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Background: While both seminal vesicle (SVI) and lymph-node invasion (LNI) have been identified as adverse prognostic variables among men undergoing radical prostatectomy (RP), the relative impact of each of these features on subsequent oncologic outcomes has not been well defined. We assessed the impact of LNI on long-term oncologic outcomes among patients with SVI at RP., Methods: We reviewed 19,519 patients who underwent RP and identified 2043 with SVI. Metastasis-free (MFS), cancer-specific (CSS), and overall survival (OS) were estimated for patients with SVI, stratified by the presence and number of pelvic lymph node metastases. Cox proportional hazards models were used to evaluate the independent association of the number of metastatic nodes and lymph node density with oncologic outcomes among patients with SVI, controlling for age, year of surgery, margin status, preoperative PSA, pathologic Gleason score, extraprostatic extension, and use of adjuvant therapies., Results: At a median follow up of 12.1 years (IQR 7.0,18.6), 548 patients developed metastatic disease and 1331 died, including 406 who died from prostate cancer (PCa). We found that, among patients with SVI, the presence of a single positive lymph node was not associated with incrementally adverse oncologic outcomes compared to no nodal metastasis at RP, with 10-year MFS, CSS, and OS rates of 81.3% versus 78.3%(p = 0.18), 86.5% versus 89.8%(p = 0.32), and 72.8% versus 76.7%(p = 0.53), respectively. In contrast, on multivariable analyses, the presence of ≥2 metastatic nodes and a 20% lymph-node density cut off remained independently associated with worse survival., Conclusions: SVI represents an adverse pathologic feature such that the presence of a single positive pelvic lymph node did not further adversely impact prognosis. Meanwhile, a significant number of involved nodes was associated with decreased survival. These findings may aid in risk-stratification as well as clinical trial design for such high-risk patients following surgery., (© 2023. The Author(s), under exclusive licence to Springer Nature Limited.)

Purpose: Vesicourethral anastomotic stenosis after radical prostatectomy is a complication with significant adverse quality-of-life implications. Herein, we identify groups at risk for vesicourethral anastomotic stenosis and further characterize the natural history and treatment patterns., Materials and Methods: Years 1987-2013 of a prospectively maintained radical prostatectomy registry were queried for patients with the diagnosis of vesicourethral anastomotic stenosis, defined as symptomatic and inability to pass a 17F cystoscope. Patients with follow-up less than 1 year, preoperative anterior urethral stricture, transurethral resection of prostate, prior pelvic radiotherapy, and metastatic disease were excluded. Logistic regression was performed to identify predictors of vesicourethral anastomotic stenosis. Functional outcomes were characterized., Results: Out of 17,904 men, 851 (4.8%) developed vesicourethral anastomotic stenosis at a median of 3.4 months. Multivariable logistic regression identified associations with vesicourethral anastomotic stenosis including adjuvant radiation, BMI, prostate volume, urine leak, blood transfusion, and nonnerve-sparing techniques. Robotic approach (OR 0.39, P < .01) and complete nerve sparing (OR 0.63, P < .01) were associated with reduced vesicourethral anastomotic stenosis formation. Vesicourethral anastomotic stenosis was independently associated with 1 or more incontinence pads/d at 1 year (OR 1.76, P < .001). Of the patients treated for vesicourethral anastomotic stenosis, 82% underwent endoscopic dilation. The 1- and 5-year vesicourethral anastomotic stenosis retreatment rates were 34% and 42%, respectively., Conclusions: Patient-related factors, surgical technique, and perioperative morbidity influence the risk of vesicourethral anastomotic stenosis after radical prostatectomy. Ultimately, vesicourethral anastomotic stenosis is independently associated with increased risk of urinary incontinence. Endoscopic management is temporizing for most men, with a high rate of retreatment by 5 years.

Introduction: To develop a technique to collect fluid expressed during robot-assisted radical prostatectomy (RARP) to assess whether malignant cells may have been inadvertently introduced into the surgical field., Methods: Men with clinically localized grade group 2 to 5 prostate adenocarcinoma undergoing RARP were identified. Following bladder neck division, fluid expressed via prostatic urethra during seminal vesicle dissection was aspirated (specimen A). After specimen removal, an ex vivo seminal vesicle aspiration was performed as well (specimen B). Specimens were prepared with ThinPrep (Hologic, Marlborough, MA) and stained with 4 immunohistochemical markers: keratin-7, PAX-8, prostate-specific antigen (PSA), and prostatic acid phosphatase (PACP)., Results: Between December 2018 and May 2019, 15 men undergoing RARP were included. Median age was 60 years (range: 47-77), median PSA 8.5 ng/ml (range 5.1-24), and 7 (47%) had AUA high-risk disease. Specimen A had adequate cellularity in 13 patients (87%). Five patients were excluded from assessment of malignancy due to acellularity of specimen A (n = 2) or specimen B (n = 3). Three of the remaining 10 patients (30%) had cytologic features suspicious for malignancy on specimen A. Immunohistochemistry supported prostatic origin with positive PSA and PACP staining and negative PAX8 stains. Specimen B was not suspicious in any patient., Conclusion: We report a technique for intraoperative collection of fluid expressed during RARP. Three patients with adverse pathologic features had evidence of cancer cells within the operative field. Further work is needed to confirm this observation and to determine whether these cells are associated with adverse oncologic outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: We evaluated the natural history and long-term outcomes of incidentally detected prostate cancer (PCa) at radical cystectomy (RC) for bladder cancer (BCa)., Patients and Methods: We identified 1,640 male patients who underwent RC between 1992 and 2012. Patients were stratified as clinically insignificant and clinically significant PCa, based on Grade Group (GG) 1 and ≥2, respectively. Survival was assessed using the Kaplan-Meier method., Results: There were 329 (20%) patients with incidentally detected PCa at RC: 245 (15%) GG1, 52 (3.2%) GG2, 20 (1.2%) GG3, 6 (0.4%) GG4, and 6 (0.4%) GG5. Median follow-up among survivors was 9.6 years (interquartile range 7.5-13.3), during which time 253 patients died, of whom 127 died of BCa and 1 died of PCa. Nine patients experienced biochemical recurrence (BCR), 4 underwent salvage PCa therapies, and 2 developed PCa metastases. Patients with clinically significant PCa were significantly more likely to experience BCR (6% vs. 1.6%; P = 0.04) and had shorter median time to BCR (1.8 vs. 10.4 years; P = 0.01) than those with clinically insignificant PCa. No patients with BCR had greater than pT2N0 BCa or positive BCa margins. Ten-year PCa-specific survival, BCa-specific survival, other cause-specific survival, and overall survival were 99%, 57%, 63%, and 35%, respectively., Conclusions: In a large RC series, we note a 20% rate of incidental PCa, the majority of which are clinically insignificant. On long-term follow-up, we determined that BCR and PCa mortality are extremely rare events among these patients. Pending validation, future guidelines may consider omission of PCa surveillance for some patients with incidental PCa at RC., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Single-port robotic surgery is being adopted for various surgical procedures. There have been interest in and clinical use of single-port robot-assisted radical prostatectomy (spRARP), but little reported data on feasibility and early outcomes., Objective: To describe our institution's initial experience with spRARP utilizing the da Vinci single-port (SP) robotic system., Design, Setting, and Participants: A retrospective review of the initial experience of three high-volume robotic prostate surgeons performing an spRARP utilizing the da Vinci SP robotic system was carried out., Surgical Procedure: An spRARP using the da Vinci SP robotic system was performed following the traditional retropubic or Retzius-sparing approach., Measurements: Patient demographics, operative time, blood loss, postoperative hospital stay, complications, and catheter duration were obtained and analyzed., Results and Limitations: In a cohort of 49 patients undergoing spRARP, median age was 62yr and prostate-specific antigen 6.4. Of the patients, 35 (71%) had cT1c disease on presentation, 92% had Gleason grade group ≥2 disease, and 85% were pT2 on final pathology. Median operative time was 161min. Median blood loss was 200ml. Seven Retzius-sparing cases were performed. Four Clavien 2 complications occurred (complication rate 8.1%). Median hospital stay was 1d and median catheter duration 7d. Operative time was <200min for all three surgeons by their third case., Conclusions: The da Vinci SP system spRARP is safe and feasible, with acceptable operative time and blood loss. Further research is needed to establish noninferiority to the da Vinci Xi and Si systems, and impact of spRARP on patient-assessed cosmesis and pain., Patient Summary: Robotic prostatectomy using a purpose-built da Vinci single-port robotic system is safe and feasible, and warrants further study to determine whether it can improve patient outcomes., (Copyright © 2019 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Introduction: To determine the impact of time from biopsy to surgery on outcomes following radical prostatectomy (RP) as the optimal interval between prostate biopsy and RP is unknown., Material and Methods: We identified 7, 350 men who underwent RP at our institution between 1994 and 2012 and had a prostate biopsy within one year of surgery. Patients were grouped into five time intervals for analysis: ≤ 3 weeks, 4-6 weeks, 7-12 weeks, 12-26 weeks, and > 26 weeks. Oncologic outcomes were stratified by NCCN disease risk for comparison. The associations of time interval with clinicopathologic features and survival were evaluated using multivariate logistic and Cox regression analyses., Results: Median time from biopsy to surgery was 61 days (IQR 37, 84). Median followup after RP was 7.1 years (IQR 4.2, 11.7) while the overall perioperative complication rate was 19.7% (1,448/7,350). Adjusting for pre-operative variables, men waiting 12-26 weeks until RP had the highest likelihood of nerve sparing (OR: 1.45, p = 0.02) while those in the 4-6 week group had higher overall complications (OR: 1.33, p = 0.01). High risk men waiting more than 6 months had higher rates of biochemical recurrence (HR: 3.38, p = 0.05). Limitations include the retrospective design., Conclusions: Surgery in the 4-6 week time period after biopsy is associated with higher complications. There appears to be increased biochemical recurrence rates in delaying RP after biopsy, for men with both low and high risk disease., Competing Interests: None declared, (Copyright® by the International Brazilian Journal of Urology.)

Objects: This study hypothesized that biopsy Gleason score 8 (b.G.S. 8) disease may dilute the substantial poor risk associated with b.G.S. 9 disease, specifically associated with primary Gleason 5 disease., Materials and Methods: The study reviewed 18,299 patients treated with radical prostatectomy (R.P.) between 1990 and 2011, and identified 1,080 men with b.G.S. 4 + 4 (n = 614, 56.9%), 4 + 5 (n = 347, 32.1%), and 5 + 4 (n = 119, 11%) P.Ca. Variation trends of high risk prostate cancer (H.R.P.Ca.) characteristics were recorded over time: The association of b.G.S. with survival outcomes was assessed using Kaplan Meier and multivariable Cox regression analyses. Median follow-up was 6.1 years (I.Q.R. = 3-10.8)., Results: The number of patients included in H.R.P.Ca. due to their b.G.S. increased consistently over time. On multivariable regression, b.G.S. 4 + 5 and b.G.S. 5 + 4 vs b.G.S. 4 + 4 were found to be independently associated with seminal vesical involvement (Odds ratio [O.R.] = 1.58 and 2.22; p < 0.005), extracapsular extension (O.R. = 1.51 and 1.7; p < 0.02) and surgical margins (O.R. = 1.50 and 2.03; p < 0.01), respectively. Ten-year cancer-specific survival was 83%, 73% and 70% in patients with b.G.S. 4 + 4, 4 + 5 and 5 + 4, respectively (p < 0.01). b.G.S. 4 + 5 and b.G.S. 5 + 4 compared to b.G.S. 4 + 4 were associated with an increased risk of cancer-specific mortality (C.S.M.) (Hazard ratio = 1.76, p = 0.02 and 2.38, p = 0.003, respectively)., Conclusions: B.G.S. 9 and specifically pattern 5 + 4 P.Ca. is associated with substantial disease burden, adverse pathological features and the presence of locally advanced disease, in addition to inferior survival outcomes in comparison to b.G.S. 4 + 4 disease. Distinction of b.G.S. 9 patients from b.G.S. 8 patients at diagnosis may permit more precise pre-treatment risk stratification.

