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Erectile dysfunction (ED) remains a significant problem in up to 63% of men after robot-assisted radical prostatectomy (RARP). After the discovery of the neurovascular bundle (NVB), additional anatomic description and variation in nerve-sparing (NS) techniques have been described to improve post-RARP ED. However, it remains questionable whether ED rates have improved over time, and this is concerning as competing treatments are introduced that have better ED outcomes. In this review, we describe RARP NS technical modifications that improve erectile function recovery. We focused on reports that included detailed anatomical descriptions as well as video illustrations to disseminate technique. We found that the alternative RARP NS surgical techniques provide better outcomes compared with standard NS RARP. The use of validated quality of life questionnaires is necessary for the appropriate comparison of outcomes. However, the retrospective character and inherent weaknesses of the included studies do not allow one to conclude which is the best NS approach. Overall, there is significant variation in RARP NS techniques and outcomes, and the ideal technical maneuvers to optimize outcomes remains subject to debate. However, there is a consensus on the importance of anatomically dissecting the NVB, minimizing traction and thermal injury as well as preserving the periprostatic fascia. Well-designed randomized controlled trials with videos describing details of different surgical techniques for generalizability are needed to consistently and objectively evaluate sexual function outcomes after RARP to optimize postoperative potency.

Purpose: Salvage radical prostatectomy is rare due to the risk of postoperative complications. We compare salvage Retzius-sparing robotic assisted radical prostatectomy (SRS-RARP) with salvage standard robotic assisted radical prostatectomy (SS-RARP). Materials and Methods: A total of 72 patients across 9 centers were identified (40 SRS-RARP vs 32 SS-RARP). Demographics, perioperative data, and pathological and functional outcomes were compared using Student's t-test and ANOVA. Cox proportional hazard models and Kaplan-Meier curves were constructed to assess risk of incontinence and time to continence. Linear regression models were constructed to investigate postoperative pad use and console time. Results: Median followup was 23 vs 36 months for SRS-RARP vs SS-RARP. Console time and estimated blood loss favored SRS-RARP. There were no differences in complication rates or oncologic outcomes. SRS-RARP had improved continence (78.4% vs 43.8%, p 0-1 pad (HR 0.28, 95% CI 0.10-0.79, p=0.016), although not when defined as >0 pad (HR 0.56, 95% CI 0.31-1.01, p=0.053). On adjusted analysis SRS-RARP was associated with decreased pads per day. Lymph node dissection and primary treatment with stereotactic body radiation therapy were associated with longer console time. Conclusions: SRS-RARP is a feasible salvage option with significantly improved urinary function outcomes. This may warrant increased utilization of SRS-RARP to manage men who fail nonsurgical primary treatment for prostate cancer.

Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has been shown to improve continence. However, questions remain regarding feasibility and generalizability of technique and outcomes.To compare the outcomes of 140 consecutive standard robot-assisted radical prostatectomy (S-RARP) versus RS-RARP.A total of 70 S-RARPs were performed followed by 70 RS-RARPs. Demographic, pathologic, and functional outcomes were compared preoperatively and through 12 mo. Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) was used to compare functional outcomes. Logistic and linear regression analyses were utilized to analyze variables associated with EPIC-CP urinary incontinence and overall quality of life (QOL) scores, and oncologic outcomes. Cox regression analysis was used to analyze incontinence at 12 mo.RS-RARP versus S-RARP.Patient and tumor characteristics (age, body mass index, prostate-specific antigen, Charlson Comorbidity Index, Gleason group, clinical stage, and Prostate Imaging Reporting and Data System score), perioperative outcomes (console time, estimated blood loss, postoperative complications, and length of stay), oncologic outcomes (positive surgical margin [PSM], and biochemical recurrence), overall and 12-mo continence rates (zero pads and zero to one safety pad), time to continence, potency (erection sufficient for sexual activity), EPIC-CP urinary incontinence, sexual function, and overall QOL scores.Median follow-up for S-RARP versus RS-RARP was 46.3 versus 12.3 mo. RS-RARP versus S-RARP had improved overall continence rates at total follow-up (95.7% vs 85.7%, p = 0.042) and 12-mo follow-up (97.6% vs 81.4%, p = 0.002), and faster return to continence (zero to one safety pad, 44 vs 131 d, p 0.001). RS-RARP EPIC-CP urinary incontinence and overall QOL scores remained significantly better at 12 mo. There were no differences in overall PSM rates, although RS-RARP had lower rates of nonfocal PSMs. There were no differences in sexual function. In multivariate analysis, RS-RARP was significantly associated with improved 12-mo EPIC-CP urinary incontinence and improved QOL scores, but was not associated with PSM or biochemical recurrence. Limitations include retrospective study design and unequal follow-up; however, significantly better RS-RARP continence at 12 mo is striking despite fewer patients attaining 12-mo follow-up.RS-RARP significantly improves early and long-term continence without compromising oncologic outcomes and leads to overall improved QOL.Retzius-sparing robot-assisted radical prostatectomy is an emerging technique for robotic radical prostatectomy that improves urinary function and quality of life without compromising cancer control.

Radical prostatectomy has undergone many adaptations since its inception, including the Retzius-sparing robotic-assisted radical prostatectomy approach. In this article, we review the origins of radical prostatectomy, the theoretic basis for Retzius-sparing robotic-assisted radical prostatectomy, and outline the key steps of the procedure. To date, there have been 9 studies comparing the outcomes of Retzius-sparing robotic-assisted radical prostatectomy with standard robotic-assisted radical prostatectomy, which have demonstrated improved continence outcomes for Retzius sparing robotic assisted radical prostatectomy within the first year and equivalent oncologic efficacy out to 18 months. Further research is needed to evaluate sexual function outcomes as well as long-term oncologic outcomes.

Background Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) has improved urinary function compared with standard robotic-assisted radical prostatectomy (S-RARP). As RS-RARP spares the dorsal vascular complex, pelvic fascia, and anterior abdominal fascia, it may also lower the incidence of “neglected” postprostatectomy sequelae such as penile shortening, Peyronie’s disease, and inguinal hernias. Objective To determine whether there are patient-perceived differences in penile shortening, Peyronie’s disease, and inguinal hernia rates among men undergoing RS-RARP versus S-RARP. Design, setting, and participants Researchers uninvolved in clinical care and blinded to surgical approach surveyed 60 RS-RARP versus 57 S-RARP men with validated patient-reported items to assess penile shortening, Peyronie’s disease, and inguinal hernia sequelae following surgery. Intervention RS-RARP versus S-RARP. Outcome measurements and statistical analysis Univariate differences between the two cohorts were analyzed using Student t test. Logistic regression was used to analyze variables associated with postoperative penile shortening. Cox proportional hazards models were used to assess the risk of developing Peyronie’s disease and inguinal hernia postoperatively. Results and limitations RS-RARP was associated with less patient-reported penile shortening (41.7% vs 64.9%, p = 0.012), Peyronie’s disease (0% vs 8.7%, p = 0.020), and inguinal hernia (0.0% vs 13.0%, p = 0.004). In adjusted analyses, RS-RARP (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.09–0.63, p = 0.004) was associated with lower odds of penile shortening, while a higher body mass index was associated with increased odds of penile shortening (OR 1.13, 95% CI 1.01–1.26, p = 0.037). RS-RARP was not associated with a decreased risk of Peyronie’s disease on Cox proportion hazard model; however, these models are limited due to a limited number of events in our cohort. Limitations include retrospective design, patient-reported outcomes, and small cohorts. Conclusions RS-RARP is associated with less patient-reported penile shortening and may decrease the risk of Peyronie’s disease and postoperative inguinal hernia development. These new findings add to research, showing improved urinary continence and quality of life following RS-RARP; however, a prospective study is needed to validate these findings. Patient summary Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) is an evolving surgical technique for prostate cancer treatment, which has shown improved postoperative urinary control compared with the standard technique, likely due to preservation of natural pelvic anatomy. Our findings suggest that the preservation of normal pelvic anatomy during RS-RARP may also reduce the risk of postprostatectomy penile shortening, Peyronie’s disease, and inguinal hernia., Take Home Message Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) is an evolving surgical technique for prostate cancer treatment that has shown improved postoperative urinary control compared with the standard technique, likely due to the preservation of natural pelvic anatomy. Our findings suggest that the preservation of normal pelvic anatomy during RS-RARP may also reduce the risk of postprostatectomy penile shortening, Peyronie’s disease, and inguinal hernia.

