A prospective comparison of UroVysion FISH and urine cytology in bladder cancer detection.

BACKGROUND: UroVysion fluorescence in situ hybridization (uFISH) was reported to have superior sensitivity to urine cytology. However uFISH studies are limited by varying definitions of what is considered a positive result, absence of histopathology and small sample size. The aim of our study was to better determine the performance characteristics of uFISH and urine cytology by overcoming some of the deficiencies of the current literature. METHODS: Intraoperative bladder wash cytology and uFISH were collected prospectively on all patients. Strict definitions for positivity of uFISH and cytology were determined before initiating the study. A re-review of false-negative uFISH specimens was performed to analyze potential sources of error. Sixteen bladder tumors embedded in paraffin were analyzed by uFISH and compared with the result in the urine. RESULTS: One hundred and twenty-nine specimens were analyzed. Sensitivity was 67% and 69% (p = 0.54); specificity was 72% and 76% (p = 1.0), for uFISH and cytology, respectively. Thirty-two false negative uFISH samples were re-reviewed. Low grade tumors often showed cells with abnormal morphology and patchy DAPI staining but diploid chromosomal counts and a few high grade tumors had tetraploid counts but less than needed to interpret uFISH as positive. uFISH study of the tumors revealed three categories; positive in both tumor and urine (9), negative in both tumor and urine (5) and positive in tumor but negative in urine (2). CONCLUSION: In a pathologically-confirmed analysis of bladder washed urine specimens, uFISH does not outperform urine cytology in cancer detection.

Improvement of severe baseline lower urinary tract symptoms following robotic-assisted laparoscopic prostatectomy.

AIMS: This study was designed to assess lower urinary tract symptoms (LUTS) following robotic-assisted laparoscopic prostatectomy. METHODS: In a single surgeon series, 938 patients underwent robotic prostatectomy and completed International Prostate Symptom Score surveys at baseline and 6-month follow-up. Patients preoperative LUTS were categorized as mild, moderate, or severe according to the original International Prostate Symptom Score validation. Patient demographics, in addition to clinical and pathologic outcomes were obtained from an Institutional Review Board-approved database. RESULTS: Preoperatively, 55.8% of patients presented with mild, 36.4% with moderate, and 7.8% with severe LUTS. Increased prostate size trended with increased LUTS severity (P < 0.001). Patients who had severe preoperative LUTS witnessed a 57% reduction in International Prostate Symptom Score (from 24.1 to 10.7, P < 0.001). Men with moderate preoperative LUTS also witnessed a significant decrease in postoperative LUTS (from 12.1 to 8.3, P < 0.001). CONCLUSIONS: The majority of patients with moderate or severe LUTS improved significantly following robotic prostatectomy, with the largest improvements seen in the severe group. Prostate cancer patients with severe LUTS should be counseled on the beneficial role of robotic prostatectomy in an effort to improve their voiding dysfunction and as a viable cancer treatment.

Pathological T0 following radical cystectomy with or without neoadjuvant chemotherapy: a useful surrogate.

