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Background During robotic-assisted radical prostatectomy (RARP), the use of electrocautery near the neurovascular bundles (NVBs) frequently results in thermal injury to the cavernous nerves. The cut and “touch” monopolar cautery technique has been suggested to reduce desiccating thermal injury caused by bipolar energy when vessels are sealed. Objective To compare potency outcomes between an athermal technique (AT) and touch cautery (TC) to transect the prostatic vascular pedicles (PVPs) and dissect the NVBs. Design, setting, and participants A retrospective concomitant nonrandomized study of AT versus TC was performed in 733 men. A total of 323 undergoing AT had “thin” pedicles, easily suitable for suture ligation. TC was based on “thick” pedicles (n = 230) difficult to suture ligate. Men were excluded for an International Index of Erectile Function (IIEF-5) score of Surgical procedure Single-surgeon RARP. Measurements Patient-reported outcomes with erectile function (EF) recovery defined as two affirmative answers to erections sufficient for intercourse (ESI; “are erections firm enough for penetration?” and “are the erections satisfactory?”), IIEF-5 scores 15–25, and a novel percent fullness score comparing pre- versus postoperative erection fullness. Logistic regression models assessed the correlation between cautery technique, covariates, and EF recovery. Results and limitations In an unadjusted analysis, preoperative IIEF-5, age, body mass index (BMI), and prostate weight were significant predictors of potency recovery. Follow-up was similar (AT 52.7 mo vs TC 54.6 mo, p = 0.534). In logistic regression, preoperative IIEF-5, age, and BMI were significant predictors of EF recovery, defined as IIEF-5 scores 15–25, ESI, and percent fullness >75%. Results were similar when IIEF-5 and percent fullness were assessed continuously. Conclusions During transection of the PVPs and dissection of the NVBs, TC did not impact EF recovery significantly, compared with an AT. Patient summary Electrocautery can be applied safely, with similar outcomes to those of an athermal technique.

OBJECTIVE To comprehensively assess total and calculated free testosterone levels in a consecutive group of patients with prostate cancer (PCa) and any potential impact on disease aggressiveness and recurrence outcomes. PARTICIPANTS AND METHODS The study included a single-centre prospective cohort of 882 patients presenting for radical prostatectomy from 2009 to 2018. Data on total testosterone (TT), sex hormone-binding globulin (SHBG), and calculated free testosterone (cFT) were prospectively collected. Stepwise logistic regression models were used to assess correlations of TT and cFT with pathological Gleason Grade Group (GGG), extraprostatic extension (EPE), seminal vesicle invasion (SVI) and biochemical recurrence (BCR). RESULTS Total testosterone remained nearly constant across decades (40s-80s): 0.09 decrease/year (R = 0.02), while SHBG increased 0.87/year (R = 0.32) and cFT decreased 0.08/year (R = -0.02). Low cFT of

BACKGROUND: Coronavirus disease-19 (COVID-19) pandemic caused delays in definitive treatment of patients with prostate cancer. Beyond the immediate delay a backlog for future patients is expected. Such delays can lead to disease progression. OBJECTIVE: We aimed to develop guidance on criteria for prioritization for surgery and reconfiguring management pathways for non-metastatic stage of prostate cancer who opt for surgical treatment. A second aim was to identify the infection prevention and control (IPC) measures to achieve low likelihood of COVID-19 hazard if radical prostatectomy was to be carried out during the outbreak and whilst the disease is endemic. DESIGN, SETTING AND PARTICIPANTS: An accelerated consensus process and systematic review. We conducted a systematic review of the evidence on COVID-19 and reviewed international guidance on prostate cancer. These were presented to an international prostate cancer expert panel (n=34) through an online meeting. The consensus process underwent three rounds of survey in total. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. OUTCOME MEASURES: Consensus opinion was defined as ≥80% agreement, which were used to reconfigure the prostate cancer pathways. RESULTS: Evidence on the delayed management of patients with prostate cancer is scarce. There was 100% agreement that prostate cancer pathways should be reconfigured and develop measures to prevent nosocomial COVID-19 for patients treated surgically. Consensus was reached on prioritization criteria of patients for surgery and management pathways for those who have delayed treatment. IPC measures to achieve a low likelihood of nosocomial COVID-19 were coined as "COVID-19 cold sites". CONCLUSION: Re-configuring management pathways for prostate cancer patients is recommended if significant delay (>3-6 months) in surgical management is unavoidable. The mapped pathways provide guidance for such patients. The IPC processes proposed provide a framework for providing radical prostatectomy within an environment with low COVID-19 risk during the outbreak or when the disease remains endemic. The broader concepts could be adapted to other indications beyond prostate cancer surgery.

