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Purpose: To evaluate oncologic parameters of men with bothersome LUTS undergoing surgical treatment with HoLEP or TURP. Methods: Five hundred and eighteen patients undergoing HoLEP ( n = 289) or TURP ( n = 229) were retrospectively analyzed for total PSA, prostate volume, PSA density, history of prostate biopsy, resected prostate weight, and histopathological features. Univariate and multivariate logistic regression models were used to identify independent predictors of incidental PCa (iPCa). Results: Men undergoing HoLEP had a significantly higher total PSA (median 5.5 vs. 2.3 ng/mL) and prostate volume (median 80 vs. 41 cc), and displayed a greater reduction of prostate volume after surgery compared to TURP patients (median 71 vs. 50%; all p < 0.001). With a prevalence of incidental PCa (iPCa) of 15 and 17% for HoLEP and TURP, respectively, the choice of procedure had no influence on the detection of iPCa ( p = 0.593). However, a higher rate of false-negative preoperative prostate biopsies was noted among iPCa patients in the HoLEP arm (40 vs. 8%, p = 0.007). In multivariate logistic regression, we identified patient age (OR 1.04; 95% CI 1.01-1.07, p = 0.013) and PSA density (OR 2.13; 95% CI 1.09-4.18, p = 0.028) as independent predictors for the detection of iPCa. Conclusions: Despite differences in oncologic parameters, the choice of technique had no influence on the detection of iPCa. Increased patient age and higher PSA density were associated with iPCa. A higher rate of false-negative preoperative prostate biopsies was noted in HoLEP patients. Therefore, diagnostic assessment of LUTS patients requires a more adapted approach to exclude malignancy, especially in those with larger prostates. [ABSTRACT FROM AUTHOR]

Abstract: A total of 305 consecutive patients who were treated with the GreenLight HPS laser (American Medical Systems, Minnetonka, Minnesota, USA) at eight international centres since July 2006 were included. This subgroup analysis involved 63 patients in urinary retention, 70 patients on anticoagulants, and 52 patients with prostate volume ≥ 80ml. Observation period was a maximum of 11 mo, and mean follow-up was 4.2 mo (SD: 4.5). For all patients, the changes in maximum flow rate (Qmax), postvoid residual urine, International Prostate Symptom Score, and prostate volume from baseline to follow-up were significant (p <0.001). For those patients in retention prior to therapy, the only significant difference between groups with regard to change from baseline was for Qmax (p <0.001). The use of anticoagulants had no significant effect on changes from baseline values. For those patients with glands ≥ 80ml, the only significant difference in change from baseline was for prostate volume reduction (p <0.001). The rate of complications reported was low in all groups. This study shows that the GreenLight HPS 120-W laser can be used effectively and safely in patients in retention, on anticoagulant therapy, and with large prostates. [Copyright &y& Elsevier]

Abstract: We report the technical recommendations of the International GreenLight User Group on photoselective vaporization of the prostate in men with benign prostatic hyperplasia using the GreenLight HPS system (American Medical Systems, Minnetonka, Minnesota, USA). This high-power system employs a 120-W laser, which is a modification of the previous 80-W potassium-titanyl-phosphate (KTP) laser. The objective of this report is to optimize the efficacy and safety of the procedure by drawing on the experience of this multicentre international group. In this regard, recommendations for training are made, which relate to existing users of the 80-W KTP laser as well as to new laser users. [Copyright &y& Elsevier]

