MRI - ultrasound fusion guided biopsy of the prostate: lesion volume as a predictor of cancer in patients with repeat biopsies.

INTRODUCTION: The objective was to analyze the diagnostic value of multiparametric magnetic resonance imaging (MRI) prostate lesion volume (PLV) and its correlation with the subsequent MRI-ultrasound (MRI-US) fusion biopsy results. MATERIALS AND METHODS: Between March 2014 and July 2016, 150 men underwent MRI-US fusion biopsies at our institution. All suspicious prostate lesions were graded according to the Prostate Imaging Reporting and Data System (PIRADS) and their volumes were measured. These lesions were subsequently biopsied. All data were prospectively collected and retrospectively analyzed. The PLV of all suspicious lesions was correlated with the presence of cancer on the final MRI-US fusion biopsy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: There were 206 suspicious lesions identified in 150 men. The overall cancer detection rate was 102/206 (49.5%). The mean PLV for benign lesions was 0.63 ± 0.94 cm3 versus 1.44 ± 1.76 cm3 for cancerous lesions (P < 0.01). There was a statistically significant difference between the PLV of PIRADS 5 lesions when compared to PIRADS 4, 3, and 2 lesions (P < 0.0001, < 0.0001, and 0.006, respectively). The area under the curve for volume in predicting prostate cancer (PCa) was 0.66. The optimal volume for predicting PCa was 0.26 cm3 with a sensitivity, specificity, PPV, and NPV of 80.7%, 42.7%, 41.2%, and 74.6%, respectively. CONCLUSION: PLV may serve as a useful measure to triage patients prior to MRI-US fusion biopsy and help better understand the limits of this technology for individual patients.

Outcome and toxicity for patients treated with intensity modulated radiation therapy for localized prostate cancer.

PURPOSE: We evaluate long-term disease control and chronic toxicities observed in patients treated with intensity modulated radiation therapy for clinically localized prostate cancer. MATERIALS AND METHODS: A total of 302 patients with localized prostate cancer treated with image guided intensity modulated radiation therapy between July 2000 and May 2005 were retrospectively analyzed. Risk groups (low, intermediate and high) were designated based on National Comprehensive Cancer Network guidelines. Biochemical control was based on the American Society for Therapeutic Radiology and Oncology (Phoenix) consensus definition. Chronic toxicity was measured at peak symptoms and at last visit. Toxicity was scored based on Common Terminology Criteria for Adverse Events v4. RESULTS: The median radiation dose delivered was 75.6 Gy (range 70.2 to 77.4) and 35.4% of patients received androgen deprivation therapy. Patients were followed until death or from 6 to 138 months (median 91) for those alive at last evaluation. Local and distant recurrence rates were 5% and 8.6%, respectively. At 9 years biochemical control rates were 77.4% for low risk, 69.6% for intermediate risk and 53.3% for high risk cases (log rank p = 0.05). On multivariate analysis T stage and prostate specific antigen group were prognostic for biochemical control. At last followup only 0% and 0.7% of patients had persistent grade 3 or greater gastrointestinal and genitourinary toxicity, respectively. High risk group was associated with higher distant metastasis rate (p = 0.02) and death from prostate cancer (p = 0.0012). CONCLUSIONS: This study represents one of the longest experiences with intensity modulated radiation therapy for prostate cancer. With a median followup of 91 months, intensity modulated radiation therapy resulted in durable biochemical control rates with low chronic toxicity.

Marital status and prostate cancer outcomes.