To assess the impact of statin use on overall and time to biochemical failure following primary treatment of localized prostate cancer (PCa). 1581 patients undergoing radical prostatectomy (RP) or radiation therapy (RT) for primary treatment of PCa between July 2007 and January 2020 were evaluated for statin use, demographic/oncologic characteristics, and biochemical outcomes. Rate of biochemical failure (BF) was assessed overall and at 1, 3, and 5 years; time to BF was estimated with Kaplan–Meier. Logistic and linear regression were used to control for treatment modality and disease characteristics. The average age was 63.0 ± 7.5 years and median pre-treatment PSA was 6.55 (IQR 4.94). 1473 (93.2%) and 108 (6.8%) underwent RP and RT, respectively. RP patients were younger, had lower pre-PSA, lower BMI, and lower risk disease. At 3.4 ± 2.7 years follow-up, 323 (20.4%) experienced BF. When stratified by statin use, BF overall and within 1, 3, and 5 years were not different. Time to BF, was lower in patients using statins (1.8 ± 1.9 years vs. 2.4 ± 2.6 years; p = 0.016). These results persisted in multivariate analysis, wherein statin use was not associated with BF but was associated with a shorter time to BF. Overall, statin use was not associated with a reduced risk of BF in RP or RT patients. However, for patients with BF, statin use was associated with a decreased time to BF. Future investigations are warranted to further elucidate the impact of statin use on PCa recurrence.

Background We previously reported a new post–radical prostatectomy (RP) prediction model for men with normal baseline erectile function (EF) using 90-d postoperative erection fullness to identify men who might benefit from early EF rehabilitation. Objective To prospectively internally and externally validate the use of this risk assessment model in predicting 1- and 2-yr post-RP EF recovery. Design, setting, and participants We randomly assigned 297 patients with a preoperative International Index of Erectile Function 5 score of 22–25 undergoing robot-assisted RP by a single surgeon to a training set and internal validation set at a ratio of 2:1. A prospective external validation set included 91 patients treated by five high-volume surgeons. Outcome measurements and statistical analysis Potency was defined as erections sufficient for intercourse. To predict 1- and 2-yr potency recovery, logistic regression models were developed in the training set based on 90-d erection fullness of 0–24% or 25–100%. The resultant models were applied to the internal and external validation sets to calculate risk scores for 1- and 2-yr potency for each patient. Predictive validity was assessed using receiver operating characteristic (ROC) curves. Results and limitations Percentage erection fullness was an independent predictor of 1- and 2-yr potency recovery in all data sets. Internal validation confirmed strong reliability in predicting 2-yr potency outcomes (area under the ROC curve [AUC] 0.87) and external validation illustrated similar reliability in predicting 1-yr potency outcomes (AUC 0.80). In the external validation, the model predicted a mean 1-yr potency recovery rate of 39.7% (standard deviation 3.2%), compared to the actual rate of 36.26%. Limitations include the short follow-up for this cohort. Conclusions We present internal and external validation of a 90-d percentage erection fullness score, confirming that this metric is a robust predictor of post-RP EF recovery. Patient summary Percentage erection fullness at 3 mo after radical prostatectomy discriminates patients with a low or a high probability of recovery of erectile function (EF), which can facilitate identification of a need for early EF rehabilitation.