OBJECTIVE: Retzius-sparing robot-assisted radical prostatectomy (RSP) is a novel approach for radical prostatectomy that was described by our group for the first time in 2010 and is spreading all around the world. The aim of the present study was to assess the effect of surgical experience (SE) on perioperative, functional and oncological outcomes during the first 50 RSP cases performed by a naive surgeon for this novel approach. MATERIALS AND METHODS: We retrospectively evaluated the initial cases operated by 14 surgeons in 12 different international centers. Pre-, peri- and post- operative features of the first 50 patients operated by each surgeon in all the participating centers were collected. The effect of the SE on perioperative, functional and oncological outcomes was firstly evaluated after stratification of surgical experience in initial (≤25) and expert cases (>25) and after using locally weighted scatter-plot smoother (LOWESS) function to graphically explore the relationship between SE and the outcomes of interest. RESULTS: We evaluated 626 patients. Median follow-up was 13 months in the first group and 9 months in the second (p=0.002). Preoperative features were overlapping between the two groups. Lower console time (140 min vs 120 minutes, p=0.001) and a trend for lower complications rates (13 vs 5.5%, p=0.038) were observed in the second group. The relationship between SE and console time, immediate urinary continence recovery and Clavien Dindo complications ≥2 was linear without reaching a plateau after 50 cases. Conversely, a non-linear relationship was observed between SE and PSMs. CONCLUSIONS: We reported the first multi-center experience of Retzius-sparing RARP during the learning curve. We found that console time, immediate urinary continence recovery and postoperative complications are optimal from the beginning and further quickly improve during the learning process, while PSMs rates did not clearly enhance over the first 50 cases.

Purpose: Cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer (MIBC). However, NAC is used in less than 20% of patients with MIBC. Our goal is to investigate factors that contribute to underutilization NAC to facilitate more routine incorporation into clinical practice. Materials and Methods: We identified 5,915 patients diagnosed with cT2-T3N0M0 MIBC who underwent RC between 2004 and 2014 from the National Cancer Database. Univariate and multivariable models were created to identify variables associated with NAC utilization. Results: Only 18.8% of patients received NAC during the study period. On univariate analyses, NAC utilization was more likely at academic hospitals, US South and Midwest (p

Objective To evaluate the outcomes of men diagnosed with prostate cancer (CaP) following implanted treatments for advanced heart failure. Given the increasingly favorable 10-year life expectancy, MedStar Washington Hospital Center screens heart transplant (HT) candidates for CaP and other malignancies prior to intervention. Methods Men aged 18-90 with available pretransplant Prostate Specific Antigen (PSA) who underwent left ventricular assist device (LVAD) and/or HT at MedStar Washington Hospital Center from 2007 to 2018 were identified. Serum PSA, CaP diagnosis, and treatment were captured and analyzed. Survival was analyzed using Kaplan-Meier curves. Results Data were available for 34 patients. Median age was 53 [IQR = 51-58]. Median follow-up was 77 months (95% CI = 40-87 months). Six men had postimplant elevated PSA (5.3; SD = 8.5) and 4 were diagnosed with CaP. Median age of CaP diagnosis was 59 [IQR = 58.5-62). As of 2018, 31 of the 34 patients were living, and none died from CaP. Five-year survival was 96% in those without CaP and 100% in those with CaP (Figure 2). Conclusion Our cohort represents the largest known cohort with heart failure treated by LVAD and/or HT and CaP. Our median age of 59 at CaP diagnosis is considerably younger than the national median of 66. 1 Of the 4 individuals diagnosed with CaP, 3 had high-grade disease. Given the favorable long-term survival of these patients post-LVAD and/or HT, age-appropriate treatment for CaP should be continued postimplantation.

INTRODUCTION AND OBJECTIVE:The digital rectal exam (DRE), as a component of prostate cancer screening, may have predictive value complementary to or independent of serum prostate-specific antigen (...

Recent clinical trials have investigated the benefit of combining tyrosine kinase inhibitors (TKIs) and cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma. Our goal is to determine whether the perioperative use of TKIs increases the postoperative morbidity following CN in renal cell carcinoma patients. We identified 627 patients with Stage IV renal cell carcinoma who underwent CN from 2007–2010 utilizing the SEER-Medicare database. Eighty-two patients treated with TKIs were matched (3:1) to 246 controls. We calculated 30- and 90-day incidence rates of postoperative complications and mortality. On unadjusted analysis, TKI use prior to CN was associated with higher overall complication rate within 30 days (HR = 2.73, 95% CI: 1.09–6.8) after surgery. On multivariate analysis, perioperative TKI use was independently associated with higher risk for postoperative complications within 30 days (HR = 2.93, 95% CI: 1.17–7.36), as well as 90 days (HR = 1.84, 95% CI: 1.02–3.32) after nephrectomy. A higher Charlson comorbidity index also emerged to represent an independent risk factor for postoperative complications within 30 days (HR = 2.41, 95% CI: 1.44–4.02) and 90 days (HR = 2.23, 95% CI: 1.51–3.29) after nephrectomy. TKI treatment was not associated with an increased postoperative mortality at 30 and 90 days after surgery. Thus, TKI treatment was associated with an increased complication rate but not overall mortality following CN. Our results suggest that renal surgeons should be aware of possibly increased complications following CN in renal cell carcinoma patients, when TKI treatment is administered.

Lymphoceles are common following prostatectomy with lymph node dissection, but the vast majority are asymptomatic. We present a unique case of a large complex lymphocele tracking into the anterior space of Retzius following Retzius sparing prostatectomy and bilateral pelvic lymphadenectomy. The patient initially presented with shortness of breath and subsequent diagnosis of a submassive pulmonary embolism. Further evaluation revealed compression of the iliac vessels by the fluid collection. Following multiple failed attempts of drainage percutaneously, the patient required return to the operating room for peritoneal marsupialization, drainage of fluid collection, and evacuation of large amounts of clot within the collection.

INTRODUCTION AND OBJECTIVE:Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) is reported to improve urinary functional outcomes faster over standard RARP. However, there are reports of...

Primary adenomas are common in the gastrointestinal tract but exceedingly rare on the periurethral surface and vagina. The pathogenesis remains unknown but vaginal adenomas are hypothesized to arise from vaginal adenosis or embryonic cloacal remnants and possess malignant potential. We present a case of a large primary vaginal tubulovillous adenoma in an eighty-one-year-old, likely diethylstilbestrol naïve patient. To the best of our knowledge the patient's 7.4 x 4.5 × 1.4 cm primary vaginal tubulovillous adenoma is the largest ever reported in literature., Highlights - Primary vaginal adenomas in diethylstilbestrol naïve patients are exceedingly rare - Vaginal adenomas have malignant potential and must be fully resected - There is no consensus on management of primary vaginal adenomas

Patients presenting with prostate cancers undergo clinical staging evaluations to determine the extent of disease to guide therapeutic recommendations. Management options may include watchful waiting, surgery, or radiation therapy. Thus, initial risk stratification of prostate cancer patients is important for achieving optimal therapeutic results or cancer cure and preservation of quality of life. Predictive biomarkers for risks of complications or late effects of treatment are needed to inform clinical decisions for treatment selection. Here, we analyzed pre-treatment plasma metabolites in a cohort of prostate cancer patients (N = 99) treated with Stereotactic Body Radiation Therapy (SBRT) at Medstar-Georgetown University Hospital in a longitudinal, quality-of-life study to determine if individuals experiencing radiation toxicities can be identified by a molecular profile in plasma prior to treatment. We used a multiple reaction mass spectrometry-based molecular phenotyping of clinically annotated plasma samples in a retrospective outcome analysis to identify candidate biomarker panels correlating with adverse clinical outcomes following radiation therapy. We describe the discovery of candidate biomarkers, based on small molecule metabolite panels, showing high correlations (AUCs ≥ 95%) with radiation toxicities, suitable for validation studies in an expanded cohort of patients.