PURPOSE: Several large, randomized, controlled trials provide evidence that neoadjuvant chemotherapy improves the outcome of radical cystectomy for muscle invasive urothelial bladder cancer. We analyzed the designs, methods and observations of these trials to identify patient subgroups that appeared most likely to benefit. We also identified distinguishing features compared to groups that did not achieve improved outcomes. MATERIALS AND METHODS: We analyzed initial and updated methods and results of the 4 main prospective trials of neoadjuvant chemotherapy (SWOG, Medical Research Council, and Nordic I and II) and subsequent meta-analyses. These series are the basis for advocating neoadjuvant chemotherapy in all patients with muscle invasive urothelial bladder cancer who undergo radical cystectomy. RESULTS: The greatest apparent benefit was seen in patients free of cancer at radical cystectomy (pT0). They had markedly improved overall and disease specific survival compared to patients with residual disease. However, improvements occurred regardless of whether there was down-staging from muscle invasive urothelial bladder cancer to pT0 after transurethral resection alone (controls) or after resection plus neoadjuvant chemotherapy. Thus, the major benefit of chemotherapy appeared to be that more patients achieved pT0. We also explored the study limitations that may have influenced outcomes and considered the potential for overtreatment in patients not likely to benefit from chemotherapy. Finally, we used risk stratification to create a decision tree model for selecting patients for neoadjuvant chemotherapy that could conceivably maximize oncologic outcome and minimize overtreatment. CONCLUSIONS: Patients with pT0 in the 4 main neoadjuvant chemotherapy trials and their subsequent meta-analyses experienced similar survival, far exceeding that in groups that did not achieve pT0. The benefit of neoadjuvant chemotherapy appears to be the larger number of cases than in the transurethral resection only group that were down-staged to pT0, suggesting that variables other than chemotherapy may have influenced outcomes. Therefore, strategies to selectively administer neoadjuvant chemotherapy to certain patients at risk have the potential to maintain improved bladder cancer outcomes while reducing overtreatment and its associated toxicity.

Validation of online administration of the sexual health inventory for men.

PURPOSE: Previously we reported the development of a novel, inexpensive, online method to collect health related quality of life information to facilitate responses among patients and decrease loss to followup. We validated the practice by comparing responses to the SHIM (Sexual Health Inventory for Men), a representative validated instrument, when administered on line and in the traditional paper form. MATERIALS AND METHODS: Consented patients were administered validated health related quality of life instruments, including the SHIM, in office and via e-mail. Responses to the SHIM were compared between the administration formats. Paired sample testing was done to analyze test-retest reliability, concordance was assessed by intraclass analysis and a Bland-Altman plot, and the Cronbach α was used to examine internal reliability. Criterion validity was measured using SHIM defined erectile function categories and a dichotomized potency definition (SHIM 17 or greater). RESULTS: Of the 508 men who consented to participate 359 (71%) completed the SHIM in person, 277 (55%) completed the online form (p <0.001) and 116 (23%) contemporaneously completed each instrument. Comparison of scores revealed little variation and strong correlation (r(2) = 0.83, p <0.001). Intraclass and Bland-Altman analysis revealed strong agreement between the media. The Cronbach α was excellent (0.97) for the online tool. Erectile function classification was identical in 73% of patients with only 7% differing by more than 1 class. Dichotomized potency was consistently defined in 94% of patients. CONCLUSIONS: The online administered SHIM maintains validity and provides consistent responses. Online administration can capture patients who do not complete paper questionnaires and may serve as a reliable adjunct to paper administration for validated outcomes research.

Do Gleason patterns 3 and 4 prostate cancer represent separate disease states?

