Search

Background Intermediate risk prostate cancer (IR PCa) may exhibit a wide array of phenotypes, from favorable to unfavorable. NCCN criteria help distinguishing between favorable versus unfavorable subgroups. We studied and attempted to improve this classification. Methods Within the SEER database 2010-2016, we identified 19,193 IR PCa patients treated with radical prostatectomy. A multivariable logistic regression model predicting unfavorable IR PCa was developed and externally validated, in addition to a head-to-head comparison with NCCN IR PCa stratification. Results Model development (development cohort n=13,436: 3,585 unfavorable versus 9,851 favorable) rested on age, PSA, clinical T stage, biopsy Gleason Grade Group (GGG) and percentage of positive cores. All were independent predictors of unfavorable IR PCa. In external validation cohort (n=5,757: 1,652 unfavorable versus 4,105 favorable), NCCN stratification was 61.8% accurate in discriminating between favorable versus unfavorable, compared to 67.6% for nomogram, which exhibited excellent calibration, less pronounced departures from ideal prediction and greater net-benefit in decision curve analyses (DCA) than NCCN stratification. The optimal nomogram cutoff misclassified 312 of 1976 patients (15.8%) versus 598 of 2877 (20.8%) for NCCN stratification. Of NCCN misclassified patients, 90.0% harbored pT3-4 stages versus 84.6% of nomogram. Conclusions The newly developed, externally validated nomogram discriminates better between favorable versus unfavorable IR PCa, according to overall accuracy, calibration, DCA, and actual numbers and stage distribution of misclassified patients.

Using institutional data, we have previously developed an algorithm to identify the optimal candidates for adjuvant radiotherapy (aRT) among men with pN1 prostate cancer (PCa) at radical prostatectomy (RP). This study aimed to test the external validity of our previous findings using a nationwide database while focusing on overall mortality as an endpoint. To this end, we identified 5498 pN1 PCa patients who were treated with RP, pelvic lymph node dissection, and androgen deprivation therapy with or without aRT, within the National Cancer Database, between 2004 and 2015. Patients were divided into five groups based on our previously published algorithm. Similar to our previous report, multivariable Cox regression analysis showed that only two of these groups benefit from aRT: (1) those with one to two positive nodes, pathological Gleason score 7-10, and pT3b/4 disease or positive surgical margins (hazard ratio [HR]=0.75); and (2) those with three to four positive nodes, regardless of local tumor characteristics (HR=0.57, both p=0.01). In the remaining patients (25% of the cohort), aRT had no significant survival benefit. Results were confirmed on sensitivity analyses using 1:1 propensity score-matched cohorts, excluding men who died within 3 yr of surgery and using cut-off of 6 mo post-surgery to identify receipt of aRT. Our findings corroborate the validity of our previously published criteria and highlight the importance of patient selection in pN1 PCa patients who are considered for aRT.

Introduction The purpose of this paper is to compare oncological outcomes of partial nephrectomy (PN) versus radical nephrectomy (RN) in renal cell carcinoma (RCC) clinical stages ≥T1b, in a retrospective propensity-score matched cohort of a high-volume, tertiary referral center. This paper also aims to compare renal function and complication rates between groups. Material and methods Our single-institution RCC database was queried to select patients with clinical stages defined by tumor size (T), lymph nodes(N), and metastasis (M) scores of T1b-4 N0 M0, that underwent PN or RN between 2000 and 2014. All images of patients that underwent RN were reviewed, and only patients deemed eligible for PN were included. Medical records were reviewed to obtain data on tumor characteristics, comorbidities, renal function, and complications. After propensity score matching, 152 patients (76 per group) were included in the final analysis. Primary outcomes were cancer specific survival (CSS), overall survival (OS), and clinical progression-free survival (CPFS). Secondary outcomes were renal function preservation and post-operative complication rates. Results Groups were propensity-score matched. The only parameters that were significantly different between groups were the median follow-up time (RN: 79 months, range 24.1–100.5 vs. PN: 38.5 months, range 20.5–72.1) and a better performance status in the RN group (p = 0.002). The five-year CPFS, CSS, and OS rates were 77.2%, 90.5%, and 86.4%, respectively, in the RN group, and 83.6%, 91.1%, and 82.0%, respectively, in the PN group (p = 0.33, p = 0.55, and p = 0.33, respectively). In the multivariate Cox model, the surgical method was not an independent predictor of CPFS, CSS, or OS. The RN group showed a significantly greater reduction in estimated glomerular filtration rate (RN: 14.1 vs. PN: 5.4 ml/min per 1.73 m²; p

Background: Aborted radical prostatectomy (aRP) in lymph node (LN) metastatic (pN1) prostate cancer (PCa) patients showed worse survival in European patients. Contemporary rates of aRP are unknown in North America. Objective: To examine the rate of aRP and its effect on cancer-specific mortality (CSM) in contemporary North American patients. Design, setting, and participants: Within the Surveillance Epidemiology and End Results database (2004-2014), we identified 3719 pN1 PCa patients. Intervention: RP. Outcome measurements and statistical analysis: Incidence proportion and median survival of LN metastatic PCa patients who underwent aRP versus completed RP (cRP). Cumulative incidence plots and competing-risks regression (CRR) models tested CSM and other-cause mortality rates according to aRP versus cRP. The effect of selected variables on CSM rate was graphically depicted using LOESS methodology. All analyses were repeated after propensity score matching. Results and limitations: Between 2004 and 2014, the rate of aRP decreased from 20.4% to 5.6% (p< 0.001). Ten-year CSM rates were significantly higher after aRP (38.9% vs 21.6%) versus cRP (p< 0.001). In multivariable CRR models, aRP yielded higher CSM (hazard ratio [HR]: 1.99) than cRP. A higher 5-yr CSM rate was recorded after aRP through the entire range of baseline prostate-specific antigen (PSA) values and in patients with up to nine LN metastases. After propensity score matching, aRP resulted in overall higher CSM (HR: 1.72). Higher CSM was recorded after aRP for PSA values up to 50. ng/ml and in patients with up to seven LN metastases. Results were limited by a selection bias that applies to aRP patients. Conclusions: Of contemporary North American patients, 5% are affected by aRP. It confers a significant survival disadvantage that applies to patients with baseline PSA values up to 50. ng/ml and in those with up to seven LN metastases. Patient summary: Radical prostatectomy should not be aborted in pN1 prostate cancer individuals. Aborted radical prostatectomy (RP) still affects 5% of contemporary North American patients. It confers a significant survival disadvantage that was quantified in 13.5% higher cancer-specific mortality rate, which appears to apply even to patients with baseline prostate-specific antigen values up to 50. ng/ml and with up to seven lymph node metastases. An emphasis on the persistent rate of aborted RP is warranted, with the intent of further decreasing or ultimately eliminating such clinical practice.