Objective To evaluate risk of prostate cancer biochemical recurrence (BCR) after radical prostatectomy (RP) in men receiving vs not receiving testosterone replacement therapy (TRT). Patients and methods A total of 850 patients underwent RP by a single surgeon. All patients had preoperative testosterone and sex hormone-binding globulin levels determined; free testosterone was calculated prospectively. In all, 152 (18%) patients with low preoperative calculated free testosterone (cFT) levels and delayed postoperative sexual function recovery were placed on TRT and proportionately matched to 419 control patients by pathological Gleason Grade Group (GGG) and stage. Rates and time to BCR [two consecutive prostate-specific antigen (PSA) levels of ≥0.2 ng/mL] were compared in univariate and multivariate regression; Cox regression was used to generate a survival function at the mean of covariates. Results The median follow-up was 3.5 years. There were no statistically significant differences in demographics or general health complications between groups. BCR occurred in 11/152 (7.2%) and 53/419 (12.6%) patients in the TRT and control groups, respectively. In adjusted time-to-event analysis, TRT was an independent predictor of recurrence-free survival. After accounting for GGG, pathological stage, preoperative PSA level, and cFT, patients on TRT were ~54% less likely to recur (hazard ratio 0.54, 95% confidence interval 0.292-0.997). In men destined to recur, TRT delayed time to recurrence by an average of 1.5 years. Conclusion In our experience, TRT after RP significantly reduced BCR and delayed time to BCR. There was no identifiable general health complications associated with TRT. These findings are hypothesis-generating and require confirmation with multi-centred, prospective randomised controlled trials.

Background In recent years, the assessment of erectile dysfunction (ED) has experienced a paradigm shift from objective, quantitative methods to subjective, qualitative patient-reported outcomes. Facilitated by this shift is the ongoing debate on questionnaire selection and need for standardization, particularly among sexual medicine specialists. Aim To review current literature on assessment of erectile function via patient-reported outcomes and discuss the context, advantages, and limitations of currently available questionnaires. Methods A thorough literature search of erectile function questionnaires developed from 1990 through 2019 was carried out using 3 methods: a search of the MedLine databases; hand-search of peer-reviewed urologic, sexual medicine, and health policy journals; and expert review. The following keywords were used: [assessment of], [inventory], [questionnaire], or [validated measure]; in combination with: [sexual function] or [erectile function]. Measures were stratified into one of the following 3 groups: screening, outcome, or disease-specific. 3 screening measures (International Index of Erectile Function, the Male Sexual Health Questionnaire, and Brief Male Sexual Inventory); 5 outcome measures (Sexual Health Inventory for Men, Erection Hardness Score, Erectile Dysfunction Inventory for Treatment and Satisfaction, and Treatment Satisfaction Scale); and 3 categories of disease-specific measures (cancer, Peyronie's disease, and spinal cord injury) were included. Outcomes Strengths, limitations, and valid uses of each erectile function questionnaire. Results There currently exists a wide variety of screening, outcome, and disease-specific measures for ED diagnosis, assessment, and treatment. Rigor of psychometric validation varies greatly across studies. However, depending on purpose of use, all abovementioned questionnaires have merit for use in clinical practice, are nonredundant, and can complement and supplement one another. Clinical Implications Before choosing a specific measure for ED diagnosis, assessment, or treatment, there must be careful consideration of the questionnaire's psychometric properties, context of validation, and its possible limitations. Strengths & Limitations The patient reported outcome measures highlighted in this article complement and supplement one another, as each emphasizes a related yet distinct central theme. During selection for use in clinical practice and research studies, special attention needs to be paid to the context, strengths, and weaknesses of each measure. Conclusion When used conscientiously, patient-reported questionnaires can significantly optimize patient management.

INTRODUCTION AND OBJECTIVE:Planning complex operations such as robotic-assisted laparoscopic radical prostatectomy (RALP) requires surgeons to review two-dimensional Magnetic Resonance Imaging (MRI...

Biochemical recurrence (BCR) following radical prostatectomy (RP) is an unreliable predictor of prostate cancer (PC) progression. This study was a retrospective cohort analysis of prospectively collected data (407/1895) of men with BCR at a tertiary referral center. Patients were assessed for active observation (AO) compared with a treatment group (TG) utilizing doubling time (DT) kinetics. Risk assessment was based on the initial DT (>12 vs. 12 months in 73.6% of AO versus 22.6% of TG (p < 0.001). An increasing DT pattern was observed in 71.5% of AO versus 32.7% of TG (p < 0.001). Utilizing the Cleveland Clinic’s PCSM nomogram, at 10 years, predicted and observed PCSM was 8.6% and 9.5% (p = 0.78), respectively. In conclusion, one-third of patients with BCR post-RP were managed without treatment using DT kinetics, avoiding treatment-related complications, quality-of-life issues, and expenses.