INTRODUCTION: To evaluate the influence of marriage on the survival outcomes of men diagnosed with prostate cancer. MATERIALS AND METHODS: We examined 115,922 prostate cancer cases reported to the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2003. Multivariate Cox regression techniques were used to study the relationship of marital status and prostate cancer-specific and overall mortality. RESULTS: Married men comprised 78% of the cohort (n = 91,490) while unmarried men (single, divorced, widowed, and separated) comprised 22% of the cohort (n = 24,432). Married men were younger (66.4 versus 67.8 years, p < 0.0001), more likely to be white (85% versus 76%, p < 0.0001), presented with lower tumor grades (68% are well or moderately differentiated versus 62%, p < 0.0001) and at earlier clinical stages (41% AJCC stage I/II versus 37%, p < 0.0001). Multivariate analysis revealed that unmarried men had a 40% increase in the relative risk of prostate cancer-specific mortality (HR 1.40; CI 1.35-1.44; p < 0.0001), and a 51% increase in overall mortality (HR 1.51; CI 1.48-1.54; p < 0.0001), even when controlling for age, AJCC stage, tumor grade, race and median household income. Furthermore, the 5 year disease-specific survival rates for married men was 89.1% compared to 80.5% for unmarried men (p < 0.0001). CONCLUSION: Marital status is an independent predictor of prostate cancer-specific mortality and overall mortality in men with prostate cancer. Unmarried men have a higher risk of prostate cancer-specific mortality compared to married men of similar age, race, stage, and tumor grade.

Impact of margin status at 37 months after robot assisted radical prostatectomy.

INTRODUCTION: We evaluate the impact of margin length, location, and pathologic stage on biochemical recurrence (BCR) after robot assisted radical prostatectomy (RARP) at 37 months of follow up. MATERIALS AND METHODS: A total of 1420 patients underwent a robot assisted radical prostatectomy between March 2004 and May 2010. Patients who received adjuvant therapy, those who never achieved an undetectable prostate-specific antigen (PSA), and those who had less than 18 months of follow up were excluded. Patients were then divided and evaluated based on margin status. RESULTS: In total, 419 patients were included in the analysis. Eighty-three had a positive surgical margin (PSM) (19.8%), 336 had a negative surgical margin (NSM) (80.2%). The overall mean follow up was 37 months. On multivariate analysis the Gleason sum and PSM were independent predictors of BCR. Margin length and location had no significant difference on the rate of BCR. Patients with a PSM and pT2 disease had an increased rate of BCR compared to pT2 and NSM. The relative risk of BCR was 2.03 and 3.21 for patients who have a PSM versus a NSM, overall and in those with pT2 disease respectively. No different BCR is seen in pT2 PSM versus ≥ pT3 NSM; or ≥ pT3 PSM versus NSM. CONCLUSION: With 37 months follow up; positive surgical margin and postoperative Gleason sum impact the rate of BCR. Location and length of the PSM do not appear to have an impact on BCR. There was an increased risk of BCR with PSM, especially in pT2 disease.

Urinary bladder injuries during vascular surgery.

Urologic complications related to vascular surgery involving the ureter have been well recognized. These include ureteral compression from aneurysms, congenital anomalies such as retrocaval ureter, obstruction from retroperitoneal fibrosis, iatrogenic injury, and ureteric fistulas. Complications involving the bladder are more infrequent. Most of these bladder-related complications involve the use of tunneling devices for synthetic bypass grafts. We report an unusual case of a transvesically placed femoral-femoral bypass graft with delayed presentation. We also reviewed the English literature for experience with diagnosis and treatment of bladder injuries during vascular surgical procedures.

Accuracy of ultrasound in estimation of prostate weight: comparison of urologists and radiologists.

INTRODUCTION: Measurements of prostate size are obtained to contribute in the diagnosis and follow up of patients with a variety of diseases. Since its introduction, transrectal ultrasonography (TRUS) of the prostate has become the most common method for assessment of prostate volumes. Ultrasonography, in general, has been associated with concerns of operator dependent variability. Herein, we analyze the accuracy of urologists and radiologists performing TRUS. MATERIAL AND METHODS: The accuracy of preoperative TRUS prostate volume estimation was evaluated by comparing it to gross specimen prostate weight following robot-assisted radical prostatectomy (RARP) performed from August 2004 to March 2008 in Mayo Clinic Arizona. A total of 800 RARPs were evaluated retrospectively with 302 patients having a prostate volume measurement with TRUS at our institution followed by RARP being performed within 30 days. The TRUS measurements were divided into two groups: those TRUS measurements performed by urologists (group 1), and those performed by radiologists (group 2). The accuracy of the two groups were compared using a Pearson correlation analysis. RESULTS: The estimated weight by TRUS in the total cohort of patients correlated with the pathological specimen weight at 0.802 with a standard error of 0.90. Group 1 performed a total of 114 ultrasounds with a correlation of 0.835 and a standard error of 1.27. Group 2 performed a total of 188 with a correlation of 0.786 and a standard error of 0.88. CONCLUSIONS: Urologists and radiologists are both consistently within 17%-22% of the estimated prostate specimen weight. Urologists appeared to have a slightly higher accuracy in estimation but a higher range of error for the whole group when compared to radiologists. Transrectal ultrasonography is a reliable technique to estimate prostate weight and accuracy to within 20% of the pathological weight. Urologists and radiologists are essentially equally proficient in estimating prostate weight with TRUS. These findings are particularly important with respect to specialty certification and competency/proficiency evaluation, as health care increasingly moves towards outcomes based reimbursement.