The rate of noninterventional treatment (NIT) in prostate cancer (PCa) active surveillance (AS) candidates is on the rise. However, contemporary data are unavailable. We described community-based NIT rates within 16 Surveillance Epidemiology and End Results (SEER) registries between 2010 and 2014.We identified 23,360 PCa patients who fulfilled the University of California San Francisco AS criteria (prostate-specific antigen [PSA] 10 ng/mL, clinical T stage ≤ T2a, Gleason score ≤ 6, and positive cores 33%). Annual NIT rates as well as patient distribution according to PSA, age, number of positive cores, and clinical T stage were studied. Multivariable logistic regression analysis tested NIT predictors.Between 2010 and 2014, the NIT rate increased from 30.2% to 57.5% (P = .004). Within 16 SEER registries, NIT rates ranged from 25.9% to 62%. NIT rate increased uniformly within all examined registries. Of patient and tumor characteristics (PSA4 ng/mL, cT2a and1 positive core) only the proportion of NIT patients aged 65 years increased over time from 47.3% to 53.2% (P = .03). By multivariable logistic regression analysis predicting NIT rate, older age (odd ratio [OR] = 1.05), more contemporary year of diagnosis (OR = 1.41), and being unmarried (OR = 1.45) and uninsured (OR = 2.41) were independent predictors.The NIT rate has markedly increased across all examined SEER registries. Nonetheless, important differences distinguish those who received high-end NIT from low-end NIT. PCa characteristics of NIT patients remained unchanged over time. However, in addition to geographical differences in NIT rates, patient characteristics such as age, marital status, and insurance status represent potential NIT access barriers.

Objective: The impact of positive surgical margin (SM) on cancer control outcomes in prostate cancer patients is a subject of continuous debate. We test the hypothesis that the impact of SM on clinical recurrence (CR) rate may vary based on the other clinical/pathologic characteristics of the tumor. Materials and Methods: We focused on 5290 patients treated with robot-assisted radical prostatectomy and pelvic node dissection, between 2002 and 2013, at three tertiary care centers. Regression tree analysis stratified patients into risk groups based on their tumor characteristics and the corresponding CR rate. Kaplan-Meier log-rank and multivariable Cox regression models tested the relationship between SM status and CR rate in each tree-generated risk group. Results: Mean (median) follow-up time was 47.7 (39.0) months. Regression tree analysis that considered all available covariates, except SM status, divided patients based on their CR risk into the following risk groups: (1) high risk (any pT3b/pT4 disease); (2) intermediate risk (≤pT3a disease and pGS 8-10); (3) low risk (≤pT3a, pGS ≤7, and prostate-specific antigen [PSA] >9 ng/mL); and (4) very low risk (≤pT3a, pGS ≤7, and PSA ≤9 ng/mL). Positive SM had a significant detrimental impact on CR risk only in two groups: intermediate risk (p < 0.001) and high risk (p = 0.01). These observations were confirmed by multivariable analyses. Conclusions: Our findings show that positive SM had a detrimental impact on CR only in a minority of patients (15%), specifically in those with advanced pathologic stage and/or pathologically poorly differentiated tumor. For all the remaining patients (85%), positive SM by itself did not increase the risk of CR.

Introduction: Local therapy (LT) may offer a survival advantage in highly select, newly diagnosed metastatic prostate cancer (mPCa) patients. However, it is unknown whether the benefits vary in Caucasian vs. African American (AA) patients. Methods: Within the Surveillance Epidemiology and End Results (SEER) database (2004–2014), we focused on Caucasians and AA patients with newly diagnosed mPCa treated with LT: radical prostatectomy (RP) and brachytherapy (RT). Endpoints consisted of cancer-specific mortality (CSM) and overall mortality (OM). Kaplan-Meier analyses and multivariable Cox regression models tested for racial difference in CSM and OM. Results: Between 2004 and 2014, we identified 408 (77.2%) Caucasians and 121 (22.8%) AAs with newly diagnosed mPCa treated with LT: RP (n=357) or RT (n=172). According to race, when LT is defined as RP, Caucasian patients had a significantly longer survival vs. AA patients: CSM-free survival 123 vs. 63 months (p=0.004) and OM-free survival 108 vs. 46 months (p=0.002). The CSM and OM benefits were confirmed in multivariable analyses (hazard ratio [HR] 0.56, p=0.01 for CSM; HR 0.60, p=0.01 for OM). However, no differences in CSM or OM were recorded according to race when LT consisted of RT. Conclusions: Our results indicate that race is not associated with difference in survival after LT in mPCa patients. However, when focusing on RP-treated patients, Caucasian race is associated with higher CSM and OM rates relative to AA race. This racial difference does not apply to RT. Our findings should be considered in future prospective trials for the purpose of preplanned stratification according to race.

Background: We hypothesized that a cut-off in positive lymph node (LN) counts may discriminate between cancer-specific mortality (CSM) rates in clinically localized prostate cancer patients treated with radical prostatectomy (RP). Objective: To test this relationship, we relied on different LN count cut-offs, as well as the continuously coded number of positive LNs (NPN). Methods: Within the Surveillance, Epidemiology, and End Results database (2004-2014), we identified patients with D'Amico intermediate- or high-risk characteristics who underwent RP and pelvic LN dissection, regardless of pathologic LN stage. Kaplan-Meier analyses and multivariable Cox regression models tested the effect of LN invasion (LNI) on CSM, according to the NPN. Results: Of 30. 016 patients treated with RP, 6.2% (n = 1869) exhibited LNI, with respectively higher rates of LNI in patients with D'Amico high- versus intermediate-risk characteristics (11.6% vs 3.4%). Overall, the median age was 63. yr, median prostate-specific antigen value was 6.6. ng/ml and the median number of removed LNs was six. At 60 mo after RP, CSM rates were, respectively, 6.0% versus 0.8% for patients with and without LNI: multivariable hazard ratio (HR) 4.4 (p

Contemporary data regarding the benefit of radiotherapy in surgically treated retroperitoneal sarcoma are scarce. The aim of the study was to evaluate the effect of radiotherapy on cancer specific mortality in surgically treated patients according to tumor size, histological subtype and grade.Within Surveillance, Epidemiology, and End Results database (2004-2014), we identified 1226 patients with non-metastatic retroperitoneal sarcoma. Univariable and multivariable logistic regression models tested for predictors of radiotherapy delivery. Univariable and multivariable Cox regression models tested the effect of radiotherapy on cancer specific mortality in the overall population. Subgroup analyses explored the result of tumor grade and tumor size on radiotherapy effect. All analyses were repeated after adjustment according to inverse probability of treatment. Additionally, all analyses were subjected to 1000 bootstrap resamples for internal validation.Radiotherapy was delivered in 372 patients (30.3%). In univariable and multivariable logistic regression models high grade (OR: 1.46, CI:1.12-1.90; p = 0.006), and leiomyosarcoma histologic subtype (OR: 2.14, CI: 1.55-2.95; p 0.001) predicted radiotherapy delivery. In the overall population multivariable Cox regression models showed lower cancer specific mortality (HR: 0.73, CI: 0.55-0.96; p = 0.025) with radiotherapy. In subgroup analyses multivariable Cox regression models showed radiotherapy benefit predominantly in high grade, large tumor size retroperitoneal sarcomas (HR 0.51: C.I.: 0.30-0.86; p = 0.02).In this retrospective report, delivery of radiotherapy was associated with lower cancer specific mortality in high grade, large tumor size retroperitoneal sarcoma patients. Our findings are predominantly representative of liposarcomas and leiomyosarcomas that accounted for 90% of study population. Further study is needed to evaluate the role of radiotherapy in retroperitoneal sarcoma patients.

