A contemporary comparison of laparoscopic versus open partial nephrectomy for renal cell carcinoma.

PURPOSE: To analyze surgical and oncologic outcomes of patients undergoing open partial nephrectomy (OPN) versus laparoscopic partial nephrectomy (LPN) for treatment of renal cell carcinoma (RCC). METHODS: We retrospectively investigated our institutional RCC database for patients who underwent PN for RCC from 1997 to 2018. Decision for technique was at the discretion of the operating urologist, following practice patterns and training history. Outcomes analyzed included pre/peri/post-operative parameters, pathologic outcomes, and disease recurrence rates. RESULTS: 1088 patients underwent PN from 1997 to 2018. After exclusionary criteria, 631 patients who underwent 647 unique PNs for a total of 162 OPN and 485 LPN remained. Baseline, pre-op, and pathologic characteristics were not statistically different. Surgical time was lower in laparoscopic cases [185 vs. 205 min] (p = 0.013). Margin involvement was not statistically different; LPN had lower estimated blood loss (EBL) [150 vs. 250 mL] (p < 0.001) and longer ischemia time [21 vs. 19 min] (p = 0.005). LPN had shorter length of stay [2 vs. 4 days] (p < 0.001), fewer overall complications (p < 0.001), and no significant difference in high-grade complications [2.89 vs. 4.32%] (p = 0.379). Fewer LPN patients developed metastases [1.65 vs. 4.94%] (p = 0.0499). Local recurrence rates were not statistically different [1.24 vs. 3.09%] (p = 0.193). Renal function was equivalent between cohorts post-operatively. CONCLUSION: Long-term oncologic outcomes were not significantly different between LPN versus OPN, with no statistical difference in patient and tumor characteristics. LPN was associated with lower EBL, shorter length of stay, and lower overall complication risk. Renal function was not significantly different between cohorts.

Complications and Outcomes of Salvage Cystectomy after Trimodality Therapy.

PURPOSE: Salvage cystectomy is required for some patients with intravesical recurrence after trimodality therapy. We compared postoperative outcomes between salvage cystectomy post-trimodality therapy, primary cystectomy and primary cystectomy with prior history of nontrimodality therapy abdominal or pelvic radiotherapy. MATERIALS AND METHODS: We included 265 patients who underwent radical cystectomy at Massachusetts General Hospital for cT1-T4 bladder cancer between 2003 and 2013. Patients were grouped as salvage cystectomy post-trimodality therapy, primary cystectomy or primary cystectomy with prior history of nontrimodality therapy abdominal or pelvic radiotherapy. Early (≤90 days) and late (>90 days) complications were compared. Disease-specific survival and overall survival were calculated using a Cox regression model, and adjusted survival curves were generated. RESULTS: The median followup from the time of cystectomy was 65.5 months. There was no difference in intraoperative and early complications between the groups. The detection of late complications was higher in salvage cystectomy post-trimodality therapy compared to primary cystectomy and primary cystectomy with prior history of nontrimodality therapy abdominal or pelvic radiotherapy (p=0.03). In multivariable Cox regression analysis, salvage cystectomy post-trimodality therapy was associated with a higher incidence of any late (HR 2.3, p=0.02) and major late complications (HR 2.1, p <0.05). There was no difference in disease-specific survival (p=0.8) or overall survival (p=0.9) between the groups. CONCLUSIONS: Salvage cystectomy post-trimodality therapy for intravesical recurrence post-trimodality therapy has an intraoperative and early complication rate comparable to primary cystectomy and primary cystectomy with prior history of nontrimodality therapy abdominal or pelvic radiotherapy. Salvage cystectomy post-trimodality therapy is associated with a higher risk of overall and major late complications than primary cystectomy. The disease-specific survival and overall survival of patients who require salvage cystectomy post-trimodality therapy are comparable to both groups.

Penis Transplantation: First US Experience.

