Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy
Does size matter? The significance of prostate size on pathologic and functional outcomes in...
Olsson, Carl A.; Lavery, Hugh J.; Sebrow, Dov; Akhavan, Ardavan; Levinson, Adam W.; Brajtbord, Jonathan S.; Carlucci, John; Muntner, Paul; Samadi, David B.
2011-09-01 00:00:00
Arab Journal of Urology (2011) 9, 159–164 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com LAPAROSCOPY/ROBOTICS ORIGINAL ARTICLE Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy a, b b b Carl A. Olsson , Hugh J. Lavery , Dov Sebrow , Ardavan Akhavan , b b b c Adam W. Levinson , Jonathan S. Brajtbord , John Carlucci , Paul Muntner , David B. Samadi Department of Urology, Columbia University Medical Center, New York, NY, USA Department of Urology, The Mount Sinai Medical Center, New York, NY, USA Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA Received 12 July 2011, Received in revised form 10 October 2011, Accepted 10 October 2011 Available online 16 November 2011 KEYWORDS Abstract Background: We examined the effect of prostate weight on perioperative data, and the pathological and functional outcomes of robotic-assisted laparoscopic prostatectomy (RALP). Robotic surgery; Patients and methods: Data were available from 716 consecutive patients before, during and Prostate cancer; Prostatectomy; after undergoing RALP at one institution. Prostate size was arbitrarily stratified by recorded pros- Outcomes; tate weight into <50, 50–80 and >80 g, corresponding to small, moderate and large glands, respec- Potency; tively. Perioperative data and the histopathological and functional outcomes were compared across Continence; these groups by both univariable and multivariable-adjusted analyses. Margins Results: Increased prostate size was associated with increased age, preoperative prostate-specific antigen levels, body mass index, operative duration, blood loss, lower biopsy and pathological ABBREVIATIONS Gleason scores, and lower pathological staging (P < 0.05). The incidence of extensive positive sur- RALP, robotic-assisted gical margins was 14.8%, 9.7%, and 5.3% in small, moderate and large prostates, respectively Corresponding author. Address: Department of Urology, Colum- bia University Medical Center, Integrated Medical Professionals, 3111 New Hyde Park Rd., North Hills, NY 11042, USA. Tel.: +1 516 394 9610; fax: +1 516 869 3015. E-mail address: cao2@columbia.edu (C.A. Olsson). 2090-598X ª 2011 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Production and hosting by Elsevier Peer review under responsibility of Arab Association of Urology. doi:10.1016/j.aju.2011.10.002 160 Olsson et al. laparoscopic prostatectomy; (P < 0.001). However, after multivariable adjustment, only Gleason score and pathological stage PSM, positive surgical mar- were significantly associated with the incidence of positive margins (P < 0.05); prostate weight gin; OR, operating-room; was not significantly associated. Overall, 78% and 92% of patients were potent and continent at EBL, estimated blood loss; 12 months, respectively, which was not affected by prostate size. LOS, length of hospital stay; Conclusion: Patients with larger prostates had favourable pathological outcomes after RALP. BMI, body mass index; When controlling for pathological stage, prostate size was not associated with margin positivity. SHIM, sexual health inven- Functionally, neither continence nor potency at 12 months was affected by prostate size. tory for men ª 2011 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction cer was estimated based on the percentage of slides containing tumour (the positive-block ratio). Tumour at the inked resec- The effect of prostate size on outcomes after robotic-assisted tion margin was considered a PSM, which was dichotomized prostatectomy remains unclear. Previous studies concluded into ‘focal’ or ‘extensive’ if the length of the PSM was < or that higher-volume prostates are associated with more favour- >3 mm, respectively [7]. able pathological outcomes, lower rates of positive surgical Demographic, pre and peri-operative, and pathological margins (PSMs) and improved long-term biochemical characteristics of patients undergoing RALP were calculated disease-free survival [1,2]. In open radical retropubic prostatec- using means for continuous variables and proportions for cat- tomy series, larger glands are associated with longer operating- egorical variables. These characteristics were calculated for room (OR) time, higher estimated blood loss (EBL) and blood each prostate weight category of patients separately. The transfusions, but with no difference in functional outcomes statistical significance of differences, comparing the three pros- [3,4]. However, there are conflicting results in previous reports tate weight groups, was calculated using t-tests for continuous of robotic prostatectomy. Zorn et al. [5] found no difference in variables and chi-square tests for categorical variables. EBL, transfusion rate, OR time, or length of hospital stay Additionally, the prevalence of extensive surgical margins (LOS) in patients with larger (>80 g) prostates. However, (>3 mm) was calculated by prostate weight category, overall others have reported that in patients with large prostates and by pathological staging. The statistical significance of lin- (>70 g), EBL, OR time, and LOS significantly increased [6]. ear trends across prostate weight categories was tested by lin- In an effort to elucidate the association of prostate size on ear and logistic regression models for continuous and perioperative data, as well as pathological and functional dichotomous variables, respectively. The multivariable- outcomes, we evaluated the effect of prostate weight on these adjusted odds ratios of patient characteristics associated with variables among patients undergoing robotic-assisted laparo- prostate weight were determined using a multinomial logistic scopic prostatectomy (RALP). regression model with the small prostate weight group as the reference category. The odds ratios of extensive PSMs associ- ated with patient characteristics and prostate weight were cal- Patients and methods culated using logistic regression models adjusted for all patient characteristics simultaneously. Significance was defined as An institutional review board-approved database comprising P < 0.05, and all tests were two-sided. all patients undergoing RALP by one surgeon (D.B.S.) is maintained by research staff at the Mount Sinai Medical Cen- ter. Consecutive patients undergoing RALP from May 2007 Results until February 2009 formed the base population for the cur- rent analyses (784 men). Patients were excluded for the follow- Among the 716 patients undergoing RALP, 400 (56%) had a ing missing data: body mass index (BMI, 3), preoperative PSA prostate weight of <50 g, 259 (36%) of 50–80 g, and 57 level (23), preoperative Gleason score (8), operative duration (5), EBL (10), prostate weight (15), and margin status (4). After these exclusions, perioperative and histopathological 30% data were available on 716 patients. Patients were divided arbi- 25% trarily into three categories according to their prostate weight, i.e. <50, 50–80 and >80 g, corresponding to small, moderate 20% and large glands, respectively. 