Search

Variation in outcomes Surgery remains a mainstay of initial treatment for prostate cancer, with an estimated 85,000 operations per year in the US. Radical prostatectomy is associated with important risks of erectile dysfunction, urinary incontinence and, naturally, cancer recurrence. Given the possible consequences, it would be reassuring were it known that urologic surgeons offer uniformly high-quality care. Unfortunately, the data suggest that this is far from the case. There is copious evidence that surgeons with greater case volume or total lifetime experience have better outcomes. For example, low volume surgeons have complication rates 6 to 8% greater than their higher volume counterparts[1]; in studies on the learning curve, the risk of recurrence is about 7% higher for a typical patient treated by an inexperienced surgeon than if treated by a more experienced surgeon[2, 3] There are also data that differences in outcome go over and above characteristics such as volume or experience, with large variations between surgeons even within volume categories[1, 4], with one study reporting a five-fold variation in potency rates between surgeons at a single institution[5]. The extent of differences in outcome between different surgeons, as demonstrated in these studies, suggests that many patients are receiving suboptimal care. This raises the issue of how to improve the results of underperforming surgeons.

UNLABELLED Study Type--Therapy (case series). Level of Evidence 4. What's known on the subject? And what does the study add? In lymph node dissections for cancer, the more extended the dissection, the higher the number of lymph nodes removed. In addition, the higher the number of nodes retrieved, the better the staging. This leads many investigators to set a threshold of a minimal number of nodes below which the dissection is considered inadequate. Although the minimal threshold concept is generally good, it is not based on very objective data. a number of factors might influence the final number of nodes removed: (i) the surgeon and the surgical technique; (ii) the pathologists and tissue processing technique; (iii) the patient; and (iv) the audit effect and feedback to the surgeons about the number of nodes removed. OBJECTIVE • To examine the number of lymph nodes removed over time for men undergoing a standard pelvic lymph node dissection (PLND) during radical prostatectomy. PATIENTS AND METHODS • In total, 2119 consecutive patients with clinically localized prostate cancer were scheduled for non-salvage radical prostatectomy between February 2005 and September 2009. • All patients underwent PLND, including the external iliac, hypogastric and obturator fossa nodal groups. • We tested whether the number of lymph nodes increased over time by including the date of each patient's surgery into a linear regression model using nonlinear terms. RESULTS • From 2008 onward, there appears to be a large increase in the number of nodes removed. • Date of surgery was a significant predictor of the number of nodes removed (P < 0.001). • The anatomical template of dissection, the specimen submission and pathological assessment were reportedly unchanged. • The nodal yield increase in the later part of the study coincides with an increase in the academic interest in PLND and nodal metastasis in prostate cancer at the institutional level and worldwide. CONCLUSIONS • Without any intentional change in surgical technique or pathological processing, the number of lymph nodes removed in our radical prostatectomy experience increased. • This change coincided with an increased academic interest in the subject and highlights the positive feedback effect. • The change also raises concerns about unaccounted for confounding factors that could affect multi-institutional datasets and surgical clinical trials.

Multiple therapeutic options for renal tumors that are now available have put pathologists under increasing pressure to render diagnosis on limited material. Results on biopsies by hematoxylin and eosin (H&E) have historically not been encouraging. Currently, multiple immunohistochemical markers with differential expression in these renal tumors are available. We studied the utility of such markers on needle biopsies that were obtained ex vivo. After nephrectomy, two 18-guage cores were obtained and processed routinely. Expressions of carbonic anhydrase (CA) IX, CD117, α-methylacyl-CoA racemase (AMACR), cytokeratin 7 (CK7), and CD10 were evaluated. Results, with or without immunostaining, were compared with the final nephrectomy diagnosis. We studied 145 tumors, including 119 renal cell carcinomas (83 clear cell, 18 papillary, 14 chromophobe, and 4 type unclassified), 11 oncocytomas, and 15 miscellaneous tumors. Adequate evaluable material was present in 123 (85%) cases. In such biopsies, 81% of cases were correctly classified by H&E alone, with correct diagnosis in 90% of cases in the most common tumor subtypes (clear cell, papillary and chromophobe renal cell carcinoma, and oncocytoma). By adding immunostains, the accuracy was 90% overall and 99% among the 4 most common subtypes. The following extent and patterns of immuneexpression were highly useful in the diagnoses: diffuse, membranous CAIX expression in clear cell renal cell carcinoma, diffuse positivity for AMACR in papillary renal cell carcinoma, distinct peripheral cytoplasmic accentuation for CD117 in chromophobe renal cell carcinoma, widespread and intense positivity for CK7 in chromophobe and papillary renal cell carcinoma, and diffuse membranous reactivity in clear cell and patchy/luminal in papillary renal cell carcinoma for CD10. In conclusion, utilizing immunostains improves classification of renal tumors on needle biopsy, which may be of particular help for pathologists with limited experience. Both extent and patterns must be considered for a definitive diagnosis.

Objectives: Lymphocele is the most common complication of pelvic lymphadenectomy (PLND). We sought to determine predictors of symptomatic lymphocele after radical prostatectomy (RP) and PLND, and in particular, to determine if the number of drains placed represents an independent predictor. Methods: Between January 1999 and June 2007, 4173 consecutive patients underwent bilateral PLND at the time of either open or laparoscopic RP. Lymphoceles were identified in patients undergoing imaging as a result of symptoms suspicious for lymphocele, such as fever, abdominal pain or lower extremity swelling. Routine postoperative imaging was not carried out. Cox proportional hazards analysis was carried out using forced variable entry to obtain maximum likelihood estimates of the hazard ratios and 95% confidence intervals using the number of drains placed, number of nodes removed, RP approach and use of prophylactic low-molecular-weight heparin (LMWH) as predictors of symptomatic lymphocele. Results: There were 164 patients (4%) with a symptomatic lymphocele on follow up, with a median time to presentation of 19 days. The primary presenting complaints were fever in 47%, abdominal pain in 40%, lower extremity swelling in 37%, genital swelling in 25%, groin pain in 22%, abdominal swelling in 9%, and back and flank pain in 6% and 5%, respectively. Median lymphocele diameter was 5 cm. Significant predictors of symptomatic lymphocele on multivariate analysis included number of nodes removed and use of LMWH, but not number of drains placed. Conclusions: Use of prophylactic LMWH and a higher node count are predictive of a higher incidence of symptomatic lymphocele after RP and PLND.