Background: Historically, partial nephrectomy (PN) showed no benefit on other-cause mortality (OCM) in elderly patients with small renal masses. Objective: To test the effect of PN versus radical nephrectomy (RN) on OCM, cancer-specific mortality (CSM), as well as 30-d mortality in patients with nonmetastatic T1a renal cell carcinoma (RCC), aged ≥75 yr old. Design, setting, and participants: Within the Surveillance, Epidemiology and End Results registry (2004-2014), we identified surgically treated patients with nonmetastatic pT1a RCC aged ≥75 yr. Outcome measurements and statistical analysis: We relied on propensity score (PS) matching to reduce the effect of inherent differences between PN and RN. After PS matching, cumulative incidence, multivariable competing-risks regression (CRR) and logistic regression models were used. LOESS plots graphically depicted the relation between nephrectomy type and OCM after adjustment for all the covariates. Landmark analyses at 6 mo tested for immortal time bias. Results and limitations: Of all 4541 patients, 41.6% underwent PN. After 1:1 PS matching, 2826 patients remained. In multivariable CRR models, lower OCM rates were recorded in PN patients (hazard ratio [HR]: 0.67, confidence interval [CI]: 0.54-0.84; p< 0.001). LOESS plots showed lower OCM rates after PN across all examined ages. Lower CSM rates were also recorded in PN patients (HR: 0.64, CI = 0.44-0.92; p = 0.02). Landmark analyses rejected the hypothesis of immortal time bias. Finally, PN did not result in different 30-d mortality rates (odds ratio: 1.87; CI: 0.79-4.47; p = 0.2) versus RN. Data are retrospective. Conclusions: PN results in lower OCM in elderly patients with pT1a RCC. Moreover, PN does not contribute to higher CSM or 30-d mortality in patients aged ≥75 yr. In consequence, PN should be given strong consideration, even in elderly patients. Patient summary: Partial nephrectomy (PN) may protect from renal insufficiency, hypertension, and other unfavorable health outcomes, even in elderly patients. This protective effect results in lower other-cause mortality. Moreover, PN benefits are not undermined by higher cancer-specific mortality or 30-d mortality. Partial nephrectomy should be given strong consideration even in elderly patients.

Extent of pelvic lymph node dissection (PLND) during radical prostatectomy (RP) remains a subject of debate. Here, we review the literature covering the value of extended PLND (ePLND) during RP for high-risk prostate cancer (PCa) over a standard PLND, with a focus on potential therapeutic advantage. PLND may provide valuable prognostic information to high-risk PCa patients, and incorporating the common iliac and presacral nodes to ePLND templates further improves pathologic nodal staging accuracy. Although increased PLND extent is associated with increased lymphocele/lymphedema rates, it is not associated with increased venous thromboembolism rates. The therapeutic role of ePLND remains uncertain. While recent retrospective studies suggest an increased number of nodes removed within the ePLND template are associated with improved survival outcomes, such retrospective studies cannot completely adjust for the Will Rodgers phenomenon or surgeon-specific factors. Thus, the results of randomized trials are eagerly awaited in this arena.

Background Treatment of the primary, termed local therapy (LT), may improve survival in metastatic prostate cancer (mPCa) versus no local therapy (NLT). Objective To assess cancer-specific mortality (CSM) after LT versus NLT in mPCa. Design, setting, and participants Within the Surveillance, Epidemiology and End Results database (2004–2013), 13 692 mPCa patients were treated with LT (radical prostatectomy [RP] or radiation therapy [RT]) or NLT. Outcome measurements and statistical analysis Multivariable competing risk regression analyses (MVA CRR) tested CSM after propensity score matching (PSM) in two analyses, (1) NLT versus LT and (2) RP versus RT, and were complemented with interaction, sensitivity, unmeasured confounder, and landmark analyses. Results and limitations Of 13 692 mPCa patients, 474 received LT: 313 underwent RP and 161 RT. In MVA CRR, after PSM, LT ( n =474) results in lower CSM (subhazard ratio [SHR] 0.40, 95% confidence interval [CI] 0.32–0.50) versus NLT ( n =1896). In MVA CRR after PSM, RP ( n =161) results in lower CSM (SHR 0.59, 95% CI 0.35–0.99) versus RT ( n =161). Invariably, lowest CSM rates were recorded for Gleason ≤7, ≤cT3, and M1a substage. Interaction and sensitivity analyses confirmed the robustness of results, and landmark analyses rejected the bias favouring LT. A strong unmeasured confounder (HR=5), affecting 30% of NLT patients, could obliterate LT benefit. Data were retrospective. Conclusions In mPCa, LT results in lower mortality relative to NLT. Within LT, lower mortality is recorded after RP than RT. Patients with most favourable grade, local stage, and metastatic substage derive most benefit from LT. They also derive most benefit from RP, when LT types are compared (RP vs RT). It is important to consider study limitations until ongoing clinical trials confirm the proposed benefits. Patient summary Individuals with prostate cancer that spreads outside of the prostate might still benefit from prostate-directed treatments, such as radiation or surgery, in addition to receiving androgen deprivation therapy.

BACKGROUND. National Comprehensive Cancer Network (NCCN) guidelines recommend a pelvic lymph node dissection (PLND) in prostate cancer (PCa) patients treated with radical prostatectomy (RP) if a nomogram predicted risk of lymph node invasion (LNI) is ≥2%. We examined this and other thresholds, including nomogram validation. METHODS. We examined records of 26,713 patients treated with RP and PLND between 2010 and 2013, within the Surveillance, Epidemiology, and End Results database. Nomogram thresholds of 2–5% were tested and external validation was performed. RESULTS. LNI was recorded in 4.7% of patients. Nomogram accuracy was 80.4% and maintained minimum accuracy of 75.6% in subgroup analyses, according to age, race, and nodal yield >10. With the NCCN recommended 2% nomogram threshold, PLND could be avoided in 22.3% of patients at the expense of missing 3.0% of individuals with LNI. Alternative thresholds of 3%, 4%, and 5% yielded respective PLND avoidance rates of 60.4%, 71.0%, and 79.8% at the expense of missing 17.8%, 27.2%, and 36.6% of patients with LNI. NCCN cut-off recommendation was best satisfied with a threshold of

OBJECTIVE: To externally validate the updated 2012 Partin Tables in contemporary North American patients treated with radical prostatectomy (RP) for localized prostate cancer (PCa) at community institutions. MATERIALS AND METHODS: We examined records of 25,254 patients treated with RP and pelvic lymph node dissection (PLND) between 2010 and 2013, within the surveillance, epidemiology, and end results database. The ROC derived AUC assessed discriminant properties of the updated 2012 Partin Tables of organ confined disease (OC), extracapsular extension (ECE), seminal vesical invasion (SVI), and lymph node invasion (LNI). Calibration plots focused on calibration between predicted and observed rates. RESULTS: Proportions of OC, ECE, SVI, and LNI at RP were 69.8%, 18.4%, 7.4%, and 4.4%, respectively. Accuracy for prediction of OC, ECE, SVI, and LNI was 70.4%, 59.9%, 72.9%, and 77.1%, respectively. In subgroup analyses in patients with nodal yield >10, accuracy for LNI prediction was 76.0%. Subgroup analyses in elderly patients and in African American patients revealed decreased accuracy for prediction of all four endpoints. Last but not least, SVI and LNI calibration plots showed excellent agreement, versus good agreement for OC (maximum underestimation of 10%) and poor agreement for ECE (maximum overestimation of 12%). CONCLUSION: Taken together, the updated 2012 Partin Tables can be unequivocally endorsed for prediction of OC, SVI, and LNI in community-based patients with localized PCa. Conversely, ECE predictions failed to reach the minimum accuracy requirements of 70%. Prostate 77:105–113, 2017. © 2016 Wiley Periodicals, Inc.