15% Functional outcomes and PSA data were collected at base- line, 6 weeks, and then every 3 months for the first year after 10% surgery, using the IPSS and sexual health inventory for men (SHIM) scores. Continence was defined as the use of either 5% no pads or one security pad daily. Potency was defined as 0% a SHIM score of >16, with or without the use of phospho- 30 40 50 60 70 80 90 100 diesterase-5 inhibitors, in patients who were preoperatively Prostate weight, grams potent (SHIM > 16). A single postoperative PSA level of Prostate weight distribution extends to a maximum of 200 grams >0.2 ng/mL was considered to indicate a biochemical recurrence. Figure 1 Distribution of prostate weight among 716 patients Excised prostate specimens were sectioned in four quad- undergoing RALP (prostate weight distribution extends to a rants and mounted in a standard fashion. The volume of can- maximum of 200 g). Prostate size and pathological and functional outcomes 161 Table 1 Characteristics of 716 patients undergoing robotic prostatectomy overall and by prostate weight categories. Prostate weight, grams p-trend Overall (n = 716) 650 (n = 400) 50–80 (n = 259) >80 (n = 57) Age, years 59.1 (6.9) 57.4 (7.1) 60.7 (5.9) 63.4 (5.8) <0.001 Body mass index (kg/m ) 27.5 (3.6) 27.4 (3.5) 27.5 (3.5) 28.6 (3.8) 0.051 Estimated blood loss (mL) 51.4 (10.3–256.5) 45.6 (9.5–218.8) 58.9 (12.0–286.5) 75.2 (14.8–382.5) <0.001 Time in operating room (min) 124.7 (28.4) 121.4 (28.6) 126.0 (26.0) 140.1 (32.7) <0.001 Hospital stay of 1 day (%) 74.2 75 74.5 66.7 0.258 Pathologic stage T2 (%) 83.8 79.5 86.9 94.7 <0.001 T3 (%) 16.2 20 12.7 5.3 <0.001 PSA (ng/mL) 6.0 (4.4) 5.5 (3.2) 6.4 (5.4) 7.8 (5.2) <0.001 Gleason score, biopsy 6 (%) 61.3 56 66.8 73.7 0.001 7 (%) 31.6 37 25.9 19.3 8–10 (%) 7 7 7.3 5.3 Gleason score, pathologic 6 (%) 32.3 22.5 43.6 49.1 <0.001 7 (%) 61.5 72 48.7 45.6 8–10 (%) 6.2 5.3 7.7 5.3 Extensive positive margins (%) 12.2 14.8 9.7 5.3 <0.001 Numbers in table are mean (standard deviation) or percentage except for estimated blood loss which is presented as geometric mean (95% confidence interval). (8%) had glands of >80 g (Fig. 1). The mean (range) prostate 5.3% extensive PSMs in small, moderate, and large prostates, weight was 50.1 (22–200) g. All clinical and pathological vari- respectively (P < 0.05). ables examined except LOS were associated with prostate Prostate size had no effect on functional outcomes. At weight (Table 1). Specifically, greater age, longer OR time 12 months of follow-up, 92% of patients were continent and a higher EBL were significantly associated with larger (Fig. 3); continence was not associated with prostate size prostates. Pathological stage was lower in patients with larger (P = 0.77). The overall rate of potency at 12 months was prostates, and there were significantly higher proportions of 78% (Fig. 4); this rate was also not associated with prostate patients with lower biopsy and histopathological Gleason size (P = 0.069). sums in those with larger prostates. On multivariable analysis of moderate (50–80 g) and large Prostate weight was inversely associated with higher-stage (>80 g) vs small (<50 g) prostates, age, EBL, pT2 staging, disease and extensive PSMs (Fig. 2). Overall, extensive PSMs and PSA level were all independently associated with larger decreased at higher prostate weights, i.e. 14.8%, 9.7% and prostates (Table 2). Patients with moderate or large prostates were less likely to have Gleason scores of P7 than those with smaller glands. BMI and OR time were also associated with 50% size, but only in prostates of >80 g. Neither LOS nor extensive 45.5% PSMs were associated with prostate size when controlling for 38.8% 40% other variables. Multivariable analysis of characteristics possibly associated with PSMs only identified pathological stage and Gleason 30% score as independent predictors of extensive PSMs (Table 3). 20% 14.8% Discussion 9.7% 8.8% 10% 5.6% 5.3% 4.4% The relationship between prostate size and perioperative data, 0% as well as functional and histopathological variables, is a sub- 0% ject of debate. Previous studies have examined this relation- < 50 51 - 80 > 80 ship, specifically evaluating the effect of prostate size on Prostate weight, grams surgical margin status, histopathological findings, and func- Number of patients (w/extensive margins) tional outcomes. Most studies have shown improved histopa- PT2 staging 318 (28) 225 (10) 54 (3) PT3 staging 80 33 (15) 3 (0) thological cancer features in larger prostates, including Overall* 400 (59) 259 (25) 57 (3) decreased rates of PSMs [1,2]. For example, Link et al. [6] and Msezane et al. [8] both found larger prostate weights to *Overall includes 3 individuals without staging information available be associated with more favourable pathological staging, sim- Figure 2 The proportion of extensive PSMs stratified by ilar to the present findings. However, unlike the present study, prostate weight and pathological stage. Overall includes three both reported improved PSM rates with increasing prostate men without staging information available. size in multivariable-adjusted analysis. Extensive margins, % 162 Olsson et al. 100% 92% 94% 92% 91% 90% 80% 70% 60% No 50% Yes 40% 30% 20% 9.1% 6.3% 8.1% 7.8% 10% 0% ≤ 50 > 50 to ≤ 80 >80 Overall (n=282) (n=198) (n=48) (n=594) Prostate Weight (g) Figure 3 Continence rates at 12 months (one or fewer pads per day) stratified by prostate weight (P = 0.77). 