Objectives To determine the significant independent predictors of inguinal hernia development after radical prostatectomy (RP) so that prophylactic measures can be undertaken in those at increased risk. Although inguinal hernia is a recognized complication after RP, the risk factors have not been well elucidated. Methods From January 1999 to June 2007, 4592 consecutive patients underwent open retropubic RP or laparoscopic RP without previous radiotherapy. The median follow-up was 36.9 months (interquartile range 20.3, 60.6). Comorbidities were recorded, as well as the occurrence of inguinal hernia, wound infection, and bladder neck contracture. Cox proportional hazards analysis was performed for the predictors of inguinal hernia after RP on multivariate analysis. Results Inguinal hernia developed after RP in 68 men (1.5%) men at a median follow-up of 7.9 months (interquartile range 4.3, 18.1). The laterality was bilateral in 7, right in 27, left in 24, and not documented in 10 patients. The significant independent predictors of inguinal hernia included age (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.01-1.09, P = .016), body mass index (HR 0.91, 95% CI 0.85-0.98, P = .011), history of inguinal hernia repair (HR 3.9, 95% CI 1.8-8.2, P

Study Type – Prognosis (case series) Level of Evidence 4 OBJECTIVE To determine if the location and number of positive surgical margins (PSMs) after radical prostatectomy (RP) are associated with recurrence after salvage external beam radiation therapy (sEBRT). PATIENTS AND METHODS We retrospectively reviewed the medical records of 60 patients with PSMs who underwent three-dimensional conformal sEBRT for biochemical recurrence (BCR) or clinically detected local recurrence after RP between 1996 and 2007. PSMs were categorized as present or absent at three locations, and patients were classified as having either one or more than one PSM. BCR after RP was defined as a prostate-specific antigen (PSA) level of ≥0.1 ng/mL. BCR after sEBRT was defined as a serum PSA level of ≥0.1 ng/mL above the PSA nadir after sEBRT. RESULTS In all, 24 (40%) patients had more than one PSM. Overall, the most common location of a PSM was the posterior prostate with 40 (66%) patients having a positive posterior margin. The location of PSMs was not significantly associated with secondary BCR (global P= 0.8). There was a borderline result between the number of PSMs and BCR: men with more than one PSM were less likely to recur compared with those with only one PSM (hazard ratio 0.42; P= 0.067). CONCLUSIONS This is the first study to specifically analyse location and number of PSMs as prognostic factors for men who undergo sEBRT. There was no evidence to suggest that the location of a PSM predicted secondary BCR. Further research is needed to determine whether the number of PSMs is an important predictor of BCR after sEBRT.

Background The lack of standardized reporting of the complications of radical prostatectomy in the literature has made it difficult to compare incidences across institutions and across different surgical approaches. Objective To define comprehensively the incidence, severity, and timing of onset of medical and surgical complications of open retropubic prostatectomy (RP) and laparoscopic radical prostatectomy (LP) using a standardized reporting methodology to facilitate comparison. Design, setting, and participants Between January 1999 and June 2007, 4592 consecutive patients underwent RP or LP without prior radiation or hormonal therapy. Median follow-up was 36.9 mo (interquartile range: 20.3–60.6). Intervention Open or laparoscopic radical prostatectomy. Measurements All medical and surgical complications of radical prostatectomy were captured and graded according to the modified Clavien classification and classified by timing of onset. Results and limitations There were 612 medical complications in 467 patients (10.2%) and 1426 surgical complications in 925 patients (20.1%). The overall incidences of early minor and major medical and surgical complications for RP were 8.5% and 1.5% for medical and 11.4% and 4.9% for surgical complications, respectively. The overall incidences of early minor and major medical and surgical complications for LP were 14.2% and 2.3% for medical and 23.1% and 6.6% for surgical complications, respectively. On multivariate analysis, LP approach was associated with a higher incidence of any grade medical and surgical complications but a lower incidence of major surgical complications than RP. Six hundred fifty-two men (14.2%) visited the emergency department, and 240 men (5.2%) required readmission. The main limitation is the retrospective nature. Conclusions With standardized reporting, the incidence of some complications is higher than recognized in the literature. Although most complications are minor in severity, medical and surgical complications are observed in approximately 10% and 20% of patients, respectively. Accurate reporting of complications through a standardized methodology is essential for counseling patients regarding risk of complications, for identifying modifiable risk factors, and for facilitating comparison across institutions and approaches.

OBJECTIVES To analyze our experience with laparoscopic partial nephrectomy (LPN) to detail postoperative adverse events and identify factors that may contribute to adverse surgical outcomes. Complications from LPN result from a variety of factors, both technical and inherent. METHODS Single-center review of 144 consecutive LPN (4 surgeons) performed between November 2002 and January 2008 was conducted. Identified complications were graded using standard reporting criteria. Univariate and multivariate statistical analysis of variables and their association with complication event and blood loss was performed. RESULTS A total of 39 complications occurred in 29 (20%) cases. Of these, 20 (51%) were urologic and 19 (49%) were nonurologic. Individual adverse events by grade were as follows: grade I, 6 (15.4%); grade II, 19 (48.7%), grade III, 11 (28.2%), and grade IV, 3 (7.7%). No grade V complications occurred. The median tumor size and ischemia time were 2.7 cm and 35 minutes, respectively. Univariate analysis identified increased American Society of Anesthesiologists risk score (odds ratio 2.99, 95% confidence interval [CI] 1.28, 6.94) and ischemia time (odds ratio 1.31; 95% CI 1.00, 1.71) as associated with complication risk. On multivariate analysis, longer ischemia time was associated with increased estimated blood loss (95% CI 3, 57; P = .03). Hospital readmission and reintervention was required in 15 (10.4%) and 9 (6.2%) patients, respectively. CONCLUSIONS Complications from LPN occur in a meaningful proportion of procedures although the majority does not require reintervention and half are not urologic. Increasing ischemia time and American Society of Anesthesiologists score are associated with risk for unfavorable surgical outcomes.

