Association between sociodemographic factors and diagnosis of lethal prostate cancer in early life.

OBJECTIVE: A subset of patients are diagnosed with lethal prostate cancer (CaP) early in life before prostate-specific antigen (PSA) screening is typically initiated. To identify opportunities for improved detection, we evaluated patient sociodemographic factors associated with advanced vs. localized (CaP) diagnosis across the age spectrum. METHODS: We conducted a retrospective cohort study using the National Cancer Database, identifying patients diagnosed with CaP from 2004 to 2020. We compared characteristics of patients diagnosed at the advanced (cN1 or M1) versus localized (cT1-4N0M0) stage. Using multivariable logistic regression, we evaluated the associations among patient clinical and sociodemographic factors and advanced diagnosis, stratifying patients by age as ≤55 (before screening is recommended for most patients), 56 to 65, 66 to 75, and ≥76 years. RESULTS: We identified 977,722 patients who met the inclusion criteria. The mean age at diagnosis was 65.3 years and 50,663 (5.1%) had advanced disease. Overall, uninsured (OR = 3.20, 95% CI 3.03-3.78) and Medicaid-insured (OR 2.58, 95% CI 2.48-2.69) vs. privately insured status was associated with higher odds of diagnosis with advanced disease and this effect was more pronounced for younger patients. Among patients ≤55 years, uninsured (OR 4.14, 95% CI 3.69-4.65) and Medicaid-insured (OR 3.39, 95% CI 3.10-3.72) vs. privately insured patients were associated with higher odds of advanced cancer at diagnosis. Similarly, residence in the lowest vs. highest income quartile was associated with increased odds of advanced CaP in patients ≤55 years (OR 1.15, 95% CI 1.02-1.30). Black vs. White race was associated with increased odds of advanced CaP at diagnosis later in life (OR 1.17, 95% CI 1.09-1.25); however, race was not significantly associated with advanced stage CaP in those ≤55 years (P = 0.635). CONCLUSIONS: Sociodemographic disparities in diagnosis at advanced stages of CaP were more pronounced in younger patients, particularly with respect to insurance status. These findings may support greater attention to differential use of early CaP screening based on patient health insurance.

A meta-analysis on the use of radiotherapy after prostatectomy: adjuvant versus early salvage radiation.

To determine which method of radiotherapy proves more effective after prostatectomy: Adjuvant (ART) or early salvage (ESRT), we observed the pathologic and adverse risk factors of patients and their results from both treatments, looking specifically at biochemical-free survival rates, metastasis-free survival rates, and overall survival rates. Peer review articles containing their own data collected between 1986 and 2022 were reviewed. We reviewed 67 peer review articles and included 33 that met criteria. Studies focused on the adverse risk factors and the results of patients either before/after receiving adjuvant or early salvage/salvage radiotherapy were included in the analysis. Patient characteristics had an effect on what treatment a patient would receive; if a patient had more than one adverse risk factor such as a high Gleason score, prostate-specific antigen (PSA) level, T-stage, or positive margins, they would receive immediate radiation after prostatectomy, which would classify as ART. If the patient had no adverse risk factors after surgery, they would be placed in an observation period to follow their PSA and overall health, and only if necessary, undergo ESRT. Of the 33 studies, ART was proven to be only slightly more beneficial when relating to biochemical recurrence-free survival while ART and ESRT results were similar in metastasis-free survival and overall survival. ART and ESRT are overall comparable in their patient outcomes, despite their own unique pros and cons. The use of ESRT reduces overtreatment in men who may not experience biochemical recurrence. However, in those with very high-risk pathologic features, a multi-disciplinary approach should be utilized to best determine which mode of radiation therapy after surgery is recommended.

Microvesicle induction of prostate specific gene expression in normal human bone marrow cells.

