Systematic Review of Methods for Reporting Combined Outcomes After Radical Prostatectomy and Proposal of a Novel System: The Survival, Continence, and Potency (SCP) Classification

Ficarra, Vincenzo; Sooriakumaran, Prasanna; Novara, Giacomo; Schatloff, Oscar; Briganti, Alberto; Poel, Henk van der; Montorsi, Francesco; Patel, Vip; Tewari, Ashutosh; Mottrie, Alexandre

doi:10.1016/j.eururo.2011.11.042

Cited by 85 publications

(78 citation statements)

References 18 publications

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“…8 A systematic review by Ficarra et al found that 28e92.5% of cases in their series of trifecta system is represented by its application only in preoperatively continent and potent patients who receive bilateral NVB-sparing RP. 27 In this series, 31.3% can apply trifecta system. Currently, there are no standard systems for assessing trifecta outcomes following RP.…”

Section: Clinical Datamentioning

confidence: 97%

The trifecta outcome in 300 consecutive cases of robotic-assisted laparoscopic radical prostatectomy according to D'Amico risk criteria

Yang

Wang

et al. 2013

European Journal of Surgical Oncology (EJSO)

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Section: Clinical Datamentioning

confidence: 97%

The trifecta outcome in 300 consecutive cases of robotic-assisted laparoscopic radical prostatectomy according to D'Amico risk criteria

Yang

Wang

et al. 2013

European Journal of Surgical Oncology (EJSO)

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“…1,2 This surgical approach is aimed at obtaining optimal oncologic result without compromising functional outcomes. 3 Although the former is likely to be achieved in patients affected by clinically localized PCa, the latter still represents a major challenge for practicing urologist, especially in young men with an early-stage PCa. 4,5 In this context, urinary incontinence and erectile dysfunction (ED) represent the most common sequelae after RP.…”

Section: Introductionmentioning

confidence: 99%

Preoperative erectile function is the only predictor of the use of a high number of phosphodiesterase type-5 inhibitors after bilateral nerve-sparing radical prostatectomy

Gandaglia¹,

Gallina²,

Suardi³

et al. 2014

Int J Impot Res

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It is well known that the administration of phosphodiesterase type-5 inhibitors (PDE5-Is) may improve erectile function (EF) recovery after bilateral nerve-sparing radical prostatectomy (BNSRP). The aim of our study was to identify predictors of the use of a high number of PDE5-Is (one or more per week) after surgery among 184 patients taking proerectile medications on demand. At a mean follow-up of 22.7 months, 116 patients (63%) recovered EF. Overall, EF recovery rates at 1- and 2- year follow-up were 47.3% and 65.4%, respectively. Overall, 43 (23.4%) patients used one or more PDE5-Is per week. Preoperative EF was the only predictor of the use of one or more PDE5-Is per week after BNSRP. This held true even after adjusting our analyses for age at surgery, body mass index and EF at 1 month after surgery. Particularly, patients fully potent before surgery had roughly 2.1-fold higher probability of using one or more pills per week compared with their counterparts with some degree of preoperative erectile dysfunction (ED; odds ratio: 2.16; 95% confidence interval: 1.03-4.37). In conclusion, preoperative EF represents the only determinant of the use of a higher number of PDE5-Is after surgery. Patients with better preoperative EF might represent individuals more motivated to achieve satisfactory sexual function after surgery. These observations should provide physicians with better preoperative patient counseling and management of postoperative ED.

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“…Huggins was the fi rst urologist acknowledged by the Nobel Prize in Medicine in 1966 for his fundamental discoveries concerning the hormone dependence of several tumour types, such as prostate and breast cancers. Nevertheless, in his famous lecture at the Stockholm City Hall, he clearly stated that ' despite regressions of great magnitude, it is obvious that there are many failures of endocrine therapy to control the disease ' [ 2 ] . As of today, androgen deprivation therapy is still the mainstay of treatment for advanced prostate cancer [ 3,4 ] but, in virtually all men, the tumour develops mechanisms of resistance to castration within a median of 18 -20 months [ 5 ] .…”