OBJECTIVE To determine the biochemical recurrence (BCR) rate in patients with positive surgical margins (PSMs) on the prostate specimen who have additional negative tissue resected from that site (M+ −), compared to patients with negative margins (M−) and those with persistent PSM (M+), as those with PSM at radical prostatectomy (RP) are at greater risk of BCR, and in some instances where suspicious tissue is noted in the prostate bed or when frozen-section analysis shows PSM, additional tissue is resected from the suspect site of the PSM. PATIENTS AND METHODS Between January 1999 and June 2007, 4217 consecutive patients underwent open or laparoscopic RP with no previous radiotherapy or hormonal therapy. The median (interquartile range) follow-up was 37.4 (21.1–60.7) months. RESULTS Pathological organ-confined (OC) cancer was present in 2901 men, of whom 2659 had M−, 216 had M+, and 26 had M+ −. Extracapsular extension (ECE) alone with no seminal vesicle or lymph node involvement was present in 843 men, of whom 657 had M−, 174 had M+ and 12 had M+ −. For patients with OC cancer, the 36-month actuarial BCR-free probability was 97.9% (95% confidence interval 97.3–98.5) for M−, vs 89.0 (84.1–93.9)% for M+ vs 100% for M+ −. For patients with ECE, the 36-month actuarial BCR-free probability was 83.7 (80.0–87.4)% for M− vs 73.7 (66.1–81.3)% for M+ vs 90.0 (71.4–100)% for M+ −. The main limitation of the study was its retrospective nature, with the reason for resection of additional tissue not always well documented. CONCLUSIONS While the few patients with PSMs and further negative resected tissue limited the statistical analysis, it would appear that in these patients the disease behaves as in those with negative margins.

Purpose: Recent evidence suggests significantly discordant findings regarding tumor size and the metastasis risk in renal cell carcinoma cases. We present our experience with renal cell carcinoma. We evaluated the association between tumor size and the metastasis risk in a large patient cohort.Materials and Methods: Using our prospectively maintained nephrectomy database we identified 2,691 patients who were treated surgically for a sporadic renal cortical tumor between 1989 and 2008. Associations between tumor size and synchronous metastasis at presentation (M1 renal cell carcinoma) were evaluated with logistic regression models. Metastasis-free survival after surgery was estimated using the Kaplan-Meier method in 2,367 patients who did not present with M1 renal cell carcinoma and were followed postoperatively.Results: Of the 2,691 patients 162 presented with metastatic renal cell carcinoma. Only 1 of 781 patients with a tumor less than 3 cm had M1 renal cell carcinoma at presentation and tumor size was ...

Prostate cancer is a heterogeneous disease with a wide prognostic spectrum and a variety of treatment options. Such a complex clinical scenario has led to uncertainty in risk assessment and prediction of outcome. Nomograms have served as scientific formulas designed to maximize the predictive accuracy. The use of nomograms in prostate cancer has been applied to many clinical states and outcomes and has provided the most accurate predictions. Cancer 2009;115(13 suppl):3107-11. (c) 2009 American Cancer Society.

Summary of VTE prophylaxis recommendations Level of risk Prophylactic treatmentLow Risk ● No prophylaxis other than early ambulationModerate Risk ● Heparin 5000 units every 12 hours subcutaneous starting after surgery ● OR *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily ● OR Pneumatic compression device if risk of bleeding is highHigh Risk ● Heparin 5000 units every 8 hours subcutaneous starting after surgery ● OR *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily ● OR Pneumatic compression device if risk of bleeding is highVery High Risk ● *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily and adjuvant pneumatic compression device, or ● Heparin 5000 units every 8 hours subcutaneous starting after surgery and adjuvant pneumatic compression device* Guidelines and Cautions for Enoxaparin Use ● In patients with a body weight 150 Kg. consider increasing prophylaxis dose of Enoxaparin to 40 mg. subcutaneous every 12 hours. ● Withhold Enoxaparin generally for at least 2 to 3 days after major trauma, and then only consider use after review of current patient condition and risk benefit ratio.

Purpose: To retrospectively measure the mean apparent diffusion coefficient (ADC) with diffusion-weighted magnetic resonance (MR) imaging and the mean metabolic ratio (MET) with three-dimensional (3D) hydrogen 1 (1H) MR spectroscopic imaging in regions of interest (ROIs) drawn over benign and malignant peripheral zone (PZ) prostatic tissue and to assess ADC, MET, and combined ADC and MET for identifying malignant ROIs, with whole-mount histopathologic examination as the reference standard. Materials and Methods: The institutional review board approved this HIPAA-compliant retrospective study and issued a waiver of informed consent. From among 61 consecutive patients with prostate cancer, 38 men (median age, 61 years; range, 42–72 years) who underwent 1.5-T endorectal MR imaging before radical prostatectomy and who fulfilled all inclusion criteria of no prior hormonal or radiation treatment and at least one PZ lesion (volume, >0.1 cm3) at whole-mount pathologic examination were included. ADC maps were gene...

Introduction The optimal outcome of radical prostatectomy is to cure cancer with the least impact on quality of life. The aim of this paper is to review the existent literature and attempt to compare the results of the retropubic (RRP) with the laparoscopic (LRP) approach. Methodology Extensive Medline literature search for terms “radical retropubic prostatectomy” and “laparoscopic radical prostatectomy” from 1980 to 2006 to compare cancer control, functional outcomes and morbidity for both groups. Only full length English language articles including 100 or more patients were considered. Results The 5-year biochemical recurrence rates range from 70–92% for the RRP vs. 82–91% for the LRP. The global positive surgical margin rates are 12–20% for the RRP and 17–30% for the LRP. The continence rate for the RRP varies from 70–93%; the LRP varies from 82–95% for 12 months. Considering potency 12 months after surgery, the rates are 17–75% for the RRP vs. 52–78% for the LRP. The blood loss for the RRP ranges from 818 to 1,500 ml and 220 to 1,100 for the LRP. Conclusions The concurrent literature lacks randomized trials comparing the different surgical techniques. No definitive conclusions can be drawn.

