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In this randomized trial, conducted between 1989 and 2022 to compare radical prostatectomy with watchful waiting, radical prostatectomy led to a 48% lower risk of death from prostate cancer and to 2.2 life-years gained.

To quantify the ability of two new comorbidity indices to adjust for confounding, by benchmarking a target trial emulation against the randomized controlled trial (RCT) result. Observational study including 18,316 men from Prostate Cancer data Base Sweden 5.0, diagnosed with prostate cancer between 2008 and 2019 and treated with primary radical prostatectomy (RP, n = 14,379) or radiotherapy (RT, n = 3,937). The effect on adjusted risk of death from any cause after adjustment for comorbidity by use of two new comorbidity indices, the multidimensional diagnosis-based comorbidity index and the drug comorbidity index, were compared to adjustment for the Charlson comorbidity index (CCI). Risk of death was higher after RT than RP (hazard ratio [HR] = 1.94; 95% confidence interval [CI]: 1.70–2.21). The difference decreased when adjusting for age, cancer characteristics, and CCI (HR = 1.32, 95% CI: 1.06–1.66). Adjustment for the two new comorbidity indices further attenuated the difference (HR 1.14, 95% CI 0.91–1.44). Emulation of a hypothetical pragmatic trial where also older men with any type of baseline comorbidity were included, largely confirmed these results (HR 1.10; 95% CI 0.95–1.26). Adjustment for comorbidity using two new indices provided comparable risk of death from any cause in line with results of a RCT. Similar results were seen in a broader study population, more representative of clinical practice. [Display omitted] •Target trial emulation comparing surgery vs radiotherapy for prostate cancer.•Risk of death was comparable after adjustment for two new comorbidity indices.•Treatments were not comparable when adjusting for Charlson comorbidity index.

Background Current management for men with lower urinary tract symptoms (LUTS) is a pathway that results in prostate surgery in a significant proportion. While helpful in relieving benign prostatic obstruction (BPO), surgery may be ineffective for men suffering from difficulties not relating to BPO. The UPSTREAM trial started recruitment in October 2014 with the aim of establishing whether a care pathway including urodynamics (a diagnostic tool for BPO and thus an indication of whether surgery is needed) is no worse for men, in terms of symptomatic outcome, than one without (routine care). Methods/design This analysis plan outlines the main outcomes of the study and specific design choices, such as non-inferiority margins. The trial is currently recruiting in 26 hospitals across the UK, randomising men to either urodynamics or routine care, with recruitment set to end on the 31 December 2016. All outcomes will be measured 18 months after randomisation to allow sufficient time for surgical procedures and recovery. The primary outcome is based on a non-inferiority design with a margin of 1 point on the International Prostate Symptom Score (IPSS) scale. The key secondary outcome for this trial is surgery rate per arm, which is estimated to be at least 18% lower in the urodynamics arm. Surgery rates, adverse events, flow rate, urinary symptoms and sexual symptoms are secondary outcomes to be assessed for superiority. This is an update to the UPSTREAM protocol, which has already been published in this journal. Discussion This a priori statistical analysis plan aims to reduce reporting bias by allowing access to the trial’s objectives and plans in advance of recruitment end. The results of the trial are expected to be published soon after the trial end date of 30 September 2018. Trial registration ISRCTN registry, ISRCTN56164274 . Registered on 8 April 2014.