We present the first published case of a pediatric robot-assisted prostatectomy and pelvic lymphadenectomy for refractory prostatic embryonal rhabdomyosarcoma. The patient is a 7-year-old male who had been treated with 3 cycles of chemotherapy and radiation, who underwent prostatectomy and lymphadenectomy for a recurrent mass. Surgery was uncomplicated and yielded negative surgical margins. We highlight the surgical technique and feasibility of utilizing robotic surgery for pediatric prostatectomy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Sarcopenia is associated with inferior perioperative and oncologic outcomes in patients undergoing surgery for multiple malignancies. The purpose of this study was to evaluate the association between sarcopenia and outcomes after radical prostatectomy (RP) for men with prostate cancer., Patients and Methods: Using a representative computed tomographic image from the L3 level, preoperative skeletal muscle indices (SMI) calculated for 698 patients who underwent RP between 2007 and 2010. Patients were classified as sarcopenic if they had a SMI < 55 cm 2 /kg 2 according to international consensus. The associations between sarcopenia and biochemical recurrence (BCR), systemic progression (SP), and all-cause mortality (ACM) were investigated by Cox proportional hazards regression., Results: Sarcopenic patients were older than nonsarcopenic patients (mean age, 63.0 vs. 60.4 years, P < .001) but were otherwise similar with regard to clinical and pathologic characteristics. There was no significant difference in the perioperative complication rate after RP between sarcopenic and nonsarcopenic patients (16.5% vs. 17.4%, P = .82). At a median follow-up after surgery of 6.0 years, 152 patients were diagnosed with BCR, patients were diagnosed with SP, and 50 patients died. In multivariable analysis, the presence of sarcopenia was not significantly associated with the risks of BCR, SP, or ACM. Similar results were obtained when analyzing SMI as a continuous variable., Conclusion: Sarcopenia was not found to be independently associated with perioperative complications or oncologic outcomes after RP. As such, the presence of sarcopenia may not be prognostic marker for inferior outcomes among men with localized prostate cancer undergoing RP., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: We sought to independently validate the AJCC (American Joint Committee on Cancer) 8th edition prostate cancer staging classification, which includes the elimination of pT2 subcategories and the reclassification of patients with prostate specific antigen 20 ng/ml or greater and Gleason Grade Group 5 as stage groups III-A and III-C, respectively., Materials and Methods: We identified 13,839 men who underwent radical prostatectomy at Mayo Clinic between 1987 and 2011 from our institutional registry. Outcomes included biochemical recurrence-free, metastasis-free and cancer specific survival. Kaplan-Meier analyses and Cox regression models with the c-index were used., Results: Median followup was 10.5 years (IQR 7.1-15.3). Among patients with pT2 prostate cancer the subclassification demonstrated limited discrimination for biochemical recurrence-free, metastasis-free and cancer specific survival (c-index 0.531, 0.545 and 0.525, respectively). At the same time patients with 7th edition stage group II prostate cancer and prostate specific antigen 20 ng/ml or greater had significantly worse 15-year biochemical recurrence-free survival (42.2% vs 58.8%), metastasis-free survival (78.2% vs 88.8%) and cancer specific survival (88.0% vs 94.4%, all p <0.001) than patients with 7th edition stage group II prostate cancer and prostate specific antigen less than 20 ng/ml. However, patients with 7th edition stage group II prostate cancer and prostate specific antigen 20 ng/ml or greater had significantly better 15-year biochemical recurrence-free survival (42.2% vs 31.3%, p = 0.007), metastasis-free survival (78.2% vs 68.0%, p <0.001) and cancer specific survival (88.0% vs 83.4%, p = 0.01) than patients with 7th edition stage group III. Also, patients with 7th edition stage group II prostate cancer and Gleason Grade Group 5 had significantly worse 15-year biochemical recurrence-free survival (37.1% vs 57.9%, p <0.001), metastasis-free survival (63.8% vs 88.5%, p <0.001) and cancer specific survival (73.0% vs 94.3%, p <0.001) than patients with 7th edition stage group II prostate cancer and Gleason Grade Group 1-4 as well as worse 15-year cancer specific survival (73.0% vs 83.4%, p = 0.005) than patients with 7th edition stage group III prostate cancer., Conclusions: Our data support the changes in the new AJCC classification., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate if adjuvant radiation therapy (ART) is associated with improved long-term oncologic outcomes for pT2N0R1 prostate cancer (PCa)., Methods: Men with pT2N0 PCa and a single positive surgical margin following radical prostatectomy and pelvic lymphadenectomy were identified (1987-1996). Men who received ART were matched 1:1 to men who did not receive ART based on age, year of surgery, Gleason score, preoperative prostate-specific antigen, site of positive surgical margin, and DNA ploidy. Biochemical recurrence (BCR), local recurrence, distant metastasis, and overall survival (OS) were compared between groups in time-to-event analyses., Results: The cohort included 152 men (76 per group) with a median follow-up of 20 years (interquartile range 19,22). ART was associated with a lower cumulative incidence of BCR (25% vs 52%; P <.001) and local recurrence (3% vs 12%; P = .03), but no significant differences in cumulative incidence of distant metastasis (10% vs 7%; P = .44) or in probability of OS (56% vs 68%; P = .08) at 20 years. In competing risks models, receipt of ART was associated with reduced risks of BCR (hazard ratio [HR] = 0.40; 95% confidence interval [CI] 0.23-0.70; P <.001) and local recurrence (HR = 0.21; 95% CI .05-0.98; P = .05), but not distant metastasis (HR = 1.56; 95% CI 0.51-4.75; P = .43). In the Cox model, ART was not associated with improved OS (HR = 1.56; 95% CI 0.94-2.57; P = .08)., Conclusion: ART was associated with reduced risks of BCR and local recurrence for men with pT2N0R1 PCa. However, ART was not significantly associated with metastasis-free or OS benefits, as recurrences in these patients generally followed an indolent trajectory with 20 years of median follow-up., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Long-term data supporting the role of primary tumor resection in node positive prostate cancer are lacking. We evaluated the impact of adding radical retropubic prostatectomy to surgical castration on long-term oncologic outcomes in pathological node positive prostate cancer., Materials and Methods: We identified men who underwent pelvic lymphadenectomy and orchiectomy within 90 days for pathological node positive prostate cancer from 1966 to 1995. Men treated with radical retropubic prostatectomy in addition to orchiectomy were matched 1:1 to men who underwent orchiectomy alone based on age, year of surgery, clinical grade, clinical T stage, number of positive nodes and preoperative serum prostate specific antigen, the latter from 1987 and thereafter. Kaplan-Meier and Cox regression analyses were done to compare cancer specific and overall survival., Results: The matched cohort included 158 men with 79 in each group. Of men who underwent orchiectomy alone 76 died, including 60 of prostate cancer. Of patients treated with radical retropubic prostatectomy plus orchiectomy 70 died, including 28 of prostate cancer. On Kaplan-Meier analyses prostatectomy plus orchiectomy vs orchiectomy alone was associated with prolonged cancer specific survival (at 20 years 59% vs 18%, log rank p <0.001) and overall survival (at 20 years 22% vs 9%, log rank p <0.001). In Cox models prostatectomy plus orchiectomy vs orchiectomy alone was associated with improved cancer specific survival (HR 0.28, 95% CI 0.17-0.46, p <0.001) and overall survival (HR 0.48, 95% CI 0.34-0.66, p <0.001). Findings were similar in the subset with available preoperative prostate specific antigen values., Conclusions: With lifelong followup in nearly the entire cohort, this study demonstrates that adding radical retropubic prostatectomy to surgical castration for pathological node positive prostate cancer is associated with improved cancer specific and overall survival. When technically feasible in well selected patients, aggressive locoregional resection should be considered for node positive prostate cancer as part of a multimodal approach., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Radical prostatectomy (RP) for locally advanced prostate cancer may reduce the risk of metastasis and cancer-specific death. Herein, we evaluated the outcomes for patients with pT4 disease treated with RP., Materials and Methods: Among 19,800 men treated with RP at Mayo Clinic from 1987 to 2010, 87 were found to have pT4 tumors. Biochemical recurrence (BCR)-free survival, systemic progression (SP) free survival and overall survival (OS) were estimated using the Kaplan-Meier method and compared with the log-rank test. Cox proportional hazards regression models were used to assess the association of clinic-pathological features with outcome., Results: Median follow-up was 9.8 years (IQR 3.6, 13.4). Of the 87 patients, 50 (57.5%) were diagnosed with BCR, 30 (34.5%) developed SP, and 38 (43.7%) died, with 11 (12.6%) dying of prostate cancer. Adjuvant androgen deprivation therapy was administered to 77 men, while 32 received adjuvant external beam radiation therapy. Tenyear BCR-free survival, SP-free survival, and OS was 37%, 64%, and 70% respectively. On multivariate analysis, the presence of positive lymph nodes was marginally significantly associated with patients' risk of BCR (HR: 1.94; p=0.05), while both positive lymph nodes (HR 2.96; p=0.02) and high pathologic Gleason score (HR 1.95; p=0.03) were associated with SP., Conclusions: Patients with pT4 disease may experience long-term survival following RP, and as such, when technically feasible, surgical resection should be