Background Cigarette smoking seems to be associated with prostate cancer (PCa) incidence and mortality. Objective To elucidate the association between pretreatment smoking status, cumulative smoking exposure, and time since smoking cessation and the risk of biochemical recurrence (BCR) of PCa in patients treated with radical prostatectomy (RP). Design, setting, and participants Retrospective analysis of 6538 patients with pathologically node-negative PCa treated with RP between 2000 and 2011. Clinicopathologic and smoking variables, including smoking status, number of cigarettes per day (CPD), duration in years, and time since smoking cessation were collected. Intervention RP without neoadjuvant therapy. Outcome measurements and statistical analysis Univariable and multivariable Cox regression analyses assessed the association between smoking and risk of PCa BCR. Results and limitations Of 6538 patients, 2238 (34%), 2086 (32%), and 2214 (34%) were never, former, and current smokers, respectively. Median follow-up for patients not experiencing BCR was 28 mo (interquartile range 14–42). RP Gleason score ( p = 0.3), extracapsular extension ( p = 0.2), seminal vesicle invasion ( p = 0.8), and positive surgical margins ( p = 0.9) were comparable among the three groups. In multivariable Cox regression analysis, former smokers (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.30–2.04; p < 0.001) and current smokers (HR 1.80, 95% CI 1.45–2.24; p < 0.001) had a higher risk of PCa BCR compared with non-smokers. Smoking cessation for ≥10 yr mitigated the risk of BCR in multivariable analyses (HR 0.96, 95% CI 0.68–1.37; p = 0.84). In multivariable analysis, no significant association between cumulative smoking exposure and risk of BCR could be detected. Limitations of the study include the retrospective design and potential recall bias regarding smoking history. Conclusion Smoking seems to be associated with a higher risk of PCa BCR after RP. The effects of smoking appear to be mitigated by ≥10 yr of cessation. Smokers should be counseled regarding the detrimental effects of smoking on PCa prognosis. Patient summary We investigated the effect of smoking on the risk of prostate cancer recurrence in patients with treated with surgery. We found that former smokers and current smokers were at higher risk of cancer recurrence compared to patients who never smoked; the detrimental effect of smoking was mitigated after 10 yr or more of smoking cessation. We conclude that smokers should be counseled regarding the detrimental effects on prostate cancer outcomes. [ABSTRACT FROM AUTHOR]

Objective: To compare the performance of the Epstein criteria and the Prostate Cancer Research International: Active Surveillance (PRIAS) criteria in the identification of patients eligible for active surveillance (AS) but treated with radical prostatectomy. Materials and Methods: We evaluated the baseline characteristics, final pathologic examination, and prostate-specific antigen follow-up (median 43 months, range 1-118) in a series of 492 consecutive patients with prostate cancer managed by radical prostatectomy without AS from 2001 to 2011 at a single institution. Using the postoperative histologic findings, multivariate analysis was used to identify the preoperative predictors of unfavorable AS selection (Gleason score >6 and/or greater than stage pT2c on the final pathologic examination). Biochemical recurrence-free survival was compared between favorably and unfavorably selected patients. Results: Applying the Epstein and PRIAS criteria, 29.2% and 32.2% of the patients had Gleason score >6 or stage pT3 on final pathologic examination, respectively. After a median follow-up of 35.5 and 38 months, 4.2% and 4.3% of patients developed biochemical recurrence in the Epstein and PRIAS criteria groups, respectively. Patients with unfavorable selection had significantly worse biochemical recurrence-free survival than patients with favorable selection (P <.05). Although the median biopsy core number was 8, a biopsy core number <9 was a significant and independent predictor for unfavorable preoperative AS selection in the PRIAS group. Conclusion: We found a non-negligible risk of underestimating unfavorable cancer in patients theoretically qualifying for AS in our cohort. The current use of a sufficient number of biopsy cores might improve the selection process for AS. [ABSTRACT FROM AUTHOR]

Abstract: Background: Cancer initiation and progression might be driven by small populations of cells endowed with stem cell-like properties. Here we comparatively addressed the expression of genes encoding putative stemness regulators including c-Myc, Klf4, Nanog, Oct4A and Sox2 genes in benign prostatic hyperplasia (BPH) and prostate cancer (PCA). Methods: Fifty-eight PCA and thirty-nine BPH tissues samples were used for gene expression analysis, as evaluated by quantitative real-time polymerase chain reaction (qRT-PCR). The expression of specific Klf4 isoforms was tested by conventional PCR. Klf4 specific antibodies were used for protein detection in a tissue microarray including 404 prostate samples. Results: Nanog, Oct4A and Sox2 genes were comparably expressed in BPH and PCA samples, whereas c-Myc and Klf4 genes were expressed to significantly higher extents in PCA than in BPH specimens. Immunohistochemical studies revealed that Klf4 protein is detectable in a large majority of epithelial prostatic cells, irrespective of malignant transformation. However, in PCA, a predominantly cytoplasmic location was observed, consistent with the expression of a differentially spliced Klf4α isoform. Conclusion: Klf4 is highly expressed at gene and protein level in BPH and PCA tissues but a cytoplasmic location of the specific gene product is predominantly detectable in malignant cells. Klf4 location might be of critical relevance to steer its functions during oncogenesis. [Copyright &y& Elsevier]