Background Nodal metastasis is the strongest risk factor of disease recurrence in patients with localized prostate cancer (PCa) treated with radical prostatectomy (RP). Objective To develop a model that allows quantification of the likelihood that a pathologically node-negative patient is indeed free of nodal metastasis. Design, setting, and participants Data from patients treated with RP and pelvic lymph node dissection (PLND; n = 7135) for PCa between 2000 and 2011 were analyzed. For external validation, we used data from patients (n = 4209) who underwent an anatomically defined extended PLND. Intervention RP and PLND. Outcome measurements and statistical analysis We developed a novel pathologic (postoperative) nodal staging score (pNSS) that represents the probability that a patient is correctly staged as node negative based on the number of examined nodes and the patient's characteristics. Results and limitations In the development and validation cohorts, the probability of missing a positive node decreases with an increasing number of nodes examined. Whereas in pT2 patients, a 90% pNSS was achieved with one single examined node in both the development and validation cohort, a similar level of nodal staging accuracy was achieved in pT3a patients by examining five and nine nodes, respectively. The pT3b/T4 patients achieved a pNSS of 80% and 70% when 17 and 20 nodes in the development and validation cohort were examined, respectively. This study is limited by its retrospective design and multicenter nature. The number of nodes removed was not directly correlated with the extent/template of PLND. Conclusions Every patient needs PLND for accurate nodal staging. However, a one-size-fits-all approach is too inaccurate. We developed a tool that indicates a node-negative patient is indeed free of lymph node metastasis by evaluating the number of examined nodes, pT stage, RP Gleason score, surgical margins, and prostate-specific antigen. This tool may help in postoperative decision making. © 2013 European Association of Urology.

Objectives To examine contemporary rates of pathological features and mortality for adenocarcinoma of the urinary bladder in the USA using population-based data analysis. Methods We relied on 10 024 patients with non-metastatic bladder cancer diagnosed between 2004 and 2013 within the Surveillance, Epidemiology and End Results registries. Logistic regression analyses focused on grade and stage. Kaplan–Meier analyses assessed cancer-specific mortality rates in adenocarcinoma and urothelial carcinoma of the bladder. Cox regression analyses assessed the impact of histological subtype on cancer-specific mortality. Results Overall, 215 (2.1%) adenocarcinoma and 9809 (97.9%) urothelial carcinoma patients were identified. The rate of non-organ-confined disease was higher in adenocarcinoma (64.7% vs 50.8%, P < 0.001). In multivariable logistic regression analyses, adenocarcinoma patients had a 2.2-fold higher risk of harboring non-organ-confined disease (95% confidence interval 1.7–3.0; P < 0.001) than urothelial carcinoma patients. Cancer-specific mortality-free survival rates were lower in adenocarcinoma (P < 0.01). This disadvantage only applied to non-organ-confined disease (P = 0.044), and not to organ-confined disease (P = 0.9). In multivariable Cox regression analyses, adenocarcinoma conferred a 1.3-fold higher rate of cancer-specific mortality (hazard ratio 1.30, 95% confidence interval 1.05–1.60; P = 0.01). Among adenocarcinoma patients, 30.7% harbored signet-ring cell adenocarcinoma and portended particularly poor cancer-specific mortality rates. Conclusions In bladder cancer, adenocarcinoma presents at higher stages than urothelial carcinoma. However, cancer-specific mortality rates do not differ. A more unfavorable stage at diagnosis and higher cancer-specific mortality apply to the signet-ring cell variant.

OBJECTIVE To examine the effect of annual prostatectomy volume (APV) on contemporary intraoperative rectal laceration (RL) rates after radical prostatectomy. METHODS From 1999 to 2008, 36 699 radical prostatectomy procedures were performed in Florida. First, logistic regression models predicting the RL rate were fitted. Second, other logistic regression models were used to examine the association between RL and 2 other secondary outcomes: prolonged length of stay (> 3 days) and increased hospital charges (> $37 621). The covariates included APV quintiles, surgical approach (minimally invasive vs open radical prostatectomy), lymph node dissection status, age, year of surgery, race, and baseline Charlson comorbidity index. RESULTS The overall RL rate was 0.7%. The RL rate was 0.3%, 0.6%, 0.7%, 0.9%, and 1.0% for the very high, high, intermediate, low, and very low APV quintiles, respectively (P < .001). In multivariate analyses predicting RL, patients treated by intermediate (odds ratio 2.39, P = .003), low (odds ratio 2.95, P < .001), and very low (odds ratio 3.26, P < .001) APV surgeons had a greater likelihood of experiencing an RL relative to patients treated by very high APV surgeons. Second, in the multivariate analyses, patients with a RL were 9.1-fold more likely to have a prolonged length of stay (P < .001) and were 3.4-fold more likely to have increased total hospital charges (P < .001). CONCLUSION A greater APV exerts a protective effect on RL rates. Additionally, RL increases the length of stay and hospital charges. UROLOGY 79: 796-803, 2012. (C) 2012 Elsevier Inc.

Introduction. Several studies have shown that erectile function (EF) recovery in patients undergoing bilateral nerve sparing radical prostatectomy (BNSRP) improves significantly when phosphodiesterase type 5 inhibitors (PDE5) are administered following surgery. Methods. We included 293 patients treated with BNSRRP at a single center. Postoperative EF recovery was defined as an EF domain score of the International Index of Erectile Function (IIEF) >= 22. No patient received any treatment for postoperative erectile dysfunction (ED). Kaplan-Meier curves assessed time to EF recovery according to patient age, preoperative EF, and Charlson comorbidity index (CCI). Univariable and multivariable Cox regression models tested the association between predictors and EF recovery. Finally, the rate of EF recovery of untreated patients after BNSRP was compared with a subset of patients with similar preoperative characteristics but receiving PDE5. Main Outcome Measure. The main outcome measure of this article was the IIEF-EF domain score. Results. Overall, 105/293 (35.8%) reached an IIEF-EF >= 22 after a mean follow-up of 26.8 months. At multivariable analyses, age, preoperative IIEF-EF, and CCI achieved independent predictor status (all P 70 years (P < 0.001). Similarly, preoperatively fully potent patients (IIEF-EF >= 26) had a 56.6% chance of recovering EF after surgery compared with 18% of patients with severe ED before surgery (P < 0.001). The rate of EF recovery in untreated patients < 55 years and with a pre-op IIEF-EF >= 22 was higher but did not differ significantly from comparable patients receiving PDE5 (P = 0.11). Conclusions. Overall, the rate of EF postoperative recovery in patients left untreated after surgery is modest (35.8%). Although younger patients with a good preoperative EF may experience good EF recovery rates even without any treatment, use of PDE5 after surgery further improved their functional outcomes. Therefore, a therapy for ED should be offered to all patients treated with BNSRP. Gallina A, Ferrari M, Suardi N, Capitanio U, Abdollah F, Tutolo M, Bianchi M, Sacca A, Salonia A, Rigatti P, Montorsi F, and Briganti A. Erectile function outcome after bilateral nerve sparing radical prostatectomy: Which patients may be left untreated? J Sex Med 2012; 9: 903-908. Introduction. Several studies have shown that erectile function (EF) recovery in patients undergoing bilateral nerve sparing radical prostatectomy (BNSRP) improves significantly when phosphodiesterase type 5 inhibitors (PDE5) are administered following surgery. Methods. We included 293 patients treated with BNSRRP at a single center. Postoperative EF recovery was defined as an EF domain score of the International Index of Erectile Function (IIEF) >= 22. No patient received any treatment for postoperative erectile dysfunction (ED). Kaplan-Meier curves assessed time to EF recovery according to patient age, preoperative EF, and Charlson comorbidity index (CCI). Univariable and multivariable Cox regression models tested the association between predictors and EF recovery. Finally, the rate of EF recovery of untreated patients after BNSRP was compared with a subset of patients with similar preoperative characteristics but receiving PDE5. Main Outcome Measure. The main outcome measure of this article was the IIEF-EF domain score. Results. Overall, 105/293 (35.8%) reached an IIEF-EF >= 22 after a mean follow-up of 26.8 months. At multivariable analyses, age, preoperative IIEF-EF, and CCI achieved independent predictor status (all P 70 years (P < 0.001). Similarly, preoperatively fully potent patients (IIEF-EF >= 26) had a 56.6% chance of recovering EF after surgery compared with 18% of patients with severe ED before surgery (P < 0.001). The rate of EF recovery in untreated patients < 55 years and with a pre-op IIEF-EF >= 22 was higher but did not differ significantly from comparable patients receiving PDE5 (P = 0.11). Conclusions. Overall, the rate of EF postoperative recovery in patients left untreated after surgery is modest (35.8%). Although younger patients with a good preoperative EF may experience good EF recovery rates even without any treatment, use of PDE5 after surgery further improved their functional outcomes. Therefore, a therapy for ED should be offered to all patients treated with BNSRP. Gallina A, Ferrari M, Suardi N, Capitanio U, Abdollah F, Tutolo M, Bianchi M, Sacca A, Salonia A, Rigatti P, Montorsi F, and Briganti A. Erectile function outcome after bilateral nerve sparing radical prostatectomy: Which patients may be left untreated? J Sex Med 2012; 9: 903-908.

