.1%)
0.77
Reference
0.96 ( ); 0.95
1.15( ); 0.81
Compromised pelvis
Yes
219 (85.2%)
54 (78.3%)
38 (14.8%)
15 (21.7%)
0.16
Capulotomy
202 (84.2%)
71 (82.6%)
38 (15.8%)
15 (21.4%)
0.72
Overall difficulty
Easy
Mixed
difficult
115 (87.1%)
71 (80.7%)
87 (82.1%)
17 (12.9%)
17 (19.3%)
19 (17.9%
0.38
Biochemical recurrence (BCR) is observed in up to 35% of patients following radical prostatectomy.1
These patients will require further treatments. Hence, it is essential to predict recurrence for accurate prognostication and for treatment purposes.
OBJECTIVE
To identify and assess new predictive factors for BCR in patients undergoing robotic assisted radical prostatectomy (RARP) in a Canadian cohort.
METHODOLOGY
Data was collected prospectively on 326 patients.
All patients were operated by a single surgeon (AEH) between
Minimum follow up was 2 years.
None of the patients had neo-adjuvant therapy.
Variables analyzed included age, body mass index (BMI), year of surgery, statin use, oncological parameters, prostate volume, operative time, estimated blood loss, number of neurovascular bundles (NVB) preservation, NVB preservation time, apical dissection time, presence of capsulotomy, and difficult pelvis anatomy (narrow and deep).
BCR was defined as PSA >0.2 ng/ml, or patients who received adjuvant or salvage radiotherapy, and/or hormonal deprivation therapy.
Univariate and multivariate logistic regression analysis were performed to identify perioperative factors associated independently with BCR. [Tables 1 and 2]
Kaplan Meier curves and Log Rank test were used to assess the risk of BCR in negative versus positive SM groups. [ Fig. 1]
Table 1. Baseline characteristics.
Table 2. Perioperative predictive factors.
Figure 2. Positive surgical margin locations and risk of BCR.
Figure 1. Kaplan Meier shows the comparison of risk of BCR in SM groups (0= -ve SM; 1= +ve SM)
STUDY LIMITATIONS
REFERENCES
RESULTS
Retrospective study
Shorter follow up period compared to the literatures
Limited number of patients
1- Han M, Partin AW, Pound CR, et al. Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy: the 15-year Johns Hopkins experience. Urol Clin North Am 2001; 28:
53 (16.2%) out of 326 patients had BCR.
Independent predictors of BCR on multivariate analysis included:
year of surgery
PSM
Operative time
Association with BCR on Univariate analysis included:
Prostate specific antigen (PSA)
PSA density
Pathological grade
Pathological stage
NVB release time
Apical dissection time
CONCLUSION
PSM, prolonged operative time, and earlier year of surgery were independent predictors of BCR after RARP. These factors emphasize the role of surgeon’s experience in oncological outcomes post RARP.
Single apical and anterior positive surgical margin had less impact on BCR compared to basal and posterolateral margins, and multiple positive margins.