Identification of Bladder Diverticular Stone on 99mTc-Methyl Diphosphonate Bone Scintigraphy and SPECT/CT.

We report a bladder diverticular stone with increased 99mTc-methyl diphosphonate uptake on bone scintigraphy and SPECT/CT. Diverticular stone is a known risk factor for bladder malignancy. The deposition of 99mTc-methyl diphosphonate on the crystal surface of the diverticular stone is a rare phenomenon but of clinical significance. Cystolitholapaxy is indicated to remove the diverticular stone and to reduce the risk of bladder cancer.

The effect of urinary diversion on long-term kidney function after cystectomy.

OBJECTIVES: Cystectomy with urinary diversion is associated with decreased long-term kidney function due to several factors. One factor that has been debated is the type of urinary diversion used: ileal conduit (IC) vs. neobladder (NB). We tested the hypothesis that long-term kidney function will not vary by type of urinary diversion. METHODS AND MATERIALS: We retrospectively identified all patients who underwent cystectomy with urinary diversion at our institution from January 1, 2007, to January 1, 2018. Data were collected on patient demographics, comorbid conditions, perioperative radiotherapy, and complications. Creatinine values were measured at several time points up to 120 months after surgery. Glomerular filtration rate (GFR) (ml/min per 1.73 m2) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed model with inverse probability of treatment weighting (IPTW) was used to compare GFR between the IC and NB cohorts over time. Multiple sensitivity analyses were performed based on 2 different calculations of GFR (Chronic Kidney Disease Epidemiology Collaboration equation vs. Modification of Diet in Renal Disease), with and without excluding patients with preoperative GFR less than 40 ml/min per 1.73 m2. RESULTS: Among 563 patients who underwent cystectomy with urinary diversion, a NB was used for 72 (12.8%) individuals. Patients who had a NB were significantly younger, had a lower American Society of Anesthesiologists score, greater baseline GFR, better Eastern Cooperative Oncology Group performance status, lower median Charlson comorbidity index, and were less likely to have received preoperative abdominal radiation (all P < 0.05). Both NB and IC patients had decreased kidney function over time, with mean GFR losses at 5 years of 17% and 14% of baseline values, respectively. The IPTW-adjusted linear mixed model revealed that IC patients had slightly more deterioration in kidney function over time, but this was not statistically significant (estimate, 0.12; P = 0.06). The sensitivity analyses yielded a similar trend, in that GFR decrease appeared to be greater in the IC cohort. This trend was statistically significant when using Modification of Diet in Renal Disease (P = 0.04). CONCLUSIONS: Among highly selected patients with an NB, deterioration of kidney function may potentially be lower over time than among IC patients. However, the statistical significance varied between analyses and we cautiously attribute these observed differences to patient selection.

Does a history of previous surgery or radiation to the prostate affect outcomes of robot-assisted radical prostatectomy?