Purpose: We examined the impact of hospital volume on short-term outcomes after nephrectomy for nonmetastatic renal cell carcinoma. Materials and Methods: Using the Nationwide Inpatient Sample we identified 48,172 patients with nonmetastatic renal cell carcinoma treated with nephrectomy (1998 to 2007). Postoperative complications, blood transfusions, prolonged length of stay and in-hospital mortality were examined. Stratification was performed according to teaching status, nephrectomy type (partial vs radical nephrectomy) and surgical approach (open vs laparoscopic). Multivariable logistic regression models were fitted. Results: Patients treated at high volume centers were younger and healthier at nephrectomy. High hospital volume predicted lower blood transfusion rates (8.5% vs 9.7% vs 11.8%), postoperative complications (14.4% vs 16.6% vs 17.2%) and shorter length of stay (43.1% vs 49.8% vs 54.0%, all p 0.05) and blood transfusions in nephrectomies performed laparoscopically (OR 0.68, p >0.05). Conclusions: On average, high hospital volume results in more favorable outcomes during hospitalization after nephrectomy.

OBJECTIVE A formal validation and head-to-head comparison of the National Comprehensive Cancer Network (NCCN) practice guideline lymph node invasion (LNI) nomogram, Partin tables, and D'Amico risk-classification was conducted for prediction of LNI at radical prostatectomy (RP). METHODS We focused on 20,877 patients treated with RP and pelvic lymph node dissection (PLND) between 2004 and 2006 within the Surveillance, Epidemiology and End Results database. The discrimination of the 3 tools in predicting histologically confirmed LNI was quantified using the area under the curve (AUC). Calibration plots were used to graphically depict the performance characteristics of the examined tools. In addition, we relied on decision curve analyses to compare the 3 models directly in a head-to-head fashion. RESULTS Overall, 2.5% of patients had LNI. The NCCN LNI nomogram (AUC 82%) outperformed the Partin tables (73%) and the D'Amico risk-classification (75%) for prediction of LNI. Calibration plots revealed that all 3 tools overestimated the risk of LNI. Partin tables showed the highest net-benefit for probability threshold range between 1% and 4%. Conversely, the NCCN LNI nomogram showed the highest net-benefit for the remaining threshold probabilities. CONCLUSION The NCCN LNI nomogram had the highest discrimination accuracy. However, using the decision curve analysis, the Partin tables demonstrated the highest net benefit when a threshold probability of LNI is

Background. Retroperitoneal lymphadenectomy (RPLND), chemotherapy, and active surveillance represent treatment options for patients with nonseminomatous germ-cell tumors of the testis (NSGCTT). Our objective was to assess the utilization rate of RPLND in patients with NSGCTT. Methods. Within the Surveillance, Epidemiology and End Results (SEER) cohort, 4,620 and 1,671 patients with stage I and II NSGCTT were diagnosed between the years 1988 and 2006. Univariable and multivariable logistic regression analyses were performed to test the predictors of RPLND use in respectively patients with stage I and II NSGCTT. Results. The rate of RPLND according to stage I and II was 27 and 58%, respectively. In patients with stage I disease, the rate of RPLND decreased from 39% in 1988-1995 to 18% in 2004-2006 (P < 0.001), and remained stable for stage II patients (62-56%, P = 0.2). Regional variability existed regarding the rate of RPLND use only in stage I (Utah: 51% vs. Louisiana: 16%). Multivariable analyses performed in stage I NSGCTT revealed that year of diagnosis, SEER registry, and age were significant predictors of RPLND use. However, none of these variables achieved statistical significance within stage II NSGCTT patients. Conclusions. In patients with stage I NSGCCT, the RPLND utilization rate decreased during the study span. This observation may be ascribed to wider use of surveillance or chemotherapy. No temporal difference was recorded in patients with stage II NSGCCT.

OBJECTIVES To revisit whether the perioperative mortality differs between septuagenarian and octogenarian patients and younger patients in a large contemporary population-based cohort. The data from tertiary care centers have suggested that perioperative mortality after radical cystectomy is not considerably different in septuagenarian or octogenarian patients compared with younger patients. However, population-based data have stated otherwise. METHODS From 1988 to 2006, 12 722 radical cystectomies were performed for urothelial carcinoma of the urinary bladder in 17 Surveillance, Epidemiology, and End Results registries. Of those 12 722 patients, 4480 (35.2%) were aged 70-79 years and 1439 (11.3%) were aged >= 80 years. Univariate and multivariate logistic regression models tested the 90-day mortality after radical cystectomy. Covariates consisted of sex, race, year of surgery, Surveillance, Epidemiology, and End Results registry, and histologic grade and stage. RESULTS The overall 90-day mortality rate was 4% for the entire population, 2% for patients aged

At radical cystectomy (RC), continent urinary diversion (CUD) provides functional outcomes that most closely approximate that of a native bladder. We tested the hypothesis that patients treated at high RC caseload hospitals and/or by high RC caseload surgeons have higher CUD rates. We identified 9,493 bladder cancer patients treated with RC between 1998 and 2007, within the Nationwide Inpatient Sample. Univariable and multivariable analyses tested the relationship between hospital and surgical caseload at RC, and CUD rate. Generalized estimating equations models were used to adjust for clustering among hospitals and surgeons. Only 8% of patients received a CUD at RC. The CUD rate was 5 vs. 7 vs. 13% for low versus intermediate versus high annual hospital caseload (AHC) tertiles (P < 0.001). The CUD rate was 6 vs. 10 vs. 16% for low versus intermediate versus high annual surgical caseload (ASC) tertiles (P < 0.001). In multivariable analyses, and after adjusting for clustering, ASC emerged as independent predictors of CUD rate (P < 0.001), while AHC failed to achieve the independent predictor status for the same end point (P a parts per thousand yen 0.1). Our findings indicate that CUD is performed in a minority (8%) of RC patients. Surgical caseload represents an important determinant of CUD rate, while hospital caseload failed to achieve independent predictor status. Efforts should be made to optimize CUD rate a RC.