100% 90% 83% 78% 80% 73% 74% 70% 60% No 50% Yes 40% 27% 26% 30% 22% 17% 20% 10% 0% ≤ 50 > 50 to ≤ 80 > 80 Overall (n=224) (n=139) (n=31) (n=394) Prostate Weight (g) Figure 4 Potency rates at 12 months (SHIM > 16), at 12 months, stratified by prostate weight (P = 0.069). Table 2 Multivariable analysis comparing prostate weight and various patient characteristics. Results are adjusted odds ratios (95% confidence interval). Prostate weight, grams 650 (n = 400) >50 to 680 (n = 259) >80 (n = 57) * * Age, 5 years 1 (reference) 1.70 (1.47–1.96) 2.90 (2.15–3.92) 2 * Body mass index, 5 kg/m 1 (reference) 1.13 (0.88–1.46) 1.84 (1.20–2.82) * * Estimated blood loss, 20 ml 1 (reference) 1.10 (1.03–1.16) 1.15 (1.04–1.26) Time in operating room, 30 min 1 (reference) 1.19 (0.97–1.45) 1.91 (1.38–2.65) Hospital stay of 1 day 1 (reference) 0.96 (0.64–1.45) 0.79 (0.39–1.63) * * Pathologic stage pT2 1 (reference) 1.78 (1.02–3.11) 4.94 (1.16–21.0) * * PSA, 5 units 1 (reference) 1.70 (1.30–2.24) 2.23 (1.57–3.16) Gleason score, post-operative * * 7 versus 6 1 (reference) 0.26 (0.17–0.39) 0.15 (0.08–0.31) 8 or 9 versus 6 1 (reference) 0.59 (0.25–1.42) 0.19 (0.03–1.12) Extensive margins 1 (reference) 0.58 (0.32–1.06) 0.35 (0.09–1.33) All variables were included in the model simultaneously. p < 0.05. The evidence for less aggressive pathological outcomes and failed to detect a difference in the rate of PSM, but that study even decreased PSM rates in large prostates has also been pooled all prostates >50 g together, whereas most other reported in open and laparoscopic prostatectomy cohorts reports set the threshold for large prostates at 70–80 g. [1,4,9–12], although a study by Levinson et al. [13] found no Histopathologically, men with larger prostates were found such association. Another negative study by Singh et al. [14] to have significantly lower pathological stage and Gleason % Continence % Potent Prostate size and pathological and functional outcomes 163 reasons can explain why the removal of a sizeable gland could Table 3 Multivariable analysis of an extensive positive affect functional outcomes. Assuming the patient regains con- margin associated with patient characteristics. tinence, the removal of a large obstructive gland will likely im- Odds ratios (95% CI) prove urinary flow and increase a patient’s subjective of extensive margins assessment of urinary functional improvement. Conversely, Age, 5 years 1.10 (0.91–1.32) the increased bladder outlet resistance associated with a large Body mass index, 5 kg/m 0.84 (0.58–1.19) prostate over time might result in an overactive bladder, Estimated blood loss, 20 ml 1.02 (0.93–1.11) potentially leading to increased rates of incontinence. Conti- Time in operating room, 30 min 0.99 (0.76–1.29) nence might also be adversely affected by a shorter urethral Hospital stay of 1 day 1.12 (0.63–2.00) stump after removing a large prostate. PT2 pathology stage 0.19 (0.11–0.33) A large prostate makes exposing and dissecting the neuro- PSA, 5 units 1.22 (0.98–1.52) vascular bundles more difficult, potentially leading to either Gleason score, post-operative direct injury from poor visualization or traction injuries that 7 versus 6 2.43 (1.09–5.46) can cause neuropraxia. Postoperative potency could therefore 8 or 9 versus 6 3.94 (1.35–11.5) be compromised. That the present patients with larger pros- tates had no decreased urinary or sexual function after RALP, Pathology weight, grams 50–80 0.67 (0.37–1.20) compared to their smaller-prostate counterparts, is an interest- >80 0.47 (0.12–1.74) ing finding that could reflect surgeon-specific variables. Improved histopathological outcomes among men with Multivariable adjusted model includes all variables simultaneously. larger prostates are understandable. Larger prostates have p < 0.05. been shown to be associated with higher preoperative PSA levels due to PSA production from BPH tissue [21]. This increased PSA might lead to earlier biopsy and detection in the natural history of the disease, leading to the diagnosis of scores. Patients with smaller prostates had higher rates of comparatively lower-risk cancers [6]. PSMs, although this association was lost in a multivariable analysis, probably reflecting the effect of the higher patholog- Prostate size might be a therapeutic issue to be considered ical stage seen in patients with smaller prostates. by the patient with prostate cancer. Men with the most severe Thus, recent reports are somewhat divided on the relation- preoperative LUTS have been shown to experience the greatest ship between prostate size and pathological stage, Gleason improvement in their symptoms after radical prostatectomy. score and margin status. Differences in statistical methods, This finding is presumably due to the association between prostate size and severity of LUTS, and the beneficial effects surgical technique, definitions of PSMs, stratification of pros- of removing a large, obstructive gland. When combined with tate size, and baseline patient characteristics are probably the increased likelihood of having lower grade cancer on path- responsible for the discrepancies. Differences among these ological examination, the choice to undergo radical prostatec- studies and ours might also be secondary to surgeon-specific tomy could become a more appealing treatment option for approaches towards large prostates. The high volume of men with large prostates. This is especially relevant given the RALP procedures performed at our institution, coupled with need for neoadjuvant androgen deprivation, higher radiation the use of a non-traditional approach to robotic extirpation dose treatment, and higher subsequent risk for acute urinary of large prostates described elsewhere [15], might have posi- toxicity among men with large prostates who choose to under- tively affected our results. Our study is one of only a few exam- go brachytherapy or intensity-modulated radiotherapy [22]. ining this issue using multivariable analysis, which is important Our study has several limitations, including problems of given the discrepancy noted between our univariable and mul- generalisation and selection bias arising from a single-surgeon tivariable results for PSMs. cohort. There were relatively few patients with prostates of The data suggest that surgical difficulty might be higher but >80 g (57). The overall number of patients in our study, while functional outcomes are unaffected in RALP performed in greater than those analysed in some other studies, is also rela- men with large prostates [3,5]. To better evaluate this problem, tively small. To attain consensus on the nature of prostate we analysed prostate weight among patients who underwent weight and RALP outcomes, our results should be confirmed RALP by one surgeon. The postoperative continence rate of in larger cohorts with more men having larger prostates. 