Background The incidence of infected urolithiasis is unknown, and evidence describing the optimal management strategy for obstruction is equivocal. Objective To examine the trends of infected urolithiasis in the United States, the practice patterns of competing treatment modalities, and to compare adverse outcomes. Design, setting, and participants A weighted estimate of 396385 adult patients hospitalized with infected urolithiasis was extracted from the Nationwide Inpatient Sample, 1999–2009. Outcome measurements and statistical analysis Time trend analysis examined the incidence of infected urolithiasis and associated sepsis, as well as rates of retrograde ureteral catheterization and percutaneous nephrostomy (PCN) for urgent/emergent decompression. Propensity-score matching compared the rates of adverse outcomes between approaches. Results and limitations Between 1999 and 2009, the incidence of infected urolithiasis in women increased from 15.5 (95% confidence interval [CI], 15.3–15.6) to 27.6 (27.4–27.8)/100 000); men increased from 7.8 (7.7–7.9) to 12.1 (12.0–12.3)/100000. Rates of associated sepsis increased from 6.9% to 8.5% ( p =0.013), and severe sepsis increased from 1.7% to 3.2% ( p p =0.150). Among those undergoing immediate decompression, 113 459 (28.6%), PCN utilization decreased from 16.1% to 11.2% ( p =0.001), with significant regional variability. In matched analysis, PCN showed higher rates of sepsis (odds ratio [OR]: 1.63; 95% CI, 1.52–1.74), severe sepsis (OR: 2.28; 95% CI, 2.06–2.52), prolonged length of stay (OR: 3.18; 95% CI, 3.01–3.34), elevated hospital charges (OR: 2.71; 95%CI, 2.57–2.85), and mortality (OR: 3.14; 95%CI, 13–4.63). However, observational data preclude the assessment of timing between outcome and intervention, and disease severity. Conclusions Between 1999 and 2009, women were twice as likely to have infected urolithiasis. Rates of associated sepsis and severe sepsis increased, but mortality rates remained stable. Analysis of competing treatment strategies for immediate decompression demonstrates decreasing utilization of PCN, which showed higher rates of adverse outcomes. These findings should be viewed as preliminary and hypothesis generating, demonstrating the pressing need for further study.

Objective To evaluate the use and outcomes of adjuvant radiation therapy (ART) for men with lymph node (LN)-positive disease after radical prostatectomy (RP) using a population-based approach. Patients and Methods Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 1995 to 2007 was used to identify 577 men with LN metastases discovered during RP and absence of distant metastases, of which 177 underwent ART ≤1 year of RP. Propensity score models were used to compare overall mortality and prostate cancer-specific mortality (PCSM) for men that did and those that did not receive ART. Results Men in both groups received adjuvant androgen-deprivation therapy at similar rates after propensity weighting adjustments (33.6% vs 33.7%, P = 0.977). ART was not associated with differences in overall (5.09 vs 3.77 events per 100 person-years, P = 0.153) or PCSM (2.89 vs 1.31, P = 0.090) relative to men who did not receive ART. Conclusions ART after RP in men with LN-positive prostate cancer was not associated with improved overall or disease-specific survival, in contrast to previous single-centre studies. Prospective randomised studies are needed to assess the effectiveness of ART in this patient population.

BACKGROUND Approximately 1.7 million individuals per year are affected with health care-associated infections (HAIs) in the United States. The authors examined trends in the incidence of HAI after major cancer surgery (MCS) and risk factors for HAI to describe the effects of HAI on mortality after MCS. METHODS Patients undergoing 1 of 8 MCS procedures within the Nationwide Inpatient Sample between 1999 and 2009 were identified (n = 2,502,686). Generalized linear regression models were used to estimate the impact of the primary predictors (procedure type, age, sex, race, insurance status, Charlson comorbidity index, hospital volume, and hospital bed size) on the odds of HAI and in-hospital mortality. Trends in incidence were evaluated with linear regression. RESULTS Overall, MCS-associated HAI incidence increased 2.7% per year (P < .001), whereas mortality decreased 1.3% per year (P < .001). Male gender (odds ratio [OR], 1.12, 95% confidence interval [CI], 1.10-1.14), advancing age (OR, 1.02; 95% CI, 1.02-1.02), black race (OR, 1.26; 95% CI, 1.21-1.31), ≥1 comorbidities (OR, from 1.08 [95% CI, 1.04-1.13] to 1.31 [95% CI, 1.27-1.35]), and nonprivate insurance (OR, from 1.18 [95% CI, 1.15-1.22] to 1.67 [95% CI, 1.59-1.76]) were associated with an increased odds of HAI on multivariable analysis. Conversely, increasing hospital volume was associated with lower odds of HAI (OR, 0.999; 95% CI, 0.99-0.99). Patients with MCS-associated HAI had increased odds of mortality (OR, 8.66; 95% CI, 8.51-8.82). CONCLUSIONS Between 1999 and 2009, the incidence of MCS-associated HAI events increased; however, HAI-associated mortality decreased. That said, significant disparities exist in the hospital and demographic attributes associated with MCS-associated HAI, with attendant health policy implications. Moreover, HAI remains detrimentally linked to mortality during hospitalization. Cancer 2013;119:2317–2324. © 2013 American Cancer Society.

Purpose Robotic-assisted laparoscopic prostatectomy (RALP) offers reportedly comparable oncologic outcomes for localized disease compared with open radical retropubic prostatectomy (ORRP). However, the oncologic efficacy of RALP in locally-advanced prostate cancer (PCa) is less clear. We report and compare our experience with RALP and ORRP in men with locally advanced PCa. Methods Patients with locally advanced PCa (stage T3 or greater) were identified in both robotic and open cohorts. Clinicopathologic features including age, clinical stage, prostate-specific antigen, surgical margins, and Gleason score were reviewed. We further examined the incidence of positive surgical margins, the effect of the surgical learning curve on margins, and the need for adjuvant therapy. Results From 1997 to 2010, 1,011 patients underwent RALP and 415 patients were identified who underwent radical retropubic prostatectomy (RRP) across four institutions. 140 patients in the RALP group and 95 in the RRP group had locally advanced PCa on final pathology. The overall robotic positive margin rate 47.1% compared with 51.4% in the RRP group. A trend towards a lower positive margin rate was seen after 300 cases in the RALP group, with 66.7% positive margin rate in the first 300 cases compared with 41.8% in the latter 700 cases. In addition, a lower incidence of biochemical recurrence was also noted in the latter cases (30.6% vs. 9.5%). Conclusions Up to 2 out of 3 men undergoing RALP for locally-advanced PCa had positive margins during our initial experience. However, with increasing surgeon experience the overall positive margin rate decreased significantly and was comparable to the positive margin rate for patients with locally advanced disease undergoing ORRP over four academic institutions. We also noted a lower incidence of biochemical recurrence with increasing RALP experience, suggesting better oncologic outcomes with higher volume. Given this data, RALP has comparable oncologic outcomes compared to ORRP, especially with higher volume surgeons.