The relationship between provider volume and complication and transfusion rates in patients undergoing minimally invasive prostatectomy (MIRP) for prostate cancer has not been assessed. Temporal trends in MIRP annual surgical caseload (AC), impact of MIRP surgical experience (SE), and in-hospital complication and transfusion rates were evaluated. Between 2002 and 2008, 2,666 patients in Florida underwent MIRP. Surgical experience was defined as the number of procedures performed from the beginning of the study until each individual MIRP. Multivariable logistic regression models using generalized estimating equations assessed the relationship between SE and in-hospital complication and transfusion rates. Overall AC and SE ranged from 1-171 and 1-500, respectively. Between 2002 and 2005, 94-100% of surgeons were considered as low AC tertile (a parts per thousand currency sign15 MIRP) vs. 76-82% between 2006 and 2008. For the same time periods, low AC tertile surgeons performed 46-100 and 27-32% of all MIRPs respectively. Multivariable logistic regression models revealed 51 and 68% lower complication rates in patients operated on by surgeons of intermediate (17-76 MIRPs) and high SE (a parts per thousand yen77 MIRPs) relative to surgeons of low SE (a parts per thousand currency sign16 MIRPs). Similarly, transfusion rates were 80 and 83% lower for the same groups. Our study is the first to indicate that high SE reduces MIRP complication and transfusion rates. Despite this observation, even in the most contemporary study year, most MIRP surgeons (82%) were in the low AC tertile and contributed to as many as 32% of all MIRPs. These findings should be considered at informed consent.

Background Long-term cancer control outcomes in clinically high-risk prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy (RARP) remain unknown. Objective To report on long-term biochemical recurrence (BCR)-free survival, clinical recurrence (CR)-free survival, and salvage therapy rates in these patients. Given the heterogeneity of high-risk patients, a second objective was to stratify them according to their BCR risk (using preoperative parameters), in an effort to counsel them better preoperatively regarding their cancer control outcomes. Design, setting, and participants We evaluated 1100 D'Amico high-risk PCa patients who underwent RARP between 2002 and 2013 at three tertiary care centers. Outcome measures and statistical analyses Outcomes consisted of BCR-free survival, CR-free survival, and salvage therapy rates. Regression tree analysis stratified patients into novel risk groups based on preoperative characteristics and corresponding BCR risk. Kaplan-Meier curves estimated BCR-free survival, CR-free survival, and salvage therapy rates in the entire cohort and after stratification according to the novel risk groups (RGs). Results and limitations Median age and prostate-specific antigen (PSA) were 63 yr and 6.5 ng/ml, respectively. Biopsy Gleason score (GS) was ≥8 in 57.7%. Mean follow-up was 53 mo (median: 49 mo). At 10 yr, BCR-free survival, CR-free survival, and salvage therapy rates were 50%, 87%, and 37%, respectively. Regression tree analysis stratified patients into five novel RGs): RG1, very low risk (GS ≤6); RG2, low risk (PSA ≤10 ng/ml; GS: 7); RG3, intermediate risk (PSA ≤10 ng/ml; GS ≥8); RG4, high risk (PSA >10 ng/ml; GS: 7); RG5, very high risk (PSA >10 ng/ml; GS ≥8). In these RGs, the 10-yr BCR-free survival rates were 86%, 70%, 36%, 31%, and 26% (p < 0.001), respectively; the 10-yr CR-free survival rates were 99%, 96%, 85%, 67%, and 55% (p < 0.001), respectively; and the 10-yr salvage therapy rates were 9.8%, 16%, 42%, 47%, and 64% (p < 0.001), respectively. Conclusions Most patients with clinically high-risk PCa treated with RARP alone remain CR free at long term. Nonetheless, almost 37% of the patients at 10 yr require salvage therapy. Our novel tool allows accurate stratification of these heterogeneous patients according to their BCR, CR, and salvage therapy risks. This may help inform patients preoperatively about their cancer control outcomes postoperatively. Patient summary Robot-assisted radical prostatectomy confers lasting long-term oncologic control in most high-risk prostate cancer patients. Our novel risk grouping might serve as a useful tool for setting expectations and counseling patients regarding their cancer control outcomes.

Background: The overall mortality (OM) and cancer-specific mortality (CSM) benefits of adjuvant radiotherapy (aRT) in treating prostate cancer (PCa) patients with adverse pathologic characteristics at radical prostatectomy (RP) are unclear. Objective: To test the impact of aRT on survival in PCa patients treated with RP according to adverse pathologic characteristics (Gleason score [GS] 8-10; pT3b/4, lymph node invasion [LNI]) and age categories (

Objectives: To test the effect of radiotherapy administered within 6 months after radical prostatectomy on cancer-specific mortality in prostate cancer patients after stratification according to a risk score. Methods: Overall, 7616 patients with pT3/4 N0/1 prostate cancer treated with radical prostatectomy between 1995 and 2009 within the Surveillance Epidemiology and End Results Medicare-linked database were included in the study. Competing-risks regression models were carried out to test the effect of early radiotherapy on cancer-specific mortality in the entire cohort, and after stratifying patients according to the risk score based on the number and nature of adverse pathological characteristics (Gleason score 8-10; pT3b/4, lymph node invasion). Results: The risk score was associated with increasing 5- and 10-year cancer-specific mortality rates (P

Objective: The aim of this study was to compare the predictive ability of lymph node density (LND) and number of positive lymph nodes in patients with prostate cancer and lymph node invasion. Materials and methods: We included 568 patients with lymph node invasion treated with radical prostatectomy and extended pelvic lymph node dissection between January 1990 and July 2011 at a single center. The Kaplan-Meier method and multivariable Cox regression models tested the association between the number of positive lymph nodes or LND and cancer-specific survival (CSS). The predictive accuracy of a baseline model was assessed using Harrell's concordance index and then compared with that of a model including either the number of positive nodes or LND. Results: The median number of positive lymph nodes was 2, whereas the median LND was 11.1%. At 5, 8, and 10 years, CSS rates were 92.5%, 83.9%, and 82.8%, respectively. At multivariable analyses, number of positive lymph nodes and LND, considered as continuous variables, were independent predictors of CSS (all P≤0.01). A 30% LND cutoff was found to be highly predictive of CSS (P = 0.004), and a cutoff of 2 positive nodes was confirmed to be a strong predictor of CSS (P = 0.02). The number of positive nodes and LND similarly, continuous or dichotomized, increased the accuracy for CSS predictions (0.68-0.69 vs. 0.61 of baseline model). LND cutoff of 30% increased the discrimination the most (0.69; +0.083). Conclusions: The number of positive lymph nodes and LND showed comparable discriminative power for long-term CSS predictions. A cutoff of 30% LND might be suggested for the selection of patients candidate for adjuvant systemic therapy, because it increased the model's discrimination the most. © 2014 Elsevier Inc.