Objective To describe fluctuations in prostate-specific antigen (PSA) levels in men managed with active surveillance (AS) to determine if a single PSA increase is a consistent measure to use to trigger intervention. Patients and Methods We evaluated data on 541 patients undergoing AS between 1995 and 2011. PSA variation was described by studying the Kaplan–Meier probability of patients’ PSA levels reaching 4 or 7 ng/mL, falling below those thresholds, and then rising to those thresholds again. We also examined PSA variation by calculating the Kaplan–Meier probability of a PSA change followed by an equal or greater change in the opposite direction. Results We analysed data on 541 patients undergoing AS with a median (interquartile range [IQR]) of 8 (6–12) PSA measurements and undergoing AS for a median (IQR) of 4 (2–6) years. The 5-year estimate of the probability of reaching a threshold PSA of 7 ng/mL was 40% (95% confidence interval [CI] 35–46%) and the 5-year estimate of subsequently falling below this threshold was 90% (95% CI 82–95%). The 5-year estimate of a PSA direction change was 95% (95% CI 93–97%) overall and 56% (95% CI 51–61%) for PSA direction changes of ≥1 ng/mL. Conclusions We observed a high probability of variability in PSA levels for patients on AS. The probability of changes in PSA, defined by an increase to the specified thresholds or a rise >1 ng/mL within 6 months and subsequent decrease of equal or greater value on a subsequent measurement, increases over time; therefore, a single change in PSA level is not a reliable endpoint for patients on AS.

Active surveillance is increasingly recommended for older men with low risk prostate cancer. Although older men have higher all cause mortality, they also have higher prostate cancer specific mortality. We hypothesized that older age is associated with an increased risk of Gleason score upgrading at confirmatory biopsy when controlling for prostate volume.We retrospectively reviewed data on 1,130 patients with prostate cancer who were treated with active surveillance from 1991 through 2011. We included 646 patients with clinical Gleason 6 or less, stage T2a or less prostate cancer, a confirmatory biopsy within 2 years of diagnostic biopsy and prostate magnetic resonance imaging before confirmatory biopsy. The primary outcome was Gleason score upgrading to 7 or greater on confirmatory biopsy. We used logistic regression to estimate the effect of age on upgrading, adjusting for magnetic resonance imaging prostate volume and other potential confounders.Median age was 66 years (IQR 61-72) and median magnetic resonance imaging prostate volume was 41 ml (IQR 29-55). At confirmatory biopsy disease was upgraded in 55 of 646 patients (9%) and unchanged in 290 (45%) and biopsy was negative in 297 (46%). Older age was associated with higher odds of upgrading (adjusted OR 1.05, 95% CI 1.01-1.09, p=0.009). Larger prostate volume was associated with lower odds of upgrading (adjusted OR 0.80/10 ml increase, 95% CI 0.7-0.9, p=0.012).Our findings suggest that older age is associated with an increased risk of misclassification on diagnostic biopsy. Older men who are interested in active surveillance should be counseled about the risks and benefits of confirmatory biopsy.

Tumor characteristics affect surgical complexity and outcomes of partial nephrectomy (PN).To develop an Arterial Based Complexity (ABC) scoring system to predict morbidity of PN.Four readers independently scored contrast-enhanced computed tomography images of 179 patients who underwent PN.Renal cortical masses were categorized by the order of vessels needed to be transected/dissected during PN. Scores of 1, 2, 3S, or 3H were assigned to tumors requiring transection of interlobular and arcuate arteries, interlobar arteries, segmental arteries, or in close proximity of the renal hilum, respectively during PN.Interobserver variability was assessed with kappa values and percentage of exact matches between each pairwise combination of readers. Linear regression was used to evaluate the association between reference scores and ischemia time, estimated blood loss, and estimated glomerular filtration rates at 6 wk and 6 mo after surgery adjusted for baseline estimated glomerular filtration rate. Fisher's exact test was used to test for differences in risk of urinary fistula formation by reference category assignment.Pairwise comparisons of readers' score assignments were significantly correlated (all p0.0001); average kappa = 0.545 across all reader pairs. The average proportion of exact matches was 69%. Linear regression between the complexity score system and surgical outcomes showed significant associations between reference category assignments and ischemia time (p0.0001) and estimated blood loss (p=0.049). Fisher's exact test showed a significant difference in risk of urinary fistula formation with higher reference category assignments (p=0.028). Limitations include use of a single institutional cohort to evaluate our system.The ABC scoring system for PN is intuitive, easy to use, and demonstrated good correlation with perioperative morbidity.The ABC scoring system is a novel anatomy-reproducible tool developed to help patients and doctors understand the complexity of renal masses and predict the outcomes of kidney surgery.

INTRODUCTION AND OBJECTIVES: We developed a surgical complexity score system based on the arterial vascular anatomy of the kidney in an attempt to overcome the limitations of available nephrometry scoring systems including inconsistent ability to predict clinical outcomes of partial nephrectomy. METHODS: Contrast-enhanced computed tomography images of 179 patients who underwent partial nephrectomy were independently scored by 4 readers. According to the order of vessels involved by the tumor or needed to be transected during partial nephrectomy, assigned score was 1 for interlobular and arcuate arteries; 2 for interlobar arteries; 3S for segmental arteries; and 3H for renal hilum (Fig. 1). The Interobserver variability was assessed with kappa values and percentage of exact matches between each pairwise combination of the 4 readers. Spearman correlation was used to evaluate the association between scores of the most experienced reader (reference score) and ischemia time, estimated blood loss, incidence of urinary fistula within 30 days, and percent change in eGFR from baseline to 6 weeks and 6 months after surgery. RESULTS: All pairwise comparisons of readers’ score assignments were significantly correlated (all p

Objective Describe the rationale for and surgical modifications to the original Montsouris technique for laparoscopic radical prostatectomy (LRP). Methods This is a retrospective review of laparoscopic prostatectomy and experience involving 1071 cases performed between January 1998 and March 2006 at two centres: the Departments of Urology of the Institut Mutualiste Montsouris, Paris, France (first 502 cases) and Memorial Sloan-Kettering Cancer Center, New York, NY (next 569 cases). Results Since the first systematic description of the LRP technique, several modifications have been implemented. Most of the modifications have not yet been subjected to rigorous prospective evaluation, but, in our experience, they reduce complications or shorten operative time, and presumably lead to better oncologic results with improved preservation of quality of life. We describe those modifications to the LRP technique 8 yr after the program started, including urachal-sparing transperitoneal approach, extended lymph node dissection, systematic identification of the posterior longitudinal fascia of the detrusor muscle during dissection of the posterior bladder neck, intra/inter/extrafascial dissection of the neurovascular bundles, anatomic dissection of the apex with ligature of the dorsal vascular complex after its sectioning, anchoring of the anterior urethrovesical anastomotic stitches to the endopelvic fascia and pubovesical ligaments, extraction and evaluation of the specimen before completing the anastomosis, and use of postoperative care pathways. Conclusions LRP technique has been refined, which allowed us to decrease the positive surgical margins rate and improve functional outcomes. It is hoped younger laparoscopic surgeons can take advantage of our experience to build on their expertise.