While higher radical prostatectomy hospital and surgeon volume are associated with better outcomes, the effect of provider volume on health care costs remains unclear. We performed a population based study to characterize the effect of surgeon and hospital volume on radical prostatectomy costs.We used SEER (Surveillance, Epidemiology and End Results)-Medicare linked data to identify 11,048 men who underwent radical prostatectomy from 2003 to 2009. We categorized hospital and surgeon radical prostatectomy volume into tertiles (low, intermediate, high) and assessed costs from radical prostatectomy until 90 days postoperatively using propensity adjusted analyses.Higher surgeon volume at intermediate volume hospitals (surgeon volume low $9,915; intermediate $10,068; high $9,451; p = 0.021) and high volume hospitals (surgeon volume low $11,271; intermediate $10,638; high $9,529; p = 0.002) was associated with lower radical prostatectomy costs. Extrapolating nationally, selective referral to high volume radical prostatectomy surgeons at high and intermediate volume hospitals netted more than $28.7 million in cost savings. Conversely, higher hospital volume was associated with greater radical prostatectomy costs for low volume surgeons (hospital volume low $9,685; intermediate $9,915; high $11,271; p = 0.010) and intermediate volume surgeons (hospital volume low $9,605; intermediate $10,068; high $10,638; p = 0.029). High volume radical prostatectomy surgeon costs were not affected by varying hospital volume, and among low volume hospitals radical prostatectomy costs did not differ by surgeon volume.Selective referral to high volume radical prostatectomy surgeons operating at intermediate and high volume hospitals nets significant cost savings. However, higher radical prostatectomy hospital volume was associated with greater costs for low and intermediate volume radical prostatectomy surgeons.

Although most prostatectomy studies emphasize optimal nerve-sparing dissection planes, subtle technical variation also affects functional outcomes. The impact of minimizing assistant/surgeon tension on urinary function has not been quantified. We assess urinary function after attenuating neurovascular bundle (NVB) and rhabdosphincter tension during robotic-assisted radical prostatectomy (RARP). Retrospective study of prospectively collected data for 268 (RARP-T) versus 342 (RARP-0T) men with versus without tension on the NVB and rhabdosphincter during RARP. Outcomes compared include Expanded Prostate Cancer Index (EPIC) urinary function, estimated blood loss (EBL), operative time, and positive surgical margins (PSM). In unadjusted analysis, men undergoing RARP-T versus RARP-0T were older, had higher biopsy and pathologic Gleason grade, and higher preoperative prostate specific antigen (all p ≤ 0.023). Baseline urinary function was similar. Postoperatively, RARP-0T versus RARP-T was associated with higher 5-month urinary function scores (69.7 versus 64, p = 0.049). In adjusted analyses, RARP-0T versus RARP-T was associated with improved 5-month urinary function [Parameter Estimate (PE) 7.37, Standard Error (SE) 2.67, p = 0.006], while bilateral versus non-/unilateral nerve-sparing was associated with improved 12-month urinary function and continence (both p ≤ 0.035). RARP-0T versus RARP-T was associated with shorter operative times (PE 6.66, SE 1.90, p = 0.001) and higher EBL (PE 20.88, SE 6.49, p = 0.001). There were no significant differences in PSM. While the use of tension aids in dissection of anatomic planes, avoidance of NVB counter-traction and minimizing tension on the rhabdosphincter during apical dissection attenuates neuropraxia and leads to earlier urinary function recovery. Bilateral versus non-/unilateral nerve-sparing also improves urinary function recovery.

Robotic-assisted laparoscopic prostatectomy (RALP) has surged in popularity since US Food and Drug Administration approval in 2000. Advantages include improved visualization and increased instrument dexterity within the pelvis. Obesity and narrow pelves have been associated with increased difficulty during open retropubic radical prostatectomy (RRP), but the robotic platform theoretically allows one to perform a radical prostatectomy despite these challenges. We present an example of a RALP performed following an aborted RRP. A 49-year-old male with intermediate risk prostate cancer and body mass index of 38 kg/m(2) presented for RALP after RRP was aborted by an experienced open surgeon following incision of the endopelvic fascia due to poor visualization, a prominent pubic tubercle, and a narrow pelvis. The enhanced visualization and precision of the robotic platform allowed adequate exposure of the prostate and allowed us to proceed with an uncomplicated prostatectomy, which was not possible to perform easily via an open approach. The bladder was densely adherent to the pubis and the anterior prostatic contour and apex were difficult to develop due to a dense fibrotic reaction from the previous endopelvic fascia incision. However, we were able to successfully complete RALP with subtle technical modifications. Estimated blood loss was 160 mL and operating time was 145 min. The patient's pathology was significant for a positive peri-prostatic lymph node and he has been referred to radiation oncology for adjuvant radiotherapy and androgen deprivation therapy. At 3 months follow-up he had a prostate-specific antigen level of 0.06 ng/mL, partial erections, and mild urinary incontinence requiring one pad per day. Superior intracorporeal laparoscopic visualization and improved instrument dexterity afforded by the robotic surgical platform may make RALP the preferred approach in obese men or men with difficult pelvic anatomy who are deemed poor RRP candidates.

Although the use of minimally invasive radical prostatectomy (MIRP) has increased, there are few comprehensive population-based studies assessing temporal trends and outcomes relative to retropubic radical prostatectomy (RRP).Assess temporal trends in the utilization and outcomes of MIRP and RRP among US Medicare beneficiaries from 2003 to 2007.A population-based retrospective study of 19 594 MIRP and 58 638 RRP procedures was performed from 2003 to 2007 from the 100% Medicare sample, composed of almost all US men ≥ 65 yr of age.MIRP and RRP.We measured 30-d outcomes (cardiac, respiratory, vascular, genitourinary, miscellaneous medical, miscellaneous surgical, wound complications, blood transfusions, and death), cystography utilization within 6 wk of surgery, and late complications (anastomotic stricture, ureteral complications, rectourethral fistulae, lymphocele, and corrective incontinence surgery).From 2003 to 2007, MIRP increased from 4.9% to 44.5% of radical prostatectomies while RRP decreased from 89.4% to 52.9%. MIRP versus RRP subjects were younger (p0.001) and had fewer comorbidities (p0.001). Decreased MIRP genitourinary complications (6.2-4.1%; p = 0.002), miscellaneous surgical complications (4.7-3.7%; p=0.030), transfusions (3.5-2.2%; p=0.005), and postoperative cystography utilization (40.3-34.1%; p0.001) were observed over time. Conversely, overall RRP perioperative complications increased (27.4-32.0%; p0.001), including an increase in perioperative mortality (0.5-0.8%, p=0.009). Late RRP complications increased, with the exception of fewer anastomotic strictures (10.2-8.8%; p=0.002). In adjusted analyses, RRP versus MIRP was associated with increased 30-d mortality (odds ratio [OR]: 2.67; 95% confidence interval [CI], 1.55-4.59; p0.001) and more perioperative (OR: 1.60; 95% CI, 1.45-1.76; p0.001) and late complications (OR: 2.52; 95% CI, 2.20-2.89; p0.001). Limitations include the inability to distinguish MIRP with versus without robotic assistance and also the lack of pathologic information.From 2003 to 2007, there were fewer MIRP transfusions, genitourinary complications, and miscellaneous surgical complications, whereas most RRP perioperative and late complications increased. RRP versus MIRP was associated with more postoperative mortality and complications.

Study Type – Therapy (prospective cohort) Level of Evidence 2a What's known on the subject? and What does the study add? Despite the increased popularity of emerging therapies for localised prostate cancer, such as cryotherapy and brachytherapy, outcomes data remains sparse beyond single-centre comparative studies. The present study identified that although less costly, cryotherapy was associated with more urinary and ED complications and a greater need for salvage ADT. Conversely, cryotherapy was associated with fewer bowel complications. Patients and providers alike should consider these population-based outcomes when discussing therapeutic options for localised prostate cancer. OBJECTIVE • To compare prostate cryotherapy vs brachytherapy outcomes and costs, as despite the greater popularity of these emerging therapies for localised prostate cancer, outcomes data remains sparse beyond single-centre comparative studies. PATIENTS AND METHODS • Observational study of 10 928 men who underwent primary cryotherapy (943 patients) or brachytherapy (9985) with ≥2 years of follow-up using USA Surveillance, Epidemiology, and End Results (SEER-) Medicare linked data. • Weighted propensity score methods were used. RESULTS • Use of cryotherapy increased four-fold whereas brachytherapy utilization remained the same from 2001 to 2005 (P < 0.001). Men who underwent cryotherapy vs brachytherapy were older (P < 0.001), more likely to be Black (P < 0.001), less likely to live in areas of higher education (P < 0.001), less likely to live in areas with greater income (P < 0.001), and were more likely to live in urban vs rural areas (P= 0.007). • In propensity score-weighted analyses, cryotherapy was associated with more urinary (41.4% vs 22.2%, P < 0.001) and erectile dysfunction (ED) complications (34.7% vs 21.0%, P < 0.001) while brachytherapy was associated with more bowel complications (19.0% vs 12.1%, P < 0.001). • Cryotherapy was associated with greater use of salvage androgen deprivation therapy (ADT; 1.4 vs 0.5 per 100 person-years, P < 0.001), suggesting worse cancer control. • Finally costs were significantly greater for brachytherapy vs cryotherapy ($16 887 vs $12 629 USA dollars, P < 0.001). CONCLUSIONS • Although less costly, cryotherapy was associated with more urinary and ED complications and greater need for salvage ADT. • Conversely, cryotherapy was associated with fewer bowel complications. Patients and providers alike should consider these population-based outcomes when discussing therapeutic options for localised prostate cancer.