OBJECTIVE: We describe the first successful penis transplant in the United States in a patient with a history of subtotal penectomy for penile cancer. BACKGROUND: Penis transplantation represents a new paradigm in restoring anatomic appearance, urine conduit, and sexual function after genitourinary tissue loss. To date, only 2 penis transplants have been performed worldwide. METHODS: After institutional review board approval, extensive medical, surgical, and radiological evaluations of the patient were performed. His candidacy was reviewed by a multidisciplinary team of surgeons, physicians, psychiatrists, social workers, and nurse coordinators. After appropriate donor identification and recipient induction with antithymocyte globulin, allograft procurement and recipient preparation took place concurrently. Anastomoses of the urethra, corpora, cavernosal and dorsal arteries, dorsal vein, and dorsal nerves were performed, and also inclusion of a donor skin pedicle as the composite allograft. Maintenance immunosuppression consisted of mycophenolate mofetil, tacrolimus, and methylprednisolone. RESULTS: Intraoperative, the allograft had excellent capillary refill and strong Doppler signals after revascularization. Operative reinterventions on postoperative days (PODs) 2 and 13 were required for hematoma evacuation and skin eschar debridement. At 3 weeks, no anastomotic leaks were detected on urethrogram, and the catheter was removed. Steroid resistant-rejection developed on POD 28 (Banff I), progressed by POD 32 (Banff III), and required a repeat course of methylprednisolone and antithymocyte globulin. At 7 months, the patient has recovered partial sensation of the penile shaft and has spontaneous penile tumescence. Our patient reports increased overall health satisfaction, dramatic improvement of self-image, and optimism for the future. CONCLUSIONS: We have shown that it is feasible to perform penile transplantation with excellent results. Furthermore, this experience demonstrates that penile transplantation can be successfully performed with conventional immunosuppression. We propose that our successful penile transplantation pilot experience represents a proof of concept for an evolution in reconstructive transplantation.

Patterns of Recurrence in Upper Tract Transitional Cell Carcinoma: Imaging Surveillance.

OBJECTIVE: The objective of our study was to evaluate recurrence patterns of upper tract transitional cell carcinomas (UT-TCCs) after radical nephroureterectomy (RNU). MATERIALS AND METHODS: Sixty-eight patients (mean age, 78 years; 34 men and 34 women) with UT-TCC after having undergone RNU from 2001 to 2008 were included in this study. Radiologic examinations and clinical notes were reviewed to record tumor location, tumor morphology, histologic T stages and grades, lymphovascular invasion (LVI) status, and surgical procedures. Five-year imaging and clinical follow-up (2001-2013) findings were noted at 3, 6, 12, 18, 24, 36, 48, 60, and more than 60 months after RNU for recurrence pattern and tumor-free survival. Kaplan-Meier survival curves and Cox regression models were used to assess tumor-free survival and to perform a multivariate analysis. RESULTS: Forty-one postoperative recurrences were noted in 20 patients. The mean time to relapse was 16 months, and time to relapse ranged from 1 to 66 months. Tumor site (multifocal lesions involving both renal collecting system and ureter), tumor morphology (mass), T stage (muscle invasion [T2-T4]), histologic grade (grade 3), and the presence of LVI were identified as risk factors for postoperative recurrence in UT-TCC. T stage was the only independent risk factor. CONCLUSION: Urinary tract, lymph node, liver, bone, and lung recurrences were common in patients with UT-TCC and were detected most frequently at 3-24 months. Tumor site, tumor morphology, T stage, grade, and LVI status were associated with recurrence after RNU. T stage was the only independent predictor of tumor-free survival. Close surveillance for extra-urinary tract recurrences in high-risk groups and a shorter-interval follow-up of the urinary tract in low-risk patients with adjuvant chemotherapy are recommended. Identifying recurrence patterns in UT-TCC can aid in planning an effective tailored imaging surveillance strategy.

Anatomical Location of the Vesical Branches of the Inferior Hypogastric Plexus in Human Cadavers.