Objectives A paucity of literature discusses biochemical recurrence (BCR) after laparoscopic radical prostatectomy (LRP). We report the intermediate-term cancer control and variables associated with BCR based on the 8-yr experience of a single surgeon. Methods Between January 1998 and March 2006, one surgeon performed LRP on 1071 patients at two institutions. Excluded from analysis are 20 patients who received neoadjuvant therapy, 27 lost to follow-up, and 23 without prostate-specific antigen (PSA) controls due to recent date of surgery. Kaplan-Meier curves were generated to estimate time to BCR, defined as a PSA of 0.2ng/ml and rising or start of secondary therapy. The log-rank test was used to compare pathologic variables. Positive surgical margin (PSM) was defined as cancer cells at the inked margins. Cox regression analysis estimated variables associated with time to BCR. Results Of the study population, 1%, 75%, 23%, and 1% had pT0, pT2, pT3, and pT4 disease, respectively; 41%, 1%, and 58% had no nodal involvement, lymph node metastases, and no lymph node dissection, respectively. The cumulative 5-yr BCR-free rate was 75% for the 1001 evaluable patients, with 95 patients fulfilling criteria for BCR. The mean follow-up was 22.3 mo (95%CI, 20,24.6). In multivariable Cox regression analysis, higher serum PSA ( p p =0.009), presence of extracapsular extension (ECE; p =0.038), seminal vesicle invasion (SVI; p p p Conclusion LRP seems to offer comparable oncologic outcomes to open surgery; however, more extended follow-up of patients is needed to better assess the oncologic safety of the LRP.

Objective: To review the literature and answer the question of whether the laparoscopic approach meets the quality standards. Methods: We conducted an extensive Medline literature search. The articles obtained and the experience at Memorial Sloan-Kettering Cancer Center were used for interpretation and critical analysis of results. Long-term quality indicators are oncologic efficacy, potency rate, and continence rate. Short-term quality indicators are blood loss and transfusion rate, hospital stay, postoperative recovery, and rate and severity of complications. Results: Long-term quality indicators. Oncologic efficacy. Despite recent evidence that pelvic lymph node dissection (PLND) at radical prostatectomy may be necessary to detect occult positive lymph nodes, and that extended node dissection may also have a positive impact on disease-free survival, PLND is rarely performed during laparoscopic radical prostatectomy (LRP), which may have a negative impact on the long-term recurrence-free probability. Positive margins rates range from 11% to 26%, ranging from 6% to 8% for organ-confined disease and from 35% to 60% in those with extraprostatic extension. Most of these data include the first patients operated on when the technique of LRP was in early development. These rates seem high as compared to the contemporary data achieved in retropubic radical prostatectomy. Short-term biochemical recurrence rate have been published by only two centers and generalization to the whole laparoscopic patients and to long-term results are at present time hazardous. Functional outcome. Given the complexity of measuring, interpreting, and reporting continence and erectile dysfunction, the available results after LRP do not allow drawing any conclusion. Furthermore, the number of patients on whom results are reported is disproportionately low in relation to the large LRP experience accumulated so far. Short-term quality indicators. Assessment of LRP equanimity includes factors such as blood loss, transfusion rates, hospital stay, duration of catheterization, and complication profile. All the reports are concordant and demonstrate a benefit for the laparoscopic approach. However, no prospective and parallel studies compare the respective advantages of LRP and radical retropubic prostatectomy in reference centers. Conclusions: In a review of the published literature results of LRP, there is not enough evidence to answer the question of whether the laparoscopic approach meets the quality standards. The available biochemical recurrence information is promising but limited to the short-term and the experience of two centers only. The question of omitting the PLND or performing a limited one in high-risk patients needs to be answered. The functional results analyses suffer from a lack of uniformity in methodology, a limited follow-up, and a disproportionately small number of patients in relation to the accumulated experience. Future reports of the post-learning phase era are dramatically needed.

The incidence of accessory pudendal arteries (APAs) varies from 4% to 70% depending on the means used to identify them. We provide a detailed laparoscopic anatomical description of their appearance, location and identification rate based on our series of radical prostatectomies.The distribution of APAs was prospectively recorded in 285 consecutive patients between October 2002 and November 2004. We defined an APA as any artery located within the periprostatic region running parallel to the dorsal vascular complex and extending caudal toward the anterior perineum, other than cavernous arteries, corona mortis and satellite arteries to the superficial and deep vascular complex.We identified 92 APAs in 72 of 285 patients (25%). Two distinct varieties of APAs were identified. In 10% of patients an APA coursed along the lateral aspect of the prostate, termed lateral APA, and in 13% an APA emerged through the levator ani fibers near the apical region of the prostate, termed apical APA. Five patients (1.7%) were found to have apical and lateral APAs.APAs are more frequent than previously reported in the surgical literature. To our knowledge apical APAs have never been reported previously. The visualization and accessibility advantages of laparoscopy may account for a higher intraoperative APA identification rate. Their roles in continence and potency remain to be determined.