PURPOSE: Transfer of genetic material from cancer cells to normal cells occurs via microvesicles. Cell specific phenotypes can be induced in normal cells by the transfer of material in microvesicles, leading to genetic changes. We report the identification and expression of prostate specific genes in normal human marrow cells co-cultured with human prostate cancer cells. MATERIALS AND METHODS: We harvested prostate tissue from 11 patients with prostate cancer. In 4 cases prostate tissue was co-cultured across from human marrow for 2 or 7 days but separated from it by a 0.4 µM polystyrene membrane. In 5 cases conditioned medium from patient cancer tissue was collected and ultracentrifuged, and microvesicles were collected for co-culture (3) and vesicle characterization (3). Explanted human marrow was harvested from cultures and RNA extracted. Real-time reverse transcriptase-polymerase chain reaction was done for select prostate specific genes. RESULTS: Marrow exposed to human prostate tumor or isolated microvesicles in culture in 4 and 3 cases, respectively, showed at least 2-fold or greater prostate gene expression than control marrow. In 1 case in which normal prostate was co-cultured there were no prostate gene increases in normal marrow. CONCLUSIONS: Prostate cancer tumor cells co-cultured with human bone marrow cells induce prostate specific gene expression. The proposed mechanism of transfer of genetic material is via microvesicles. This represents an opportunity for novel therapeutic agents, such as antibodies, to block microvesicle release from cancer cells or for agents that may block cells from accepting microvesicles.

Diffusion-weighted MRI of peripheral zone prostate cancer: comparison of tumor apparent diffusion coefficient with Gleason score and percentage of tumor on core biopsy.

OBJECTIVE: The objective of our study was to determine the relationship between the apparent diffusion coefficient (ADC) value on diffusion-weighted imaging (DWI) and Gleason score of prostate cancer and percentage of tumor involvement on prostate core biopsy. MATERIALS AND METHODS: We performed a retrospective study of 57 patients with biopsy-proven prostate cancer who underwent endorectal MRI with DWI between July 2007 and March 2008. Regions of interest (ROIs) were drawn on ADC maps at sites of visible tumor on DW images and ADC maps. A hierarchic mixed linear model was used to compare the ADC value of prostate cancer with the Gleason score and the percentage of tumor on core biopsy. RESULTS: Eighty-one sites of biopsy-proven prostate cancer were visible on DW images and ADC maps. The least-squares mean ADC for disease with a Gleason score of 6 was 0.860 x 10(-3) mm(2)/s (standard error of the mean [SEM], 0.036); Gleason score of 7, 0.702 x 10(-3) mm(2)/s (SEM, 0.030); Gleason score of 8, 0.672 x 10(-3) mm(2)/s (SEM, 0.057); and Gleason score of 9, 0.686 x 10(-3) mm(2)/s (SEM, 0.067). Differences between the mean ADC values for a prostate tumor with a Gleason score of 6 and one with a Gleason score of 7 (p = 0.0096) and for a prostate tumor with a Gleason score of 6 and one with a Gleason score of 8 (p = 0.0460) were significant. Comparison between the ADC and percentage of tumor on core biopsy showed a mean ADC decrease of 0.006 (range, 0.004-0.008 x 10(-3) mm(2)/s) for every 1% increase in tumor in the core biopsy specimen. CONCLUSION: DWI may help differentiate between low-risk (Gleason score, 6) and intermediate-risk (Gleason score, 7) prostate cancer and between low-risk (Gleason score, 6) and high-risk (Gleason score > 7) prostate cancer. There is an inverse relationship between the ADC and the percentage of tumor involvement on prostate core biopsies.

Subcutaneous in situ gel delivered leuprolide acetate's consistent and prolonged drug delivery maintains effective testosterone suppression independent of age and weight in men with prostate cancer.