92% and potency rate of 78% among all study participants, Last, we did not analyse each patient’s LUTS before and regardless of prostate size, are similar to those from other large after RALP. This might have provided additional useful infor- published robotic prostatectomy series [16–20]. When patients were stratified by prostate weight we found no significant dif- mation given the postoperative improvement seen among men ferences in postoperative potency or continence between the with large prostates. Further studies are needed to show this groups, a finding consistent with that reported by Zorn et al. benefit. [5]. As expected, patients with larger prostates were older In conclusion, Larger prostates are associated with in- and had higher preoperative PSA levels. We also noted that creased BMI, greater age, higher preoperative PSA levels, longer OR time, higher EBL, and lower Gleason scores and patients with larger prostates had a higher BMI, perhaps due pathological staging in patients undergoing RALP. While the to a different hormonal milieu or PSA haemodilution in the incidence of extensive PSMs was higher in patients with smal- obese. Larger prostates were associated with longer OR times ler prostates, we found this to be an artefact of the differences and higher EBL, although the 30 mL difference in EBL is of in pathological stage. Neither continence nor potency at minimal clinical significance. 12 months was associated with prostate size. RALP remains Although we found no difference in postoperative conti- a good option for patients with large prostates. nence or potency among patients with larger prostates, several 164 Olsson et al. 75 cm predicts for a favorable outcome after radical prostatec- Conflict of interest tomy for localized prostate cancer. Urology 1998;52:631–6. [11] Foley CL, Bott SR, Thomas K, Parkinson MC, Kirby RS. A This article contains no references to any commercial organi- large prostate at radical retropubic prostatectomy does not zation, pharmaceutical firm or medical device manufacturer. adversely affect cancer control, continence or potency rates. As such, none of the authors have any conflict of interest. BJU Int 2003;92:370–4. [12] Frota R, Turna B, Santos BM, Lin YC, Gill IS, Aron M. The References effect of prostate weight on the outcomes of laparoscopic radical prostatectomy. BJU Int 2008;101:589–93. [13] Levinson AW, Ward NT, Sulman A, Mettee LZ, Link RE, Su [1] Liu JJ, Brooks JD, Ferrari M, Nolley R, Presti Jr JC. Small LM, et al. The impact of prostate size on perioperative outcomes prostate size and high grade disease-biology or artifact? J Urol in a large laparoscopic radical prostatectomy series. J Endourol 2011;185:2108–11. 2009;23:147–52. [2] Freedland SJ, Isaacs WB, Platz EA, Terris MK, Aronson WJ, [14] Singh A, Fagin R, Shah G, Shekarriz B. Impact of prostate size Amling CL, et al. Prostate size and risk of high-grade, advanced and body mass index on perioperative morbidity after laparo- prostate cancer and biochemical progression after radical prosta- scopic radical prostatectomy. J Urol 2005;173:524–52. tectomy: a search database study. J Clin Oncol 2005;23:7546–54. [15] Rehman J, Chughtai B, Guru K, Shabsigh R, Samadi DB. [3] Pettus JA, Masterson T, Sokol A, Cronin AM, Savage C, Sandhu JS, et al. Prostate size is associated with surgical difficulty but not Management of an enlarged median lobe with ureteral orifices at functional outcome at 1 year after radical prostatectomy. J Urol the margin of bladder neck during robotic-assisted laparoscopic 2009;182:949–55. prostatectomy. Can J Urol 2009;16:4490–4. [4] Hsu EI, Hong EK, Lepor H. Influence of body weight and [16] Zorn KC, Gofrit ON, Orvieto MA, Mikhail AA, Zagaja GP, prostate volume on intraoperative, perioperative, and postoper- Shalhav AL. Robotic-assisted laparoscopic prostatectomy func- ative outcomes after radical retropubic prostatectomy. Urology tional and pathologic outcomes with interfascial nerve preserva- 2003;61:601–6. tion. Eur Urol 2007;51:755–62. 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Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy
Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy
Abstract
AbstractBackground: We examined the effect of prostate weight on perioperative data, and the pathological and functional outcomes of robotic-assisted laparoscopic prostatectomy (RALP).Patients and methods: Data were available from 716 consecutive patients before, during and after undergoing RALP at one institution. Prostate size was arbitrarily stratified by recorded prostate weight into <50, 50–80 and >80 g, corresponding to small, moderate and large glands, respectively....
Arab Journal of Urology (2011) 9, 159–164 Arab Journal of Urology (Official Journal of the Arab Association of Urology) www.sciencedirect.com LAPAROSCOPY/ROBOTICS ORIGINAL ARTICLE Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy a, b b b Carl A. Olsson , Hugh J. Lavery , Dov Sebrow , Ardavan Akhavan , b b b c Adam W. Levinson , Jonathan S. Brajtbord , John Carlucci , Paul Muntner , David B. Samadi Department of Urology, Columbia University Medical Center, New York, NY, USA Department of Urology, The Mount Sinai Medical Center, New York, NY, USA Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA Received 12 July 2011, Received in revised form 10 October 2011, Accepted 10 October 2011 Available online 16 November 2011 KEYWORDS Abstract Background: We examined the effect of prostate weight on perioperative data, and the pathological and functional outcomes of robotic-assisted laparoscopic prostatectomy (RALP). Robotic surgery; Patients and methods: Data were available from 716 consecutive patients before, during and Prostate cancer; Prostatectomy; after undergoing RALP at one institution. Prostate size was arbitrarily stratified by recorded pros- Outcomes; tate weight into <50, 50–80 and >80 g, corresponding to small, moderate and large glands, respec- Potency; tively. Perioperative data and the histopathological and functional outcomes were compared across Continence; these groups by both univariable and multivariable-adjusted analyses. Margins Results: Increased prostate size was associated with increased age, preoperative prostate-specific antigen levels, body mass index, operative duration, blood loss, lower biopsy and pathological ABBREVIATIONS Gleason scores, and lower pathological staging (P < 0.05). The incidence of extensive positive sur- RALP, robotic-assisted gical margins was 14.8%, 9.7%, and 5.3% in small, moderate and large prostates, respectively Corresponding author. Address: Department of Urology, Colum- bia University Medical Center, Integrated Medical Professionals, 3111 New Hyde Park Rd., North Hills, NY 11042, USA. Tel.: +1 516 394 9610; fax: +1 516 869 3015. E-mail address: cao2@columbia.edu (C.A. Olsson). 