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      Comparison of perioperative outcomes in elderly (age ≧ 75 years) vs. younger men undergoing robot-assisted radical prostatectomy

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          Abstract

          Objectives

          To investigate perioperative, oncologic, and functional outcomes of robot-assisted radical prostatectomy (RARP) in men of age ≥ 75 years in comparison with younger men.

          Methods

          From November 2011 to December 2018, six hundred and thirty patients with prostate cancer underwent robot-assisted radical prostatectomy (RARP). A total of 614 patients were analyzed after excluding 16 patients who were treated with hormone therapy prior to RARP. Patients were divided into 2 groups based on their age (age ≥ 75 years: N = 46 patients and age < 75 years: N = 568 patients). Perioperative parameters regarding oncologic/functional outcomes and complication status were compared between the 2 groups. Clavien-Dindo classification was used to classify perioperative complications. Clinical and pathological status including stage, positive margin, continence, and potency status after RARP were analyzed.

          Results

          Five-hundred sixty-eight and forty-six men were of age <75 and ≥ 75 years, respectively. There were no significant differences between the 2 groups in terms of oncologic outcomes (positive resection margin rate and PSA failure). The duration of hospitalization was longer in older patients but was not statistically significant (P = 0.051). A total number of Clavien ≥3 complications that occurred within a month after RARP were 15 (2.6%) and 2 (4.3%) in younger men (age < 75 years) and older men (age ≥ 75 years), respectively (P = 0.359).

          Conclusion

          The present study showed that the oncologic and surgical outcomes in the elderly group were similar to those in the younger population. However, the duration of hospitalization seemed to be longer in older patients (age ≥ 75 years), despite similar complication rates.

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          Most cited references 26

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          Proposed classification of complications of surgery with examples of utility in cholecystectomy.

          Lack of uniform reporting of negative outcomes makes interpretation of surgical literature difficult. We attempt to define and classify negative outcomes by differentiating complications, sequelae, and failures. Complications and sequelae result from procedures, adding new problems to the underlying disease. However, complications are unexpected events not intrinsic to the procedure, whereas sequelae are inherent to the procedure. Failures are events in which the purpose of the procedure is not fulfilled. We propose a classification of complications based on four grades: Grade I complications are alterations from the ideal postoperative course, non-life-threatening, and with no lasting disability. Complications of this grade necessitate only bedside procedures and do not significantly extend hospital stay. Grade II complications are potentially life-threatening but without residual disability. Within grade II complications a subdivision is made according to the requirement for invasive procedures. Grade III complications are those with residual disability, including organ resection or persistence of life-threatening conditions. Finally, grade IV complications are deaths as a result of complications. To illustrate the relevance of the classification, we reviewed 650 cases of elective cholecystectomy. Risk factors for development of complications were determined, and the classification was also used to analyze the value of a modified APACHE II as a preoperative prognostic score. Both supported the relevance of the proposed classification. The advantages of such a classification are (1) increased uniformity in reporting results, (2) the ability to compare results of two distinct time periods in a single center, (3) the ability to compare results of surgery between different centers, (4) the ability to compare results of surgical versus nonsurgical measures, (5) the ability to perform adequate metaanalysis, (6) the ability to identify objective preoperative risk factors, and (7) the ability to establish preoperative prognostic scores.
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            A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer.

            Radical prostatectomy is widely used in the treatment of early prostate cancer. The possible survival benefit of this treatment, however, is unclear. We conducted a randomized trial to address this question. From October 1989 through February 1999, 695 men with newly diagnosed prostate cancer in International Union against Cancer clinical stage T1b, T1c, or T2 were randomly assigned to watchful waiting or radical prostatectomy. We achieved complete follow-up through the year 2000 with blinded evaluation of causes of death. The primary end point was death due to prostate cancer, and the secondary end points were overall mortality, metastasis-free survival, and local progression. During a median of 6.2 years of follow-up, 62 men in the watchful-waiting group and 53 in the radical-prostatectomy group died (P=0.31). Death due to prostate cancer occurred in 31 of 348 of those assigned to watchful waiting (8.9 percent) and in 16 of 347 of those assigned to radical prostatectomy (4.6 percent) (relative hazard, 0.50; 95 percent confidence interval, 0.27 to 0.91; P=0.02). Death due to other causes occurred in 31 of 348 men in the watchful-waiting group (8.9 percent) and in 37 of 347 men in the radical-prostatectomy group (10.6 percent). The men assigned to surgery had a lower relative risk of distant metastases than the men assigned to watchful waiting (relative hazard, 0.63; 95 percent confidence interval, 0.41 to 0.96). In this randomized trial, radical prostatectomy significantly reduced disease-specific mortality, but there was no significant difference between surgery and watchful waiting in terms of overall survival. Copyright 2002 Massachusetts Medical Society
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              Perioperative outcomes of robot-assisted radical prostatectomy compared with open radical prostatectomy: results from the nationwide inpatient sample.