Objectives: To assess the impact of patient age and weight on the pharmacokinetics (PK), testosterone (T) suppression and safety from four fixed dosing regimens (7.5, 22.5, 30, or 45 mg for 1-, 3-, 4-, or 6-months, respectively) of subcutaneous in situ gel delivered leuprolide acetate (Gel-LA) injected via the ATRIGEL Delivery System in patients with prostate cancer (PCa). Patients and methods: Two patient populations were specified for analysis: a small cohort of surgically castrated PCa patients and a large, pooled population of PCa patients from four pivotal trials of Gel-LA. Two separate analyses of the impact of age and weight on study endpoints were conducted: (1) PK and safety of a single monthly dose of Gel-LA in a Phase 1 study with PCa patients who had undergone bilateral surgical orchiectomy ("Bilaterally orchiectomized male study"); (2) PK/pharmacodynamic (PD) effects and safety using pooled data from four pivotal trials assessing 1-, 3-, 4-, and 6-month dosing of Gel-LA in patients with advanced PCa, stratified by age and body weight (pivotal trials). Results: Eight orchiectomized patients from the "Bilaterally orchiectomized male study" and 438 patients from the pivotal trials were included in the analyses. Age and body weight did not appear to affect the PK results in the orchiectomized patient population. Pooled pivotal trial data showed that serum T levels did not appear to be influenced by age or weight; ≥90% of patients across all age groups and ≥92% of patients across all weight groups achieved T ≤ 50 ng/dL by week 4. Median T levels for castration (T ≤ 50 ng/dL) were maintained from week 3 until the end of the study and all subgroups achieved median T ≤ 20 ng/dL by week 4. Patients from the orchiectomized patient study did not report any serious treatment-related adverse events (AEs) and there were no AE-related withdrawals from the study. The most common AEs were hot flashes and injection site events. The safety profiles from pivotal trials have been previously described and, as expected, were consistent with known effects of LHRH agonist therapy and suppression of T levels. Conclusion: PK and PD of Gel-LA appear to be unaffected by age and body weight, as demonstrated by persistence of effective drug levels through the dosing period and consistent T suppression across different ages and body weights.

Nonmetastatic Castration-resistant Prostate Cancer: A Modern Perspective.

Nonmetastatic castration-resistant prostate cancer (nmCRPC) presents a challenge to urologists as currently there are no Food and Drug Administration-approved therapies. However, there are new imaging modalities, including fluciclovine positron emission tomography-computed tomography and Ga-PSMA (prostate specific membrane antigent) positron emission tomography-computed tomography, which are improving accuracy of diagnosis. With improved imaging, we are better able to target therapy. Today there are 3 ongoing clinical trials studying second-generation antiandrogens in nmCRPC, which hold the promise of a new treatment paradigm. In this article, we will review the new imaging techniques and the rationale behind novel treatment modalities in nmCRPC.

Salvage Pelvic Lymph Node Dissection After Fluciclovine Positron Emission Tomography/Computed Tomography Detected Prostate Cancer Recurrence.

Background: Multiple new systemic agents have been targeted to metastatic prostate cancer, with decreased progression of disease but no cure. Surgical management of metastatic disease has been gaining interest, primarily in the setting of high-risk prostatectomies. However, metastasis-directed surgical intervention has been employed in rare scenarios, especially in oligometastatic disease. We report here on a salvage robot-assisted pelvic lymph node dissection for a solitary metastatic site. Case Presentation: A 63-year-old Hispanic man who was initially treated with prostatectomy for intermediate risk cancer developed rapid biochemical recurrence. After salvage radiation, fluciclovine positron emission tomography (PET)/computed tomography (CT) scan showed a solitary pelvic lymph node metastasis. A robot-assisted laparoscopic pelvic lymph node dissection was carried out, with subsequent nadir of his prostate-specific antigen at 0.026. Conclusion: To our knowledge, this is the first report of salvage pelvic lymph node dissection after metastatic detection by fluciclovine PET/CT scan. Our patient experienced a complete biochemical response; however, it remains to be seen whether this will be a lasting response. Surgical resection of metastatic sites in prostate cancer offers a safe alternative to systemic therapy and avoids systemic side effects.

The State of Prescreening Discussions About Prostate-specific Antigen Testing Following Implementation of the 2012 United States Preventive Services Task Force Statement.