PURPOSE: The Gleason scoring system has been the traditional basis for studies on the assessment and treatment of prostate cancer. Recent reports of long-term prostate cancer outcomes stratified by Gleason score based on the 2005 ISUP (International Society of Urological Pathology) update suggest that important aspects of the biology of prostate cancer correlate with commonly available histopathological information. In this review we present a conceptual framework for the possible existence of distinct but interrelated developmental pathways in the context of the Gleason score in considering various biological and clinical aspects of prostate cancer. This may be useful in characterizing prostate cancer as an indolent condition in some and an aggressive disease in others, in decision making for treatment, and in the interpretation of the biological course and treatment outcomes. MATERIALS AND METHODS: A comprehensive review of clinical, pathological and investigational biological literature on this topic was conducted. In addition, the biological behavior of prostate cancer as interpreted from this survey was compared to that of other solid neoplasms in developing a schema for characterizing the pathogenesis of various forms of the disease. RESULTS: The Gleason scoring system has been found to have fundamental value in predicting the behavior of prostate cancer and assessing outcomes of its treatment. Increasingly, the proportion of Gleason pattern 4 in a prostatectomy specimen is being recognized as a critical factor in predicting the rates of biochemical recurrence and prostate cancer specific mortality. Under the current Gleason classification, a Gleason 3 + 3 = 6 cancer carries a minimal long-term risk of progression or mortality. Risk of biochemical recurrence and prostate cancer specific mortality increases with increasing proportions of the Gleason 4 component in the prostatectomy specimen, from 3 + 3 = 6 with tertiary 4 (ie less than 5% of a 4 component) to 3 + 4 = 7, 4 + 3 = 7 and 4 + 4 = 8. Assuming that the Gleason 4 component increases in volume more rapidly with time than well differentiated components, it can be inferred that a smaller proportion of Gleason 4 could mean that the cancer has been identified at an earlier phase in the natural history of the disease. This could explain the improved prognosis on the basis of length and lead time biases, and conceivably on the basis of a decreased likelihood of cancer cells having metastasized. Correspondingly, increasing amounts of Gleason 4 cancer in a prostate specimen might be explained in 2 ways, as the preferential growth of a single clone of Gleason 4 cells, possibly with intraprostatic spread, or the evolution of Gleason 3 cancer cells to become Gleason 4. These hypotheses have been examined by genetic analysis of metastatic deposits and by comparisons of multiple foci of cancer within individual prostates. The clinical significance of these concepts in regard to disease status at diagnosis, treatment selection, outcomes of treatment, and implications for future research on the basis of clinical and molecular observations are the basis of the developmental schemata we propose. CONCLUSIONS: Given the relatively benign nature of homogeneous, low volume Gleason 3 tumors, and the progressive risk of biochemical recurrence and prostate cancer specific mortality with increasing quantities of Gleason 4 components, we propose that Gleason 4 (and 5) cancers constitute cancer diatheses distinct from that of Gleason 3 cancer. This distinction may contribute to the understanding of the prognosis intrinsic to these biological behavioral patterns, and help guide the translation of findings at molecular and histological levels to a more precise selection of treatments.

Baseline functional status may predict decisional regret following robotic prostatectomy.

PURPOSE: Physician knowledge of factors related to patient decisional regret following definitive management for localized prostate cancer is an important but under evaluated element in comprehensive patient counseling. Using validated instruments, we analyzed the relationships of pathological, perioperative and functional health related quality of life variables to treatment related regret following robot-assisted laparoscopic prostatectomy. MATERIALS AND METHODS: Of 953 consecutive patients presenting for followup after robot-assisted laparoscopic prostatectomy 703 (74%) completed validated measures of health related quality of life and treatment decisional regret. Baseline functional measures were assessed with the Sexual Health Inventory for Men and International Prostate Symptom Score. Questionnaires were administered a median of 11.1 months (IQR 4.6-26.1) after surgery. Clinicopathological, perioperative and functional outcomes were analyzed with univariable and multivariable models to examine associations with patient decisional regret. RESULTS: Of the patients 88% did not regret the decision to undergo robot-assisted laparoscopic prostatectomy. Baseline health related quality of life, specifically baseline incontinence and superior erectile function, independently predicted increased postoperative decisional regret. In addition, older age, postoperative incontinence measured by pad use, postoperative erectile dysfunction and longer time from surgery were independent predictors of increased decisional regret. Preoperative cancer risk, and histopathological and short-term biochemical outcomes were unrelated to decisional regret. CONCLUSIONS: Decisional regret following robot-assisted laparoscopic prostatectomy is independently predicted by age, baseline urinary and erectile function, perioperative outcomes, and postoperative urinary and erectile function. These results may be useful to urologists during preoperative patient counseling to set realistic expectations for the postoperative course, potentially improving the surgical experience.

Decreasing rates of lymph node dissection during radical nephrectomy for renal cell carcinoma.