Abstract: Arginase 2, inducible- and endothelial-nitric-oxide synthase (iNOS and eNOS), indoleamine 2,3-dioxygenase (IDO) and TGF-β, might impair immune functions in prostate cancer (PCA) patients. However, their expression was not comparatively analysed in PCA and benign prostatic hyperplasia (BPH). We evaluated the expression of these genes in PCA and BPH tissues. Seventy-six patients (42 BPH, 34 PCA) were enrolled. Arginase 2, eNOS and iNOS gene expression was similar in BPH and PCA tissues. TGF-β1 gene expression was higher in BPH than in PCA tissues (p =0.035). IDO gene expression was more frequently detectable (p =0.00007) and quantitatively higher (p =0.00001) in PCA tissues than in BPH. IDO protein, expressed in endothelial cells from both BPH and PCA, was detectable in tumour cells in PCA showing evidence of high specific gene expression. In these patients, IDO gene expression correlated with kynurenine/tryptophan ratio in sera. Thus high expression of IDO gene is specifically detectable in PCA. [Copyright &y& Elsevier]

Abstract: Background: Long-term data of photoselective vaporization of the prostate (PVP) for treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH) is scanty. Objective: Evaluate the long-term efficacy and the complication rate in 80-watt (W) PVP. Design, Setting, and Participants: 500 consecutive patients with LUTS secondary to BPH underwent PVP between September 2002 and April 2007. The mean follow-up was 30.6±16.6 (5.2–60.6) mo. Intervention: All patients underwent 80-W PVP performed by seven surgeons. Measurements: We evaluated perioperative parameters, including operation time, delivered energy, changes of hemoglobin and serum sodium, catheterization, and hospitalization time as well as intraoperative and postoperative complications. Patients presenting for follow-up had data assessed on the International Prostate Symptom Score and quality-of-life questionnaire (IPPS-QoL), maximal flow rate (Qmax), and post-voiding residual volume (Vres). Results and Limitations: Mean patient age was 71.4±9.6 (46–96) yr, with a mean preoperative prostate volume of 56.1±25.3 (10–180) ml. Mean operation time was 66.4±26.8 (10–160) min, and mean energy delivery was 206±94 (2.4–619.0) kJ. Despite ongoing oral anticoagulation in 45% of the patients (n =225), no severe intraoperative complications were observed. Mean catheterization and postoperative hospitalization time was 1.8±1.2 (0–10) and 3.7±2.9 (0–35) d, respectively. The mean IPSS after 3 yr was 8.0±6.2, the QoL score was 1.3±1.3, the Qmax was 18.4±8.0ml/s, and the Vres was 28±42ml. The retreatment rate was 6.8%. Urethral and bladder neck strictures were observed in 4.4% and 3.6% of the patients, respectively. Localized prostate cancer was diagnosed during follow-up in six patients. Conclusion: PVP is a safe and effective procedure for treatment of LUTS secondary to BPH. Patients on ongoing oral anticoagulation can be safely operated on. PVP leads to an immediate and sustained improvement of subjective and objective voiding parameters. The late complication rate is comparable to that of transurethral electroresection of the prostate. [Copyright &y& Elsevier]