OBJECTIVE Studies have individually assessed the expenses for medical students desiring a surgical residency in neurosurgery, orthopaedic surgery, otolaryngology, plastic surgery, and urology. A detailed comparison of expenses by geographic region have not been reported. The aim was to geographically compare the expenses of United States medical students applying to the 5 most competitive surgical residencies. SETTING/PARTICIPANTS Anonymous nationwide survey of plastic surgery, orthopaedic surgery, otolaryngology, urology, and neurological surgery residency applicants. DESIGN A cross sectional, retrospective analysis of the 2019-2020 Texas STAR Dashboard database, an online tool generated from a nationwide survey of students. Individual (application, away rotation, interview) and total costs for medical school seniors were recorded in addition to applicant characteristics. Mean and median costs were reported for each specialty with percentile distributions and geographic comparisons. A Kruskal-Wallis H test was performed to compare differences in costs between surgical specialties and medical school region. RESULTS In total, 1136 applicants to surgical residency were included. The number of applicants to orthopaedic surgery (OS) (n = 459), neurological surgery (NS) (n = 121), urology (UR) (n = 191), plastic surgery (PS) (n = 117), and otolaryngology (OTO) (n = 248) were reported. Mean total costs were (OS; $8,205), (NS; $11,882), (UR; $8,207), (PS; $10,845), and (OTO; $7,516) (p ≤ 0.029). Application fees were only significantly different in the northeast and southern applicants between the different specialties, notably orthopaedic surgery applicants spent the most. In all geographic regions excluding the west, neurosurgery and plastic surgery applicants spent significantly more than other specialties for interview costs and away rotation costs. In all geographic regions neurosurgery and plastic surgery applicants spent significantly more than other specialties in total costs. CONCLUSIONS Orthopaedic surgery applicants spend the most on application fees in select geographic regions. Neurosurgery and plastic surgery applicants spend more on interviews, away rotations, and total costs in nearly all geographic regions.

Background: The functional and oncologic outcomes of robot-assisted radical prostatectomy (RARP) in octogenarians are not well studied. We sought to study the perioperative, functional, and oncologic outcomes of RARP in octogenarian men. Methods: Between January 2009 and 2019, 46 patients ≥80 years with localized prostate cancer (PCa) underwent RARP in three high-volume robotic urologic practices in the United States. Clinical and pathologic features, and perioperative and postoperative complications were retrospectively evaluated. Functional outcomes for urinary and sexual function were collected via patient-reported questionnaires. Continence was defined as the use of zero or one safety pad per day. Results: The median (interquartile range) age was 81 (80-82), the mean (standard deviation [SD]) operative time was 116.5 (36.4) minutes, and the mean (SD) blood loss was 132 (35.6) mL. All cases were completed robotically, no intraoperative complications were encountered, and the mean length of stay was 1.21 (0.78) days. Regarding 30- and 90-day complication, nine patients had postoperative complications; seven were Clavien-Dindo grade I-II, and two were Clavien-Dindo grade ≥III. Post-RARP continence rates at 3 and 12 months were 68.4% and 84.8%, respectively. Conclusions: RARP represents a feasible option to treat PCa in well-selected octogenarian men. Careful patient selection and counseling are critical before offering surgical treatment for these men.

