Metastatic prostate cancer in the modern era of PSA screening.

INTRODUCTION: To characterize initial presentation and PSA screening status in a contemporary cohort of men treated for metastatic prostate cancer at our institution. MATERIALS AND METHODS: We reviewed records of 160 men treated for metastatic prostate cancer between 2008-2014 and assessed initial presentation, categorizing patients into four groups. Groups 1 and 2 presented with localized disease and received treatment. These men suffered biochemical recurrence late (>1 year) or earlier (<1 year), respectively, and developed metastases. Groups 3 and 4 had asymptomatic and symptomatic metastases at the outset of their diagnosis. Patients with a first PSA at age 55 or younger were considered to have guideline-directed screening. RESULTS: Complete records were available on 157 men for initial presentation and 155 men for PSA screening. Groups 1, 2, 3 and 4 included 27 (17%), 7 (5%), 69 (44%) and 54 (34%) patients, respectively. Twenty (13%) patients received guideline-directed PSA screening, 5/155 (3%) patients presented with metastases prior to age 55 with their first PSA, and 130/155 (84%) had their first PSA after age 55, of which 122/130 (94%) had metastasis at the time of diagnosis. CONCLUSION: Despite widespread screening, most men treated for metastatic prostate cancer at our institution presented with metastases rather than progressed after definitive treatment. Furthermore, 25 (16%) patients received guideline-directed PSA screening at or before age 55. These data highlight that, despite mass screening efforts, patients treated for incurable disease at our institution may not have been a result of a failed screening test, but a failure to be screened.

Reporting positive surgical margins after radical prostatectomy: time for standardization.

OBJECTIVES: To assess the consistency of reporting on positive surgical margins (PSMs) and associated prognostic variables after radical prostatectomy (RP) in the current literature To provide a standardized methodology for quantifying the characteristics and the prognostic impact of PSMs after RP. PATIENTS AND METHODS: We conducted a review of articles that assessed the prognostic value of characteristics of PSMs after RP. The articles were identified using a MEDLINE search. The methodology and quality of the reporting of PSMs were analysed according to six criteria defined according to the guidelines of the College of American Pathologists and the International Society of Uropathologists. Forty-four studies, involving ≥100 patients and published from January 2005 to the present, were reviewed. RESULTS: Each of the 44 studies was assessed for their reporting of the six defined PSM criteria, as well as for the significance of PSM characteristics on biochemical recurrence (BCR). The definition of a PSM was the only criterion that was consistently reported. All studies were deficient in defining and reporting one or more of the PSM criteria. Major inconsistencies were observed in the reporting of PSM site and length, and the presence of intraprostatic incision. The many conflicting reports gave little insight into the true significance of particular PSM-associated variables on BCR. CONCLUSIONS: There is a lack of consistency in the reporting on and prognostic significance of PSMs and PSM-associated prognostic variables. We hypothesize that these conflicting results are partly attributable to a lack of use of a standardized reporting methodology for PSMs. Implementation of a previously reported standardized scoring system for PSMs may help eliminate these inconsistencies in the future.

Postoperative Outcomes After Radical Cystectomy in Patients With Prior Pelvic Radiation.

OBJECTIVE: To compare complication rates, perioperative outcomes, and survival after radical cystectomy (RC) in patients with prior abdominal or pelvic radiation therapy (RT) vs those without an RT history. MATERIALS AND METHODS: We retrospectively reviewed patients undergoing RC for urothelial carcinoma between January 2008 and January 2016. Patients were stratified by receipt of RT, and differences in complications (any, minor, and major) at 30 and 90 days, as well as estimated blood loss, length of surgery, length of hospital stay, and pathologic stage, were compared. Recurrence-free, cancer-specific, and overall survival were compared using the Kaplan-Meier method and log-rank test. RESULTS: We identified 518 patients who underwent RC between 2008 and 2016. Of these patients, 55 (11%) had a history of RT. There were no significant differences in complication rates (66% vs 69%, P= .80) between patients who did not and patients who did have a history of RT. Similarly, there were no differences in any perioperative or pathologic outcome by receipt of prior RT (all P>.05). Meanwhile, at a median follow-up of 26 (interquartile range 13-46) months among patients alive at last follow-up, no differences in survival were observed by prior RT (P= .08). CONCLUSION: Among patients with a history of prior abdominal or pelvic RT treated at a tertiary referral center, there was no difference in complication rates, perioperative, or pathologic outcomes. Importantly, no differences in survival were noted by prior RT receipt. Therefore, our data support the use of RC, when indicated, in patients with a prior history of abdominal or pelvic RT.

Robotic-assisted Laparoscopic Pyeloplasty: Analysis of Symptomatic Patients With Equivocal Renal Scans.

OBJECTIVES: To review the objective and subjective success rates of robotic-assisted laparoscopic pyeloplasty in symptomatic patients with radiographic findings suggestive of uretero-pelvic junction obstruction (UPJO), but equivocal renal scans (diuretic T1/2 <20 minutes). METHODS: We reviewed 77 patients with symptomatic UPJO, who underwent robotic-assisted laparoscopic pyeloplasty between August 2006 and March 2013. We grouped patients by renal scan findings into 1 of 2 groups, obstructed (diuretic T1/2 ≥20 minutes) or equivocal (diuretic T1/2 <20 minutes). All patients were symptomatic and had radiographic findings suggestive of UPJO (eg hydronephrosis). RESULTS: Mean age was 40.7 years (range 17-80) with 70% female. UPJO occurred 44% left and 56% right, with 92% presenting with flank pain. Of 77 patients, 45 had obstruction on renal scan, with 41 (91%) having resolution of obstruction postoperatively and 44 of 45 (98%) having complete resolution of their initial symptoms. Thirty-two patients had equivocal findings with mean diuretic T1/2 of 12.6 minutes (range: 5.5-19.26) on renal scan. In this latter group, patients had significantly less of a decrease in their diuretic T1/2 postoperatively (4 vs 64 minutes, P = .018) and reported less pain resolution (53% vs 98%, P ≤.001) than group 1. CONCLUSION: Many studies have demonstrated excellent success of pyeloplasty, with most series including patients meeting strict diagnostic criteria for obstruction. Our study examines outcomes in patients with clinically symptomatic UPJO and equivocal diuretic renography. In our cohort, equivocal patients were significantly less likely to have subjective resolution of symptoms than patients in the obstructed group.