Abstract: Objectives: A prototype diode laser was used to evaluate the feasibility and postoperative outcome of diode laser vaporisation of the prostate in patients with bladder outlet obstruction (BOO) necessitating interventional desobstruction. Methods: Ten patients were included in this pilot study. The prostate was vaporised via a side-fire laser fibre (diode laser at 1470nm, 50W; Biolitec-AG, Jena, Germany). IPSS, quality of life, Qmax, and PVR volume were measured pre- and postoperatively and 1 yr after the intervention. Results: Prostate volumes were 35–78ml. A mean 121kJ (61–200kJ) of energy was delivered. No patient had significant blood loss or fluid absorption. Three-way catheters were removed after a median of 33h. Qmax increased from 8.9ml/s (3.6–13.2ml/s) preoperatively to 15.7ml/s (10.5–22ml/s) (p <0.01) postoperatively. After the 12-mo follow-up, Qmax increased to 22.35ml/s (±4.32ml/s; p <0.001). PVR volume changed from a baseline of 243ml to 26.9ml (p <0.001) after 12 mo. Volume reduction was estimated by transrectal ultrasound postoperatively (15cc±6.39), and by PSA levels before surgery (3.8ng/ml±2.3) and after 6 mo (2.64ng/ml±1.51). No patient is incontinent. Two patients required recatheterisation postoperatively on days 1 and 2, respectively. Two patients required TURP within 2 mo. All patients without reintervention have presented for the 1-yr follow-up examination and are satisfied with the outcome. Conclusions: Our preliminary findings indicate that 50-W diode laser vaporisation prostatectomy at 1470nm is feasible and appears to be effective for acutely relieving BOO. [Copyright &y& Elsevier]

Abstract: Objectives: To evaluate quality of life (QoL) after laparoscopic radical prostatectomy (LRP) and investigate whether the learning curve of laparoscopic novices has a negative influence on patients’ QoL. Methods: Evaluation of QoL with the EORTC QLQ C-30 and the PR25 preoperatively (t0) as well as postoperatively after 1–3 mo (t1), 4–6 mo (t2), 7–12 mo (t3), 13–24 mo (t4), and yearly thereafter (t5–t7). Surgeons were grouped according to their prior experience in laparoscopy into experienced and novices. Results: LRP was performed in 343 patients; 268 (78%) participated in the study. The mean patient age was 63.3±6.3 yr; mean PSA, 10.0±9.2ng/ml; mean follow-up, 26 mo. Global health was impaired for t1 (p <0.001) and then returned to baseline. Emotional functioning improved (p <0.001) for t2–t7 versus baseline. Physical functioning remained impaired for t1–t2, and role and social functioning for t1–t6. Only sexual functioning did not return to baseline for t1–t7. Urinary symptoms were worse at t1 and then improved gradually (p <0.001). No significant difference in any QoL domain could be identified for experienced surgeons versus novices except for financial difficulties at t2–t3, which related to social differences. Thirty-one (9%) patients with adjuvant therapy had significantly worse global health, bowel symptoms, urinary symptoms, fatigue, and sexual functioning. Conclusions: The learning curve of laparoscopic novices does not have a negative impact on patients’ QoL. For intermediate- to long-term follow-up, patients reach their baseline or score even better in all domains except for sexual functioning but are significantly impaired if adjuvant treatment is performed. [Copyright &y& Elsevier]

Abstract: Introduction: Recently, some controversy has arisen as to whether pelvic lymphadenectomy is still necessary for patients with prostate cancer who are undergoing radical prostatectomy. We prospectively evaluated the results and morbidity of laparoscopic extended pelvic lymph node dissection in patients with high-risk prostate cancer defined as a serum prostate-specific antigen (PSA) level greater than 10 ng/mL or preoperative biopsy Gleason score of 7 or more. Technical Considerations: In 123 consecutive patients with clinically organ-confined high-risk prostate cancer, laparoscopic extended pelvic lymphadenectomy was performed before laparoscopic radical prostatectomy. The boundaries of the pelvic lymph node dissection were the bifurcation of the common iliac artery superiorly, the node of Cloquet inferiorly, the external iliac vein laterally, and the bladder wall medially. Preparation was done with bipolar forceps and scissors, with meticulous coagulation of all lymphatic tissue. The mean PSA level was 14.8 ng/mL (range 1.5 to 43.4). The mean number of lymph nodes removed was 21 (range 9 to 55). A total of 21 patients (17%) had lymph node metastases. The overall complication rate was 4%. Conclusions: Laparoscopic extended pelvic lymph node dissection is safe and effective. The results and morbidity are equivalent to those of open surgery, with the advantage of a minimally invasive operative technique. [Copyright &y& Elsevier]