OBJECTIVE: To evaluate retrospectively whether or not previous treatment to the prostate alters the perioperative outcomes from robot-assisted radical prostatectomy (RARP) after the initial 'learning curve', as there are conflicting data on outcomes of RP in patients with previous treatment to the prostate. PATIENTS AND METHODS: We retrospectively reviewed the charts of patients who had RARP between March 2005 and August 2007, and analysed demographic, perioperative variables and pathological data. In all, 510 patient charts were reviewed, identifying 24 patients with a history of previous treatment to the prostate including transurethral resection or incision of the prostate, transurethral microwave therapy, transurethral needle ablation, photoselective vaporization, simple prostatectomy, external beam radiotherapy, brachytherapy, and open bladder neck reconstruction (group 1) and 486 with no previous treatment (group 2). RESULTS: There was no significant difference between the groups in body mass index, clinical stage, grade or prostate volume, but the patients in group 1 were older (70 vs 65 years, P = 0.001). Outcome analysis comparing groups 1 and 2 showed an estimated blood loss of 155 vs 137 mL, length of hospital stay of 2.2 vs 1.5 days, operative duration of 200 vs 186 min and catheter time of 12 vs 8 days, respectively; only the last was statistically significant (P = 0.03). There was an 8.3% and 6.8% complication rate in groups 1 and 2, respectively, and the respective overall positive margin rate was 20.8% and 22.6%. CONCLUSIONS: A history of previous treatment of the prostate does not appear to compromise the perioperative outcomes of RARP.

Interval from prostate biopsy to robot-assisted radical prostatectomy: effects on perioperative outcomes.

OBJECTIVE: To determine whether shorter intervals (<4 and 6 weeks) between prostate biopsy and robot-assisted radical prostatectomy (RARP) have a detrimental effect on perioperative outcomes, as recent studies showed that open RP shortly after prostate biopsy does not adversely influence surgical difficulty or efficacy, but RARP relies solely on visual cues rather than tactile sensation to determine posterior surgical planes of dissection. PATIENTS AND METHODS: A series of 559 patients undergoing RARP from March 2004 to July 2007 was retrospectively reviewed. The interval between prostate biopsy and RARP was determined and patients with intervals of 4 weeks. Patient characteristics and perioperative outcomes were analysed to determine statistically significant differences between the groups. This comparison was then repeated with a 6-week interval, and examined with a multivariate logistic regression analysis. RESULTS: In the 4-week group (509 patients), there was a significantly (P < 0.05) higher rate of complications (18.5% vs 6.9%). In the 6-week group (455 patients) there was a smaller but still significantly higher rate of complications (13.6% vs 6.4%). These results were still significant when controlling for patient and disease characteristics and the 'learning curve'. There was also a significantly higher rate of transfusion in the 6-week group (0.7%). CONCLUSIONS: Our data suggest that RARP should be delayed after prostate biopsy; RARP within 6 weeks of biopsy was associated with a greater risk of complications even when controlling for disease and patient characteristics.

Bilateral laparoscopic nephrectomy for significantly enlarged polycystic kidneys: a technique to optimize outcome in the largest of specimens.

OBJECTIVE: To present our experience with bilateral laparoscopic nephrectomy (BLN) for symptomatic autosomal-dominant polycystic kidney disease (ADPKD), as surgical management of massively enlarged polycystic kidneys can be a daunting task. PATIENTS AND METHODS: The study was a retrospective chart review of all patients undergoing BLN for ADPKD. Patient demographics, indications for the procedure, perioperative data, and pathological data were analysed. RESULTS: In all, 12 patients underwent BLN at our institution; eight were performed before transplant, three after transplant, and one with a concomitant kidney transplant. Indications for surgery included abdominal pain, fullness and early satiety, recurrent urinary tract infections, and need for space for future transplant. The mean patient age was 49.6 years, with a body mass index of 27.0 kg/m(2). The mean operative duration was 214 min, estimated blood loss was 169 mL, and the hospital stay was 4 days. There were no conversions to open surgery. The mean (range) pathological kidney mass was 2243 (656-4200) g on the left and 2379 (789-5042) g on the right. No patients with a previous renal transplant had deterioration in postoperative renal function. There was one minor intraoperative complication, one postoperative complication, and one patient with preoperative anaemia required a blood transfusion. CONCLUSIONS: Symptomatic patients with ADPKD due to massively enlarged kidneys should be considered for BLN when performed by an experienced laparoscopic surgeon. This includes patients with an existing renal allograft and candidates for concomitant transplantation. The approach should be tailored to avoid injury to adjacent structures secondary to displacement from the mass effect of these kidneys.

Analysis of Benign Prostatic Hyperplasia Patients' Perspective Through a Third Party-administered Survey.