BACKGROUND: The utility of lymph node dissection (LND) during radical nephrectomy for renal cell carcinoma (RCC) continues to be controversial, yet its use by urologists in the United States is unknown. We analyzed the incidence of and trends in LND from a large, nationally representative cancer registry. METHODS: Using the Surveillance, Epidemiology, and End Results registry we identified 37,279 patients with RCC who underwent radical nephrectomy from 1988 to 2005. LND was defined as a surgeon removing ≥5 nodes; however, sensitivity tests were performed using cutoffs of ≥3 and ≥1 nodes. We analyzed changes in LND rates over time and used multivariable logistic regression to predict those who underwent LND. RESULTS: Of the 37,279 patients with RCC, 2,463 (6.6 %) received a LND. There was a gradual decline in LND beginning in 1988 that accelerated after 1997, with the period of 1998-2005 having significantly decreased odds of LND compared with the period 1988-1997 (odds ratio [OR]: 0.65; 95 % confidence interval [95 % CI]: 0.59-0.71). This decline was driven primarily by a 63 % reduction in LND rates among localized tumors (p < .001). CONCLUSIONS: There has been a significant decline in LND rates during radical nephrectomy for localized kidney cancer over the past 7 years. In contrast to prior estimates, very few urologists in the United States are removing ≥5 nodes during lymph node dissection for RCC.

Active patient decision making regarding nerve sparing during radical prostatectomy: a novel approach.

PURPOSE: The motivation to preserve sexual function can vary widely among patients before prostatectomy. Increasing patient involvement may allow a more personalized experience and may improve satisfaction. We assessed a strategy of surgeon deference to patient choice in regard to nerve sparing to determine to what degree patients are rational actors and capable of active decision making. MATERIALS AND METHODS: A total of 150 patients treated with prostatectomy participated in a standardized preoperative discussion regarding the concept of nerve sparing, extracapsular extension and the potential need for adjuvant radiation in the event of local recurrence. Each patient was given his nomogram predicted risk of extracapsular extension and then elected nerve sparing or nonnerve sparing. The corresponding procedure was performed unless grossly invasive disease was encountered. RESULTS: Of the 150 patients 109 chose nerve sparing (73%) and 41 chose nonnerve sparing (27%). In patients with a nomogram predicted risk of extracapsular extension less than 20%, 20% to 50% and greater than 50%, nerve sparing was elected by 88%, 41% and 25%, respectively. Patients with lower risks of extracapsular extension electing nonnerve sparing were older and had higher rates of erectile dysfunction. CONCLUSIONS: Empowering patients to decide on their nerve sparing status is a reasonable strategy that did not lead to a high rate of patients with a high risk of extracapsular extension electing nerve sparing. With proper counseling informed patients made reasonable decisions, and appeared to be conservative, prioritizing cancer control in the majority of instances where extracapsular extension risk was high. In addition, they may have been overly conservative in electing nonnerve sparing when the risk was low.

Robotic extended pelvic lymphadenectomy for bladder cancer with increased nodal yield.

STUDY TYPE: Therapy (case series). LEVEL OF EVIDENCE: 4. What's known on the subject? and What does the study add? The standard of care for invasive bladder cancer is open radical cystectomy with the extent of pelvic lymph node dissection impacting oncological outcomes. Scepticism remains regarding whether an adequate node dissection can be performed in minimally-invasive fashion as previously reported nodal yields of laparoscopic or robotic lymphadenectomy are well below those reported with open surgery. This study demonstrates that extended pelvic lymphadenectomy can be performed robotically with equivalent nodal yields to open series from centres of excellence. OBJECTIVE: To report our initial experience with robot-assisted extended pelvic lymph node dissection (ePLND) using a standardized open template. PATIENTS AND METHODS: In total, 15 consecutive patients underwent robotic radical cystectomy at a single center by a single surgeon using a standard dissection template. Operating time, time to perform ePLND, pathological stage, estimated blood loss, length of hospital stay, number of nodes obtained and nodal positivity were assessed. Postoperative complications and re-admissions were reviewed. RESULTS: The mean (range) age and body mass index was 66 (46-87) years and 29 (22-43) kg/m2, respectively. The mean (range) operating time and ePLND time was 423 (300-506) min and 107 (66-160) min. Mean (range) estimated blood loss was 160 (50-500) mL. The mean (range) and median length of hospital stay were 3.4 (3-7) days and 3 days, respectively. The mean (range) nodal yield was 41.8 (18-67) nodes, with greater than 25 nodes in 13 patients. Three patients were found to have nodal positivity. Of the fifteen patients, four received neoadjuvant chemotherapy. Two patients were re-admitted for postoperative complications within 30 days. There were no complications directly resulting from the ePLND. CONCLUSIONS: Robot-assisted ePLND at the time of cystectomy can be safely and effectively performed on the robotic platform with comparable nodal yields to open series at centers of excellence for cystectomy. Nodal yields are likely to comprise a factor related to the effort of the surgeon, and not the method by which the lymphadenectomy is performed.