2090-598X ª 2011 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Production and hosting by Elsevier Peer review under responsibility of Arab Association of Urology. doi:10.1016/j.aju.2011.10.002 160 Olsson et al. laparoscopic prostatectomy; (P < 0.001). However, after multivariable adjustment, only Gleason score and pathological stage PSM, positive surgical mar- were significantly associated with the incidence of positive margins (P < 0.05); prostate weight gin; OR, operating-room; was not significantly associated. Overall, 78% and 92% of patients were potent and continent at EBL, estimated blood loss; 12 months, respectively, which was not affected by prostate size. LOS, length of hospital stay; Conclusion: Patients with larger prostates had favourable pathological outcomes after RALP. BMI, body mass index; When controlling for pathological stage, prostate size was not associated with margin positivity. SHIM, sexual health inven- Functionally, neither continence nor potency at 12 months was affected by prostate size. tory for men ª 2011 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Introduction cer was estimated based on the percentage of slides containing tumour (the positive-block ratio). Tumour at the inked resec- The effect of prostate size on outcomes after robotic-assisted tion margin was considered a PSM, which was dichotomized prostatectomy remains unclear. Previous studies concluded into ‘focal’ or ‘extensive’ if the length of the PSM was < or that higher-volume prostates are associated with more favour- >3 mm, respectively [7]. able pathological outcomes, lower rates of positive surgical Demographic, pre and peri-operative, and pathological margins (PSMs) and improved long-term biochemical characteristics of patients undergoing RALP were calculated disease-free survival [1,2]. In open radical retropubic prostatec- using means for continuous variables and proportions for cat- tomy series, larger glands are associated with longer operating- egorical variables. These characteristics were calculated for room (OR) time, higher estimated blood loss (EBL) and blood each prostate weight category of patients separately. The transfusions, but with no difference in functional outcomes statistical significance of differences, comparing the three pros- [3,4]. However, there are conflicting results in previous reports tate weight groups, was calculated using t-tests for continuous of robotic prostatectomy. Zorn et al. [5] found no difference in variables and chi-square tests for categorical variables. EBL, transfusion rate, OR time, or length of hospital stay Additionally, the prevalence of extensive surgical margins (LOS) in patients with larger (>80 g) prostates. However, (>3 mm) was calculated by prostate weight category, overall others have reported that in patients with large prostates and by pathological staging. The statistical significance of lin- (>70 g), EBL, OR time, and LOS significantly increased [6]. ear trends across prostate weight categories was tested by lin- In an effort to elucidate the association of prostate size on ear and logistic regression models for continuous and perioperative data, as well as pathological and functional dichotomous variables, respectively. The multivariable- outcomes, we evaluated the effect of prostate weight on these adjusted odds ratios of patient characteristics associated with variables among patients undergoing robotic-assisted laparo- prostate weight were determined using a multinomial logistic scopic prostatectomy (RALP). regression model with the small prostate weight group as the reference category. The odds ratios of extensive PSMs associ- ated with patient characteristics and prostate weight were cal- Patients and methods culated using logistic regression models adjusted for all patient characteristics simultaneously. Significance was defined as An institutional review board-approved database comprising P < 0.05, and all tests were two-sided. all patients undergoing RALP by one surgeon (D.B.S.) is maintained by research staff at the Mount Sinai Medical Cen- ter. Consecutive patients undergoing RALP from May 2007 Results until February 2009 formed the base population for the cur- rent analyses (784 men). Patients were excluded for the follow- Among the 716 patients undergoing RALP, 400 (56%) had a ing missing data: body mass index (BMI, 3), preoperative PSA prostate weight of <50 g, 259 (36%) of 50–80 g, and 57 level (23), preoperative Gleason score (8), operative duration (5), EBL (10), prostate weight (15), and margin status (4). After these exclusions, perioperative and histopathological 30% data were available on 716 patients. Patients were divided arbi- 25% trarily into three categories according to their prostate weight, i.e. <50, 50–80 and >80 g, corresponding to small, moderate 20% and large glands, respectively. 15% Functional outcomes and PSA data were collected at base- line, 6 weeks, and then every 3 months for the first year after 10% surgery, using the IPSS and sexual health inventory for men (SHIM) scores. Continence was defined as the use of either 5% no pads or one security pad daily. Potency was defined as 0% a SHIM score of >16, with or without the use of phospho- 30 40 50 60 70 80 90 100 diesterase-5 inhibitors, in patients who were preoperatively Prostate weight, grams potent (SHIM > 16). A single postoperative PSA level of Prostate weight distribution extends to a maximum of 200 grams >0.2 ng/mL was considered to indicate a biochemical recurrence. Figure 1 Distribution of prostate weight among 716 patients Excised prostate specimens were sectioned in four quad- undergoing RALP (prostate weight distribution extends to a rants and mounted in a standard fashion. The volume of can- maximum of 200 g). Prostate size and pathological and functional outcomes 161 Table 1 Characteristics of 716 patients undergoing robotic prostatectomy overall and by prostate weight categories. Prostate weight, grams p-trend Overall (n = 716) 650 (n = 400) 50–80 (n = 259) >80 (n = 57) Age, years 59.1 (6.9) 57.4 (7.1) 60.7 (5.9) 63.4 (5.8) <0.001 Body mass index (kg/m ) 27.5 (3.6) 27.4 (3.5) 27.5 (3.5) 28.6 (3.8) 0.051 Estimated blood loss (mL) 51.4 (10.3–256.5) 45.6 (9.5–218.8) 58.9 (12.0–286.5) 75.2 (14.8–382.5) <0.001 Time in operating room (min) 124.7 (28.4) 121.4 (28.6) 126.0 (26.0) 140.1 (32.7) <0.001 Hospital stay of 1 day (%) 74.2 75 74.5 66.7 0.258 Pathologic stage T2 (%) 83.8 79.5 86.9 94.7 <0.001 T3 (%) 16.2 20 12.7 5.3 <0.001 