OBJECTIVE: To determine if the quality of prescreening discussions has changed following release of the United States Preventive Services Task Force statement against prostate cancer screening. METHODS: This cross-sectional study used the 2012 and 2014 Behavioral Risk Factor Surveillance System surveys. Respondents were categorized based on the year in which they responded to the Behavioral Risk Factor Surveillance System Survey. Quality of prescreening discussion was operationalized as having discussed only advantages, only disadvantages, both advantages and disadvantages, or neither. Race/ethnicity, education level, income, insurance status, and having a prostate-specific antigen (PSA) level actually drawn after prescreening counseling served as confounders in our multivariate analysis. RESULTS: Among 217,053 men in the analytic sample, 37% were told about only advantages of PSA screening compared to 30% of men who were advised about both advantages and disadvantages. Men who were told about neither advantages nor disadvantages were more likely to be Hispanic, not graduate high school, have low income, and not have insurance. Controlling for covariates, men in 2014 were significantly more likely to have undergone PSA testing without having discussed either advantages or disadvantages than men in 2012. CONCLUSION: Comprehensive prescreening discussions about advantages and disadvantages of PSA testing are critical to informed decision making about prostate cancer screening. Disparities not only exist with regard to the quality of prescreening discussions that patients receive from their providers prior to PSA testing across categories of race/ethnicity, education, income, and insurance status, but these disparities became more substantial between 2012 and 2014. Further investigation is warranted to elicit more specific reasons behind these variations.

The Role of a Standardized Clinical Care Pathway in Patient Satisfaction and Quality of Life Outcomes after Robotic Assisted Laparoscopic Radical Prostatectomy.

INTRODUCTION: Clinical care pathways reduce length of stay, variability in practice and costs, yet avoid compromising quality of care or increasing complications. In this study we describe a standardized care pathway, focusing on preoperative and postoperative education as well as immediate postoperative patient care after robotic assisted laparoscopic radical prostatectomy. METHODS: A standardized robotic assisted laparoscopic radical prostatectomy care pathway was introduced at our institution in July 2014. A total of 108 men who underwent robotic assisted laparoscopic radical prostatectomy during 2014 were enrolled in this retrospective chart review and were subsequently mailed a quality of life survey. Data regarding length of stay and number of unplanned calls to the urology office or visits to the emergency department were collected from the chart review. The mailed survey was composed of original questions as well as questions adapted from the FACT-P (Functional Assessment of Cancer Therapy-Prostate). Patients who underwent robotic assisted laparoscopic radical prostatectomy between January and June 2014 were compared to those who underwent the same surgery between July and December 2014. RESULTS: Demographically the 2 cohorts of men who underwent robotic assisted laparoscopic radical prostatectomy were similar. There was a significant reduction in postoperative length of stay in the post-care pathway cohort. Hospital readmissions were reduced by 75%. Despite earlier discharge home, there was no difference in the number of postoperative calls to the urology office or visits to the emergency department, or in overall patient satisfaction. CONCLUSIONS: The implementation of a standardized care pathway for patients undergoing robotic assisted laparoscopic radical prostatectomy at our institution resulted in a reduced postoperative length of stay and readmission rate. Despite a more rapid discharge from the hospital, patient satisfaction and postoperative quality of life were not negatively impacted.

Upgrading and upstaging at radical prostatectomy in the post-prostate-specific antigen screening era: an effect of delayed diagnosis or a shift in patient selection?

Prostate cancer management changed in recent times given the recommendation against prostate-specific antigen screening, adherence to active surveillance, and "cytoreductive" surgery. We hypothesized that radical prostatectomy (RP) findings changed as well. All consecutive RPs (n=1348) and first time prostate needle biopsies (n=1719) in a period of 9 years were reviewed. The cohort was separated into 3 groups: (1) from May 2006 to April 2009, (2) from May 2009 to April 2012, and (3) from May 2012 to April 2015. The number of RPs decreased 15% from 551 in group 1 to 476 in group 2 and decreased a further 35% to 311 in group 3. Pure Gleason 6 (grade group 1) decreased from 46% in group 1 to 24% in group 2 (P<.001) to 12% in group 3 (P<.001). Gleason score 4+3=7 (grade group 3) increased from 9.8% in group 1 to 13.4% in group 2 (P=.07) to 20.6% in group 3 (P=.01). Gleason score 8, 9, or 10 (grade groups 4 and 5) increased from 0.9% in group 1 to 8.4% in group 2 (P<.001) to 13.2% in group 3 (P=.04). Pathologic stage pT3 or above increased from 15.5% in group 1 to 29.2% in group 2 (P<.01) to 38.3% in group 3 (P=.01). In needle biopsies, there was no difference in number of cancer diagnoses, number of positive cores, or distribution of grades among 3 groups. More patients with low-risk disease are opting for active surveillance, and patients with high-risk disease are offered cytoreductive surgery. Lack of similar changes in needle biopsies suggests that a decrease in screening is not playing a role in the changes seen at RPs.