OBJECTIVE: To assess patient-reported functional and quality-of-life (QoL) outcomes associated with various surgical treatments for benign prostate hyperplasia (BPH). MATERIALS AND METHODS: An independent third-party survey was sent to all patients who underwent any surgical treatment for BPH at our institution from January 2007 through January 2013. Overall satisfaction and urinary and sexual outcomes were evaluated using Sexual Health Inventory for Men (SHIM), International Prostate Symptoms Score (IPSS) for urinary function, and International Continence Society-Short Form (ICSmaleSF) questionnaires. RESULTS: Four hundred and seventy-nine respondents (response rate, 55.6%) had undergone holmium laser enucleation of the prostate (HoLEP; n = 214), transurethral resection of the prostate (n = 210), holmium laser ablation of the prostate (n = 21), photoselective vaporization (n = 18), transurethral incision of the prostate (n = 9), and open simple prostatectomy (n = 7). Postoperatively, Sexual Health Inventory for Men scores were not different. However, total IPSS varied significantly among surgical techniques (P < .001). Mean (standard deviation) IPSS was lowest for open simple prostatectomy (4.0 [2.6]), followed by HoLEP (5.8 [5.4]). For individual domains, significant differences were in intermittency (P < .001), weak stream (P = .003), straining (P < .001), and QoL (P = .001). In all these domains, HoLEP had the lowest scores. Regarding International Continence Society-Short Form, we observed a significant difference favoring transurethral resection of the prostate in incontinence (P < .001) and favoring HoLEP in voiding (P = .02) and QoL domains (P = .03). Most patients were satisfied with their surgical intervention, independent of the procedure type. Regret was least in patients who underwent HoLEP (P = .02). CONCLUSION: Patients generally expressed satisfaction with various interventions for BPH. However, those who underwent HoLEP had the best outcomes.

Routine postoperative chest x-ray following laparoscopic nephrectomy.

PURPOSE: To determine whether a routine postoperative chest x-ray is required following uneventful laparoscopic nephrectomy to rule out pneumothorax. METHODS: From June 1999 to May 2003, 308 laparoscopic nephrectomy cases were performed by 5 different surgeons. This consisted of 121 radical nephrectomies, 106 donor nephrectomies, 29 simple nephrectomies, 29 partial nephrectomies, and 23 nephroureterectomies. Of the 308 procedures, 186 postoperative chest x-ray s were obtained in the recovery room: 183 routinely and 3 for known intraoperative diaphragmatic injuries. Routine chest x-rays were not obtained in 122 cases due to the individual surgeon's preference. Of these 122 patients, 15 underwent chest x-ray performed while hospitalized secondary to pulmonary issues or fever. RESULTS: Of the 308 cases, 4 pneumothoraces were identified on chest x-ray. Three were identified in the patients who had intraoperative identification of diaphragmatic injury. The fourth pneumothorax was identified in a patient who did not have a routine postoperative chest x-ray but did have a chest x-ray obtained due to postoperative shoulder pain. The pneumothorax in this patient resolved spontaneously. No incidental findings existed of pneumothorax in any patient who underwent routine postoperative chest x-ray. CONCLUSION: In our series, a pneumothorax was identified either intraoperatively or based on postoperative clinical findings. None of the 183 routine postoperative chest x-rays changed patient management. Routine postoperative chest x-ray is not necessary in uncomplicated laparoscopic nephrectomy.

Salvage radiotherapy for palpable, locally recurrent prostate cancer after radical prostatectomy.

PURPOSE: A retrospective study to evaluate the outcome of salvage radiotherapy (RT) for clinically apparent, palpable prostate cancer recurrence after radical prostatectomy (RP). METHODS AND MATERIALS: Forty-two patients underwent RT for clinically apparent recurrent prostate cancer after RP between 1993 and 1999. The end points and treatment variables of biochemical disease-free survival were evaluated statistically. RESULTS: The median follow-up was 4.3 years. All 42 patients experienced resolution of clinically detectable recurrence within 1 year after RT. The 5-year biochemical disease-free survival, local control, freedom from distant metastases, and overall survival rate was 27%, 94%, 82%, and 78%, respectively. The initial pathologic stage (T3 or T4; p = 0.04) and interval (<2 years from RP to RT; p = 0.01) were independent predictors of biochemical failure, and RT simulation without contrast (p = 0.05) was nearly significant on multivariate analysis. Three patients (7%) experienced chronic Grade 3 or 4 RT-related toxicity. CONCLUSION: Salvage prostate bed RT for clinically apparent locally recurrent prostate cancer after RP provides effective local tumor control with modest durable biochemical control. Patients irradiated with a better simulation technique were found to have a more favorable outcome. A consensus on a definition of biochemical disease-free survival after salvage RT is critical for meaningful comparison of the available data and to future progress in treating this disease process.