Purpose The most favorable outcome that can be achieved after radical prostatectomy is complete tumor resection without recurrence and full recovery of continence and potency. Risks of erectile dysfunction, incontinence, and disease recurrence are well described, but in isolation, do not adequately inform patients of the possibility of becoming cancer-free while at the same time returning to their preoperative functional state. We sought to determine the frequency of optimal outcomes after radical prostatectomy and the time to such outcomes. Patients and Methods Patients who underwent radical prostatectomy performed at a tertiary referral center between July 1998 and July 2003 for clinical stage T1 to T3 prostate cancer were identified. Patients were excluded if they were incontinent or impotent preoperatively, or if they had received radiotherapy or neoadjuvant androgen deprivation therapy previously. Six hundred forty-seven patients were analyzed for time to recovery of full continence and potency without cancer recurrence after surgery. Optimal outcome probability was calculated with a Markov state transition model to simulate clinical outcomes in the first 4 years following radical prostatectomy. Results Mean patient age was 58 years, and mean pretreatment prostate-specific antigen was 6.9 ng/mL. Cancer-free status with full continence and potency was achieved in 30% of men at 12 months, 42% at 24 months, 47% at 36 months, and 53% at 48 months postoperatively. Conclusion Optimal outcomes after radical prostatectomy can be achieved in a small majority of cases. Time to full recovery is primarily dictated by recovery of erectile function. This information is helpful for patients interested in their chances of returning to their preoperative functional state.

OBJECTIVE To report the experience of partial nephrectomy in patients with a solitary kidney at one institution, with analysis of renal function, complications, oncological efficacy and survival. PATIENTS AND METHODS We identified 54 consecutive patients with a solitary kidney who had a partial nephrectomy between December 1989 and July 2003. Variables examined included patient age and gender, renal function, renal ischaemia time, surgical margin status and complications. Pathological features, e.g. tumour size, histological subtype and tumour stage, were also assessed. Disease-free probability and overall and cancer-specific survivals were determined. RESULTS The histological subtype was clear cell in 35 cases (65%), papillary in 10 (19%), oncocytoma in four (7%), chromophobe in two (4%), unclassified in one (2%) and multiple subtypes in two (2%). The median creatinine level before surgery was 14 mg/L, which increased to 16 mg/L 6 months afterward, and at 1 and 2 years after surgery it was 15 mg/L. Two patients developed end-stage renal disease requiring haemodialysis, one soon after surgery and another 8 years after nephron-sparing surgery. In all, 26% of patients developed at least one perioperative complication, with acute renal failure and urinary fistula being the most common. At 5 years the overall and cancer-specific survival, and disease-free probability were 68%, 88% and 73%, respectively. CONCLUSIONS Partial nephrectomy is safe in patients with a solitary kidney, with an acceptable decline in renal function and low likelihood of requiring temporary or permanent haemodialysis. After an initial decline, renal function appears to stabilize during the first year.

Laparoscopic radical prostatectomy is a relatively new approach to the surgical treatment of localized prostate cancer. Since its inception, the technique, however challenging, is undergoing continuous refinements which make it today a feasible, reproducible, and teachable operation practiced by urologists worldwide. The advantages of the laparoscopic approach are a magnified view of the anatomic structures, and a decreased venous bleeding in the surgical field allowing an accurate dissection of the prostate and neurovascular bundles. These advantages translate to a low positive surgical margin rate, low morbidity profile, and favorable postoperative quality of life outcomes. However, since the technique has only been performed for the past 6 years, long term cancer control and functional results data following laparoscopic radical prostatectomy are not available. For a successful laparoscopic prostatectomy program, advanced laparoscopic skills, knowledge of the prostatic anatomy, and expertise in surgical oncology are required.

Pelvic lymph node dissection (PLND) remains the best means for detecting lymph node metastasis (LNM) in prostate cancer (PCa). PLND yields valuable staging information thatmay help to guide future therapies and provides durable long-term cancer control in nearly 30% of men found to have LNM after radical prostatectomy [1]. The staging accuracy of PLND depends on the extent of the anatomical template used; the higher the number of lymph nodes retrieved, the greater is the likelihood of detecting metastatic nodes [2]. This finding represents a convincing argument for utilizing an extended anatomical template for PLND, particularly since the indications for radical prostatectomy have shifted from low-risk disease and increasingly include patients with high-risk PCa, who are likely to present with LNM. However, extended PLND is not fully adopted by all surgeons [3]. Possible reasons for underutilization of extended PLND include the potential risk of greater morbidity, the longer operating time [4], and the fact that the extended template may not encompass all the lymphatic drainage sites. In a study by Mattei et al [5], up to 35% of prostate lymphatic drainage sites remained outside the extended anatomical template, which includes the external iliac, hypogastric, and obturator fossa nodal packets. To circumvent these limitations, several investigators have explored the possibility of dissection based on a sentinel lymph node. These investigations include injection of radiotracers such as colloid-bound Tc directly into the prostate to detect the lymphatic drainage of the prostate preoperatively on single-photon emission computed

Objective To build a predictive model of urinary continence recovery after radical prostatectomy (RP) that incorporates magnetic resonance imaging (MRI) parameters and clinical data. Patients and Methods We conducted a retrospective review of data from 2 849 patients who underwent pelvic staging MRI before RP from November 2001 to June 2010. We used logistic regression to evaluate the association between each MRI variable and continence at 6 or 12 months, adjusting for age, body mass index (BMI) and American Society of Anesthesiologists (ASA) score, and then used multivariable logistic regression to create our model. A nomogram was constructed using the multivariable logistic regression models. Results In all, 68% (1 742/2 559) and 82% (2 205/2 689) regained function at 6 and 12 months, respectively. In the base model, age, BMI and ASA score were significant predictors of continence at 6 or 12 months on univariate analysis (P

To assess interobserver variability of R.E.N.A.L., preoperative aspects and dimensions used for an anatomical classification system (PADUA), and centrality index (C-Index) systems among observers with varying degrees of clinical experience and each system’s subscale correlation with surgical outcome metrics. Computed tomography images of 90 patients who underwent open, laparoscopic, or robot-assisted laparoscopic partial nephrectomy were scored by one radiology fellow, two urology fellows, one radiology resident, and one secondary school student. Agreement among readers was determined calculating intraclass correlation coefficients. Associations between radiology fellow scores (reference standard as reader with greatest clinical experience), ischemia time, and percent change in postoperative estimated glomerular filtration rate (eGFR) were evaluated using Spearman’s correlation. Agreement using C-Index method (ICC = 0.773) was higher than with PADUA (ICC = 0.677) or R.E.N.A.L (ICC = 0.660). Agreement between reference and secondary school student was lower than with other physicians, although the differences were not statistically significant. The reference’s scores were significantly (p