considered in the multimodal treatment approach to these men., Competing Interests: Conflicts of Interest: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Objective: To evaluate the incidence, predictors and oncological outcomes of pT0 prostate cancer (PCa)., Methods: We conducted a retrospective analysis of 20 222 patients undergoing radical prostatectomy (RP) for PCa at the Mayo Clinic between 1987 and 2012. Disease recurrence was defined as follow-up PSA >0.4 ng/mL or biopsy-proven local recurrence. Systemic progression was defined as development of metastatic disease on imaging. Comparisons of baseline characteristics between pT0 and non-pT0 groups were carried out using chi-squared tests. Recurrence-free survival was estimated using the Kaplan-Meier method and compared using the log-rank test., Results: A total of 62 patients (0.3%) had pT0 disease according to the RP specimen. In univariable analysis, pT0 disease was significantly associated with older age (P = 0.045), lower prostate-specific antigen (PSA; P = 0.002), lower clinical stage (P < 0.001), lower biopsy Gleason score (P = 0.042), and receipt of preoperative transurethral resection, hormonal and radiation therapies (all P < 0.001). In multivariable analysis, lower PSA levels, lower Gleason score, and receipt of preoperative treatment were independently associated with pT0 (all P < 0.05). Seven patients (11%) with pT0 PCa developed disease recurrence over a median follow-up of 10.9 years. All seven patients had preoperative treatment(s) and three had recurrence with a PSA doubling time of <9 months. Compared with non-pT0 disease, pT0 disease was associated with longer recurrence-free survival (P < 0.05). Only one (1.6%) patient with pT0 disease developed systemic progression., Conclusions: pT0 stage PCa is a rare phenomenon and is associated with receipt of preoperative treatment and features of low-risk PCa. Although pT0 has a very favourable prognosis, some men, especially those who received preoperative treatment, experience a small but non-negligible risk of disease recurrence and systemic progression., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Purpose: Lymph node positive (pN+) prostate cancer after radical prostatectomy has wide variability in long-term oncologic outcomes. We present a large institutional series with extended followup to create an oncologic risk stratification system that clarifies the prognostic heterogeneity for patients with pN+ disease after radical prostatectomy., Materials and Methods: Men with pN+ prostate cancer after radical prostatectomy during 1987 to 2012 were included in the study. Regression models were created to identify significant predictors of biochemical recurrence, metastasis, cancer specific mortality and overall mortality. A cancer specific mortality risk score was then created and internally validated to stratify patients in terms of risk of cancer specific mortality., Results: For our cohort of 1,011 men with a median followup of 17.6 years the 20-year rate of cancer specific mortality was 31%. On multivariate Cox regression modeling 3 or more positive nodes (HR 1.75, p=0.003), pathological Gleason score 7 vs 6 (HR 1.74, p=0.04) and 8-10 vs 6 (HR 2.63, p=0.001), and positive surgical margins (HR 1.96, p=0.001) were significantly associated with increased cancer specific mortality, while adjuvant radiotherapy (HR 0.40, p=0.008) was associated with decreased cancer specific mortality. A cancer specific mortality risk score was then created using these 4 variables to stratify patients with markedly different prognoses, yielding 20-year cancer specific mortality rates of 19.1% vs 34% vs 46% (p <0.001) for low, intermediate and high risk categories, respectively., Conclusions: The prognosis of patients with pN+ prostate cancer varied significantly after radical prostatectomy. A risk score created using the number of positive nodes, pathological Gleason score, margin status and adjuvant radiotherapy status successfully separated patients into low, intermediate and high risk groups., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Multiple definitions of biochemical recurrence for prostate cancer exist after radical prostatectomy, and variation continues in prostate cancer outcome reporting and secondary treatment initiation. We reviewed long-term prostatectomy outcomes to assess the most appropriate prostate specific antigen cut point that predicts future disease progression., Materials and Methods: We identified 13,512 patients with cT1-2N0M0 prostate cancer who underwent radical prostatectomy between 1987 and 2010. Single prostate specific antigen cut points of 0.2, 0.3, 0.4 and 0.5 ng/ml or greater, as well as confirmatory prostate specific antigen value definitions of 0.2 ng/ml or greater followed by prostate specific antigen greater than 0.2 ng/ml and 0.4 ng/ml or greater followed by prostate specific antigen greater than 0.4 ng/ml were tested. Continued prostate specific antigen increase after a designated cut point definition was estimated using cumulative incidence. The strength of association between biochemical recurrence definitions and subsequent systemic progression were analyzed using Cox proportional hazard models and the O'Quigley event based R(2) test., Results: At a median postoperative followup of 9.1 years (IQR 4.9-14.3) a detectable prostate specific antigen developed in 5,041 patients and systemic progression developed in 512. After reaching the prostate specific antigen cut point of 0.2, 0.3 and 0.4 ng/ml, the percentage of patients experiencing a continued prostate specific antigen increase over 5 years was 61%, 67% and 74%, respectively, plateauing at 0.4 ng/ml. The strongest association between biochemical recurrence and systemic progression occurred using a single prostate specific antigen cut point of 0.4 ng/ml or greater (HR 36, R(2) 0.92)., Conclusions: A prostate specific antigen cut point of 0.4 ng/ml or greater reflects the threshold at which a prostate specific antigen increase becomes durable and shows the strongest correlation with subsequent systemic progression. Consideration should be given to using a prostate specific antigen of 0.4 ng/ml or greater as the standard biochemical recurrence definition after radical prostatectomy., (Copyright © 2016 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Telemedicine in an ambulatory surgical population remains incompletely evaluated., Objective: To investigate patient encounters in the outpatient setting using video visit (VV) technology compared to traditional office visits (OVs)., Design, Setting, and Participants: From June 2013 to March 2014, 55 prescreened men with a history of prostate cancer were prospectively randomized. VVs, with the patient at home or at work, were included in the outpatient clinic calendar of urologists., Intervention: Remote VV versus traditional OV., Outcome Measurements and Statistical Analysis: An equivalence analysis was used to assess the primary outcome, visit efficiency as measured by time studies. Secondary outcomes were patient/provider satisfaction and costs., Results and Limitations: There were 28 VVs and 27 OVs. VVs were equivalent in efficiency to relative to OVs, as measured by patient-provider face time (mean 14.5 vs 14.3min; p=0.96), patient wait time (18.4 vs 13.0min; p=0.20), and total time devoted to care (17.9 vs 17.8min; p=0.97). There were no significant differences in patient perception of visit confidentiality, efficiency, education quality, or overall satisfaction. VVs incurred lower costs, including distance traveled (median 0 vs 95 miles), travel time (0 vs 95min), missed work (0 vs 1 d), and money spent on travel ($0 vs $48; all p<0.0001). There was a high level of urologist satisfaction for both VVs (88%) and OVs (90%). The major limitation was sample size., Conclusions: VV in the ambulatory postprostatectomy setting may have a future role in health care delivery models. We found equivalent efficiency, similar satisfaction, but significantly reduced patient costs for VV compared to OV. Further prospective analyses are warranted., Patient Summary: Among men with surgically treated prostate cancer, we evaluated the utility of remote video visits compared to office visits for outpatient consultation with a urologist. Video visits were associated with equivalent efficiency, similar satisfaction, and significantly lower patient costs when compared to office visits. We conclude that video visits may have a future role in health care delivery models., (Copyright © 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To evaluate survival among patients with urothelial carcinoma (UC) within the prostate in order to assess the impact of depth of tumour invasion as well as the importance of a concurrent bladder tumour., Patients and Methods: We identified 201 patients who underwent radical cystectomy (RC) between 1980 and 2006 and were found to have UC involving the prostate. All specimens were re-reviewed by a genitourinary pathologist. Survival was estimated using the Kaplan-Meier method and compared with the log-rank test. Cox hazard regression models tested the association of clinicopathological variables with outcome., Results: In all, 93 patients had pTis disease in the prostate, 43 had pT2 tumours, and 66 patients were pT4a. The median follow-up was 10.5 years. The 5-year cancer-specific survival for patients with pTis, pT2, and pT4a prostate UC was 73%, 57%, and 21% respectively (P < 0.001). On multivariable analysis, higher prostate tumour stage (hazard ratio [HR] 2.09; P = 0.01), positive lymph node status (HR 2.09; P = 0.002), and concurrent ≥pT3 bladder cancer (HR 4.16; P < 0.001) were significantly associated with an increased risk of death from UC., Conclusions: Among patients with prostatic UC involvement, depth of tumour invasion was significantly associated with cancer-specific mortality, validating the staging reclassification. Concurrent locally advanced bladder cancer also negatively impacted survival, suggesting the potential prognostic value of reporting a secondary tumour stage in such cases., (© 2013 The Authors. BJU International © 2013 BJU International.)