PSA (ng/mL) 6.0 (4.4) 5.5 (3.2) 6.4 (5.4) 7.8 (5.2) <0.001 Gleason score, biopsy 6 (%) 61.3 56 66.8 73.7 0.001 7 (%) 31.6 37 25.9 19.3 8–10 (%) 7 7 7.3 5.3 Gleason score, pathologic 6 (%) 32.3 22.5 43.6 49.1 <0.001 7 (%) 61.5 72 48.7 45.6 8–10 (%) 6.2 5.3 7.7 5.3 Extensive positive margins (%) 12.2 14.8 9.7 5.3 <0.001 Numbers in table are mean (standard deviation) or percentage except for estimated blood loss which is presented as geometric mean (95% confidence interval). (8%) had glands of >80 g (Fig. 1). The mean (range) prostate 5.3% extensive PSMs in small, moderate, and large prostates, weight was 50.1 (22–200) g. All clinical and pathological vari- respectively (P < 0.05). ables examined except LOS were associated with prostate Prostate size had no effect on functional outcomes. At weight (Table 1). Specifically, greater age, longer OR time 12 months of follow-up, 92% of patients were continent and a higher EBL were significantly associated with larger (Fig. 3); continence was not associated with prostate size prostates. Pathological stage was lower in patients with larger (P = 0.77). The overall rate of potency at 12 months was prostates, and there were significantly higher proportions of 78% (Fig. 4); this rate was also not associated with prostate patients with lower biopsy and histopathological Gleason size (P = 0.069). sums in those with larger prostates. On multivariable analysis of moderate (50–80 g) and large Prostate weight was inversely associated with higher-stage (>80 g) vs small (<50 g) prostates, age, EBL, pT2 staging, disease and extensive PSMs (Fig. 2). Overall, extensive PSMs and PSA level were all independently associated with larger decreased at higher prostate weights, i.e. 14.8%, 9.7% and prostates (Table 2). Patients with moderate or large prostates were less likely to have Gleason scores of P7 than those with smaller glands. BMI and OR time were also associated with 50% size, but only in prostates of >80 g. Neither LOS nor extensive 45.5% PSMs were associated with prostate size when controlling for 38.8% 40% other variables. Multivariable analysis of characteristics possibly associated with PSMs only identified pathological stage and Gleason 30% score as independent predictors of extensive PSMs (Table 3). 20% 14.8% Discussion 9.7% 8.8% 10% 5.6% 5.3% 4.4% The relationship between prostate size and perioperative data, 0% as well as functional and histopathological variables, is a sub- 0% ject of debate. Previous studies have examined this relation- < 50 51 - 80 > 80 ship, specifically evaluating the effect of prostate size on Prostate weight, grams surgical margin status, histopathological findings, and func- Number of patients (w/extensive margins) tional outcomes. Most studies have shown improved histopa- PT2 staging 318 (28) 225 (10) 54 (3) PT3 staging 80 33 (15) 3 (0) thological cancer features in larger prostates, including Overall* 400 (59) 259 (25) 57 (3) decreased rates of PSMs [1,2]. For example, Link et al. [6] and Msezane et al. [8] both found larger prostate weights to *Overall includes 3 individuals without staging information available be associated with more favourable pathological staging, sim- Figure 2 The proportion of extensive PSMs stratified by ilar to the present findings. However, unlike the present study, prostate weight and pathological stage. Overall includes three both reported improved PSM rates with increasing prostate men without staging information available. size in multivariable-adjusted analysis. Extensive margins, % 162 Olsson et al. 100% 92% 94% 92% 91% 90% 80% 70% 60% No 50% Yes 40% 30% 20% 9.1% 6.3% 8.1% 7.8% 10% 0% ≤ 50 > 50 to ≤ 80 >80 Overall (n=282) (n=198) (n=48) (n=594) Prostate Weight (g) Figure 3 Continence rates at 12 months (one or fewer pads per day) stratified by prostate weight (P = 0.77). 100% 90% 83% 78% 80% 73% 74% 70% 60% No 50% Yes 40% 27% 26% 30% 22% 17% 20% 10% 0% ≤ 50 > 50 to ≤ 80 > 80 Overall (n=224) (n=139) (n=31) (n=394) Prostate Weight (g) Figure 4 Potency rates at 12 months (SHIM > 16), at 12 months, stratified by prostate weight (P = 0.069). Table 2 Multivariable analysis comparing prostate weight and various patient characteristics. Results are adjusted odds ratios (95% confidence interval). Prostate weight, grams 650 (n = 400) >50 to 680 (n = 259) >80 (n = 57) * * Age, 5 years 1 (reference) 1.70 (1.47–1.96) 2.90 (2.15–3.92) 2 * Body mass index, 5 kg/m 1 (reference) 1.13 (0.88–1.46) 1.84 (1.20–2.82) * * Estimated blood loss, 20 ml 1 (reference) 1.10 (1.03–1.16) 1.15 (1.04–1.26) Time in operating room, 30 min 1 (reference) 1.19 (0.97–1.45) 1.91 (1.38–2.65) Hospital stay of 1 day 1 (reference) 0.96 (0.64–1.45) 0.79 (0.39–1.63) * * Pathologic stage pT2 1 (reference) 1.78 (1.02–3.11) 4.94 (1.16–21.0) * * PSA, 5 units 1 (reference) 1.70 (1.30–2.24) 2.23 (1.57–3.16) Gleason score, post-operative * * 7 versus 6 1 (reference) 0.26 (0.17–0.39) 0.15 (0.08–0.31) 8 or 9 versus 6 1 (reference) 0.59 (0.25–1.42) 0.19 (0.03–1.12) Extensive margins 1 (reference) 0.58 (0.32–1.06) 0.35 (0.09–1.33) All variables were included in the model simultaneously. p < 0.05. The evidence for less aggressive pathological outcomes and failed to detect a difference in the rate of PSM, but that study even decreased PSM rates in large prostates has also been pooled all prostates >50 g together, whereas most other reported in open and laparoscopic prostatectomy cohorts reports set the threshold for large prostates at 70–80 g. [1,4,9–12], although a study by Levinson et al. [13] found no Histopathologically, men with larger prostates were found such association. Another negative study by Singh et al. [14] to have significantly lower pathological stage and Gleason % Continence % Potent Prostate size and pathological and functional outcomes 163 reasons can explain why the removal of a sizeable gland could Table 3 Multivariable analysis of an extensive positive affect functional outcomes. Assuming the patient regains con- margin associated with patient characteristics. tinence, the removal of a large obstructive gland will likely im- Odds ratios (95% CI) prove urinary flow and increase a patient’s subjective of extensive margins assessment of urinary functional improvement. Conversely, Age, 5 years 1.10 (0.91–1.32) the increased bladder outlet resistance associated with a large Body mass index, 5 kg/m 0.84 (0.58–1.19) prostate over time might result in an overactive bladder, Estimated blood loss, 20 ml 1.02 (0.93–1.11) potentially leading to increased rates of incontinence. Conti- Time in operating room, 30 min 0.99 (0.76–1.29) nence might