Introduction: This is a timely update of incidence and mortality for renal cell carcinoma (RCC) in the United States.Methods: Relying on the Surveillance, Epidemiology, and End Results (SEER) database, we computed age-adjusted incidence, mortality rates and 5-year cancer-specific survival (CSS) for patients with histologically confirmed kidney cancer between 1975 and 2009. Long-term (1975–2009) and short-term (2000–2009) trends were examined by joinpoint analysis, and quantified using the annual percent change (APC). The reported findings were stratified according to disease stage.Results: Age-adjusted incidence rates of RCC increased by +2.76%/year between 1975 and 2009 (from 6.5 to 17.1/100 000 person years, p < 0.001), and by +2.85%/year between 2000 and 2009 (p < 0.001). For the same time points, the corresponding APC for the incidence of localized stage were +4.55%/year (from 3.0 to 12.2/100 000 person years, p < 0.001), and +4.42%/year (p < 0.001), respectively. The incidence rates of regional stage increased by +0.88%/year between 1975 and 2009 (p < 0.001), but stabilized in recent years (2000–2009: +0.56%/year, p = 0.4). Incidence rates of distant stage remained unchanged in long- and short-term trends. Overall mortality rates increased by +1.72%/year between 1975 and 2009 (from 1.2 to 5.0/100 000 person-years, P

Objectives: To examine the rates of cancer-specific mortality, other-cause and bladder cancer mortality in patients with upper-tract urothelial carcinoma undergoing radical nephroureterectomy. Methods: Relying on the Surveillance, Epidemiology, and End Results database, 9899 patients treated with radical nephroureterectomy were identified. A 20-strata graphical aid was constructed using age (79years) and American Joint Committee on Cancer/TNM stage (pT1N0/x, pT2N0/x, pT3N0/x, pT4N0/x, pTanypN1-3) as stratifying variables. The 5-year cancer-specific mortality, other-cause and bladder cancer mortality rates were generated through competing-risks Poisson regression methodologies. Multivariable competing-risks regression models were used to test the effect of age and stage on three different end-points: cancer-specific mortality, other-cause and bladder cancer mortality. Results: Overall, 1797 (18.1%), 891 (9.1%) and 3090 (31.2%) patients died of cancer-specific mortality, other-cause and bladder cancer mortality, respectively. Following stratification according to age and stage, the proportion of patients who succumbed to cancer-specific mortality (11.7-21.9%) and other-cause mortality (8.9-30.4%) increased with age. In contrast, with increasing stage, the proportion of patients who died of cancer-specific mortality increased (7.2-37.5%), whereas the proportion of other-cause mortality remained stable (18.9-22.0%). The rate of bladder cancer mortality increased with advancing stage. At multivariable competing-risk regression model, besides age and stage, women, type of surgery, grade and location were associated with higher cancer-specific mortality. Furthermore, ureteral location, stage and grade were associated with bladder cancer mortality. Conclusions: The developed graphical aid for prediction of cancer-specific mortality, other-cause, and bladder cancer mortality according to age and stage in patients with upper-tract urothelial carcinoma undergoing radical nephroureterectomy can be useful for physicians and patients during clinical counseling. © 2013 The Japanese Urological Association.

Objective To quantify in absolute terms the potential benefit of regionalisation of care from low- to high-volume hospitals. Patients and Methods Patients with a primary diagnosis of bladder cancer treated with radical cystectomy (RC) were identified within the Nationwide Inpatient Sample, a retrospective observational population-based cohort of the USA, between 1998 and 2009. Intraoperative and postoperative complications, blood transfusions, prolonged length of stay, and in-hospital mortality rates represented the outcomes of interest. Potentially avoidable outcomes were calculated by subtracting predicted rates (i.e. estimated outcomes if care was delivered at a high-volume hospital) from observed rates (i.e. actual observed outcomes after care delivered at a low-volume hospital). Multivariable logistic regression models and number needed to treat were generated. Results Patients treated at high-volume hospitals had lower odds of complications during hospitalisation than those treated in low-volume hospitals. Potentially avoidable intraoperative complications, postoperative complications, blood transfusions, prolonged hospitalisation, and in-hospital mortality rates were 0.6, 7.4, 2.8, 9.4, and 2.0%, respectively. This corresponds to a number needed to redirect from low- to high-volume hospitals in order to avoid one adverse event of 166, 14, 36, 11 and 50, respectively. Conclusion This is the first report to quantify the potential benefit of regionalisation of RC for muscle-invasive bladder cancer to high-volume hospitals. © 2013 The Authors. BJU International © 2013 BJU International.

Objective Positron emission tomography (PET)/computed tomography (CT) has been shown to be a valid tool in detecting lymph node (LN) metastases in men with biochemical recurrence after radical prostatectomy. We assessed its validity in detecting a single positive LN at pathologic examination in regard to an increasing interest in lesion-targeted salvage therapies. Methods and materials We included 46 patients with biochemical recurrence after radical prostatectomy and a single positive spot at [ 11 C]choline PET/CT who underwent pelvic or pelvic and retroperitoneal LN dissection. The ability of [ 11 C]choline PET/CT in identifying the exact positive LN was assessed with the positive predictive value (PPV) in the overall population and according to androgen deprivation therapy, prostate-specific antigen value, and site of PET/CT positivity. Results Overall, 30 patients (65%) had positive LNs at pathologic examination. Of these, only 16 (35%) had pathologically confirmed metastases in the same lymphatic region and 11 (24%) had involvement of 1 single LN. Conversely, 28 patients had positive LNs in other areas and 8 had no evidence of metastases. The overall PPV of PET/CT was 34.8% and 23.9% when exact concordance was defined according to the lymphatic landing site and single positive LN, respectively. The PPV ranged from 33.3% to 44.4% and from 17.9% to 28.6%, in men with and without androgen deprivation therapy, respectively. Conclusions The PPV [ 11 C]choline of PET/CT in correctly identifying patients with a single positive LN at salvage LN dissection is poor (24%). Therefore, extensive salvage treatment approaches are needed to maximize the chance of cure.

Erectile dysfunction (ED) is one of the complications associated with pelvic surgery. The significance of ED as a complication following pelvic surgery, especially radical prostatectomy (RP), lies in the negative impact that it has on patients’ sexual and overall life. In the literature, rates of ED following RP range from 25% to 100%. Such variety is associated with pelvic dissection and conservation of neurovascular structures. Another important factor impacting on postoperative ED is the preoperative erectile function of the patient. Advances in the knowledge of pelvic anatomy and pathological mechanisms led to a refinement of pelvic surgical techniques, with attention to the main structures that if damaged compromise erectile function. These improvements resulted in lower postoperative ED rates and better erectile recovery, especially in patients undergoing RP. Furthermore, surgery alone is not sufficient to prevent this complication, and thus, several medical strategies have been tested with the aim of maximizing erectile function recovery. Indeed it seems that prevention of postoperative ED must be addressed by a multimodal approach. The aim of this review is to give a picture of recent knowledge, novel techniques and therapeutic approaches in order to reach the best combination of treatments to reduce the rate of ED after pelvic surgery. © 2012, SAGE Publications. All rights reserved.