Background: The presence of a positive surgical margin (PSM) at radical prostatectomy (RP) has been linked to an increased risk of biochemical recurrence and receipt of secondary therapy; however, its association with other oncologic end points remains controversial., Objective: To evaluate the association of primary Gleason grade (GG) at the site of PSM with subsequent clinical progression and mortality among patients with Gleason score (GS) 7 prostate cancer (PCa)., Design, Setting, and Participants: We identified 1036 patients who underwent RP between 1996 and 2002. A single uropathologist re-reviewed all specimens noted to have a PSM to record GG at the margin., Outcome Measurements and Statistical Analysis: Survival was estimated using the Kaplan-Meier method. Cox models were used to analyze the association of margin primary GG with outcome., Results and Limitations: Overall, 338 men (33%) had a PSM; of those, 242 had PSM GG3 and 96 had PSM GG4. Median postoperative follow-up was 13 yr. Compared with men with PSM GG3 or a negative SM, we noted that men with PSM GG4 had significantly worse 15-yr systemic progression-free survival (74% vs. 90% vs. 93%, respectively; p<0.001) and cancer-specific survival (86% vs. 96% vs. 97%, respectively; p=0.002). On multivariable analysis, the presence of PSM GG4 was associated with increased risks of systemic progression (hazard ratio [HR]: 2.77; p=0.003) and death from PCa (HR: 3.93; p=0.02) among men with a PSM. Limitations include the relatively small rate of disease recurrence., Conclusions: PSM primary GG4 was independently associated with adverse oncologic outcomes among men with GS7 PCa. Pending external validation, GG at the PSM may be considered for inclusion in pathologic reports and risk stratification following RP., Patient Summary: Among patients with Gleason grade 7 prostate cancer and a positive surgical margin at the time of prostatectomy, we found that higher Gleason grade at the margin was associated with worse oncologic outcomes., (Copyright © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: Our objective is to assess the outcomes of patients with prostate cancer (PCa) diagnoses undergoing holmium laser enucleation of the prostate (HoLEP)., Methods: From 2009 to 2012, 450 patients underwent HoLEP at our institution. We performed a retrospective review of these patients to identify those with PCa., Results: PCa was diagnosed in 57 (12.7%) HoLEP patients: 11 (19.2%) preoperatively, 43 (75.4%) in the operative specimen, and 3 (5.4%) during follow-up. Mean time to PCa development in the postoperative group was 16 months (9-23). There was no difference in patient characteristics for those diagnosed with PCa at the time of HoLEP or in the postoperative period. There were 5 patients with a Gleason score (GS)>8 and 52 with GS<8 PCa. In the operative group, 39 (91%) elected for active surveillance and 4 (9%) elected to have cancer treatment. In subgroup analysis, men diagnosed with GS>8 intraoperatively or postoperatively had significantly elevated preoperative, postoperative, and percent change prostate-specific antigen (PSA) levels when compared to patients diagnosed GS ≤ 7 (P=0.01, 0.02, and 0.01, respectively). There were no complications, all voided spontaneously, and one patient had persistent incontinence., Conclusion: HoLEP for the treatment of lower urinary tract symptoms (LUTS) in selectively chosen men with known PCa can safely improve urination. Furthermore, PCa is diagnosed at the time of or post HoLEP in nearly 12% of patients. Those patients with persistently elevated post HoLEP PSA levels or low percent change PSA levels should raise suspicion for high GS PCa. Finally, HoLEP does not preclude active surveillance or treatment for PCa when appropriate.