Intravesical Hemostatic Clip Migration After Robotic Prostatectomy: Case Series and Review of the Literature.

INTRODUCTION: The Weck Hem-o-lok™ Ligating clip is a routinely used hemostatic tool in robotic and laparoscopic surgery. It has been the practice in our institution to use such clips for hemostasis of the vascular bundles during robotic prostatectomy. Migration of such clips has been reported in the literature as single case reports. In this study, we present a case series of intravesical Weck clip extrusions presenting as bladder calculi. Such events have led to a change in our practice, and more research is needed to assess the impact of this change. MATERIALS AND METHODS: A retrospective chart review was conducted over the period 2006-2011. Patients included in the study required cystoscopic intervention for removal of encrusted or impacted Weck clips. Primary data points included type of intervention required, time to presentation, and number of presentations. Postoperative anastomotic leak, duration of postoperative hospital stay, and initial operative time were also investigated. RESULTS: Out of 570 total men undergoing robotic-assisted laparoscopic radical prostatectomy (RALRP), eight required return to the operating room for clip extraction (1.4%). Extraction methods included laser lithotripsy, blunt litholapaxy, and grasper extraction. Men experiencing clip migration were hospitalized for a longer period of time (7.6 days vs. 2.1 days, P < .01) and they required more blood transfusions (1.4 units vs. 0.05 units, P < .01) than men who did not experience clip migration. The most common site for clip intrusion was the bladder neck. Average time to presentation was 1.75 years. DISCUSSION: Weck clip migration is a recognized complication of robotic-assisted radical prostatectomy. Men with recurrent urinary tract infection, bothersome voiding symptoms, or hematuria following RALRP should be considered for cystoscopic evaluation. Increased length of hospital stays and the need for a larger volume blood transfusion following prostatectomy were significant predictors of clip migration. More research is needed to determine if implemented changes to our surgical technique have mitigated these risks.

Radium-223 dichloride: illustrating the benefits of a multidisciplinary approach for patients with metastatic castration-resistant prostate cancer.

Improving options for patients with metastatic castration-resistant prostate cancer (mCRPC) provide latitude in designing treatment plans that meet patients' medical needs and personal goals. The field's rapid evolution opens avenues for contributions by multiple medical specialties and requires considering more options to ensure that each patient receives the most appropriate care. A multidisciplinary clinic (MDC) focusing on patients with cancers of the genitourinary tract demonstrates an efficient and cost-effective means of integrating the diverse professional knowledge and skills needed to develop an optimal patient treatment plan. As a guide to establishing an MDC for patients with mCRPC, this article describes the operation of the Genitourinary MDC at The Miriam Hospital in Providence, RI - specifically, the successful incorporation of radium-223 dichloride (radium-223) into the treatment algorithm for men with mCRPC and symptomatic bone metastases. Radium-223 is a new treatment that, unlike earlier radionuclide therapies, has shown a survival advantage in a large randomized phase 3 trial (ALSYMPCA). The overall survival benefit was comparable to that of newer immuno-and hormonal therapies in similar populations. Radium-223 treatment also delayed onset of symptomatic skeletal events. Both benefits were independent of prior docetaxel therapy or concurrent bisphosphonate use. In our clinic, radium-223 is used primarily to extend patient survival. Patient selection, patient management, and treatment sequencing are discussed here in the context of a multidisciplinary environment.