Introduction In our series of 1,900 endoscopic extraperitoneal radical prostatectomies (EERPE) the incidence of symptomatic lymphocele following simultaneous pelvic lymph node dissection (PLND) is between 3 and 14% depending on the extent of lymph node dissection. We report the impact of bilateral peritoneal fenestration after completion of extraperitoneal prostatectomy and PLND on the incidence of lymphocele, postoperative pain and complications. Patients and methods A total of 100 consecutive patients undergoing EERPE and extended PLND were allocated into two groups. In Group A ( n  = 50) a 4–6 cm incision was performed bilaterally over the external iliac vessels down to the obturator fossa after completion of the main procedure. In Group B ( n  = 50) no peritoneal incisions were made. The postoperative assessment protocol included a visual analogue pain scale administered three times daily for 6 days, analgesia requirement, and ultrasound examination on 4th and 8th days, and 3 months postoperatively. CRP and leucocyte counts were measured on 1st and 2nd postoperative days. Complications were recorded according to our standard protocol using the Clavien classification. Results Three patients (6%) in Group A were found to have lymphoceles, none of which were symptomatic. Significantly more patients in Group B developed a lymphocele, ( n  = 16, 32%, P  < 0.001) of which a significant number were symptomatic ( n  = 7, 14%, P  < 0.001) and required laparoscopic fenestration. No significant difference was observed between the pain score in either group. Mean pain scores were 3.4 versus 3.8 at 6 h, and 0.8 versus 1.1 at 6 days, respectively. No difference in analgesia requirement, serum inflammatory markers and return to normal bowel activity was observed between the groups. Conclusions This study demonstrates that peritoneal fenestration significantly reduces the incidence of both symptomatic and asymptomatic lymphocele, without an increase in postoperative morbidity. As symptomatic lymphocele is one of the most common complications of extraperitoneal PLND requiring reintervention, we recommend that peritoneal fenestration should be performed routinely after extraperitoneal radical prostatectomy and PLND.

The standard low lithotomic position, used during robot-assisted radical prostatectomy (RARP), with prolonged positioning in stirrups together with steep Trendelenburg may expose the patient to neurapraxia phenomena of the lower limbs and can rarely be used in patients with problems of hip abduction. To overcome these hurdles, we evaluated the clinical benefits of “side docking” (SD) of the da Vinci ® robotic system in comparison to “traditional docking” (TD). A cohort of 120 patients submitted to RARP were prospectively randomized into two groups by docking approach: SD with the patient supine with lower limbs slightly abducted on the operating table, and TD docking time, intraoperative number of collisions between the robotic arms and postoperative neurological problems in the lower limbs were noted. Descriptive statistics was used to analyze outcomes. Docking time was shorter for the SD group [SD: median 13 min (range 10–18); TD: median 21 min (range 15–34)]. None in the SD group and six of 60 patients (10 %) in the TD group suffered from temporary (<30 days) unilateral neurological deficits of the lower limbs. In both groups no collisions between the robotic arms occurred. The SD approach is technically feasible. It does not cause collisions between the robotic arms, and is a reliable method for reducing the setup time of RARP. The supine position of the patient may prevent neurological complications of the lower limbs. Based on these results, SD has become the standard docking technique used by our department.

Apical dissection is a crucial step of radical prostatectomy (RP) for postoperative functional outcomes. Robot-assisted laparoscopic RP (RALRP) represents a good visualization for this stage and bleeding during ligation of dorsal vein complex (DVC) is a challenging problem in open RP (ORP). In our study, the results of finger dissection technique in open RP were evaluated and compared with RALRP. We retrospectively reviewed 184 patients who underwent RP for clinically localized prostate cancer. Blunt finger dissection technique performed for ligation of DVC in ORP and patients were divided into two groups according to the surgical method (Group 1:RALRP; Group 2:FD-ORP – Finger dissection-ORP). The primary outcomes were continence status and erectile functions. Ninety-two patients in each group were enrolled in the study. Demographics, operative outcomes, preoperative and postoperative oncological data were also recorded. Demographics and preoperative data were similar. There is no statistically difference between groups in terms of operation time, blood loss, transfusion rates, hospitalization time, and peri- and postoperative complications ( p  > 0.05). Continence rates (82.6% vs. 89.1%, p  = 0.439) and erectile functions (mean IIEF: 10.62 vs. 11.34, p  = 0.107) showed no statistically significant difference between FD-ORP and RALRP in the first year after surgery. Finger dissection of the DVC during ORP is a simple and feasible technique that provides the correct plane on the urethra, resulting in better apical dissection with effective hemostasis. Although it shows similar early functional results as RALRP, more research is needed. These findings suggest that FD-ORP may serve as a viable surgical option in settings where robotic technology is inaccessible.