Objective: To assess recommendations for prostate-specific antigen (PSA) screening in a national survey of radiation oncologists and urologists following the recent USA Preventive Services Task Force (USPSTF) grade D recommendation., Methods: A random sample of 1366 radiation oncologists and urologists were identified from the American Medical Association Physician Masterfile. From November 2011 to April 2012, a mail survey was sent to query PSA screening recommendations for men at average risk of prostate cancer for the following age groups: 40-49, 50-59, 60-69, 70-74, 75-79 and ≥80 years. Multivariable logistic regression was used to test for differences in PSA-based screening recommendations by physician characteristics., Results: Response rates were similar at 52% for radiation oncologists and urologists (P = 0.92). Overall, 51.5% of respondents recommended PSA-based screening for men aged 40-49 years, while nearly all endorsed it for those aged 50-74 years (96.1% for 50-59, 97.3% for 60-69, and 87.7% for 70-74 years). However, screening recommendations decreased to 43.9% and 12.8% for men aged 75-79 and ≥80 years, respectively. On multivariable analysis, urologists were more likely to recommend screening for men aged 40-49 (odds ratio [OR] 3.09; P < 0.001) and 50-59 years (OR 3.81; P = 0.01), but less likely for men aged 75-79 (OR 0.66; P = 0.01) and ≥80 years (OR 0.45; P = 0.002) compared with radiation oncologists., Conclusion: While radiation oncologists and urologists recommended PSA screening for men aged 50-69 years, there was less agreement about screening for younger (40-49 years old) and older (≥70 years) men at average risk for prostate cancer., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objectives: Determining clinicopathologic features that stratify the risk of disease progression in patients with seminal vesicle invasion at radical prostatectomy remains critical for patient counseling, clinical trial enrollment, and the judicious application of secondary therapies. Then, we evaluated the prognostic significance of concomitant extracapsular extension (ECE) in patients with seminal vesicle invasion and negative lymph nodes at radical prostatectomy., Methods: We identified 1,132 patients who underwent prostatectomy between 1987 and 2009 and were found to have pT3bN0 disease. Median postoperative follow-up was 10.6 years (interquartile range, 5.9-15.3). Survival was estimated using the Kaplan-Meier method and compared for patients with and without ECE with the log-rank test. The association of ECE with outcome was evaluated using Cox proportional hazards regression models., Results: A total of 693 (61%) patients were noted to have ECE. Compared with pT3bN0 patients without ECE, patients with pT3bN0 tumors and ECE had a significantly worse 15-year biochemical recurrence-free survival (29% vs. 39%; P<0.001), systemic progression-free survival (71% vs. 81%; P<0.001), cancer-specific survival (80% vs. 89%; P<0.001), and overall survival (50% vs. 63%; P<0.001). On multivariate analysis, the presence of ECE was associated with significantly increased risks of systemic progression (hazard ratio [HR], 1.56; P=0.006), death from prostate cancer (HR, 1.71; P=0.01), and all-cause mortality (HR, 1.35; P=0.007). Meanwhile, adjuvant hormonal therapy, which was received by 334 patients (29.5%), was associated with significantly decreased risks of systemic progression (HR, 0.50; P=0.0004) and cancer death (HR, 0.57; P=0.03), but not all-cause mortality (HR, 0.81; P=0.09). Limitations included retrospective design and nonstandardized application of secondary treatments., Conclusions: The presence of ECE in patients with pT3bN0 prostate cancer is associated with increased risks of systemic progression and cancer death. Pending validation, ECE may be incorporated into risk stratification or staging classification or both. Meanwhile, these patients continue to represent ideal candidates for adjuvant therapy trials., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Objective: To establish the feasibility of magnetic resonance imaging (MRI)-guided cryoablation in patients with previous radical prostatectomy and MRI visualized biopsy-proven local recurrence of prostate adenocarcinoma., Materials and Methods: Eighteen postprostatectomy patients (mean 67, 57-78 years) were treated with MRI-guided cryoablation for recurrent prostate carcinoma. Patients were found to have a hyperenhancing nodule using multiparametric MRI with endorectal coil followed by a positive transrectal ultrasound-guided biopsy. Of 18 postsurgical patients, 6 had additional salvage external beam radiation with subsequent recurrence. Under general anesthesia and MRI guidance (wide-bore 1.5T MRI), 2-5 cryotherapy probes were placed in or around the recurrence by transperineal approach and cryoablation performed. The patients were stratified into 2 groups: the initial 9 consecutive patients had cryoprobes placed 1 cm apart with 2 freeze-thaw cycles (group 1), and the subsequent 9 patients had cryoprobes placed 0.5 cm apart with 3 freeze-thaw cycles (group 2)., Results: In group I, the average preprocedure prostate-specific antigen (PSA) was 1.21 ± 1.12 ng/mL, and 1-3 months postprocedure PSA was 0.14 ± 0.11 ng/mL (P <.01). Sixty-seven percent of patients had PSA ≤0.2 ng/mL at 1-3 months follow-up, but only 25% at 4-6 months. No change in impotence or incontinence occurred. In group II, average preprocedure PSA was 2.24 ± 2.71 ng/mL, and 1-3 month postprocedure PSA was 0.08 ± 0.10 ng/mL (P <.05). Eighty-nine percent of patients had PSA ≤0.2 ng/mL at 1-3 months follow-up and at 4-6 months. Complications in group 2 included worsening incontinence in 3 patients., Conclusion: MRI-guided salvage cryoablation of postradical prostatectomy prostate cancer recurrence is safe and feasible. Both techniques produce early PSA decrease with more lasting PSA results in the more aggressive group II methodology., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To assess the treatment recommendations from a nationally representative sample of radiation oncologists and urologists on adjuvant radiotherapy for patients with pathologically advanced prostate cancer after radical prostatectomy., Methods: From a random sample of 1422 physicians (n = 711 radiation oncologists; n = 711 urologists) in the American Medical Association Masterfile, a mail survey queried treatment recommendations for adjuvant radiotherapy that varied by the following pathologic features: extraprostatic extension (pT3a) vs seminal vesicle invasion (pT3b), Gleason 7 vs Gleason 8-10, and margin negative (MN) vs margin positive (MP). Pearson chi-square and multivariable logistic regression were used to test for differences in treatment recommendations by physician specialty., Results: Response rates for radiation oncologists and urologists were similar (44% vs 46%; P = .42). Radiation oncologists were more likely to recommend adjuvant radiotherapy than urologists for all the varying pathologic scenarios from pT3a, Gleason 7, and MN (42.5% vs 9.7%; adjusted odds ratio [OR]: 7.82, P <.001) to pT3b, Gleason 8-10, and MP disease (94.5% vs 89.1%, adjusted OR: 2.46, P <.001). Compared with radiation oncologists, urologists were more likely to recommend salvage radiotherapy pT3a, Gleason 7, and MN (90.3% vs 57.7%; adjusted OR: 7.72, P <.001) to pT3b, Gleason 8-10, and MP disease (10.9% vs 5.5%; adjusted OR: 2.22, P <.001)., Conclusion: In this national survey, radiation oncologists and urologists have markedly different treatment recommendations for adjuvant and salvage radiotherapy. Patients with adverse pathologic features after radical prostatectomy should consult with both a urologist and radiation oncologist to hear a diversity of opinions to make the most informed decision possible., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objectives: To examine the ability of standard and saturation transrectal prostate biopsy techniques to predict appropriate candidates for active surveillance., Methods: Between 2005 and 2007, 500 consecutive patients underwent transrectal ultrasound-guided biopsy by a standard template (12 cores) or saturation template (≥18 cores, median 27 cores), with subsequent radical prostatectomy. Using the criteria of Gleason score ≤6, clinical stage T1 or T2a, prostate-specific antigen <10 and ≤33% of cores involved, 218 patients were potential candidates for active surveillance. Pathology results from the prostatectomy specimens were used to determine the accuracy of each biopsy technique. Biochemical failure after prostatectomy was evaluated using logistic and Cox proportional hazards regression., Results: A standard biopsy was carried out for 124 patients and saturation biopsy for 94 patients. There was no statistically significant difference between the groups in terms of median age (P = 0.14), preoperative prostate-specific antigen (P = 0.52) and clinical stage (P = 0.23). Similar rates of Gleason score ≥7 at the time of radical prostatectomy were found, with 14% for standard biopsy and 15% for saturation biopsy (P = 0.70). Upstaging was shown in two standard biopsy patients (1.6%) and no saturation biopsy patients (P = 0.62). A multivariate analysis adjusting for prior prostate biopsy, preoperative prostate-specific antigen and clinical stage showed no difference in the rate of upgrading based on biopsy technique (P = 0.26). During follow up, 5-year biochemical failure-free survival estimates were not significantly different (P = 0.11)., Conclusions: In men with prostate cancer, standard and saturation transrectal prostate biopsies techniques are equally predictive of candidates for active surveillance., (© 2012 The Japanese Urological Association.)