Studies comparing pain after minimally invasive vs retropubic and perineal radical prostatectomy are conflicting. We characterized population based outpatient narcotic prescribing patterns after minimally invasive, retropubic and perineal radical prostatectomy.We evaluated outpatient prescription data after minimally invasive, retropubic and perineal radical prostatectomy from 2003 to 2006 using MarketScan®. Baseline and postoperative narcotic prescriptions were identified using the National Drug Code. Total prescribed narcotic strength in morphine sulfate equivalents, the number of prescriptions filled and costs were compared. We performed multivariate analysis adjusted for surgical approach, age, comorbidity, baseline narcotic use, health plan and geographic region.We identified 2,206 minimally invasive, 8,037 retropubic and 463 perineal radical prostatectomies with no differences in baseline narcotic prescription use. Perineal and retropubic operations were associated with greater total morphine sulfate equivalent use than the minimally invasive operation. Perineal prostatectomy was associated with more narcotic refills than minimally invasive and retropubic prostatectomy (42.3% vs 20.2% and 28.9%, respectively, p0.001). Median narcotic costs were lower for minimally invasive than for perineal and retropubic prostatectomy. On adjusted analysis perineal radical prostatectomy, younger age, baseline narcotic use and preferred provider organization health plan were associated with greater morphine sulfate equivalents and narcotic refills while minimally invasive surgery was associated with fewer refills and lower costs but not with total morphine sulfate equivalents. There was significant geographic variation in narcotic use and costs.Postoperatively minimally invasive radical prostatectomy required fewer narcotic refills and had lower narcotic costs while perineal radical prostatectomy required the greatest amount of narcotics. However, minimally invasive vs retropubic radical prostatectomy morphine sulfate equivalent requirements did not differ on adjusted analysis. While our findings support the purported advantage of minimally invasive radical prostatectomy of less postoperative pain, confirmatory prospective studies with objective outcomes are needed.

Although subtle technical variation affects potency preservation during robot-assisted laparoscopic radical prostatectomy (RARP), most prostatectomy studies focus on achieving the optimal anatomic nerve-sparing dissection plane. However, the impact of active assistant/surgeon neurovascular bundle (NVB) countertraction on sexual function outcomes has not been studied or quantified.To illustrate technique and compare sexual function outcomes for nerve sparing without (NS-0C) versus with (NS-C) assistant and/or surgeon NVB countertraction.This is a retrospective study of 342 NS-0C versus 268 NS-C RARP procedures performed between August 2008 and February 2011.RARP.We used the Expanded Prostate Cancer Index Composite (EPIC) sexual function and potency scores, estimated blood loss (EBL), operative time, and positive surgical margin (PSM).In unadjusted analysis, men undergoing NS-0C versus NS-C were older, had worse baseline sexual function, higher biopsy and pathologic Gleason grade, and higher preoperative prostate-specific antigen (PSA) levels (all p ≤ 0.023). However, NS-0C versus NS-C was associated with higher 5-mo sexual function scores (20 vs 10; p0.001), and this difference was accentuated for bilateral intrafascial nerve sparing in preoperatively potent men (35.8 vs 16.6; p0.001). Similarly, 5-mo potency for preoperatively potent men was better with bilateral intrafascial NS-0C versus NS-C (45.0% vs 28.4%; p = 0.039). However, no difference in sexual function or potency was observed at 12 mo. In adjusted analyses, NS-0C versus NS-C was associated with improved 5-mo sexual function (parameter estimate: 10.90; standard error: 2.16; p0.001) and potency (odds ratio: 1.69; 95% confidence interval, 1.01-2.83; p = 0.046). NS-0C versus NS-WC was associated with shorter operative times (p = 0.001) and higher EBL (p = 0.001); however, there were no significant differences in PSM. Limitations include the retrospective, single-surgeon study design and smaller numbers for 12-mo comparison.Reliance on countertraction to facilitate dissecting NVB away from the prostate leads to neuropraxia and delayed recovery of sexual function and potency. Subtle technical modification to dissect the prostate away from the NVB without countertraction enables earlier return of sexual function and potency.

Background Large prostate size, median lobes, and prior benign prostatic hyperplasia (BPH) surgery may pose technical challenges during robot-assisted laparoscopic prostatectomy (RALP). Objective To describe technical modifications to overcome BPH sequelae and associated outcomes. Design, settings, and participants A retrospective study of prospective data on 951 RALP procedures performed from September 2005 to November 2010 was conducted. Outcomes were analyzed by prostate weight, prior BPH surgical intervention ( n =59), and median lobes >1cm ( n =42). Surgical procedure RALP. Measurements Estimated blood loss (EBL), blood transfusions, operative time, positive surgical margin (PSM), and urinary and sexual function were measured. Results and limitations In unadjusted analysis, men with larger prostates and median lobes experienced higher EBL (213.5 vs 176.5ml; p p =0.002), and larger prostates were associated with more transfusions (4 vs 1; p =0.037). Operative times were longer for men with larger prostates (164.2 vs 149.1min; p =0.002), median lobes (185.8 vs 155.0min; p =0.004), and prior BPH surgical interventions (170.2 vs 155.4min; p =0.004). Men with prior BPH interventions experienced more prostate base PSM (5.1% vs 1.2%; p =0.018) but similar overall PSM. In adjusted analyses, the presence of median lobes increased both EBL ( p =0.006) and operative times ( p p =0.014). However, prostate size did not affect EBL, PSM, or recovery of urinary or sexual function. Conclusions Although BPH characteristics prolonged RALP procedure times and increased EBL, prostate size did not affect PSM or urinary and sexual function.

To review the various methods of outcomes assessment used for effectiveness studies comparing retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic prostatectomy (RALP). A review of the peer reviewed literature was performed for reported series of RRP, LRP, and RALP using Pubmed and MEDLINE with emphasis on comparing perioperative, functional, and oncologic outcomes. Common methods used for outcomes assessment were categorized and compared, highlighting the pros and cons of each approach. The majority of the literature comparing RRP, LRP, and RALP comes in the form of observational data or administrative data from secondary datasets. While randomized controlled trials are ideal for outcomes assessment, only one such study was identified and was limited. Non-randomized observational studies contribute to the majority of data, however are limited due to retrospective study design, lack of consistent endpoints, and limited application to the general community. Administrative data provide accurate assessment of operative outcomes in both academic and community settings, however has limited ability to convey accurate functional outcomes. Non-randomized observational studies and secondary data are useful resources for assessment of outcomes; however, limitations exist for both. Neither is without flaws, and conclusions drawn from either should be viewed with caution. Until standardized prospective comparative analyses of RRP, LRP, and RALP are established, comparative outcomes data will remain imperfect. Urologic researchers must strive to provide the best available outcomes data through accurate prospective data collection and consistent outcomes reporting.