TissueLink device for laparoscopic nephron-sparing surgery.

BACKGROUND AND PURPOSE: One of the most challenging aspects of laparoscopic partial nephrectomy is achieving adequate control of bleeding from the tumor bed. We report our initial experience with laparoscopic nephron-sparing surgery using the TissueLink floating-ball radiofrequency dissector. PATIENTS AND METHODS: From March 2002 to April 2003, we performed 14 purely laparoscopic nephron-sparing nephrectomies using the floating-ball device on 11 patients. RESULTS: The mean operative time was 124 minutes (range 90-210 minutes). The mean estimated blood loss was 168 mL (range 20-600 mL). One patient had a small urine leak and was sent home with the drain in place. CONCLUSIONS: We successfully treated 14 small renal lesions using the TissueLink floating-ball device. The procedure was performed in an expeditious fashion with minimal blood loss. Long-term follow-up is required to determine the oncologic efficacy.

Mayo Clinic Scottsdale Experience with laparoscopic nephroureterectomy.

OBJECTIVES: To evaluate the efficacy of laparoscopic nephroureterectomy for patients with transitional cell carcinoma of the upper urinary tract. METHODS: Eighteen patients underwent attempted transperitoneal laparoscopic nephroureterectomy between June 2000 and October 2002. Mean patient age was 67.5 years. The specimen was removed intact through a 7- to 9-cm extraction incision in the lower midline. In the majority of patients, the distal ureter was dissected through the extraction incision. RESULTS: Sixteen cases were completed laparoscopically. Two cases required conversion to an open procedure. In these cases, dense fibrosis was present around the renal hilum preventing further dissection. The mean operative time was 180 minutes, and the mean estimated blood loss was 160 mL. The mean length of stay was 3.3 days. Complications included the 2 conversions, and 1 patient with a postoperative Mallory Weiss tear. No port-site or distant metastasis occurred; however, 1 patient developed a retroperitoneal recurrence. CONCLUSION: Laparoscopic nephroureterectomy is an alternative to open nephroureterectomy. Cases with high-stage and grade may cause the laparoscopic dissection to be difficult. The extraction incision allows for easy dissection of the distal ureter.

Proton beam therapy for localized prostate cancer 101: basics, controversies, and facts.

Proton beam therapy for prostate cancer has become a source of controversy in the urologic community, and the rapid dissemination and marketing of this technology has led to many patients inquiring about this therapy. Yet the complexity of the technology, the cost, and the conflicting messages in the literature have left many urologists ill equipped to counsel their patients regarding this option. This article reviews the basic science of the proton beam, examines the reasons for both the hype and the controversy surrounding this therapy, and, most importantly, examines the literature so that every urologist is able to comfortably discuss this option with inquiring patients.

Anatomic site-specific disparities in survival outcomes for penile squamous cell carcinoma.

OBJECTIVE: To identify the predictors of cancer-specific mortality of penile squamous cell carcinoma (PSCC) using a population-based database. METHODS: Using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results registry, we performed a time-to-event analysis to determine which clinical parameters were useful in predicting cancer-specific mortality. RESULTS: Our cohort consisted of 2515 cases of PSCC diagnosed from 1973 to 2007. The patients were divided into 2 groups: primary tumors of the prepuce (n = 722) and primary tumors of the glans, body, and overlapping lesions of the skin (n = 1793). The median follow-up for the cohort was 39 months (range 1-411). Compared with tumors of the prepuce, tumors of the body (hazard ratio 1.61, 95% confidence interval 1.00-2.60, P = .05) and overlapping tumors of the skin (hazard ratio 1.79, 95% confidence interval 1.13-2.83, P = .01) had a greater risk of cancer-specific mortality, even when controlling for age, Surveillance, Epidemiology, and End Results stage, and tumor grade. Furthermore, the disease-specific 10-year survival rate of those with preputial tumors was 89.4% compared with 78.7% for the other 3 groups combined (P < .0001). CONCLUSION: Anatomic site-specific disparities for PSCC survival appear to exist. Patients diagnosed with PSCC of the prepuce have greater overall long-term disease-specific survival than patients with primary tumors elsewhere.