Objective To assess the impact of metformin on biochemical failure (BF) in localized prostate cancers (PC) treated with radical prostatectomy or radiation therapy. Materials and Methods About 1449 patients undergoing radical prostatectomy (n = 1338, 92.3%) or radiation therapy (n = 108, 7.5%) for localized PC between July 2007 and January 2020 were evaluated for metformin use, demographic/oncologic characteristics, and biochemical outcomes. Androgen deprivation therapy was utilized per NCCN guidelines. BF rates were assessed overall and at 1, 3, and 5 years. Time to BF was estimated via Kaplan-Meier; logistic regression and Cox proportionate hazards models were generated to adjust for significant differences. Results Of 1449 patients, 148 (10.2%) utilized metformin at time of diagnosis, while 1,301 (89.8%) did not. Patients on metformin were significantly older, had higher body mass indexes, and more aggressive disease (Gleason score >7). At a mean ± SD follow-up of 3.6 ± 2.6 years, patients on metformin were less likely to experience BF at later timepoints; however, univariate analysis showed no differences at 1, 3, and 5 years. In multivariate analysis, patients on metformin were significantly less likely to experience BF at 5 years and overall in both treatment groups. In Cox regression, metformin was independently associated with a 40% relative risk reduction in BF. Conclusion In multivariate analysis, metformin use was associated with a significant risk reduction in BF overall and at 5 years following primary treatment; this trend was not witnessed in univariate analysis. This suggests the need for future investigations of metformin's role in disease-free survival in men with localized PC.

To assess the impact of statin use on overall and time to biochemical failure following primary treatment of localized prostate cancer (PCa).1581 patients undergoing radical prostatectomy (RP) or radiation therapy (RT) for primary treatment of PCa between July 2007 and January 2020 were evaluated for statin use, demographic/oncologic characteristics, and biochemical outcomes. Rate of biochemical failure (BF) was assessed overall and at 1, 3, and 5 years; time to BF was estimated with Kaplan-Meier. Logistic and linear regression were used to control for treatment modality and disease characteristics.The average age was 63.0 ± 7.5 years and median pre-treatment PSA was 6.55 (IQR 4.94). 1473 (93.2%) and 108 (6.8%) underwent RP and RT, respectively. RP patients were younger, had lower pre-PSA, lower BMI, and lower risk disease. At 3.4 ± 2.7 years follow-up, 323 (20.4%) experienced BF. When stratified by statin use, BF overall and within 1, 3, and 5 years were not different. Time to BF, was lower in patients using statins (1.8 ± 1.9 years vs. 2.4 ± 2.6 years; p = 0.016). These results persisted in multivariate analysis, wherein statin use was not associated with BF but was associated with a shorter time to BF.Overall, statin use was not associated with a reduced risk of BF in RP or RT patients. However, for patients with BF, statin use was associated with a decreased time to BF. Future investigations are warranted to further elucidate the impact of statin use on PCa recurrence.

OBJECTIVE To introduce a patient-reported erection fullness scale (%fullness) after robot-assisted radical prostatectomy (RARP) as a qualitative adjunct to the five-item version of the International Index of Erectile Function (IIEF-5) and as a 90-day predictor of 2-year potency outcomes. PATIENTS AND METHODS Prospective data were collected from 540 men with preoperative IIEF-5 scores of 22-25 who underwent RARP by a single surgeon, and of whom 299 had complete data at all time points up to 2 years. In addition to standard assessment tools (IIEF-5 and erections sufficient for intercourse [ESI]), the men were asked to 'indicate the fullness you are able to achieve in erections compared to before surgery?' (range: 0-100%). The primary outcome was prediction of potency (defined as ESI) at 24 months, based on 90-day %fullness tertile (0-24%, 25-74% and 75-100%). RESULTS A total of 299 men with complete follow-up were included in the study. Significant predictors of 24-month potency included age, body mass index, pathological stage, nerve-sparing status and %fullness tertiles. When the men (preoperative IIEF-5 score 22-25) were assessed at 90 days after RARP, 181/299 (61%) had erections inadequate for intercourse. If IIEF-5 scores of 1-6 were used, 142/181 men (78%) would be targeted for early intervention. By contrast, if 0-24% fullness was used, 88/181 men (49%) would be targeted. If both the IIEF-5 score and %fullness were used, this would be reduced to 77/181 men (43%). CONCLUSIONS We introduce %fullness as a qualitative adjunct to the IIEF-5 score, and separately as a 90-day predictor of 2-year potency recovery. This initial report is hypothesis-generating, such that the use of %fullness enables the identification of men who are most likely to benefit from early, secondary intervention.

The relationship between testosterone therapy and prostate cancer continues to challenge historic and current beliefs. A new cohort analysis revealed a ~33% reduction in prostate cancer incidence in men with increased testosterone use. The mechanisms underlying this protective effect are unclear, but these findings challenge current paradigms and warrant further investigation.