Section: The Trifecta Gives Equal Weighting To Each Endpointmentioning

confidence: 99%

“…[ 1 ] reported a trifecta rate of 76% at 2 years in a case series of 380 patients. Indeed, a recent systematic review reported on 12 separate attempts to calculate a trifecta rate [ 2 ] , including, perhaps predictably, a trifecta nomogram [ 3 ] , as well as an extension of the concept to a ' pentafecta ' , defi ned as the trifecta plus negative surgical margins and no surgical complications [ 4 ] .…”

mentioning

confidence: 99%

The trifecta: great concept, lousy statistic

Vickers

2012

BJU International

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The prostate cancer trifecta neatly encapsulates the idea that radical prostatectomy outcomes are multidimensional and competing. What we want for our patients is not just cure of cancer but recovery of urinary and erectile function; attempts to improve cure rates, by wider resection, can compromise functional recovery just as minimizing the risk of impotence or incontinence, by a more conservative resection, may increase the risk of recurrence.The problem with the trifecta comes when it is used as a statistic, with authors calculating a specifi c trifecta rate. Despite its intuitive appeal, the trifecta is a poor measure of radical prostatectomy outcomes. There are several reasons why the trifecta should not be used as an endpoint in prostate cancer research. These are discussed below. THE TRIFECTA IS STATISTICALLY INVALIDRecurrence and functional recovery occur over time; in statistical terms, they are ' time-to-event ' variables. There are two different types of time-to-event variable, failure and incidence, and it is not straightforward to combine them; yet this is exactly what is required by a trifecta analysis. A patient who recovers erectile and urinary function at 1 year, but recurs at 2 years, would be non-trifecta at 6 months, then go into trifecta at 12 months but then lose trifecta at 24 months. Exacerbating this problem is the fact that patients can lose and regain function repeatedly over time. For example, if we were to use a score of 24 on the International Index of Erectile Function-6 as the criterion for potency, one patient might have consecutive scores of 22, 25, 26, 23, 24, 23; if the patient were continent and recurrence-free, these scores would translate as non-trifecta, trifecta, trifecta, non-trifecta, trifecta, non-trifecta. By contrast, once a patient has recurred he is always considered to have recurred. So the trifecta mixes incidence and failure variables, with the former but not the latter being reversible. THE TRIFECTA IS MEANT TO INCLUDE THREE ENDPOINTS, BUT IS DRIVEN PREDOMINATELY BY ERECTILE OUTCOMESMore men recover urinary as compared with erectile function. In particular, whilst most patients who experience persistent incontinence are also impotent ( ∼ 90% in an informal analysis of data from the Memorial Sloan-Kettering Cancer Center), only a small proportion of patients who regain erectile function report pad use ( ∼ 10%). As a result, urinary outcomes have little effect on trifecta rates. It can also be shown that recurrence also has a smaller effect on trifecta than erectile dysfunction because it is less common. As a simple illustration, imagine that surgeon A has a long-term potency rate of 40% with 90% cancer control; surgeon B has slightly better potency (50%) but much poorer rates of cancer control (72%). Although these are very different outcomes, trifecta rates are identical: 40% × 90% = 50% × 72% = 36%. THE TRIFECTA IS OVERLY INFLUENCED BY SHORT-TERM OUTCOMESRecovery of urinary and erectile function typically occurs in the fi rst year or two after surgery; recurr...

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Systematic Review of Methods for Reporting Combined Outcomes After Radical Prostatectomy and Proposal of a Novel System: The Survival, Continence, and Potency (SCP) Classification

Cited by 85 publications

References 18 publications

The trifecta outcome in 300 consecutive cases of robotic-assisted laparoscopic radical prostatectomy according to D'Amico risk criteria

The trifecta outcome in 300 consecutive cases of robotic-assisted laparoscopic radical prostatectomy according to D'Amico risk criteria

Preoperative erectile function is the only predictor of the use of a high number of phosphodiesterase type-5 inhibitors after bilateral nerve-sparing radical prostatectomy

The trifecta: great concept, lousy statistic

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