We have demonstrated in canines that somatic nerve transfer to vesical branches of the inferior hypogastric plexus (IHP) can be used for bladder reinnervation after spinal root injury. Yet, the complex anatomy of the IHP hinders the clinical application of this repair strategy. Here, using human cadavers, we clarify the spatial relationships of the vesical branches of the IHP and nearby pelvic ganglia, with the ureteral orifice of the bladder. Forty-four pelvic regions were examined in 30 human cadavers. Gross post-mortem and intra-operative approaches (open anterior abdominal, manual laparoscopic, and robot-assisted) were used. Nerve branch distances and diameters were measured after thorough visual inspection and gentle dissection, so as to not distort tissue. The IHP had between 1 to 4 vesical branches (2.33 ± 0.72, mean ± SD) with average diameters of 0.51 ± 0.06 mm. Vesical branches from the IHP arose from a grossly visible pelvic ganglion in 93% of cases (confirmed histologically). The pelvic ganglion was typically located 7.11 ± 6.11 mm posterolateral to the ureteral orifice in 69% of specimens. With this in-depth characterization, vesical branches from the IHP can be safely located both posterolateral to the ureteral orifice and emanating from a more proximal ganglionic enlargement during surgical procedures.

Restoring bladder function using motor and sensory nerve transfers: a cadaveric feasibility study.

OBJECTIVE: Bladder dysfunction after nerve injury has a variable presentation, and extent of injury determines whether the bladder is spastic or atonic. The authors have proposed a series of 3 nerve transfers for functional innervation of the detrusor muscle and external urethral sphincter, along with sensory innervation to the genital dermatome. These transfers are applicable to only cases with low spinal segment injuries (sacral nerve root function is lost) and largely preserved lumbar function. Transfer of the posterior branch of the obturator nerve to the vesical branch of the pelvic nerve provides a feasible mechanism for patients to initiate detrusor contraction by thigh adduction. External urethra innervation (motor and sensory) may be accomplished by transfer of the vastus medialis nerve to the pudendal nerve. The sensory component of the pudendal nerve to the genitalia may be further enhanced by transfer of the saphenous nerve (sensory) to the pudendal nerve. The main limitations of coapting the nerve donors to their intrapelvic targets are the bifurcation or arborization points of the parent nerve. To ensure that the donor nerves had sufficient length and diameter, the authors sought to measure these parameters. METHODS: Twenty-six pelvic and anterior thigh regions were dissected in 13 female cadavers. After the graft and donor sites were clearly exposed and the branches identified, the donor nerves were cut at suitable distal sites and then moved into the pelvis for tensionless anastomosis. Diameters were measured with calipers. RESULTS: The obturator nerve was bifurcated a mean ± SD (range) of 5.5 ± 1.7 (2.0-9.0) cm proximal to the entrance of the obturator foramen. In every cadaver, the authors were able to bring the posterior division of the obturator nerve to the vesical branch of the pelvic nerve (located internal to the ischial spine) in a tensionless manner with an excess obturator nerve length of 2.0 ± 1.2 (0.0-5.0) cm. The distance between the femoral nerve arborization and the anterior superior iliac spine was 9.3 ± 1.8 (6.5-15.0) cm, and the distance from the femoral arborization to the ischial spine was 12.9 ± 1.4 (10.0-16.0) cm. Diameters were similar between donor and recipient nerves. CONCLUSIONS: The chosen donor nerves were long enough and of sufficient caliber for the proposed nerve transfers and tensionless anastomosis.

Complications and long-term results of salvage cystectomy after failed bladder sparing therapy for muscle invasive bladder cancer.