Introduction We evaluated whether a simple postcard reporting the date of becoming pad-free is accurate compared to a daily log of pad use to determine time to pad-free status after robot-assisted radical prostatectomy. Methods Prospectively at the time of discharge home we gave 439 men treated with robot-assisted radical prostatectomy between April 2010 and September 2014 a self-addressed stamped postcard to mark the date they attained pad-free urinary continence. In addition, we concurrently asked the men to fill out a daily urinary log of pad use to be faxed or emailed. Results Of the 439 men 193 (44%) reported their pad-free status via postcard and pad use log. The correlation of time to pad-free status via postcard compared to daily log was R2 = 0.98 (p Conclusions Patient reported continence postcards or pad use logs are a simple, inexpensive and reliable way to determine pad-free continence after radical prostatectomy. Either method offers surgeons a low cost, dependable and easy way to track pad-free continence outcomes and their combined use resulted in a nearly 75% response rate.

BACKGROUND While older age is associated with higher tumor grade, it is unknown whether comorbid disease burden has a similar, independent association. We sought to evaluate the impact of comorbid disease burden on tumor grade at diagnosis as indicated by biopsy Gleason score. METHODS We conducted an observational cohort study of 1260 men newly diagnosed with non-metastatic prostate cancer from 1998 to 2004 at two Veterans Affairs Medical Centers. Multivariable ordinal and multinomial logistic regression were used to evaluate the association between Charlson Comorbidity Index score and biopsy Gleason score. RESULTS Men with Charlson scores of 2 (odds ratio (OR) 1.8, P

Purpose: National Comprehensive Cancer Network prostate cancer guidelines for the prediction of life expectancy recommend subtracting 50% of life table predicted longevity for those in the lowest quartile of health. However, it is unclear how to identify these men and if their survival is uniform.Materials and Methods: We sampled records of 1,482 men diagnosed with prostate cancer from 1998 to 2004 at 2 VA hospitals. We identified men in the lowest quartile of health by age using Charlson scores, calculated their NCCN predicted life expectancy, and compared this with observed median survival in aggregate and across comorbidity subgroups.Results: Men with Charlson scores of 2+ (age less than 75 years) and 3+ (age 75 years or older) comprised the lowest quartile of health. Among those younger than 65, 65 to 69, 70 to 74, 75 to 79 and 80 years or older, observed survival vs NCCN predicted life expectancy in years was similar at 10.4 vs 11.1, 10.0 vs 7.8, 6.2 vs 6.4, 4.4 vs 4.9 and 3.7 vs 3.3, respectively. Y...

Background: Pelvic multiparametric magnetic resonance imaging (mpMRI)–determined membranous urethral length (MUL) and its surgical maximization have been reported to impact early- and long-term pad-free urinary continence after robot-assisted radical prostatectomy (RARP). Objective: The objective of this study was to present evidence (data and video) of important effects on post-RARP continence recovery from both innate mpMRI-assessed and surgical preservation of MUL. Design, setting and participants: Of 605 men undergoing RARP, 580 with complete follow-up were included: Group 1, prior (N = 355), and Group 2, subsequent (N = 225) to technique change of MUL maximization. Effect of innate, mpMRI-assessed MUL on postoperative continence was assessed. Surgical procedure: Before technique change, the dorsal venous complex was stapled before transection of the membranous urethra. After the change, the final step of extirpation was transection of the dorsal venous complex and periurethral attachments, thus facilitating surgical maximization of MUL. Measurements: Primary and secondary outcomes for technique change and mpMRI-assessed MUL were both patient-reported 30-day and 1-year pad-free continence after RARP, respectively. Results: Preoperative prostate-specific antigen, age, and disease aggressiveness were significantly higher in Group 2. After technique change and surgical maximization of MUL, 30-day and 1-year pad-free continence were both significantly improved (p 1.4 cm also independently predicted higher 30-day (odds ratio: 4.85, 95% confidence interval: 1.24-18.9) and 1-year continence recovery (odds ratio: 11.26, 95% confidence interval: 1.07-118). Conclusions: Prostatic rotation and circumferential release of apical attachments and maximization of MUL improves continence after RARP. Separately, innate MUL>1.4 cm independently increased 30-day and 1-year continence recovery. Patient summary: Surgeon efforts to maximize MUL during radical prostatectomy are highly encouraged, as maximally preserved MUL likely improves post-RARP continence recovery. In addition, individual patients’ mpMRI-assessed MUL (approximately >1.4 cm) independently limits continence recovery.