Background: With health technology innovation responsible for higher health care costs, it is essential to have accurate estimates regarding the differential costs between robot-assisted radical prostatectomy (RARP) and open radical prostatectomy (ORP)., Objective: To describe the total hospitalization costs attributable to robotic and open surgery for radical prostatectomy (RP)., Design, Setting, and Participants: Using a population-based cohort by merging the Nationwide Inpatient Sample (NIS) and the American Hospital Association (AHA) survey from 2006 to 2008, we identified 29 837 prostate cancer patients who underwent RP., Interventions: ORP and RARP., Outcome Measurements and Statistical Analysis: The primary outcome was total hospitalization costs adjusted to year 2008 US dollars. Generalized estimating equations were used to identify patient and hospital characteristics associated with total hospitalization costs and to estimate costs of ORP and RARP adjusted for case mix and hospital teaching status, location, and annual case volume., Results and Limitations: Overall, 20 424 (68.5%) patients were surgically treated with RARP, and 9413 (31.5%) patients underwent ORP. Compared to ORP, patients undergoing RARP had shorter median length of stay (1 d vs 2 d; p<0.001) and were less likely to experience any postoperative complications (8.2% vs 11.3%; p<0.001). However, patients undergoing RARP had higher median hospitalization costs ($10409 vs $8862; p<0.001). After adjusting for patient and hospital features, RARP was associated with higher total hospitalization costs compared to ORP ($11932 vs $9390; p<0.001). Our results are limited by a study design using retrospective population-based data., Conclusions: Despite RARP having lower complications and shorter length of stay than ORP, total hospitalization costs are higher for patients treated with RARP compared with those treated with ORP., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Unlabelled: What's known on the subject? and What does the study add? One of two problems plagues virtually are existing post-prostatectomy prediction tools: either (1) they predict PSA recurrences (which are of unclear importance) or (2) the predictions they make are anchored at the date of surgery and are not updated based on how patients evolve over the postoperative years. Our prediction tool is a significant improvement over existing prediction tools in that it predicts the development of metastases which is a very important clinical endpoint that indicates incurable prostate cancer. Additionally, our tool allows for updated predictions at any point following radical prostatectomy by considering commonly available postoperative information (postoperative serum PSA and use of adjuvant therapies) to modify its risk predictions. The net result is a dynamic tool that renders clinically relevant predictions that change as the patient's clinical status changes throughout the postoperative course., Objective: • To develop a dynamic algorithm that predicts the risk of metastases from any time point after radical prostatectomy (RP)., Patients and Methods: • The study cohort consisted of 5741 RP patients who were treated from 1990-99. • Patients were grouped into one of four clinical states at follow-up: State(1) , prostate-specific antigen (PSA) undetectable; State(2), PSA 0.15-0.39 ng/mL; State(3), PSA ≥0.4 ng/mL; and State(4), previous androgen deprivation or radiation therapy. • Follow-up epochs (alive and at risk of systemic progression) at 0, 2, 4 and 6 years post-RP, cumulative incidence curves and multistate Cox models were used to assess the risk of metastases over the ensuing 5-year interval. • Gleason score, seminal vesicle and surgical margin involvement, and PSA variables were evaluated as predictors., Results: • Median follow-up was 11.7 years, with 4411, 4256 and 3983 patients followed with PSA at 2, 4 and 6 years, respectively. • In total, 287 metastatic events occurred and the 5-year risk of metastasis was 0.4%, 2.1%, 8.7% and 12.6% for men in States 1, 2, 3 and 4, respectively. • Independent predictors of metastasis by group included seminal vesicle involvement (all groups), Gleason score (groups 1, 3 and 4), current PSA (groups 3 and 4) and maximum past PSA (group 4)., Conclusions: • We present a web-based prognostic tool for patients undergoing RP that is valid at many time points after surgery. • Our tool predicts the development of metastases., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Purpose: A recent report examined rates of urinary incontinence and erectile dysfunction following radical prostatectomy by evaluating administrative claims data. However, the validity of this approach for reporting functional outcomes has not been established. Therefore, we determined the prognostic value of administrative claims data for reporting urinary incontinence and erectile dysfunction after radical prostatectomy., Materials and Methods: We identified 562 patients who underwent radical prostatectomy from 2004 to 2007 and were followed at our institution with self-reported standardized survey data available at least 1 year after surgery. Urinary incontinence was assessed by self-reported pad use and the urinary function domain of the Expanded Prostate Cancer Index. Erectile dysfunction was assessed with the International Index of Erectile Function. These results were then compared with administrative claims data using ICD-9 and Hospital International Classification of Diseases Adapted codes for urinary incontinence and erectile dysfunction., Results: Administrative claims data demonstrated a poor correlation with patient self-reported questionnaire data. The administrative identification of erectile dysfunction was associated with a sensitivity of 0.598 and a specificity of 0.591. Poor correlation was also illustrated by the low kappa correlation coefficient of 0.184. Similarly urinary incontinence was poorly correlated with self-reported pad use and the urinary function domain of the Expanded Prostate Cancer Index (correlation coefficient 0.195)., Conclusions: Administrative claims data correlate poorly with validated questionnaire data when assessing functional outcomes after radical prostatectomy such as urinary incontinence and erectile dysfunction. Therefore, outcomes data generated using this approach may not reflect the development or severity of such complications., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the impact of adjuvant androgen deprivation therapy (ADT) on survival in patients with seminal vesicle invasion (pT3b) at radical prostatectomy., Patients and Methods: We reviewed 12,115 patients who underwent radical prostatectomy between 1987 and 2002 to identify patients with pT3bN0 prostate cancer who received adjuvant ADT (n= 191). These patients were matched by clinical and pathological variables to a group of patients with pT3b prostate cancer who did not receive adjuvant ADT. Median postoperative follow-up was 10 years. Clinical endpoints included biochemical progression-free survival (BPFS), local recurrence-free survival (LRFS), systemic progression-free survival (SPFS), cancer-specific survival (CSS) and overall survival., Results: Patients who underwent adjuvant ADT experienced improved 10-year BPFS (60% vs 16%, P < 0.001), LRFS (87% vs 76%, P= 0.002), SPFS (91% vs 78%, P= 0.004) and CSS (94% vs 87%, P= 0.037). Overall survival was not significantly different between groups (75% vs 69%, P= 0.12). Both luteinizing hormone-releasing hormone agonists (hazard ratio, 0.26; 95% CI, 0.15-0.46; P < 0.001) and bilateral orchiectomy (hazard ratio, 0.13; 95% CI, 0.06-0.31; P < 0.001) improved BPFS. When stratified by type of ADT (hormonal therapy vs orchiectomy), there was no difference in survival outcomes., Conclusions: Adjuvant ADT improves local, and systemic control after radical prostatectomy for pT3b prostate cancer. There is no difference in survival between patients receiving medical hormonal therapy vs patients undergoing orchiectomy. Given the lack of improvement in overall survival, continued investigation is needed to identify the cohort of pT3b patients at highest risk for cancer progression and therefore most likely to benefit from a multimodal treatment approach., (© 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.)