The introduction of the “da Vinci S HD Surgical System” marked a significant shift towards robotic surgeries in Japan. However, initial high costs and lack of efficacy data posed barriers to its widespread adoption. By 2023, more than 570 da Vinci units were operational in Japan, highlighting the growing acceptance of robotic surgery despite these challenges. This study aimed to investigate the prevalence and regional disparities in the adoption of robot-assisted laparoscopic prostatectomy (RALP) across Japan using diagnosis procedure combination data. This retrospective observational study analyzed data from 2857 urban and 4184 regional hospitals across 47 prefectures in Japan. The study focused on the number of RALP procedures, da Vinci systems, and certified urological surgery proctors. Multiple regression analysis was performed to identify significant factors influencing RALP adoption. Urban areas demonstrated a higher prevalence of RALP procedures and more da Vinci systems compared to regional areas, with urban hospitals performing an average of 937 RALP procedures compared to 195.5 in regional hospitals. The number of certified urological surgeons also showed significant urban-regional disparities, contributing to the overall imbalance. Our findings highlight substantial regional disparities in access to robot-assisted surgery in Japan, with urban areas benefiting from better access to advanced medical technologies and specialist training. Addressing these disparities will require targeted policies to improve the dissemination of robotic surgery systems and enhance training opportunities in regional cities.

Background Due to the deep location of the prostate within the pelvic cavity, procedures of robot-assisted radical prostatectomy (RARP) might be challenged by the prostate size and the limited pelvic cavity space. This study aimed to investigate the roles of bony pelvic and prostate dimensions in RARP procedures by an original study coupled with a meta-analysis. Methods In the original study, patients undergoing multiport RARP between 2021 and 2022 were consecutively assessed. The associations of anatomic features with operative time (OT), estimated blood loss (EBL), and positive surgical margin (PSM) were evaluated using linear and logistic regression analyses as well as restricted cubic spline (RCS) analysis. Based on machine-learning algorithms, this study established predictive models for surgical difficulty and interpreted the model using SHapley Additive exPlanation (SHAP). In the meta-analysis, three databases were searched for eligible studies. Quantitative syntheses were subsequently performed. Results Overall, 219 patients were enrolled in the original study. Prostate volume (PV) and the prostate volume-to-pelvic cavity index (PCI) ratio (PV-to-PCI ratio) were significantly associated with longer OT ( P  < 0.05). In the RCS models, U-shaped associations were observed between the prostate anteroposterior diameter (PAD) and OT, and between the prostate height (PH) and EBL, and an L-shaped association was observed between the anteroposterior diameter of the pelvic inlet (API) and EBL. The XGBoost model was superior to the logistic regression model in predicting prolonged OT. The meta-analysis demonstrated that greater PV was significantly associated with longer OT ( β  = 0.20; 95% confidence interval [CI] 0.12–0.27; odds ratio [OR] = 1.05; 95% CI 1.00–1.11), and a smaller PV could increase the risk of PSM (OR = 0.82; 95% CI 0.77–0.88). Conclusions A large prostate within a narrow and deep pelvis might suggest increased surgical difficulty of RARP. The size of the pelvic inlet also had a great impact on RARP. For PAD and PH, there seemed to be an optimal range with the lowest surgical difficulty. Machine-learning models based on the XGBoost algorithm could be successfully applied to predict the surgical difficulty of RARP.