Partial nephrectomy (PN) is the current gold standard treatment for small localized renal tumors.; however, the impact of duration and type of intraoperative ischemia on renal function (RF) after PN is a subject of significant debate.To review the current evidence on the relationship of intraoperative ischemia and RF after PN.A review of English-language publications on renal ischemia and RF after PN was performed from 2005 to 2014 using the Medline, Embase, and Web of Science databases. Ninety-one articles were selected with the consensus of all authors and analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.The vast majority of reviewed studies were retrospective, nonrandomized observations. Based on the current literature, RF recovery after PN is strongly associated with preoperative RF and the amount of healthy kidney parenchyma preserved. Warm ischemia time (WIT) is modifiable and prolonged warm ischemia is significantly associated with adverse postoperative RF. Available data suggest a benefit of keeping WIT25min, although the level of evidence to support this threshold is limited. Cold ischemia safely facilitates longer durations of ischemia. Surgical techniques that minimize or avoid global ischemia may be associated with improved RF outcomes.Although RF recovery after PN is strongly associated with quality and quantity of preserved kidney, efforts should be made to limit prolonged WIT. Cold ischemia should be preferred when longer ischemia is expected, especially in presence of imperative indications for PN. Additional research with higher levels of evidence is needed to clarify the optimal use of renal ischemia during PN.In this review of the literature, we looked at predictors of renal function after surgical resection of renal tumors. There is a strong association between the quality and quantity of renal tissue that is preserved after surgery and long-term renal function. The time of interruption of renal blood flow during surgery is an important, modifiable predictor of postoperative renal function.

The diffusion of minimally invasive radical prostatectomy (MIRP) in the United States may have led to adverse patient outcomes due to rapid surgeon adoption and collective inexperience. We hypothesized that throughout the early period of minimally invasive surgery, MIRP patients had inferior outcomes as compared with those who had open radical prostatectomy (ORP). We used the Surveillance, Epidemiology and End Results-Medicare dataset and identified men who had ORP and MIRP for prostate cancer from 2003–2009. Study endpoints were receipt of subsequent cancer treatment, and evidence of postoperative voiding dysfunction, erectile dysfunction (ED) and bladder outlet obstruction. We used proportional hazards regression to estimate the impact of surgical approach on each endpoint, and included an interaction term to test for modification of the effect of surgical approach by year of surgery. ORP (n=5362) and MIRP (n=1852) patients differed in their clinical and demographic characteristics. Controlling for patient characteristics and surgeon volume, there was no difference in subsequent cancer treatments (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.76–1.05), although MIRP was associated with a higher risk of voiding dysfunction (HR 1.31, 95% CI 1.20–1.43) and ED (HR 1.43, 95% CI 1.31–1.56), but a lower risk of bladder outlet obstruction (HR 0.86, 95% CI 0.75–0.97). There was no interaction between approach and year for any outcome. When stratifying the analysis by year, MIRP consistently had higher rates of ED and voiding dysfunction with no substantial improvement over time. MIRP patients had adverse urinary and sexual outcomes throughout the diffusion of minimally invasive surgery. This may have been a result of the rapid adoption of robotic surgery with inadequate surgeon preparedness.

SummaryThe lack of in vitro prostate cancer models that recapitulate the diversity of human prostate cancer has hampered progress in understanding disease pathogenesis and therapy response. Using a 3D organoid system, we report success in long-term culture of prostate cancer from biopsy specimens and circulating tumor cells. The first seven fully characterized organoid lines recapitulate the molecular diversity of prostate cancer subtypes, including TMPRSS2-ERG fusion, SPOP mutation, SPINK1 overexpression, and CHD1 loss. Whole-exome sequencing shows a low mutational burden, consistent with genomics studies, but with mutations in FOXA1 and PIK3R1, as well as in DNA repair and chromatin modifier pathways that have been reported in advanced disease. Loss of p53 and RB tumor suppressor pathway function are the most common feature shared across the organoid lines. The methodology described here should enable the generation of a large repertoire of patient-derived prostate cancer lines amenable to genetic and pharmacologic studies.

Context Prostate cancer (PCa) patients with isolated clinical lymph node (LN) relapse, limited to the regional and/or retroperitoneal LNs, may represent a distinct group of patients who have a more favorable outcome than men with progression to the bone or to other visceral organs. Some data indirectly denote a beneficial impact of pelvic LN dissection on survival in these patients. Objective To provide an overview of the currently available literature regarding salvage LN dissection (SLND) in PCa patients with clinical relapse limited to LNs after radical prostatectomy (RP). Evidence acquisition A systematic literature search was conducted using the Medline, Embase, and Web of Science databases to identify original articles, review articles, and editorials regarding SLND. Articles published between 2000 and 2012 were reviewed and selected with the consensus of all the authors. Evidence synthesis Contemporary imaging techniques, such as 11C-choline positron emission tomography and diffusion-weighted magnetic resonance imaging, appear to enhance the accuracy in identifying LN relapse in patients with biochemical recurrence (BCR) and after RP. In these individuals, SLND can be considered as a treatment option. The currently available data suggest that SLND can delay clinical progression and postpone hormonal therapy in almost one-third of the patients, although the majority will have BCR. An accurate and attentive preoperative patient selection may help improve these outcomes. The most frequent complication after SLND was lymphorrhea (15.3%), followed by fever (14.5%) and ileus (11.2%). It is noteworthy that all examined cohorts originated from retrospective single-institution series, with limited sample size and short follow-up. Consequently, the current findings cannot be generalized and warrant further investigation in future prospective trials. Conclusions The current data suggest that SLND represents an option in patients with disease relapse limited to the LNs after RP; however, more robust data derived from well-designed clinical trials are needed to validate the role of SLND in this selected patient population. Patient summary Salvage lymph node dissection (SLND) represents a treatment option in for patients with prostate cancer relapse limited to the lymph nodes; however, more robust data derived from well-designed clinical trials are needed to validate the role of SLND in this selected patient population.