Purpose: Many patients undergoing radical prostatectomy in the prostate specific antigen era have a low risk of recurrence. Aggressive postoperative prostate specific antigen surveillance is costly and anxiety provoking. In this study we investigate the need for yearly prostate specific antigen measurements in patients with surgically treated low risk prostate cancer., Materials and Methods: We identified 2,219 patients who underwent radical prostatectomy between 1994 and 2004 for low risk localized prostate cancer. Low risk was defined as prostate specific antigen less than 10 ng/ml, pathological stage pT2c or less, Gleason score 6 or less, negative lymph nodes and negative surgical margins. Patients who underwent neoadjuvant or adjuvant therapy were excluded from analysis. Biochemical failure was defined as a prostate specific antigen greater than 0.4 ng/ml and prostate specific antigen values less than 0.15 ng/ml were considered undetectable. Biochemical failure rates were calculated according to the duration of the prostate specific antigen-free period after radical prostatectomy., Results: A total of 142 (6.4%) patients experienced biochemical failure during the course of the study. The risk of biochemical failure decreased with increasing duration of the prostate specific antigen-free interval. For example 1, 3 and 5-year biochemical failure rates calculated at surgery were 1.8%, 4.2% and 6.3%, respectively. For patients with undetectable prostate specific antigen measurements 5 years after surgery the 1, 3 and 5-year biochemical failure rates were 0.0%, 0.7% and 1.3%, respectively. In addition, 1-year biochemical failure rates were 0.2%, 0.4%, 0.0% and 0.0% after a prostate specific antigen-free period of 1, 3, 5 and 10 years, respectively., Conclusions: The risk of biochemical failure is inversely proportional to the duration of the prostate specific antigen-free interval after radical prostatectomy in low risk patients. Biochemical failure 1 year after an undetectable prostate specific antigen is uncommon, especially after a prostate specific antigen-free period of 3 years. These data suggest that annual prostate specific antigen measurements are unnecessary, especially after a prostate specific antigen-free interval of 3 years. Prostate specific antigen measurements every 2 years should capture the majority of low risk patients who experience progression., (2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate whether Raman molecular imaging (RMI, which combines digital imaging and analytical spectroscopy to evaluate the biochemical composition of interrogated material) can be used to identify biochemical differences in patients with Gleason 7 prostate cancer who progress to metastatic disease and die from prostate cancer., Patients and Methods: We identified 38 patients who had a radical prostatectomy for Gleason 7 adenocarcinoma of the prostate. Half progressed to metastatic disease and half had no evidence of disease after treatment. Patients were matched for preoperative prostate-specific antigen level, surgical margin status, pathological stage, tumour volume, age at surgery, year of surgery and DNA ploidy. Sequential 5 microm sections were obtained from paraffin-embedded tissue and one genitourinary pathologist selected areas of tumour for study. Principal component analysis was used to investigate the correlation between spectral response and clinical outcome., Results: The analysis was able to distinguish between those with progressive disease and those with no evidence of disease, most notably within the Gleason 3 regions when evaluating the epithelium and stroma as separate histological elements. A two-sample t-test gave P < 0.01 for both the Gleason 3 and 4 epithelium and stroma classes., Conclusions: RMI is a novel technique that shows promise for identifying patients at risk of progression by visualizing molecular information not seen using other current methods. In Gleason 7 disease, RMI shows distinctive chemical differences in patients who progress to metastatic disease in both Gleason pattern 3 and 4 regions. This preliminary work lays the foundation for the further study of RMI for evaluating prostate tissue.

Objective: To investigate whether the clinical and pathological outcomes after radical retropubic prostatectomy (RRP) have changed since the advent of prostate-specific antigen (PSA) testing for patients with Gleason 8-10 cancers., Patients and Methods: We identified 584 men treated with RRP between 1988 and 2001 for pathological Gleason 8-10 tumours. Patients were divided for analysis by year of surgery, i.e. early (1988-93), mid (1994-97) and late PSA era (1998-2001). Survival rates after RRP were estimated using the Kaplan-Meier method, and the effect of clinicopathological factors on outcome was analysed using Cox proportional hazard regression models., Results: The median preoperative PSA level decreased from 15 ng/mL in the early to 10 ng/mL in the late PSA era (P < 0.001), while the rate of organ-confined disease increased from 22.9% to 35.1% (P = 0.007). However, the 7-year biochemical recurrence-free (37% vs 45%, P = 0.087) and cancer-specific survival (89% to 91%, P = 0.73) did not change significantly from the early to the late PSA era. Increased preoperative PSA level (P < 0.001), seminal vesicle invasion (P < 0.001) and positive lymph nodes (P = 0.02) were associated with biochemical recurrence. Seminal vesicle invasion (P = 0.005), positive nodes (P < 0.001) and positive surgical margins (P = 0.03) predicted death from cancer., Conclusion: Although the pathological features of Gleason 8-10 cancers have become more favourable over the PSA era, survival has not changed. This lack of improvement in clinical outcome probably reflects the inherent biological aggressiveness of these cancers. While RRP provides long-term cancer control in a subset of these patients, continued investigation of multi-modal treatment options is warranted.

Purpose: While the incidence of lymph node positive prostate cancer has decreased during the prostate specific antigen era, the optimal treatment of these patients remains in question. We examined the impact of lymph node metastases on the outcome of patients following radical prostatectomy and investigated prognostic factors that affect survival., Materials and Methods: We identified 507 men treated with radical prostatectomy between 1988 and 2001 who had lymph node positive disease. Of the 507 patients 455 (89.7%) were treated with adjuvant hormonal therapy. Median followup was 10.3 years (IQR 6.1-13.5). Postoperative survival rates were estimated using the Kaplan-Meier method and the impact of various clinicopathological factors on outcome was analyzed using Cox proportional hazard regression models., Results: Ten-year cancer specific survival for patients with positive lymph nodes was 85.8% with 56% of the men free from biochemical recurrence at last followup. On multivariate analysis pathological Gleason score 8-10 (p = 0.004), positive surgical margins (p = 0.016), nondiploid tumor ploidy (p = 0.023) and 2 or greater positive nodes (p = 0.001) were adverse predictors of cancer specific survival. Tumor stage, year of surgery and total number of nodes removed did not significantly affect outcome. Adjuvant hormonal therapy decreased the risk of biochemical recurrence (p <0.001) and local recurrence (p = 0.004) but it was not associated with systemic progression (p = 0.4) or cancer specific survival (p = 0.4)., Conclusions: Radical prostatectomy may offer long-term survival to patients with lymph node positive prostate cancer. Gleason score, margin status, tumor ploidy and the number of involved nodes predict survival, while the role of adjuvant hormonal therapy continues to be defined.