Background: Preclinical and retrospective data suggest that cytoreductive radical prostatectomy may benefit a subset of men who present with metastatic prostate cancer (mPCa). Herein, we report the results of the first planned Phase 1 study on cytoreductive surgery. Methods: From four institutions, 36 patients consented to the study. However, four did not complete surgery because of rapid disease progression (n = 3) and another because of an intraoperatively discovered pericolonic abscess. Men with newly diagnosed clinical mPCa to lymph nodes or bones were eligible. The primary endpoint was the rate of major perioperative complications (Clavien-Dindo Grade 3 or higher) occurring within 90 days of surgery. Results: The mean age at surgery was 64.0 years. The 90-day overall complication rate was 31.2% (n = 10), of which two (6.25%) were considered major complications: one acute tubular necrosis requiring temporary dialysis and one death. In men with more than 6 months of follow-up, 67.9% had prostate specific antigen nadir ≤0.2 ng/mL, while one patient experienced a rapid rise in prostate specific antigen and another a widely disseminated disease that resulted in death 5 months after surgery. Altogether, these results demonstrate that cytoreductive radical prostatectomy is safe and surgically feasible in selected patients who present with mPCa . Yet, there may be a small subset of patients in whom surgery may cause a significant harm. Conclusion: Therefore, cytoreductive surgery in men with mPCa should be limited to clinical trials until robust data are available. Keywords: Cytoreduction, Clinical trial, Metastasis, Prostate cancer

INTRODUCTION AND OBJECTIVES:We previously reported a new post radical prostatectomy (RP) prediction model for men with normal baseline erectile function (EF) using 90-d postoperative erection fulln...

INTRODUCTION AND OBJECTIVES:Sexual dysfunction remains a significant problem for many men post robot-assisted radical prostatectomy. Low testosterone (T) is a well-known cause of sexual dysfunction...

INTRODUCTION AND OBJECTIVES:For patients undergoing radical prostatectomy for primary treatment of localized prostate cancer, adjuvant radiotherapy (ART) is indicated by NCCN guidelines when they h...

INTRODUCTION AND OBJECTIVES:While the impacts of age and testosterone on sexual function have been well-studied, the additive relationship of these three variables has seldom been mentioned. In the...

INTRODUCTION AND OBJECTIVES:The role of testosterone in prostate growth and the development of prostate cancer is a controversial topic. Most current data suggest that lower testosterone leads to h...

INTRODUCTION AND OBJECTIVES:The role of testosterone on prostate growth and its relationship with prostate cancer development is a controversial topic. Most current data claim that low levels of te...

e17002 Background: Biochemical recurrence (BCR) following radical prostatectomy (RP) is an unreliable predictor of distant metastatic progression or prostate cancer (PC) death, consequently resulting in overtreatment. Further, little has been published about active surveillance (AS) specific management recommendations. Herein, we validate the practicality of using the kinetics (change) of PSA doubling time (PSADT) to direct continued observation versus intervention. Methods: In a retrospective cohort analysis of 406 men with BCR (defined as adjuvant therapy or PSA > 0.2 ng/dl, x2), 284 men were monitored post RP with PSADT graphs for all patients, and the PSADT was characterized as increasing vs decreasing. Receiver-operator characteristic (ROC) curves were generated to assess the sensitivity/specificity/positive predictive value/negative predictive value of PSADT progression on treatment and prostate cancer specific mortality at 10 years post-RARP, respectively. Results: The median follow-up was 7.6 (IQR: 4.6-10.6) years. Of 284 men, 109 (38%) and 175 (62%) were in the no treatment versus treatment groups, respectively. 87% of men receiving treatment had a decreasing PSADT and 100% men with PCSM had a decreasing PSADT. ROC analysis showed 0.870 sensitivity and 1.0 specificity when predicting secondary treatment (AUC = 0.935) and 0.857 sensitivity and 0.50 specificity when predicting PCSM (AUC = 0.679). Conclusions: A decreasing PSADT is a sensitive and specific metric for predicting the need for secondary intervention. We also found all men who died of PC had a decreasing PSADT. Lastly an increasing DT predicts a benign course without need for treatment. The current findings suggest that the kinetics of PSADT, increasing versus decreasing, is an accurate metric for the need of treatment. A direct comparison between PSADT kinetics and PSADT is needed.