              Prior to the introduction and dissemination of robot-assisted radical prostatectomy (RARP), population-based studies comparing open radical prostatectomy (ORP) and minimally invasive radical prostatectomy (MIRP) found no clinically significant difference in perioperative complication rates. Assess the rate of RARP utilization and reexamine the difference in perioperative complication rates between RARP and ORP in light of RARP's supplanting laparoscopic radical prostatectomy (LRP) as the most common MIRP technique. As of October 2008, a robot-assisted modifier was introduced to denote robot-assisted procedures. Relying on the Nationwide Inpatient Sample between October 2008 and December 2009, patients treated with radical prostatectomy (RP) were identified. The robot-assisted modifier (17.4x) was used to identify RARP (n=11 889). Patients with the minimally invasive modifier code (54.21) without the robot-assisted modifier were classified as having undergone LRP and were removed from further analyses. The remainder were classified as ORP patients (n=7389). All patients underwent RARP or ORP. We compared the rates of blood transfusions, intraoperative and postoperative complications, prolonged length of stay (pLOS), and in-hospital mortality. Multivariable logistic regression analyses of propensity score-matched populations, fitted with general estimation equations for clustering among hospitals, further adjusted for confounding factors. Of 19 462 RPs, 61.1% were RARPs, 38.0% were ORPs, and 0.9% were LRPs. In multivariable analyses of propensity score-matched populations, patients undergoing RARP were less likely to receive a blood transfusion (odds ratio [OR]: 0.34; 95% confidence interval [CI], 0.28-0.40), to experience an intraoperative complication (OR: 0.47; 95% CI, 0.31-0.71) or a postoperative complication (OR: 0.86; 95% CI, 0.77-0.96), and to experience a pLOS (OR: 0.28; 95% CI, 0.26-0.30). Limitations of this study include lack of adjustment for tumor characteristics, surgeon volume, learning curve effect, and longitudinal follow-up. RARP has supplanted ORP as the most common surgical approach for RP. Moreover, we demonstrate superior adjusted perioperative outcomes after RARP in virtually all examined outcomes. Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SoftwareRole: SupervisionRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: MethodologyRole: Validation
                Role: Data curationRole: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: Data curationRole: InvestigationRole: Methodology
                Role: Data curationRole: InvestigationRole: Methodology
                Role: Data curationRole: Investigation
                Role: Data curationRole: InvestigationRole: MethodologyRole: Writing – original draft
                Role: InvestigationRole: MethodologyRole: Writing – original draft
                Role: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: ValidationRole: Writing – review & editing
                Role: SupervisionRole: Writing – review & editing
                Role: MethodologyRole: SupervisionRole: ValidationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                4 June 2020
                2020
                : 15
                : 6
                Affiliations
                [1 ] Department of Urology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
                [2 ] Department of Urology, Jichi Medical University, Shimotsuke-shi, Tochigi-ken, Japan
                [3 ] Department of Urology, National Center for Global Health, Shinjuku-ku, Tokyo, Japan
                [4 ] Department of Urology, Mitsui Kinen Hospital, Tokyo, Japan
                Brigham and Women's and Harvard Medical School, UNITED STATES
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Article
                PONE-D-19-28595
                10.1371/journal.pone.0234113
                7272059
                32497131
                © 2020 Yamada et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 1, Tables: 4, Pages: 10
                Product
                Funding
                The author(s) received no specific funding for this work.
                Categories
                Research Article
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Medicine and Health Sciences
                Oncology
                Cancer Treatment
                Surgical Oncology
                Medicine and Health Sciences
                Clinical Medicine
                Clinical Oncology
                Surgical Oncology
                Medicine and Health Sciences
                Oncology
                Clinical Oncology
                Surgical Oncology
                Medicine and Health Sciences
                Geriatrics
                People and Places
                Population Groupings
                Age Groups
                Elderly
                Medicine and Health Sciences
                Oncology
                Cancer Treatment
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Reproductive System Procedures
                Prostatectomy
                Radical Prostatectomy
                Medicine and Health Sciences
                Surgical and Invasive Medical Procedures
                Surgical Excision
                Prostatectomy
                Radical Prostatectomy
                Medicine and Health Sciences
                Oncology
                Cancers and Neoplasms
                Genitourinary Tract Tumors
                Prostate Cancer
                Medicine and Health Sciences
                Urology
                Prostate Diseases
                Prostate Cancer
                Biology and Life Sciences
                Population Biology
                Population Metrics
                Life Expectancy
                Medicine and Health Sciences
                Public and Occupational Health
                Life Expectancy
                Custom metadata
                All relevant data are within the manuscript and its Supporting Information files.

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