also be adversely affected by a shorter urethral Hospital stay of 1 day 1.12 (0.63–2.00) stump after removing a large prostate. PT2 pathology stage 0.19 (0.11–0.33) A large prostate makes exposing and dissecting the neuro- PSA, 5 units 1.22 (0.98–1.52) vascular bundles more difficult, potentially leading to either Gleason score, post-operative direct injury from poor visualization or traction injuries that 7 versus 6 2.43 (1.09–5.46) can cause neuropraxia. Postoperative potency could therefore 8 or 9 versus 6 3.94 (1.35–11.5) be compromised. That the present patients with larger pros- tates had no decreased urinary or sexual function after RALP, Pathology weight, grams 50–80 0.67 (0.37–1.20) compared to their smaller-prostate counterparts, is an interest- >80 0.47 (0.12–1.74) ing finding that could reflect surgeon-specific variables. Improved histopathological outcomes among men with Multivariable adjusted model includes all variables simultaneously. larger prostates are understandable. Larger prostates have p < 0.05. been shown to be associated with higher preoperative PSA levels due to PSA production from BPH tissue [21]. This increased PSA might lead to earlier biopsy and detection in the natural history of the disease, leading to the diagnosis of scores. Patients with smaller prostates had higher rates of comparatively lower-risk cancers [6]. PSMs, although this association was lost in a multivariable analysis, probably reflecting the effect of the higher patholog- Prostate size might be a therapeutic issue to be considered ical stage seen in patients with smaller prostates. by the patient with prostate cancer. Men with the most severe Thus, recent reports are somewhat divided on the relation- preoperative LUTS have been shown to experience the greatest ship between prostate size and pathological stage, Gleason improvement in their symptoms after radical prostatectomy. score and margin status. Differences in statistical methods, This finding is presumably due to the association between prostate size and severity of LUTS, and the beneficial effects surgical technique, definitions of PSMs, stratification of pros- of removing a large, obstructive gland. When combined with tate size, and baseline patient characteristics are probably the increased likelihood of having lower grade cancer on path- responsible for the discrepancies. Differences among these ological examination, the choice to undergo radical prostatec- studies and ours might also be secondary to surgeon-specific tomy could become a more appealing treatment option for approaches towards large prostates. The high volume of men with large prostates. This is especially relevant given the RALP procedures performed at our institution, coupled with need for neoadjuvant androgen deprivation, higher radiation the use of a non-traditional approach to robotic extirpation dose treatment, and higher subsequent risk for acute urinary of large prostates described elsewhere [15], might have posi- toxicity among men with large prostates who choose to under- tively affected our results. Our study is one of only a few exam- go brachytherapy or intensity-modulated radiotherapy [22]. ining this issue using multivariable analysis, which is important Our study has several limitations, including problems of given the discrepancy noted between our univariable and mul- generalisation and selection bias arising from a single-surgeon tivariable results for PSMs. cohort. There were relatively few patients with prostates of The data suggest that surgical difficulty might be higher but >80 g (57). The overall number of patients in our study, while functional outcomes are unaffected in RALP performed in greater than those analysed in some other studies, is also rela- men with large prostates [3,5]. To better evaluate this problem, tively small. To attain consensus on the nature of prostate we analysed prostate weight among patients who underwent weight and RALP outcomes, our results should be confirmed RALP by one surgeon. The postoperative continence rate of in larger cohorts with more men having larger prostates. 92% and potency rate of 78% among all study participants, Last, we did not analyse each patient’s LUTS before and regardless of prostate size, are similar to those from other large after RALP. This might have provided additional useful infor- published robotic prostatectomy series [16–20]. When patients were stratified by prostate weight we found no significant dif- mation given the postoperative improvement seen among men ferences in postoperative potency or continence between the with large prostates. Further studies are needed to show this groups, a finding consistent with that reported by Zorn et al. benefit. [5]. As expected, patients with larger prostates were older In conclusion, Larger prostates are associated with in- and had higher preoperative PSA levels. We also noted that creased BMI, greater age, higher preoperative PSA levels, longer OR time, higher EBL, and lower Gleason scores and patients with larger prostates had a higher BMI, perhaps due pathological staging in patients undergoing RALP. While the to a different hormonal milieu or PSA haemodilution in the incidence of extensive PSMs was higher in patients with smal- obese. Larger prostates were associated with longer OR times ler prostates, we found this to be an artefact of the differences and higher EBL, although the 30 mL difference in EBL is of in pathological stage. Neither continence nor potency at minimal clinical significance. 12 months was associated with prostate size. RALP remains Although we found no difference in postoperative conti- a good option for patients with large prostates. nence or potency among patients with larger prostates, several 164 Olsson et al. 75 cm predicts for a favorable outcome after radical prostatec- Conflict of interest tomy for localized prostate cancer. Urology 1998;52:631–6. [11] Foley CL, Bott SR, Thomas K, Parkinson MC, Kirby RS. A This article contains no references to any commercial organi- large prostate at radical retropubic prostatectomy does not zation, pharmaceutical firm or medical device manufacturer. adversely affect cancer control, continence or potency rates. As such, none of the authors have any conflict of interest. BJU Int 2003;92:370–4. [12] Frota R, Turna B, Santos BM, Lin YC, Gill IS, Aron M. The References effect of prostate weight on the outcomes of laparoscopic radical prostatectomy. BJU Int 2008;101:589–93. [13] Levinson AW, Ward NT, Sulman A, Mettee LZ, Link RE, Su [1] Liu JJ, Brooks JD, Ferrari M, Nolley R, Presti Jr JC. Small LM, et al. The impact of prostate size on perioperative outcomes prostate size and high grade disease-biology or artifact? J Urol in a large laparoscopic radical prostatectomy series. J Endourol 2011;185:2108–11. 