Older age does not impact perioperative complications after robot-assisted radical prostatectomy.

To determine whether men aged 70 years and older had more perioperative complications after robot-assisted radical prostatectomy (RARP) compared with younger patients, a retrospective review was performed on patients who underwent RARP between March 2004 and September 2009. Subjects were stratified according to age into four groups (age 30-49, 50-59, 60-69, and ≥70 years). American Society of Anesthesiologists (ASA) scores were obtained. Complication rates in the perioperative period, transfusion rates, and length of stay were compared. Complications were classified using the previously validated Clavien system. There were a total of 293 patients aged 70 years and older amongst the 1,223 total subjects. ASA comorbidity scores did vary significantly amongst the different age groups, and there was modest correlation noted between ASA and age. There was no statistically significant difference amongst complication rates in men aged 70 years and older (15%) compared with the other cohorts (P = 0.832). There was also no significant difference in transfusion rates (P = 0.170) or length of stay (P = 0.131). Patients with higher ASA scores (ASA 3-4) had more Clavien I-II complications compared with patients with ASA scores of 1-2 (15.5% versus 10.3%, P = 0.03). There was no difference in transfusion rates or length of stay between the ASA scores. There are no more complications in men aged 70 years and older compared with men <70 years of age undergoing robot-assisted radical prostatectomy. RARP is a safe treatment option to offer to the selected elderly patient.

Preliminary analysis of the feasibility and safety of salvage robot-assisted radical prostatectomy after radiation failure: multi-institutional perioperative and short-term functional outcomes.

BACKGROUND AND PURPOSE: Open radical prostatectomy after radiation treatment failure for prostate cancer is associated with significant morbidity. The purpose of the study is to report multi-institutional experiences while performing salvage robot-assisted radical prostatectomy (sRARP). PATIENTS AND METHODS: We retrospectively identified 15 patients with biopsy-proven prostate cancer after definitive radiotherapy who underwent sRARP in three academic institutions over a 20-month period. Continence was defined as the use of 0 pads after surgery. Potency was defined as the ability to achieve erections adequate enough for penetration with or without the use of phosphodiesterase-5 inhibitors. Biochemical recurrence after sRARP was defined as a prostate-specific antigen value of >0.2 ng/mL. RESULTS: Radiation treatment consisted of external-beam radiation therapy (XRT) in five cases, interstitial radioactive 125-iodine brachytherapy (BT) in five cases, proton beam therapy in two cases, and XRT followed by interstitial radioactive 125-iodine BT in three cases. The median operative time, the median estimated blood loss, and the median length of hospital stay were 140.5 min (interquartile range [IQR] 97.5-157 min), 75 mL (IQR 50-100 mL), and 1 day (IQR 1-2 d), respectively. There were no rectal injuries. Two (13.3%) patients had a positive surgical margin. A total of three (20%) patients had postoperative complications. One patient had a deep vein thrombosis (Clavien grade II), one had wound infection (Clavien grade II), and one patient had an anastomotic leak (Clavien gradeId). An anastomotic stricture (Clavien grade IIIa) later developed in this same patient, which was managed by direct visual internal urethrotomy. Of the patients, 71.4% were continent. At a median follow-up of 4.6 months (IQR 3-9.75 mos), four (28.6%) patients presented with biochemical recurrence after sRARP. CONCLUSIONS: The challenge during sRALP is the presence of extensive fibrosis and loss of dissection planes secondary to radiation therapy. It is a technically challenging but feasible procedure. The early complication rates were low, and early continence rates are encouraging.