Endorectal magnetic resonance imaging has limited clinical ability to preoperatively predict pT3 prostate cancer.

OBJECTIVE: • To assess the clinical value of preoperative knowledge of the presence of extracapsular extension (ECE) or seminal vesicle invasion (SVI) in the planning for prostatectomy. MATERIALS AND METHODS: • An institutional database of 1161 robotic-assisted laparoscopic prostatectomies (RALP) performed by a single surgeon (D.B.S.) was queried for those who underwent endorectal coil magnetic resonance imaging (erMRI) before robotic-assisted laparoscopic prostatectomy. • erMRI reports were dichotomized into positive or negative and compared with the final histopathology. The erMRIs performed at academic centres were compared with those performed in non-academic settings. • A sub-group of high-risk patients was also analyzed for erMRI accuracy. RESULTS: • The 179 patients who underwent erMRI had significantly worse disease compared to the 982 patients without imaging. Of the 110 patients with histopathologically organ-confined disease, 81 (74%) were correctly diagnosed as such on erMRI, whereas 29 (26%) were felt to have cT3 disease and constituted false-positives. Among the 69 patients with pT3 disease, erMRI correctly predicted 30 (43%), whereas 39 (57%) were incorrectly considered organ-confined. • The overall sensitivity and specificity for diagnosing pT3 disease was 43% and 73%. • When stratified by pT3a and pT3b, the sensitivity and specificity of erMRI to accurately diagnose ECE is 33% and 81%, respectively. In evaluating SVI, erMRI has a sensitivity and specificity of 33% and 89%, respectively. The positive predictive value of erMRI to assess for ECE and SVI is 50% in both, with a negative predictive value of 61% and 63%, respectively. • erMRIs performed at academic centres compared to non-academic locations demonstrated similar rates of sensitivity at 67% vs 77% and specificity at 39% vs 54%, respectively (P = 0.33). CONCLUSIONS: • In the setting of the present study, which was designed to be more reflective of current practice patterns in the USA, erMRI has limited clinical value in preoperatively detecting ECE and SVI. • The accuracy of detecting T3 disease did not improve in academic centres or in high-risk patients.

'Mohs surgery of the prostate': the utility of in situ frozen section analysis during robotic prostatectomy.

OBJECTIVE • To evaluate a novel technique to lower positive surgical margin rates while preserving as much of the neurovascular bundles as possible during nerve-sparing robotic prostatectomy. MATERIALS AND METHODS • In situ intraoperative frozen section (IFS) was performed during robotic-assisted laparoscopic prostatectomy (RALP) when there was macroscopic concern for a positive margin or residual prostate tissue. • When IFS was positive, additional sections were taken from the same area until the IFS was negative, similar to the procedure of Mohs micrographic surgery. • Positive surgical margin and biochemical recurrence rates were compared between the patients who underwent IFS and those who did not. RESULTS • Of 970 patients consecutively undergoing RALP at a single institution, IFS was performed on 177 (18%). • Eleven patients (6%) had IFS positive for carcinoma, whereas another 25 (14%) had benign prostatic tissue in the IFS specimen. • IFS and non-IFS patients had similar pathological and nerve-sparing characteristics. • The IFS group had significantly lower rates of positive surgical margins, 7% vs 18% (P = 0.001) but similar rates of biochemical recurrence (5%) at a median follow-up of 11 months. CONCLUSIONS • In situ IFS is an effective way of reducing positive margins during RALP. • Twenty percent of patients who underwent IFS, representing 4% of the overall RALP population, had either malignant or benign prostate tissue removed from their prostatic fossa. • Although a reduction of biochemical recurrence was not demonstrated, the follow-up is short and a difference may become apparent as the data mature.