2009;23:147–52. [2] Freedland SJ, Isaacs WB, Platz EA, Terris MK, Aronson WJ, [14] Singh A, Fagin R, Shah G, Shekarriz B. Impact of prostate size Amling CL, et al. Prostate size and risk of high-grade, advanced and body mass index on perioperative morbidity after laparo- prostate cancer and biochemical progression after radical prosta- scopic radical prostatectomy. J Urol 2005;173:524–52. tectomy: a search database study. J Clin Oncol 2005;23:7546–54. [15] Rehman J, Chughtai B, Guru K, Shabsigh R, Samadi DB. [3] Pettus JA, Masterson T, Sokol A, Cronin AM, Savage C, Sandhu JS, et al. Prostate size is associated with surgical difficulty but not Management of an enlarged median lobe with ureteral orifices at functional outcome at 1 year after radical prostatectomy. J Urol the margin of bladder neck during robotic-assisted laparoscopic 2009;182:949–55. prostatectomy. Can J Urol 2009;16:4490–4. [4] Hsu EI, Hong EK, Lepor H. Influence of body weight and [16] Zorn KC, Gofrit ON, Orvieto MA, Mikhail AA, Zagaja GP, prostate volume on intraoperative, perioperative, and postoper- Shalhav AL. Robotic-assisted laparoscopic prostatectomy func- ative outcomes after radical retropubic prostatectomy. Urology tional and pathologic outcomes with interfascial nerve preserva- 2003;61:601–6. tion. Eur Urol 2007;51:755–62. [5] Zorn KC, Orvieto MA, Mikhail AA, Gofrit ON, Lin S, Schaeffer [17] Patel VR, Thaly R, Shah K. Robotic radical prostatectomy AJ, et al. Effect of prostate weight on operative and postoper- outcomes of 500 cases. BJU Int 2007;99:1109–12. [18] Badani KK, Kaul S, Menon M. Evolution of robotic radical ative outcomes of robotic-assisted laparoscopic prostatectomy. prostatectomy: assessment after 2766 procedures. Cancer Urology 2007;69:300–5. 2007;110:1951–8. [6] Link BA, Nelson R, Josephson DY, Yoshida JS, Crocitto LE, [19] Murphy DG, Kerger M, Crowe H, Peters JS, Costello AJ. Kawachi MH, et al. The impact of prostate gland weight in robot Operative details and oncological and functional outcome of assisted laparoscopic radical prostatectomy. J Urol robotic-assisted laparoscopic radical prostatectomy: 400 cases 2008;180:928–32. with a minimum of 12 months follow-up. Eur Urol [7] Shikanov S, Song J, Royce C, Al-Ahmadie H, Zorn K, Steinberg 2009;55:1358–66. G, et al. Length of positive surgical margin after radical [20] Menon M, Shrivastava A, Kaul S, Badani KK, Fumo M, prostatectomy as a predictor of biochemical recurrence. J Urol Bhandari M, et al. Vattikuti Institute prostatectomy. Contempo- 2009;182:139–44. rary technique and analysis of results. Eur Urol 2007;51:648–57. [8] Msezane LP, Gofrit ON, Lin S, Shalhav AL, Zagaja GP, Zorn [21] Kojima M, Troncoso P, Babaian RJ. Influence of noncancerous KC. Prostate weight: an independent predictor for positive prostatic tissue volume on prostate-specific antigen. Urology surgical margins during robotic-assisted laparoscopic radical 1998;51:293–9. prostatectomy. Can J Urol 2007;14:3697–701. [22] Keyes M, Miller S, Moravan V, Pickles T, McKenzie M, Pai H, [9] Chang CM, Moon D, Gianduzzo TR, Eden CG. The impact of et al. Predictive factors for acute and late urinary toxicity after prostate size in laparoscopic radical prostatectomy. Eur Urol permanent prostate brachytherapy: long-term outcome in 712 2005;48:285–90. consecutive patients. Int J Radiat Oncol Biol Phys [10] D’Amico AV, Whittington R, Malkowicz SB, Schultz D, Tom- aszewski JE, Wein A. A prostate gland volume of more than 2009;73:1023–32.
Journal
Arab Journal of Urology
– Taylor & Francis
Published: Sep 1, 2011
Keywords: Robotic surgery; Prostate cancer; Prostatectomy; Outcomes; Potency; Continence; Margins; RALP; robotic-assisted laparoscopic prostatectomy; PSM; positive surgical margin; OR; operating-room; EBL; estimated blood loss; LOS; length of hospital stay; BMI; body mass index; SHIM; sexual health inventory for men
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References
Small prostate size and high grade disease-biology or artifact?
Prostate size and risk of high-grade, advanced prostate cancer and biochemical progression after radical prostatectomy: a search database study
Prostate size is associated with surgical difficulty but not functional outcome at 1 year after radical prostatectomy
Influence of body weight and prostate volume on intraoperative, perioperative, and postoperative outcomes after radical retropubic prostatectomy
Effect of prostate weight on operative and postoperative outcomes of robotic-assisted laparoscopic prostatectomy
The impact of prostate gland weight in robot assisted laparoscopic radical prostatectomy
Length of positive surgical margin after radical prostatectomy as a predictor of biochemical recurrence
Prostate weight: an independent predictor for positive surgical margins during robotic-assisted laparoscopic radical prostatectomy
The impact of prostate size in laparoscopic radical prostatectomy
A prostate gland volume of more than 75 cm3 predicts for a favorable outcome after radical prostatectomy for localized prostate cancer
A large prostate at radical retropubic prostatectomy does not adversely affect cancer control, continence or potency rates
The effect of prostate weight on the outcomes of laparoscopic radical prostatectomy
The impact of prostate size on perioperative outcomes in a large laparoscopic radical prostatectomy series
Impact of prostate size and body mass index on perioperative morbidity after laparoscopic radical prostatectomy
Management of an enlarged median lobe with ureteral orifices at the margin of bladder neck during robotic-assisted laparoscopic prostatectomy
Robotic-assisted laparoscopic prostatectomy functional and pathologic outcomes with interfascial nerve preservation
Robotic radical prostatectomy outcomes of 500 cases
Evolution of robotic radical prostatectomy: assessment after 2766 procedures
Operative details and oncological and functional outcome of robotic-assisted laparoscopic radical prostatectomy: 400 cases with a minimum of 12 months follow-up
Vattikuti Institute prostatectomy. Contemporary technique and analysis of results
Influence of noncancerous prostatic tissue volume on prostate-specific antigen
Predictive factors for acute and late urinary toxicity after permanent prostate brachytherapy: long-term outcome in 712 consecutive patients
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