Development of new renal tumors or recurrence after radio frequency ablation not amendable for repeat ablation presents a difficult therapeutic dilemma. We report on the outcomes of partial nephrectomy on kidneys previously treated with radio frequency ablation.We performed a chart review of 13 patients who underwent 16 attempted partial nephrectomies following radio frequency ablation. Hospital records and operative reports were reviewed for demographic data, perioperative data and outcomes. The outcomes of the present series were compared to historical controls of published studies in similar patient populations.No cases were converted to radical nephrectomy. Median time from radio frequency ablation to surgery was 2.75 years (range 1 to 7.1). A median of 7 tumors (range 2 to 40) were removed with a median estimated blood loss of 1,500 ml (range 500 to 3,500) and a median operative time of 7.8 hours (range 5 to 10.7). Operative notes commented on the presence of severe fibrosis in the operative field in 12 of 16 cases (75%). There was a modest but statistically significant decrease in renal function. Partial nephrectomy after radio frequency ablation had a higher reoperation rate compared to other series of primary or repeat partial nephrectomies but had the lowest rate of vascular or visceral injuries.Partial nephrectomy on kidneys previously treated with radio frequency ablation is a technically challenging but feasible procedure. Residual or metachronous disease after radio frequency ablation may be salvaged with partial nephrectomy with a modest decrease in renal function. A trend toward a higher chance of reoperation and urine leak after partial nephrectomy after radio frequency ablation may be useful information for the planning and discussion of treatment decisions.

Background: Laparoscopic and robotic simple prostatectomy (SP) have been introduced with the aim of reducing the morbidity of the standard open technique. Objective: To report a large multi-institutional series of minimally invasive SP (MISP). Design, setting, and participants: Consecutive cases of MISP done for the treatment of bladder outlet obstruction (BOO) due to benign prostatic enlargement (BPE) between 2000 and 2014 at 23 participating institutions in the Americas and Europe were included in this retrospective analysis. Intervention: Laparoscopic or robotic SP. Outcome measurements and statistical analysis: Demographic data and main perioperative outcomes were gathered and analyzed. A multivariable analysis was conducted to identify factors associated with a favorable trifecta outcome, arbitrarily defined as a combination of the following postoperative events: International Prostate Symptom Score 15 ml/s, and no perioperative complications. Results and limitations: Overall, 1330 consecutive cases were analyzed, including 487 robotic (36.6%) and 843 laparoscopic (63.4%) SP cases. Median overall prostate volume was 100 ml (range: 89-128). Median estimated blood loss was 200 ml (range: 150-300). An intraoperative transfusion was required in 3.5% of cases, an intraoperative complication was recorded in 2.2% of cases, and the conversion rate was 3%. Median length of stay was 4 d (range: 3-5). On pathology, prostate cancer was found in 4% of cases. Overall postoperative complication rate was 10.6%, mostly of low grade. At a median follow-up of 12 mo, a significant improvement was observed for subjective and objective indicators of BOO. Trifecta outcome was not significantly influenced by the type of procedure (robotic vs laparoscopic; p = 0.136; odds ratio [OR]: 1.6; 95% confidence interval [CI], 0.8-2.9), whereas operative time (p = 0.01; OR: 0.9; 95% CI, 0.9-1.0) and estimated blood loss ( p = 0.03; OR: 0.9; 95% CI, 0.9-1.0) were the only two significant factors. Retrospective study design, lack of a control arm, and limited follow-up represent major limitations of the present analysis. Conclusions: This study provides the largest outcome analysis reported for MISP for BOO/BPE. These findings confirm that SP can be safely and effectively performed in a minimally invasive fashion in a variety of healthcare settings in which specific surgical expertise and technology is available. MISP can be considered a viable surgical treatment in cases of large prostatic adenomas. The use of robotic technology for this indication can be considered in centers that have a robotic program in place for other urologic indications. Patient summary: Analysis of a large data set from multiple institutions shows that surgical removal of symptomatic large prostatic adenomas can be carried out with good outcomes by using robot-assisted laparoscopy.

A middle-aged man with poor access to medical care presented with shortness of breath and 3 years of abdominal distention. On physical examination, he was found to have a palpable mass in the left upper quadrant. He was found to have undiagnosed congestive heart failure with dilated cardiomyopathy, and a CT scan of the abdomen and pelvis revealed a left renal mass. An MRI performed to further characterise the lesion demonstrated a large exophytic mass with a central scar and segmental enhancement originating from the lateral aspect of the left kidney with no evidence of renal vein or caval thrombus (figure 1). Owing to the possibility of renal malignancy, the patient underwent …

Background Obstructive voiding symptoms (OVS) are common following prostate cancer treatment with radiation therapy. The risk of urinary retention (UR) following hypofractionated radiotherapy has yet to be fully elucidated. This study sought to evaluate OVS and UR requiring catheterization following SBRT for prostate cancer. Methods Patients treated with SBRT for localized prostate cancer from February 2008 to July 2011 at Georgetown University were included in this study. Treatment was delivered using the CyberKnife® with doses of 35 Gy-36.25 Gy in 5 fractions. UR was prospectively scored using the CTCAE v.3. Patient-reported OVS were assessed using the IPSS-obstructive subdomain at baseline and at 1, 3, 6, 9, 12, 18 and 24 months. Associated bother was evaluated via the EPIC-26. Results 269 patients at a median age of 69 years received SBRT with a median follow-up of 3 years. The mean prostate volume was 39 cc. Prior to treatment, 50.6% of patients reported moderate to severe lower urinary track symptoms per the IPSS and 6.7% felt that weak urine stream and/or incomplete emptying were a moderate to big problem. The 2-year actuarial incidence rates of acute and late UR ≥ grade 2 were 39.5% and 41.4%. Alpha-antagonist utilization rose at one month (58%) and 18 months (48%) post-treatment. However, Grade 3 UR was low with only 4 men (1.5%) requiring catheterization and/or TURP. A mean baseline IPSS-obstructive score of 3.6 significantly increased to 5.0 at 1 month (p < 0.0001); however, it returned to baseline in 92.6% within a median time of 3 months. Late increases in OVS were common, but transient. Only 7.1% of patients felt that weak urine stream and/or incomplete emptying was a moderate to big problem at two years post-SBRT (p = 0.6854). Conclusions SBRT treatment caused an acute increase in OVS which peaked within the first month post-treatment, though acute UR requiring catheterization was rare. OVS returned to baseline in > 90% of patients within a median time of three months. Transient Late increases in OVS were common. However, less than 10% of patients felt that OVS were a moderate to big problem at two years post-SBRT.

BACKGROUND Molecular markers that can discriminate indolent cancers from aggressive ones may improve the management of prostate cancer and minimize unnecessary treatment. Aberrant DNA methylation is a common epigenetic event in cancers and HOXD3 promoter hypermethylation (H3PH) has been found in prostate cancer. Our objective was to evaluate the relationship between H3PH and clinicopathologic features in screening prostate biopsies. METHODS Ninety-two patients who underwent a prostate biopsy at our institution between October 2011 and May 2012 were included in this study. The core with the greatest percentage of the highest grade disease was analyzed for H3PH by methylation-specific PCR. Correlational analysis was used to analyze the relationship between H3PH and various clinical parameters. Chi-square analysis was used to compare H3PH status between benign and malignant disease. RESULTS Of the 80 biopsies with HOXD3 methylation status assessable, 66 sets were confirmed to have cancer. In the 14 biopsies with benign disease there was minimal H3PH with the mean percentage of methylation reference (PMR) of 0.7%. In contrast, the HOXD3 promoter was hypermethylated in 16.7% of all cancers and in 50% of high risk tumors with an average PMR of 4.3% (P = 0.008). H3PH was significantly correlated with age (P = 0.013), Gleason score (P = 0.031) and the maximum involvement of the biopsy core (P = 0.035). CONCLUSIONS H3PH is associated with clinicopathologic features. The data indicate that H3PH is more common in older higher risk patients. More research is needed to determine the role of this marker in optimizing management strategies in men with newly diagnosed prostate cancer. Prostate 74:714–721, 2014. © 2014 The Authors. The Prostate published by Wiley Periodicals, Inc.