Is a return to baseline sexual function possible? An analysis of sexual function outcomes following laparoscopic radical prostatectomy.

OBJECTIVES: Outcome measures following radical prostatectomy are not standardized. Though excellent potency rates are widely reported, few studies address a return to baseline function. We analyze validated sexual health-related quality-of-life outcomes by a strict definition, a return to baseline function, and compare them to less stringent, yet more frequently referenced, categorical definitions of potency. METHODS: Patients undergoing laparoscopic radical prostatectomy from April 2001 to September 2007 completed the Expanded Prostate Cancer Index Composite (EPIC) questionnaire at baseline and 3, 6, 12, and 24 months postoperatively. We defined a return to baseline as a recovery to greater than one-half standard deviation of the studied population below the patient's own baseline (clinically detectable threshold). We compared these outcomes to a categorical definition of potency involving intercourse frequency. To limit confounders, we performed subset analyses of preoperatively potent men who received bilateral nerve preservation. Factors predictive of return to baseline function were assessed in multivariable analysis. RESULTS: A total of 568 patients met inclusion criteria. Mean age and follow-up were 57.2 years and 16.9 months, respectively. Using the categorical definition, 85% of preoperatively potent men with bilateral nerve preservation were "potent" at 24 months; however, only 27% returned to their baseline sexual function. In multivariable analyses baseline function, number of nerves spared, and age were independent predictors of a return to baseline function. CONCLUSION: While most preoperatively potent men who receive bilateral nerve preservation engage in intercourse postoperatively, few return to their baseline sexual function. We believe that these data provide context for the expectations of patients who elect extirpative therapy.

Reducing nocturia in the elderly: a randomized placebo-controlled trial of staggered furosemide and desmopressin.

AIMS: The purpose of this study was to investigate efficacy, safety, and impact on quality of sleep of staggered furosemide and desmopressin in the treatment of nocturia in the elderly. METHODS: Patients aged >60 years with nocturia at least two voids per night were screened for enrollment into the study. A 3-week dose-titration phase established the optimum desmopressin dose (0.1, 0.2, or 0.4 mg). After a 1-week "washout" period, patients who showed sufficient response during the dose-titration period were randomized to receive staggered furosemide and the optimal dose of desmopressin or placebo in a double-blind design for 3 weeks. Voiding diaries were assessed before and after the treatment. RESULTS: In all, 82 patients were randomized to either staggered furosemide and desmopressin (n=41) or placebo (n=41). In the study group, most patients reported a good response with both reduced nocturnal voids (3.5 vs. 2.0, P<0.01) and urine volume (919.6 ml vs. 584.2 ml, P<0.01). The mean duration of the first sleep period was improved by 70 min (133.6 vs. 203.2, P<0.01). Compared to placebo, staggered furosemide and desmopressin resulted in a significant reduction in the mean number of nocturnal voids (43% vs. 9%; P<0.01), nocturnal urine volume (37% vs. 5%; P<0.01), and increase in the mean duration of the first sleep period (52% vs. 19%, P<0.01). Adverse events were mild. CONCLUSIONS: Staggered furosemide and desmopressin provide an effective and well-tolerated treatment for nocturia in the elderly.

Combined robotic-assisted laparoscopic prostatectomy and laparoscopic hemicolectomy.

A 60-year-old man with prostatic adenocarcinoma and a synchronous tubulovillous adenomatous polyp of the colon underwent a successful robotic radical prostatectomy combined with a laparoscopic right hemicolectomy. We describe the initial report of this combined, minimally invasive procedure involving separate organ systems and surgical disciplines, and describe our technique.