PURPOSE: Radical cystectomy has been the standard treatment for muscle invasive bladder cancer. Combined modality therapy involving transurethral bladder tumor resection, external beam radiation and chemotherapy is an effective alternative to cystectomy in selected patients. Salvage cystectomy is reserved for those in whom combined modality therapy fails. We characterized complications associated with salvage cystectomy. MATERIALS AND METHODS: From 1986 to 2007 of 348 patients undergoing bladder sparing therapy 102 (29%) underwent salvage cystectomy, 91 of whom were treated at Massachusetts General Hospital after receiving combined modality therapy for T2-T4aNxM0 bladder cancer. Patients underwent transurethral bladder tumor resection followed by chemoradiation (40 Gy). Early assessment was performed by cystoscopy/re-biopsy. Patients with complete response continued with consolidation chemoradiation (total dose 64 Gy). Immediate salvage cystectomy (50 of 91) was performed for persistent disease, while delayed salvage cystectomy (41 of 91) was performed for an invasive recurrence. Complications were classified using the Clavien system. RESULTS: Median patient age was 69.4 years (range 27.5 to 88.9) and median living patient followup was 12 years (range 0 to 23). Of the patients 99% (90 of 91) underwent ileal diversion. Complications of any grade within 90 days occurred in 69% (63 of 91) of patients and 16% (15 of 91) experienced major complications within 90 days. Of the patients 21% (19 of 91) required hospital readmission within 90 days. The 90-day mortality rate was 2.2% (2 of 91). Significant cardiovascular/hematological complications (pulmonary embolism, myocardial infarction, deep vein thrombosis, transfusion) within 90 days were more common in the immediate than in the delayed cystectomy group (37% vs 15%, p = 0.02). Tissue healing complications (fascial dehiscence, wound infection, ureteral stricture, anastomotic stricture, stoma/loop revisions) were more common in the delayed than in the immediate cystectomy group (35% vs 12%, p = 0.05). CONCLUSIONS: Salvage cystectomy is associated with acceptable morbidity, although complication rates are slightly higher than for other cystectomy series. Immediate cystectomies have more cardiovascular/hematological complications while delayed cystectomies have more tissue healing complications.

An electroencephalogram biomarker of fentanyl drug effects.

Opioid drugs influence multiple brain circuits in parallel to produce analgesia as well as side effects, including respiratory depression. At present, we do not have real-time clinical biomarkers of these brain effects. Here, we describe the results of an experiment to characterize the electroencephalographic signatures of fentanyl in humans. We find that increasing concentrations of fentanyl induce a frontal theta band (4 to 8 Hz) signature distinct from slow-delta oscillations related to sleep and sedation. We also report that respiratory depression, quantified by decline in an index of instantaneous minute ventilation, occurs at ≈1700-fold lower concentrations than those that produce sedation as measured by reaction time. The electroencephalogram biomarker we describe could facilitate real-time monitoring of opioid drug effects and enable more precise and personalized opioid administration.

Evaluation of In-Office MRI/US Fusion Transperineal Prostate Biopsy via Free-hand Device during Routine Clinical Practice.

OBJECTIVES: To describe our recent experience with in-office transperineal prostate biopsy, including the adoption of software-assisted MRI/US fusion technology. Technological improvements have recently allowed transperineal biopsy to be effectively integrated into outpatient practices with negligible risk of infection. METHODS: We retrospectively reviewed a cohort of men undergoing transperineal prostate biopsy from 2018-2020, at a single institution. We compared this to another cohort of men undergoing transrectal fusion biopsy from 2014-2018, matched to the first cohort based on age, PSA, and presence of prostate cancer diagnosis prior to biopsy. All patients underwent systematic transperineal templated biopsies in addition to fusion biopsies of MRI-visible lesions. Baseline characteristics, MRI findings, biopsy results, and complications were analyzed and compared between the 2 groups. RESULTS: One-hundred and thirty men underwent transperineal prostate biopsy, and 130 men underwent transrectal fusion biopsy. Of those who underwent transperineal biopsy, 30% underwent fusion biopsy while all men with the transrectal biopsy underwent fusion biopsy. Men who underwent transperineal vs transrectal biopsy demonstrated lower infection rates (0% vs 0.8%, P = .31) with fewer prophylactic antibiotics prescribed at provider's discretion (48% vs 100%), yet higher total post-biopsy complication rates (6.1% vs 0.8%, P = .036). CONCLUSION: Our initial experiences with transperineal prostate biopsy confirm prior findings demonstrating feasibility in outpatient urologic practice without infectious complication. Software-assisted MRI/US fusion technology can be successfully integrated with transperineal biopsies to target suspicious lesions. Higher rates of non-infectious complications were observed compared with transrectal biopsy. Further analysis is needed to determine whether risk profiles improve over the learning curve of this newly implemented approach.