The "July effect" refers to the phenomenon of adverse impacts on patient care arising from the changeover in medical staff that takes place during this month at academic medical centres in North America. There has been some evidence supporting the presence of the July effect, including data from surgical specialties. Uniformity of care, regardless of time of year, is required for patients undergoing major cancer surgery. We therefore sought to perform a population-level assessment for the presence of a July effect in this field.We used the Nationwide Inpatient Sample to abstract data on patients undergoing 1 of 8 major cancer surgeries at academic medical centres between Jan. 1, 1999, and Dec. 30, 2009. The primary outcomes examined were postoperative complications and in-hospital mortality. Univariate analyses and subsequently multivariate analyses, controlling for patient and hospital characteristics, were performed to identify whether the time of surgery was an independent predictor of outcome after major cancer surgery.On univariate analysis, the overall postoperative complication rate, as well as genitourinary and hematologic complications specifically, was higher in July than the rest of the year. However, on multivariate analysis, only hematologic complications were significantly higher in July, with no difference in overall postoperative complication rate or in-hospital mortality for all 8 surgeries considered separately or together.On the whole, the data confirm an absence of a July effect in patients undergoing major cancer surgery.L’effet « juillet » désigne les répercussions négatives que peut avoir sur les soins aux patients le roulement du personnel médical qui survient au cours de ce mois d’été dans les centres médicaux universitaires d’Amérique du Nord. Certaines preuves ont étayé l’existence de l’effet juillet, notamment des données provenant des spéciali tés chirurgicales. Peu importe le temps de l’année, l’uniformité des soins est indispensable pour les patients qui doivent subir des interventions chirurgicales majeures pour le cancer. Nous avons donc voulu effectuer une évaluation à l’échelle des populations au sujet de l’existence d’un effet juillet dans cette branche de la médecine.Nous avons utilisé la base de données Nationwide Inpatient Sample pour extraire les données relatives aux patients soumis à l’une de 8 interventions chirurgicales majeures pour le cancer dans des centres médicaux universitaires entre le 1er janvier 1999 et le 30 décembre 2009. Les principaux paramètres examinés ont été les complications postopératoires et la mortalité perhospitalière. Nous avons effectué des analyses univariées et, par la suite, des analyses multivariées en tenant compte des caractéristiques des patients et des hôpitaux afin de vérifier si la date à laquelle la chirurgie a eu lieu était un prédicteur indépendant des résultats après une chirurgie majeure pour le cancer.L’analyse univariée a révélé que les taux de complications postopératoires globales et de complications des interventions urogénitales et hématologiques plus spécifiquement ont été plus élevés en juillet qu’à d’autres moments de l’année. Toutefois, à l’analyse multivariée, seules les complications des suites d’interventions pour un cancer hématologique ont été significativement plus élevées en juillet, sans différence au plan du taux de complications postopératoires globales ou du taux de mortalité perhospitalière pour les 8 interventions considérées séparément ou ensemble.Globalement, les données confirment l’absence d’un effet juillet chez les patients soumis à une intervention chirurgicale majeure pour un cancer.

Background Stereotactic body radiation therapy (SBRT) delivers high doses of radiation to the prostate while minimizing radiation to adjacent normal tissues. Large fraction sizes may increase the risk of functional decrements. Treatment-related bother may be more important to a patient than treatment-related dysfunction. This study reports on patient-reported outcomes following SBRT for clinically localized prostate cancer. Methods Between August 2007 and July 2011, 228 consecutive hormone-naïve patients with clinically localized prostate cancer were treated with 35–36.25 Gy SBRT delivered using the CyberKnife Radiosurgical System (Accuray) in 5 fractions. Quality of life was assessed using the American Urological Association Symptom Score (AUA) and the Expanded Prostate Cancer Index Composite (EPIC)-26. Urinary symptom flare was defined as an AUA score 15 or more with an increase of 5 or more points above baseline 6 months after treatment. Results 228 patients (88 low-, 126 intermediate- and 14 high-risk) at a median age of 69 (44–90) years received SBRT with a minimum follow-up of 24 months. EPIC urinary and bowel summary scores declined transiently at 1 month and experienced a second, more protracted decline between 9 months and 18 months before returning to near baseline 2 years post-SBRT. 14.5% of patients experienced late urinary symptom flare following treatment. Patients who experienced urinary symptom flare had poorer bowel quality of life following SBRT. EPIC scores for urinary bother declined transiently, first at 1 month and again at 12 months, before approaching pre-treatment scores by 2 years. Bowel bother showed a similar pattern, but the second decline was smaller and lasted 9 months to 18 months. EPIC sexual summary and bother scores progressively declined over the 2 years following SBRT without recovery. Conclusions In the first 2 years, the impact of SBRT on urination and defecation was minimal. Transient late increases in urinary and bowel dysfunction and bother were observed. However, urinary and bowel function and bother recovered to near baseline by 2 years post-SBRT. Sexual dysfunction and bother steadily increased following treatment without recovery. SBRT for clinically localized prostate cancer was well tolerated with treatment-related dysfunction and bother comparable to conventionally fractionated radiation therapy or brachytherapy.

Background Erectile dysfunction after prostate radiation therapy remains an ongoing challenge and critical quality of life issue. Given the higher dose of radiation per fraction using stereotactic body radiation therapy (SBRT) there is concern that post-SBRT impotency would be higher than conventional radiation therapy approaches. This study sought to evaluate potency preservation and sexual function following SBRT for prostate cancer. Methods Between February 2008 and March 2011, 216 men with clinically localized prostate cancer were treated definitively with SBRT monotherapy at Georgetown University Hospital. Potency was defined as the ability to have an erection firm enough for intercourse with or without sexual aids while sexual activity was defined as the ability to have an erection firm enough for masturbation and foreplay. Patients who received androgen deprivation therapy (ADT) were excluded from this study. Ninety-seven hormone-naïve men were identified as being potent at the initiation of therapy and were included in this review. All patients were treated to 35–36.25 Gy in 5 fractions delivered with the CyberKnife Radiosurgical System (Accuray). Prostate specific antigen (PSA) and total testosterone levels were obtained pre-treatment, every 3 months for the first year and every 6 months for the subsequent year. Sexual function was assessed with the Sexual Health Inventory for Men (SHIM), the Expanded Prostate Index Composite (EPIC)-26 and Utilization of Sexual Medication/Device questionnaires at baseline and all follow-up visits. Results Ninety-seven men (43 low-, 50 intermediate- and 4 high-risk) at a median age of 68 years (range, 48–82 years) received SBRT. The median pre-treatment PSA was 5.9 ng/ml and the minimum follow-up was 24 months. The median pre-treatment total serum testosterone level was 11.4 nmol/L (range, 4.4-27.9 nmol/L). The median baseline SHIM was 22 and 36% of patients utilized sexual aids prior to treatment. Although potency rates declined following treatment: 100% (baseline); 68% (6 months); 62% (12 months); 57% (18 months) and 54.4% (24 months), 78% of previously potent patients had erections sufficient for sexual activity at 24 months post-treatment. Overall sexual aid utilization increased from 36% at baseline to 49% at 24 months. Average EPIC sexual scores showed a slow decline over the first two years following treatment: 77.6 (baseline); 68.7 (6 months); 63.2 (12 months); 61.9 (18 months); 59.3 (24 months). All sexual functions including orgasm declined with time. Prior to treatment, 13.4% of men felt their sexual function was a moderate to big problem which increased to 26.7% two years post treatment. Post-treatment testosterone levels gradually decreased with a median value at two year follow-up of 10.7 nmol/L. However, the average EPIC hormonal scores did not illustrate a statistically significant difference two years post-treatment. Review of the radiation doses to the penile bulb in this study, a potential marker of post-treatment sexual function, revealed that the dose was relatively low and at these low doses the percentage of the penile bulb receiving 29.5 Gy did not correlate with the development of ED. Conclusions Men undergoing SBRT monotherapy for prostate cancer report sexual outcomes comparable to those reported for conventional radiation modalities within the first 24 months after treatment. Longer follow-up is required to confirm the durability of these findings.