There is a scarcity of evidence about the role of patient choice and hospital competition policies on surgical cancer services. Previous evidence has shown that patients are prepared to bypass their nearest cancer centre to receive surgery at more distant centres that better meet their needs. In this national, population-based study we investigated the effect of patient mobility and hospital competition on service configuration and technology adoption in the National Health Service (NHS) in England, using prostate cancer surgery as a model. We mapped all patients in England who underwent radical prostatectomy between Jan 1, 2010, and Dec 31, 2014, according to place of residence and treatment location. For each radical prostatectomy centre we analysed the effect of hospital competition (measured by use of a spatial competition index [SCI], with a score of 0 indicating weakest competition and 1 indicating strongest competition) and the effect of being an established robotic radical prostatectomy centre at the start of 2010 on net gains or losses of patients (difference between number of patients treated in a centre and number expected based on their residence), and the likelihood of closing their radical prostatectomy service. Between Jan 1, 2010, and Dec 31, 2014, 19 256 patients underwent radical prostatectomy at an NHS provider in England. Of the 65 radical prostatectomy centres open at the start of the study period, 23 (35%) had a statistically significant net gain of patients during 2010–14. Ten (40%) of these 23 were established robotic centres. 37 (57%) of the 65 centres had a significant net loss of patients, of which two (5%) were established robotic centres and ten (27%) closed their radical prostatectomy service during the study period. Radical prostatectomy centres that closed were more likely to be located in areas with stronger competition (highest SCI quartile [0·87–0·92]; p=0·0081) than in areas with weaker competition. No robotic surgery centre closed irrespective of the size of net losses of patients. The number of centres performing robotic surgery increased from 12 (18%) of the 65 centres at the beginning of 2010 to 39 (71%) of 55 centres open at the end of 2014. Competitive factors, in addition to policies advocating centralisation and the requirement to do minimum numbers of surgical procedures, have contributed to large-scale investment in equipment for robotic surgery without evidence of superior outcomes and contributed to the closure of cancer surgery units. If quality performance and outcome indicators are not available to guide patient choice, these policies could threaten health services' ability to deliver equitable and affordable cancer care. National Institute for Health Research.

Background Benign prostatic hyperplasia (BPH) is a common cause of lower urinary tract symptoms (LUTS) in aging men, and significantly affects their quality of life and productivity. In Brazil, where most of the population relies on the Public Health System (SUS), transurethral resection of the prostate (TURP) and simple prostatectomy (SP) are the primary surgical modalities. These procedures vary in cost-effectiveness, influencing clinical decisions and healthcare resource allocation. Therefore, we aimed to describe the perioperative outcomes of surgical modalities (TURP and SP) and the financial impact of these treatments in major Brazilian regions in recent years. Method This ecological study utilized data from the Brazilian Public Health System database (DATASUS) from 2009 to 2022. The records of patients diagnosed with BPH and undergoing TURP or SP were analyzed across Brazil’s major geographic regions. The key outcomes included annual surgery volumes, patient demographic characteristics, hospitalization characteristics (e.g., length of stay and intensive care unit utilization), intrahospital mortality rates, and government reimbursements to hospitals. Statistical analyses included descriptive statistics, comparisons between the two techniques, and regression models to assess the temporal trends in mortality rates. Results Over the 14-year period analyzed, Brazil recorded 204,358 BPH surgeries, with the Southeast region accounting for 46.56% of the procedures. TURP was the predominant procedure nationwide (61.44%), particularly in the higher-income regions. Perioperative outcomes favored TURP, with lower intrahospital mortality rates (0.25% vs. 0.55% for SP) and shorter hospital stays (median, 3 days vs. 5 days for SP). Both procedures resulted in decreasing mortality trends, although the differences were not statistically significant. Government reimbursements for hospitals were lower for TURP than for SP and did not keep pace with inflation during this period. Conclusion This study underscores the prominent role of the Southeast region in BPH surgeries within Brazil's public health system and highlights TURP’s favorable perioperative outcomes of TURP over SP. It also showed a financial deficit in surgery reimbursements, which may impact the sustainability of the public health system.