Securing reliable data on functional outcomes following radical prostatectomy (RP) is paramount to patient follow-up and management.To validate an email-based patient-reported outcomes tracking system in assessing pad-free continence rates and time-to continence recovery following RP.483 men undergoing RP by a single surgeon from November 2013 to March 2019 were prospectively assigned to 1 of 3 tracking systems: 1) a preaddressed paper packet containing a pad-free card and daily urinary pad log, (N = 249); 2) an automated email questionnaire, (N = 234) or 3) both (N = 51). Patients tracked electronically received electronic Research Electronic Data Capture surveys 30 days after catheter removal, with up to 3 reminders sent automatically if no response was received within 2 days. Response rates and continence rates were compared in group 1 vs. group 2 via student t-tests; time-to pad-free status was assessed for concordance among men in group 3 via linear regression.Thirty-day response rates in group 1 (paper) vs. group 2 (electronic) were 80.7% (201/249) and 94.0% (220/234), (P0.0001); pad-free rates were 64.2% (129/201) and 64.1% (141/220), (P = 0.9847), respectively. Similarly, 1-year response rates in group 1 and 2 were 87.6% (218/249) vs. 94.0% (220/234), (P = 0.0146); pad-free rates were 91.7% (200/218) vs. 96.4% (212/220), (P = 0.0411), respectively. In group 3, time to pad-free continence recovery assessed via Patient Reported Outcomes via Online Questionnaire (PROVOQ) was highly concordant in 89.6% (43/48) of patients ± 5 days (Figure 1, RThe use of automated email survey questionnaires via PROVOQ for the assessment of patient-reported post-RP continence recovery facilitates increased response rates, timeliness of response, and accuracy. PROVOQ significantly reduce the labor of tracking continence outcomes, improve quality improvement efforts, and enables surgeons to more clearly differentiates risk of long-term incontinence.

Objectives: To investigate monocyte chemotactic protein-1 (MCP-1) as a novel urinary biomarker to predict prolonged post prostatectomy incontinence. Methods: Men submitted urine samples prior to robotic radical prostatectomy. MCP-1 values were derived using an ELISA test. Pad usage at 7, 30, and 60 days were documented by patient post cards mailed when zero pads was reached. The primary outcome was defined as no incontinence pad usage at 30 days at prostatectomy. Results: After exclusions, 76 patients were included in analyses. Continence was reached by 29% (22/76), 56% (42/76), and (75/76) 98% at 7, 30, and 60 days, respectively. The average MCP-1 (p=0.258) was not different between the continent and incontinent groups. Highest quartile of MCP-1 (MCP > 166 pg/mL) and normalized MCP-1 (MCP-1/TV >0.53) noted a significant delay in continence at 30 days (p=0.050 and p=0.003). Only 26% (5/19) in the highest MCP1/TV quartile were continent, whereas 65% (37/57) of men in the 3 lower quartiles reached zero pad continence (p=0.003). In a logistic regression model the highest quartile of MCP1/TV had a significant chance of being incontinent at 30 days (OR 0.22; 95% CI 0.058-0.80; p=0.022). Conclusion: MCP-1/TV is a urinary biomarker that may predict prolonged urinary incontinence after radical prostatectomy.

Positive surgical margins (PSM) after radical prostatectomy (RP) are a predictor of biochemical recurrence (BCR), and highly dependent on surgeon, experience, and skill. The length and location PSMs are important, with significant differences between open and robotic RP. The impact of PSMs on BCR remains secondary to other clinico-pathologic variables: Gleason Score, pathologic stage, and baseline PSA. However, lower PSM rates are associated with reduced use of secondary interventions and patient anxiety of cancer recurrence.