Objectives Although post–radical prostatectomy (RP) adjuvant radiation therapy (ART) benefits disease that is staged as pT3 or higher, the optimal ART timing remains unknown. Our objective is to characterize the outcomes and optimal timing of early vs. delayed ART. Materials and methods From the Surveillance, Epidemiology and End Results-Medicare data from 1995 to 2007, we identified 963 men with pT3N0 disease receiving early ( n = 419) vs. delayed (4–12 mo after RP, n = 544) ART after RP. Utilizing propensity score methods, we compared overall mortality, prostate cancer–specific mortality (PCSM), bone-related events (BRE), salvage hormonal therapy utilization, and intervention for urethral stricture. We then used the maximal statistic approach to determine at what time post-RP ART had the most significant effect on outcomes of interest in men with pT3N0 disease. Results When compared with delayed ART in men with pT3 disease, early ART was associated with improved PCSM (0.47 vs. 1.02 events per 100 person-years; P = 0.038) and less salvage hormonal therapy (2.88 vs. 4.59 events per 100 person-years; P = 0.001). Delaying ART beyond 5 months is associated with worse PCSM (hazard ratio [HR] 2.3; P = 0.020), beyond 3 months is associated with more BRE (HR 1.6; P = 0.025), and beyond 4 months is associated higher rates of salvage hormonal therapy (HR 1.6; P = 0.002). ART performed after 9 months was associated with fewer urethral strictures (HR 0.6; P = 0.042). Conclusion Initiating ART less than 5 months after RP for pT3 is associated with improved PCSM. Early ART is also associated with fewer BRE and less use of salvage hormonal therapy if administered earlier than 3 and 4 months after RP, respectively. However, ART administered later than 9 months after RP is associated with fewer urethral strictures. Our population-based findings complement randomized trials designed with fixed ART timing.

With the increasing incidence of small renal masses, there is greater use of ablation, nephron sparing surgery and surveillance compared to radical nephrectomy. However, patterns of care in the use of posttreatment imaging remain uncharacterized. The purpose of this study is to determine the rate of posttreatment imaging after various treatments for small renal mass.Using SEER (Surveillance, Epidemiology and End Results)-Medicare data during 2005 to 2009, we identified 1,682 subjects diagnosed with small renal mass and treated with open partial nephrectomy (330), minimally invasive partial nephrectomy (160), open radical nephrectomy (404), minimally invasive radical nephrectomy (535), thermal ablation (212) and surveillance (42). Use of imaging was compared within 24 months of treatment and multivariate regression models were constructed to identify factors associated with increased imaging use.On adjusted analyses thermal ablation was associated with almost eightfold greater odds of surveillance imaging compared with open radical nephrectomy (OR 7.7, 95% CI 1.01-59.4). Specifically, thermal ablation was associated with increased computerized tomography (OR 5.28) and magnetic resonance imaging (OR 2.19) use and decreased ultrasound use (OR 0.59). Minimally invasive partial nephrectomy (OR 3.28) and open partial nephrectomy (OR 3.19) were also associated with increased computerized tomography use to a lesser extent.Subjects undergoing nephron sparing surgery undergo more posttreatment imaging compared to open radical nephrectomy. Although possibly associated with lower morbidity, thermal ablation is associated with significantly greater use of imaging compared to other small renal mass treatments. This may increase costs and radiation exposure, although further study is needed for confirmation.

INTRODUCTION AND OBJECTIVES: Gleason score from biopsy specimens is important for prostate cancer risk stratification and influences treatment decisions. Gleason score upgrading (GSU) between biopsy and surgical pathology specimens has been reported as high as 50% and presents a challenge in counseling low-risk patients. While recent studies have investigated predictors of GSU, populations in these studies have been largely Caucasian. We report our analysis of predictors of GSU in a large urban African-American population across two institutions. METHODS: A total of 959 patients with DAEAmico low risk prostate cancer underwent radical prostatectomy at our institution between January 2005 and July 2012. Race, age, PSA, body mass index, CAPRA score and TRUS biopsy characteristics (number of reported biopsy cores showing adenocarcinoma, highest percent of biopsy core positive for adenocarcinoma, and measured TRUS prostate volume) were analyzed with both univariate and multivariate analysis to identify significant predictors of GSU while controlling for clinical parameters. RESULTS: Of the 959 cases, 288 (30.0%) were upgraded on final pathologic specimen, while the remaining 671 had the same Gleason sum as the preoperative biopsy. (Table 1) Our patient population consisted of 40.0% African-Americans and 42.0 of the AfricanAmerican population showed GSU. Mean Gleason score for those who were upgraded was 7.24. Upon univariate and multivariate analysis, BMI, total positive biopsy cores, percent of core involved with cancer, CAPRA score, and smaller prostate volume were statistically significant in the upgraded cohort. Patients who upgraded tended to be of higher BMI and of African-American descent in our analysis. Transrectal biopsies of these patients showed smaller prostate volumes but higher cores positive with high % disease per core. CONCLUSIONS: More than a quarter of low-risk prostate cancer patients were upgraded on final pathology in our series. Higher BMI and CAPRA score, smaller prostate volume and total number of cores and percent of cores involved were independent predictors of GSU. Individuals, especially African-Americans, with those clinical parameters may harbor occult high-grade disease and should be carefully counseled on treatment decisions.

Purpose Due to varying clinical definitions of lower urinary tract symptoms, it has been difficult to determine comparable prevalence and incidence rates of lower urinary tract symptoms and their treatment modalities. We assessed the incidence of emergency department visits in men with lower urinary tract symptoms who presented to emergency departments in the United States and factors associated with an increased likelihood of hospitalization. Materials and Methods Emergency department visits from 2006 to 2009 associated with a primary diagnosis of lower urinary tract symptoms using established criteria were abstracted from the Nationwide Emergency Department Sample. Age adjusted incidence rates of emergency department visits and charges were calculated. We performed multivariable analysis to examine patient and hospital characteristics of those hospitalized and those with benign prostatic hyperplasia related adverse events. Results A weighted estimate of 1,178,423 emergency department visits for lower urinary tract symptoms was recorded with a national incidence of 197.6/100,000 males per year. A total of 112,288 visits (9.5%) resulted in hospitalization. Adverse events were identified in 734,269 patients (62.3%). The most common adverse events were catheterization in 44.6% of cases, infection in 17.4%, hematuria in 9.6%, bladder stones in 1.7%, hydronephrosis in 1.2% and acute renal failure in 0.1%. On multivariable analysis independent predictors of hospital admission included comorbidities, socioeconomic status, hospital characteristics and adverse events such as sepsis, acute renal failure and hydronephrosis. Independent predictors of adverse events included patient age, year of visit, socioeconomic status, hospital characteristics and concomitant neurological disease. In 2009 total emergency department charges for lower urinary tract symptoms were $494,981,922. Conclusions The number of men with lower urinary tract symptoms who visit the emergency department has remained stable, while emergency department charges have increased by 40%. The rate of adverse events increased during the study period. These findings might suggest over reliance on medical and conservative therapy in the contemporary era.

Purpose of review The advent of robotic-assisted radical prostatectomy purported fewer complications including postprostatectomy incontinence (PPI). PPI is associated with worse quality of life. We evaluate recently reported robot-assisted radical prostatectomy surgical techniques aimed at limiting PPI, describe their anatomic basis and summarize their outcomes. Recent findings RARP techniques to reduce PPI include bladder neck preservation, bladder neck reconstruction, urethral length preservation, periurethral suspension stitch, posterior reconstruction, combined anterior and posterior reconstruction, preservation of the endopelvic fascia, complete anterior preservation, selective suturing of dorsal venous complex and nerve sparing approach. Outcomes of reconstructive techniques seem to be conflicting, whereas outcomes of techniques aiming to preserve the native urinary continence system seem to hasten urinary function recovery. However, few of these techniques have been shown to affect long-term urinary continence. Summary Surgical techniques preserving the natural urinary continence mechanism appear to improve short-term urinary continence, whereas techniques reconstructing pelvic anatomy have mixed results. The search for the ideal technique to minimize PPI remains hampered by the lack of prospective multi-institutional studies and the long-term follow up. Although reconstructive techniques are safe with few drawbacks, meticulous surgical technique and preservation of the natural continence mechanism should remain the mainstay of PPI prevention.