Transition from laparoscopic to robotic partial nephrectomy: the learning curve for an experienced laparoscopic surgeon.

BACKGROUND: The complexity of laparoscopic partial nephrectomy (LPN) has prompted many laparoscopic surgeons to adopt robotic partial nephrectomy (RPN) for the treatment of small renal masses. We assessed the learning curve for an experienced laparoscopic surgeon during the transition from LPN to RPN. METHODS: We compared perioperative outcomes of the first 20 patients who underwent RPN to the last 18 patients who underwent LPN by the same surgeon (MAP). Surgical technique was consistent across platforms. The learning curve was defined as the number of cases required to consistently perform RPN with shorter average operative times (OT) and warm ischemia times (WIT), as compared to the last 18 LPN. A line of best fit aided graphical interpretation of the learning curve on a scatter diagram of OT versus procedure date. RESULTS: The 2 groups had comparable preoperative demographics and tumor histopathology. No patients in either group had a positive surgical margin. There was a downward trend in both OT and WIT during the RPN learning curve. After the first 5 RPN cases, the average OT reached the average OT of the last 18 LPN cases. The average OT of the first 5 RPN patients was 242.8 minutes, compared with the average OT of the last 15 RPN patients of 171.3 minutes (P=0.011). CONCLUSION: The transition from LPN to RPN is rapid in an experienced laparoscopic surgeon. There were no significant differences in WIT, estimated blood loss, or length of hospital stay between LPN and RPN. RPN achieved a similar OT as LPN after 5 procedures.

High body mass index does not affect outcomes following robotic assisted laparoscopic prostatectomy.

INTRODUCTION: Given the anatomic constraints of obese patients, concern exists as to whether robotic assisted laparoscopic prostatectomy (RALP) is appropriate in patients with higher body mass index (BMI). We reviewed a large RALP database to determine if clinical outcomes are related to BMI. METHODS: The records of patients who underwent a RALP from 2003-2009 were reviewed. BMI stratifications were concordant with the Centers for Disease Control (CDC) standards: > or = 30, > or = 25 and < 30, and < 25 were classified as obese, overweight, and normal weight, respectively. Baseline, perioperative, histopathologic, and functional outcome data were collected. RESULTS: A total of 1420 patients were identified and BMI information was available for 1112 patients. Median BMI in the three strata was 23.5 (n = 270), 27.3 (n = 600), and 32.1 (n = 242). There were no significant differences in preoperative prostate specific antigen (PSA), clinical staging, and preoperative Gleason scores. Operating time was 6 minutes longer in the obese (p < 0.001) and prostate weight was 8 g greater (p < 0.001). Other perioperative factors were similar, including: EBL, pathologic stage and Gleason score and rates of positive surgical margins. The overall incidence of postoperative complications was similar between the three groups. Biochemical recurrence rates were similar among all patients, although there was a trend toward increased recurrence in the obese (p = 0.09). Recovery of erectile function and continence was similar regardless of BMI. CONCLUSIONS: RALP is an effective approach to prostatectomy in obese patients as perioperative and functional outcomes are almost identical across BMI strata. This supports the continued utilization of RALP in obese and overweight men.

Robotic prostatectomy in a patient with hemophilia.

Given the rich blood supply to the prostate and the adjacent Santorini's plexus, radical prostatectomy is associated with significant blood loss even in patients with normal coagulation profiles. In patients with hemophilia, any surgical procedure carries a risk of significant hemorrhage due to a deficiency of factors in the coagulation cascade. For these reasons, hemophiliac patients have often been encouraged to undergo radiation or other forms of nonsurgical treatment for clinically localized prostate cancer. However, the decreased blood loss associated with a laparoscopic/robotic approach and appropriate perioperative factor transfusions can minimize the risk of hemorrhage during robotic-assisted radical prostatectomy. We present the case report of a successful robotic-assisted laparoscopic prostatectomy in a patient with mild hemophilia A, with an estimated blood loss for the procedure of 20 mL. We will focus on the perioperative management of the patient's factor replacement.