A prospective study of symptom distress and return to baseline function after open versus laparoscopic radical prostatectomy.

PURPOSE: We assessed and compared outcomes following open and laparoscopic radical prostatectomy. MATERIALS AND METHODS: Patients who were scheduled to undergo open or laparoscopic radical prostatectomy were enrolled in the study and followed prospectively. Before surgery the patients were administered a multi-item validated questionnaire, and were followed by telephone and with mail questionnaires periodically for 12 months. Complications were recorded from chart review and compared. Symptom distress and return to baseline for various parameters were compared between the 2 groups. RESULTS: Of the patients 102 who underwent open prostatectomy and 104 treated with laparoscopic prostatectomy were enrolled in the study. At 1 year 90% in the open and 91% in the laparoscopic group returned the questionnaire. Symptom distress between the 2 groups did not differ at any time during followup. There was no significant difference in return to baseline at 1 year for continence, erectile function or physical function. Of the patients 95% had a return to baseline physical function, approximately 90% do not wear a pad and approximately 50% returned to baseline erectile function with or without phosphodiesterase type 5 inhibitors at 1 year. Although complications were few there was a significant difference in the number for laparoscopic vs open prostatectomy with a slightly higher rate of hematuria and lymphocele formation in the laparoscopic group. Cancer control at 1 year was excellent in both groups. CONCLUSIONS: Radical prostatectomy is an effective form of therapy for patients with clinically localized cancer of the prostate. The open and laparoscopic techniques have similar functional outcomes, and these data provide patients a realistic view of what to expect following these 2 methods of radical prostatectomy.

Colovesical fistula repair: is early Foley catheter removal safe?

BACKGROUND: Colovesical fistula (CVF) are the most common occurring fistulae secondary to diverticulitis. Review of the literature reveals great variability in postoperative Foley catheter management, as well as the role of a cystogram. The purpose of this study was to review our experience in early vs. late removal of the Foley catheter after CVF repair secondary to diverticulitis. Our hypothesis was that early Foley catheter removal is not associated with increased complications, and postoperative cystogram is of low value. METHODS: This is a retrospective study (January 2002-March 2008) of all patients with a diagnosis of CVF secondary to diverticulitis, who were treated with a sigmoidectomy and takedown of the fistula. Hospital records were reviewed and demographics, days to Foley removal, performance of cystogram, type of repair, complications, and comorbidities were recorded. Patients were separated into two groups according to early or late Foley catheter removal. Removal of the Foley catheter in < or = 7 d was considered early, and removal in >7 d was considered late. RESULTS: Thirty-two patients were identified, with a mean age of 65.2 y (42-91). Mean duration of Foley catheter stay was 15.6 d (3-42). Six patients had early postoperative Foley catheter removal and 26 patients had late Foley catheter removal. Four patients had complex bladder repair, and they all had late Foley catheter removal. From the 28 patients with simple bladder repair, six had early removal and 22 had late removal. Patients with early Foley catheter removal did not have significant complications compared with patients with late Foley catheter removal. Eleven patients got a cystogram postoperatively to detect possible bladder leaks. All cystograms performed were negative. CONCLUSIONS: Patients with a diagnosis of CVF secondary to diverticulitis may have their Foley catheter removed in 7 d without any increased complications. The role of the cystogram is unclear; however, no value was added in simple bladder repairs.

Epidural Anesthesia to Facilitate Organ Blood Flow During the First Penile Transplantation in the United States: A Case Report.