Prostate biopsy related infectious complications are associated with significant morbidity. The risk of infectious complications in patients with prostate cancer on active surveillance remains under studied.A total of 591 consecutive men who underwent prostate biopsy were prospectively enrolled in a study evaluating prostate biopsy related complications between January 2011 and January 2012. Of these men 403 were previously diagnosed with prostate cancer and were included in this study. They underwent a 14-core transrectal ultrasound guided prostate biopsy as part of an active surveillance regimen. A nurse contacted all men within 14 days of biopsy, and information was collected on potential complications, antibiotics received and bacterial culture results.Fourteen patients (3.5%) had infectious complications including 13 requiring hospitalization. Five patients had positive urine cultures, and fluoroquinolone resistant isolates were identified in 4 patients, including 2 with extended spectrum beta-lactamase producing isolates. We evaluated the impact of risk factors including diabetes, benign prostatic hyperplasia and antibiotic regimen. However, only the number of previous prostate biopsies was significantly associated with an increased risk of infectious complications (p = 0.041). For every previous biopsy the odds of an infection increased 1.3 times (OR 1.33, 95% CI 1.01-1.74).In men with prostate cancer on active surveillance the number of previous prostate biopsies is associated with a significant risk of infectious complications and every previous biopsy increases the risk of infectious complication. Fluoroquinolone resistant and extended spectrum beta-lactamase producing isolates represent the most commonly identified organisms. Men with prostate cancer on active surveillance should be informed of the risks associated with serial repeat prostate biopsies.

Active surveillance is becoming an increasingly common management strategy for low grade prostate cancer and involves repeat prostate biopsies over time. It has been hypothesized that serial biopsies can lead to reduced erectile function in patients on active surveillance and we explored this hypothesis in a longitudinally followed cohort.We identified 342 men on active surveillance whose first biopsy occurred between 2000 and 2009. We investigated erectile function using patient reported outcomes, namely the 6 erectile function questions from the IIEF-6 (International Index of Erectile Function). We estimated the change in erectile function with time using locally weighted scatterplot smoothing.The median (IQR) patient age in this cohort was 64 years (58-68). Median followup on active surveillance was 3.5 years (2.3-5.0) and the median number of biopsies was 5 (3-6). During the first 4 years on active surveillance erectile function decreased 1.0 point per year (95% CI 0.2, 1.7) on the IIEF-6 (scale 1 to 30). When stratified by comorbidities or number of biopsies we see an almost identical decrease in erectile function with time. The use of phosphodiesterase-5 inhibitors increased from 5% to 27% from baseline to year 5 on active surveillance.In this longitudinally followed active surveillance cohort we observed a small decrease in erectile function and an increase in the use of phosphodiesterase-5 inhibitors with time. While we cannot separate out the effect of multiple biopsies from that of the natural aging process on erectile function in this observational study, our data suggest that active surveillance related biopsies do not have a large impact on erectile function.

Context The clinical significance of positive surgical margins (PSMs) in radical prostatectomy (RP) specimens and the management of affected patients remain unclear. Objective To address pitfalls in the pathologic interpretation of margin status; provide an update on the incidence, predictors, and long-term oncologic implications of PSMs in the era of robot-assisted laparoscopic RP (RALRP); and suggest a practical evidence-based approach to patient management. Evidence acquisition A systematic review of the literature was performed in April 2013 using Medline/PubMed, Web of Science, and Scopus databases and the Cochrane Database of Systematic Reviews. Studies focusing on PSMs in RP pertinent to the objectives of this review were included. Particular attention was paid to publications within the last 5 yr and those concerning RALRP. Evidence synthesis A total of 74 publications were retrieved. Standardized measures to overcome variability in the pathologic interpretation of surgical margins have recently been established by the International Society of Urological Pathology. The average rate of PSMs in contemporary RALRP series is 15% (range: 6.5-32%), which is higher in men with a more advanced pathologic stage and equivalent to the rate reported in prior open and laparoscopic prostatectomy series. The likelihood of PSMs is strongly influenced by the surgeon's experience irrespective of the surgical approach. Technical modifications using the robotic platform and the role of frozen-section analysis to reduce the margin positivity rate continue to evolve. Positive margins are associated with a twofold increased hazard of biochemical relapse, but their association with more robust clinical end points is controversial. Level 1 evidence suggests that adjuvant radiation therapy (RT) may favorably affect prostate-specific antigen recurrence rates, but whether the therapy also affects systemic progression, prostate cancer-specific mortality, and overall survival remains debatable. Conclusions Although positive margins in prostate cancer are considered an adverse oncologic outcome, their long-term impact on survival is highly variable and largely influenced by other risk modifiers. Adjuvant RT appears to be effective, but further study is required to determine whether early salvage RT is an equivalent alternative. © 2013 European Association of Urology.

Many aspects of prostate cancer diagnosis and treatment could be greatly advanced with new, effective biomarkers. Prostate-specific antigen (PSA) has multiple weaknesses as a biomarker, such as not distinguishing well between cancer and benign prostatic hyperplasia or between indolent and aggressive cancers, thus leading to overtreatment, especially unnecessary biopsies. PSA also often fails to indicate accurately which patients are responding to a given treatment. Yet PSA is the only prostate cancer biomarker routinely used by urologists. Here, we provide updated information on the most relevant of the other biomarkers currently in use or in development for prostate cancer. Recent research shows improvement over using PSA alone by comparing total PSA (tPSA) or free PSA (fPSA) with new, related markers, such as prostate cancer antigen (PCA) 3, the individual molecular forms of PSA (proPSA, benign PSA, and intact PSA), and kallikreins other than PSA. Promising results have also been seen with the use of the fusion gene TMPRSS2:ERG and with various forms of the urokinase plasminogen activation receptor. Initially, there were high hopes for early PCA, but those data were not reproducible and thus research on early PCA has been abandoned. Much work remains to be done before any of these biomarkers are fully validated and accepted. Currently, the only markers discussed in this paper with Food and Drug Administration-approved tests are PCA 3 and an isoform of proPSA, [-2]proPSA. Assays are in development for most of the other biomarkers described in this paper. While the biomarker validation process can be long and filled with obstacles, the rewards will be great—in terms of both patient care and costs to the health care system.