Atypical Small Acinar Proliferation: Repeat Biopsy and Detection of High Grade Prostate Cancer.

Purpose. Atypical small acinar proliferation (ASAP) is diagnosed in 1-2% of prostate biopsies. 30-40% of patients with ASAP may be diagnosed with prostate cancer (PCa) on repeat biopsy. Our objective was to examine the association between ASAP and subsequent diagnosis of intermediate/high risk PCa. Materials and Methods. Ninety-six patients who underwent prostate biopsy from 2000 to 2013 and were diagnosed with ASAP were identified. Clinicopathologic features were analyzed. Comparison was made between those with subsequent PCa on repeat biopsy and those with benign repeat pathology. Results. 56/96 (58%) patients had a repeat biopsy. 22/56 (39%) were subsequently diagnosed with PCa. There was no significant difference in patients' characteristics. Presence of HGPIN on initial biopsy was associated with a benign repeat biopsy (68% versus 23%). 17/22 (77%) had Gleason grade (GG) 3+3 disease and only 5/22 (23%) had GG 3+4 disease. Conclusions. 22/56 patients (39%) of patients who underwent a subsequent prostate biopsy following a diagnosis of ASAP were found to have PCa. 77% of these men were diagnosed with GG 3+3 PCa. Only 23% were found to have intermediate risk PCa and no high risk PCa was identified. Immediate repeat prostate biopsy in patients diagnosed with ASAP may be safely delayed. A multi-institutional cohort is being analyzed.

Rectal swab culture-directed antimicrobial prophylaxis for prostate biopsy and risk of postprocedure infection: a cohort study.

OBJECTIVE: To examine the effect of rectal swab culture-directed prophylaxis on the incidence of prostate biopsy-associated infections. Secondary objectives were to determine the rate of fluoroquinolone resistance and extended-spectrum beta-lactamase production in local rectal flora. METHODS: All men receiving prostate biopsies from February 2013 to February 2014 were included in a retrospective institutional review board-approved study. All received either a preprocedural rectal swab and culture-directed antimicrobial prophylaxis or routine fluoroquinolone antibiotics. Clinical information was collected on infectious complications treated within 30 days of biopsy. Chi-square test, Fisher exact test, and Welch t test were used for statistical analysis. Confounding variables were included in a multivariate logistic regression model. RESULTS: Of 487 total patients, 314 received preprocedure rectal cultures and 173 did not. Average ages were 62.7 and 64.1 years, respectively (P = .07). There was no difference in mean prostate-specific antigen value (P = .9), Charlson comorbidity score (P = .8), or ethnicity (P = .1). The rectal swab group was more likely to receive supplemental gentamicin (P < .001) and had fewer infectious complications (1.9% vs 2.9%; P = .5). On multivariate analysis, decreased odds of infection was associated with culture-directed antibiotics (odds ratio, 0.70; 95% confidence interval, 0.20-2.50; P = .6). However, the study was only powered to detect a 97% reduction in infections. The incidence of fluoroquinolone resistance and extended-spectrum beta-lactamase production was 12.1% and 0.64%, respectively. CONCLUSION: Our study was underpowered but suggests that there are lower odds of infection with rectal swab-directed antimicrobial prophylaxis. The local incidence of fluoroquinolone resistance is high. A prospective, randomized, controlled trial is warranted to further evaluate this intervention.

The emergence of extracellular vesicles in urology: fertility, cancer, biomarkers and targeted pharmacotherapy.