Combined robotic radical prostatectomy and robotic radical nephrectomy.

A 60-year-old man with prostatic adenocarcinoma and an enhancing left-sided renal mass underwent successful combined robotic radical prostatectomy and robotic radical nephrectomy. We describe the initial report of this combined robotic procedure to remove 2 synchronous urological malignancies and describe our technique. An analysis was conducted of the operating room and postanesthesia care unit charges of this procedure compared with the 2 procedures performed independently.

Effect of Weekly Specialized Surgeon-led Bedside Wound Care Teams on Pressure Ulcer Time-to-heal Outcomes: Results From a National Dataset of Long-term Care Facilities.

INTRODUCTION: Delayed healing of pressure ulcers (PUs) in long-term care facilities (LTCFs) is associated with increased morbidity and expense. OBJECTIVE: The authors hypothesize that guideline-based, weekly coordinated care using specialized wound care surgeon-led bedside teams (SLBTs) may improve PU time-to-heal (TTH) outcomes when compared with usual care (UC). MATERIALS AND METHODS: Using a deidentified United States nationwide database, the authors retrospectively compared TTH outcomes of PUs diagnosed in LTCFs treated by either weekly SLBTs or UC. The SLBTs included an external specialized wound care surgeon (with or without a physician assistant and nurse practitioner) collaborating with facility nurses. Usual care was defined as all patient encounters not known to incorporate this team process. Variables assessed included patient age, gender, and comorbidities. The primary outcome measure was TTH; the TTH outcomes then were compared graphically and statistically between groups. Statistical significance was double-sided P ⟨ .05. RESULTS: In 2014, there were 39 459 consecutive PUs treated by UC and 5985 by SLBTs. The 5985 SLBT wounds originated from 3435 patients in 10 states and all geographic regions (mean age, 76.6 years; 55.9% female; 42.8% with hypertension; 23.7% with diabetes). The mean TTH for wounds managed by SLBTs was 47.5 days (median, 21 days) versus 69.0 days (median, 28 days) for wounds managed by UC, corresponding to an absolute TTH decrease of 21.5 days in wounds managed by SLBTs versus UC. Wounds managed by SLBTs also were significantly more likely to heal in less than 28 days (P ⟨ .0001). CONCLUSIONS: Pressure ulcers managed by coordinated nursing and weekly SLBTs appear to heal significantly faster than wounds managed by UC. Further studies are required to confirm these hypothesis-generating results.

Histologic Changes in Prostate Cancer Detected Subsequent to the 2012 United States Preventive Services Task Force (USPSTF) Prostate Cancer Screening Recommendation.

We report changes in the histopathology of prostate cancer diagnosed in a large urology group practice after the final United States Preventive Services Task Force (USPSTF) Grade D recommendation against prostate-specific antigen screening. All prostate biopsies performed from 2011 through 2015 in a large urology group practice were retrospectively reviewed; 2012 was excluded as a transition year. The changes in biopsy data in years following the USPSTF decision (2013-2015) were then compared with baseline (2011). A total of 10,944 biopsies were evaluated during the study period. Positive biopsy rates rose from 39.1% at baseline to 45.2% in 2015 (P < 0.01) with a marked shift toward more aggressive cancer throughout the study period. The absolute number of patients presenting with Gleason Grade Group 4 or 5 increased from 155/year at baseline to 231, 297, and 285 in 2013, 2014, and 2015, respectively (P < 0.05), unrelated to age or racial changes over time. Black men represented 16% of the cohort. Since the USPSTF recommendation against prostate cancer screening, trends toward a substantial upward grade migration and increased volume of cancers were noted in a cohort of nearly 11,000 patients in a real-world clinical practice. Additionally, continuing reductions in cancer detection in the United States may exacerbate these trends.