BACKGROUND The aim of this study was to assess the clinical characteristics of the potentially ideal candidates for focal therapy, that is, patients with unilateral, small volume (namely, pT2a) prostate cancer (PCa) at radical prostatectomy (RP). MATERIALS AND METHODS We evaluated 2,503 consecutive pT2 PCa patients treated with RP between 2002 and 2009 at a single center. Within this population, the clinical characteristics of patients with pT2a and pT2b/c disease were compared. Univariable and multivariable logistic regression models were fitted to assess clinical predictors of pT2a at RP. RESULTS Overall, 349 patients (14%) had pT2a PCa, while the remaining patients had either pT2b (n?=?334; 15.5%) or pT2c disease (n?=?1,820 patients; 84.5%). Patients with pT2a PCa had a significantly lower mean PSA value, lower mean percentage of positive biopsy cores and lower biopsy Gleason score distribution (all P?=?0.03). However, at multivariable analyses, only percentage of positive cores maintained an independent predictor status (P?=?0.01). Even when considering only patients sharing all the most favorable PCa characteristics (namely, clinical stage T1, PSA?=?4, Gleason score =6 and percentage of positive cores =25%), the rate of pT2a disease was only 24%. CONCLUSIONS The rate of small volume, unilateral PCa even among patients with extremely favourable PCa characteristics was remarkably low (roughly 25%). This suggests that: (1) Three quarters of the best candidates for focal therapy would ultimately show adverse pathological features; (2) At present, accurate identification of the ideal candidate for focal therapy is not possible with current clinical-pathologic parameters. Prostate 72:925930, 2012. (C) 2011 Wiley Periodicals, Inc. BACKGROUND The aim of this study was to assess the clinical characteristics of the potentially ideal candidates for focal therapy, that is, patients with unilateral, small volume (namely, pT2a) prostate cancer (PCa) at radical prostatectomy (RP). MATERIALS AND METHODS We evaluated 2,503 consecutive pT2 PCa patients treated with RP between 2002 and 2009 at a single center. Within this population, the clinical characteristics of patients with pT2a and pT2b/c disease were compared. Univariable and multivariable logistic regression models were fitted to assess clinical predictors of pT2a at RP. RESULTS Overall, 349 patients (14%) had pT2a PCa, while the remaining patients had either pT2b (n?=?334; 15.5%) or pT2c disease (n?=?1,820 patients; 84.5%). Patients with pT2a PCa had a significantly lower mean PSA value, lower mean percentage of positive biopsy cores and lower biopsy Gleason score distribution (all P?=?0.03). However, at multivariable analyses, only percentage of positive cores maintained an independent predictor status (P?=?0.01). Even when considering only patients sharing all the most favorable PCa characteristics (namely, clinical stage T1, PSA?=?4, Gleason score =6 and percentage of positive cores =25%), the rate of pT2a disease was only 24%. CONCLUSIONS The rate of small volume, unilateral PCa even among patients with extremely favourable PCa characteristics was remarkably low (roughly 25%). This suggests that: (1) Three quarters of the best candidates for focal therapy would ultimately show adverse pathological features; (2) At present, accurate identification of the ideal candidate for focal therapy is not possible with current clinical-pathologic parameters. Prostate 72:925930, 2012. (C) 2011 Wiley Periodicals, Inc.

The existing literature suggests that the postoperative mortality (POM) rate in radical cystectomy (RC) patients does not exceed 3%. We sought to develop and externally validate a reference table that quantifies POM after RC. We identified 12,274 patients treated with RC, between 1998 and 2007, within the Nationwide Inpatient Sample database. A total of 6188 (50.4%) randomly selected patients was used as the development cohort. Logistic regression analysis for prediction of POM adjusted for: age, sex, race, Charlson comorbidity index (CCI), urinary diversion type, year of surgery, annual hospital caseload, location/teaching status of hospital, region and bed size of hospital. The reference table was developed by using stepwise variable removal to identify the most accurate and parsimonious model. The model was externally validated in 6086 (49.6%) patients. POM occurred in 2.4% of patients. POM proportion increased with increasing age (a parts per thousand currency sign59: 0.6% vs. 60-69: 1.6% vs. 70-79: 3.1% vs. a parts per thousand yen80: 4.6%, P < 0.001), and higher CCI (CCI 0: 1.7% vs. CCI 1: 3.0% vs. CCI 2: 4.2% vs. CCI 3: 4.3% vs. CCI a parts per thousand yen 4: 12.1%, P < 0.001). In multivariable analyses, only age and CCI remained as independent predictors of POM, after stepwise variable removal. The discrimination accuracy of the reference table in predicting POM was 70%. Age and CCI represent the foremost determinants of POM after RC. The developed reference table is capable of predicting POM after RC, in an individualized fashion. The accuracy of the model is good (70%), and it is highly generalizable.

Study Type--Diagnostic (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Multifocality, age, PSA values, and biopsy protocols regarding the predictive value of high grade PIN have been discussed extensively in the literature. Our study developed for the first time a predictive nomogram that could be helpful for patient counselling and to guide the urologist to perform rPBX after an initial diagnosis of isolated HGPIN.• To evaluate factors that may predict prostate cancer (PCa) detection after the initial diagnosis of high-grade prostatic intra-epithelial neoplasia (HGPIN) on prostate biopsy (PBx) with six to 24 random cores.• We retrospectively evaluated 262 patients submitted from 1998 to 2007 to prostate re-biopsy (rPBx) after an initial HGPIN diagnosis in tertiary academic centres. • HGPIN diagnosis was obtained on initial systematic PBx with six to 24 random cores. • All patients were re-biopsied with a 'saturation' rPBx with 20-26 cores, with a median time to rPBx of 12 months. • All slides were reviewed by expert uropathologists.• Plurifocal HGPIN (pHGPIN) was found in 115 patients and monofocal HGPIN (mHGPIN) was found in 147 patients. • In total, 108 and 154 patients, respectively, were submitted to12-core initial PBx and ≤12-core initial PBx. • Overall PCa detection at rPBx was 31.7%. PSA level (7.7 vs 6.6 ng/mL; P= 0.031) and age (68 vs 64 years; P= 0.001) were significantly higher in patients with PCa at rPBx. • PCa detection was significantly higher in patients with a ≤12-core initial PBx than in those with a12-core initial PBx (37.6% vs 23.1%; P= 0.01), as well as in patients with pHGPIN than in those with mHGPIN (40% vs 25.1%; P= 0.013). • At multivariable analysis, PSA level (P= 0.041; hazards ratio, HR, 1.08), age (P0.001; HR, 1.09), pHGPIN (P= 0.031; HR, 1.97) and ≤12-core initial PBx (P= 0.012; HR, 1.95) were independent predictors of PCa detection. • A nomogram including these four variables achieved 72% accuracy for predicting PCa detection after an initial HGPIN diagnosis.• PCa detection on saturation rPBx after an initial diagnosis of HGPIN is significantly higher in patients with a ≤12-core initial PBx than those with a12-core initial PBx and in patients with pHGPIN than in those with mHGPIN. • We developed a simple prognostic tool for the prediction of PCa detection in patients with initial HGPIN diagnosis who were undergoing saturation rPBx.

OBJECTIVES To test the effect of histological subtype (NBSCC vs UC) on cancer-specific mortality (CSM), after adjusting for other-cause mortality (OCM). In Western countries, non-bilharzial squamous cell carcinoma (NBSCC) is the second most common histological subtype in bladder cancer (BCa) after urothelial carcinoma (UC). PATIENTS AND METHODS We identified 12 311 patients who were treated with radical cystectomy (RC) between 1988 and 2006, within 17 Surveillance, Epidemiology and End Results (SEER) registries. Univariable and multivariable competing-risks analyses tested the relationship between histological subtype and CSM, after accounting for OCM. Covariates consisted of age, sex, year of surgery, race, pathological T and N stages, as well as tumour grade. RESULTS Histological subtype was NBSCC in 614 (5%) patients vs UC in 11 697 (95%) patients. At RC, the rate of non-organ confined (NOC) BCa was higher in NBSCC patients than in their UC counterparts (71.7% vs 52.2%; P < 0.001). After adjustment for OCM, The 5-year cumulative CSM rates were 25.0% vs 19.8% (P = 0.2) for patients with NBSCC vs UC organ confined (OC) BCa, respectively. The same rates were 46.3% vs 49.3% in patients with NOC BCa (P = 0.1). In multivariable competing-risks analyses, histological subtype (NBSCC vs UC) failed to achieve independent predictor status of CSM in patients with OC (hazard ratio, 1.2; P = 0.06) or NOC BCa (hazard ratio, 1.1; P = 0.1). CONCLUSIONS At RC, the rate of NOC BCa is higher in NBSCC patients than in their UC counterparts. Despite a more advanced stage at surgery, NBSCC histological subtype is not associated with a less favourable CSM than UC histological subtype, after accounting for OCM and the extent of the disease (OC vs NOC).