Extracellular vesicles (EV) are small membrane-bound vesicles enriched in a selective repertoire of mRNA, miRNA, proteins and cell surface receptors from parental cells and are actively involved in the transmission of inter and intracellular signals. Cancer cells produce EV that contain cargo including DNA, mRNA, miRNA and proteins that allow EV to create epigenetic changes in target cells both locally and systemically. Cancer-derived EV play critical roles in tumorigenesis, cancer cell migration, metastasis, evasion of host immune defense, chemoresistance, and they promote a premetastatic niche favourable to micrometastatic seeding. Their unique molecular profiles acquired from originator cells and their presence in numerous body fluids, including blood and urine, make them promising candidates as biomarkers for prostate, renal and bladder cancers. EV may ultimately serve as targets for therapy and as platforms for personalized medicine in urology. As urologic malignancy comprises 28% of new solid tumour diagnoses and 15% of cancer-related deaths, EV-related research is rapidly emerging and providing unique insights into disease progression. In this report, we review the current literature on EV in the setting of genitourinary fertility and malignancy.

Dedicated robotics team reduces pre-surgical preparation time.

CONTEXT: Robot-Assisted Laparoscopic Radical Prostatectomy (RALRP) requires significant preoperative setup time for the room, staff, and surgical platform. The utilization of a dedicated robotics operating room (OR) staff may facilitate efficiency and decrease costs. AIMS: We sought to determine the degree to which preoperative time decreased as experience was gained. MATERIALS AND METHODS: A total of 476 patients with a mean age of 60.2 years were evaluated (11/2006 to 1/2010). Data was assimilated through an institutional review board approved blinded, prospective database. Utilizing time from patient arrival in the OR to robot docking as preoperative preparation, our experience was evaluated. Age, body mass index (BMI), and American Society of Anesthesiologists risk scores (ASA) were compared. STATISTICAL ANALYSIS USED: Analysis of variance; Two-sample t-test for unequal variances. RESULTS: The first and last 100 cases were found to have similar age (P=0.27), BMI (P=0.11), and ASA (P=0.09). The average preoperative times were 66. 4 and 53.4 min, respectively (P<0.05). The second 100 patients treated were found to have a significantly shorter preoperative time when compared to the first 100 patients (P<0.05). When the first 100 cases were divided into cohorts of 10 cases the mean preoperative time for the first through fourth cohorts were 80.5, 69.3, 78.8, and 64.7 min, respectively. After treatment of our first 30 patients we found a significant drop in preoperative time. This persisted throughout the remainder of our experience. CONCLUSIONS: From the time of patient arrival a number of tasks are accomplished by the non-physician operating room staff during RALRP. The use of a consistent staff can decrease preoperative setup times and, therefore, the overall length of surgery.

Clinical and histological significance of the testicular remnant found on inguinal exploration after diagnostic laparoscopy in the absence of a patent processus vaginalis.

PURPOSE: We reviewed the histological findings of cord structures excised at inguinal exploration after diagnostic laparoscopy in patients with a nonpalpable testis with the vas deferens and spermatic vessels exiting the internal inguinal ring in the absence of a patent processus vaginalis. MATERIALS AND METHODS: A retrospective review of 809 laparoscopic explorations for nonpalpable testes between 1981 and 2003 was conducted. The histological findings of the excised remnants of those patients with a closed processus vaginalis were reviewed. RESULTS: A total of 110 patients underwent excision of a testicular remnant at inguinal exploration in association with a closed processus vaginalis. Of the specimens 31 (28%) were on the right side and 79 (72%) were on the left side. The incidence of viable germ cell elements was 8 of 110 (7%). The presence of hemosiderin, calcification and fibrosis was identified in all 8 remnants with viable germ cell elements. CONCLUSIONS: The incidence of viable germ cell elements in the excised remnant when the vas deferens and spermatic vessels are identified exiting a closed internal ring in patients with a nonpalpable testis is 7%. To our knowledge no prior study has evaluated the incidence of viable germ cell elements in remnants associated with a closed internal inguinal ring. Based on these findings, we advocate inguinal exploration and excision of testicular remnants in these patients.

Abdominal aortic aneurysm in association with a congenital pelvic horseshoe kidney: sentinel report and technical consideration.

A case of an abdominal aortic aneurysm in the presence of a congenital pelvic horseshoe kidney is described and the technical approach discussed. Renal function was preserved by 'double clamping' during the proximal anastomosis and infusing cold crystalloid into cannulated renal arteries originating from the aneurysm sac.