Regional anesthesia has been used to help create local sympathectomy and improve blood flow in plastic surgery procedures involving tissue grafts and flaps. However, anesthetic techniques that reduce systemic vascular resistance must be used with caution in patients with aortic stenosis (AS). Combined neuraxial and general anesthesia with careful titration of the local anesthetic dose can be a safe approach for patients with AS undergoing microvascular procedures. We present the anesthetic management of the first North American penile transplant, on an obese patient with moderate AS.

An RNA-Based Digital Circulating Tumor Cell Signature Is Predictive of Drug Response and Early Dissemination in Prostate Cancer.

Blood-based biomarkers are critical in metastatic prostate cancer, where characteristic bone metastases are not readily sampled, and they may enable risk stratification in localized disease. We established a sensitive and high-throughput strategy for analyzing prostate circulating tumor cells (CTC) using microfluidic cell enrichment followed by digital quantitation of prostate-derived transcripts. In a prospective study of 27 patients with metastatic castration-resistant prostate cancer treated with first-line abiraterone, pretreatment elevation of the digital CTCM score identifies a high-risk population with poor overall survival (HR = 6.0; P = 0.01) and short radiographic progression-free survival (HR = 3.2; P = 0.046). Expression of HOXB13 in CTCs identifies 6 of 6 patients with ≤12-month survival, with a subset also expressing the ARV7 splice variant. In a second cohort of 34 men with localized prostate cancer, an elevated preoperative CTCL score predicts microscopic dissemination to seminal vesicles and/or lymph nodes (P < 0.001). Thus, digital quantitation of CTC-specific transcripts enables noninvasive monitoring that may guide treatment selection in both metastatic and localized prostate cancer.Significance: There is an unmet need for biomarkers to guide prostate cancer therapies, for curative treatment of localized cancer and for application of molecularly targeted agents in metastatic disease. Digital quantitation of prostate CTC-derived transcripts in blood specimens is predictive of abiraterone response in metastatic cancer and of early dissemination in localized cancer. Cancer Discov; 8(3); 288-303. ©2018 AACR.See related commentary by Heitzer and Speicher, p. 269This article is highlighted in the In This Issue feature, p. 253.

Risk Factors for Disease Progression After Postprostatectomy Salvage Radiation: Long-term Results of a Single-institution Experience.

BACKGROUND: Salvage radiotherapy (SRT) has been successfully used for recurrent prostate cancer after radical prostatectomy; however, the optimal timing of SRT remains controversial. Our objective was to identify the risk factors for disease progression after SRT, with a focus on the pre-SRT prostate-specific antigen (PSA) levels in the modern era of PSA testing. PATIENTS AND METHODS: We performed a retrospective review of 551 consecutive patients who had undergone postradical prostatectomy SRT for recurrent prostate cancer from 2000 to 2013. The exclusion criteria were hormonal therapy before or concurrent with SRT, adjuvant RT, distant metastases, and missing data. Disease progression was defined as a repeat PSA level of ≥ 0.2 ng/mL greater than the post-SRT nadir, a continued increase in the PSA level despite SRT, initiation of systemic therapy, local recurrence, nodal failure, and/or distant metastases. Univariate and multivariable Cox regression analysis were performed to identify the predictors of disease progression. Secondarily, PSA kinetics were evaluated in the model and compared using the Akaike information criterion. RESULTS: Of the 551 patients, 307 underwent SRT, of whom 134 experienced subsequent disease progression. The median interval to recurrence was 6.03 years (95% confidence interval, 3.74-8.36 years). On multivariable analysis, Gleason score, T stage, positive surgical margins, and pre-SRT PSA level were associated with progression; PSA kinetics did not independently predict for progression. When the pre-SRT PSA level was stratified (≤ 0.30, 0.31-0.50, 0.51-1.00, and > 1 ng/mL), incremental elevations were associated with an increased risk of disease progression. CONCLUSION: Multiple factors predict for progression after SRT. These risk factors could help identify those who would derive the greatest benefit from additional systemic treatment. The findings of the present study also support initiation of early SRT, irrespective of the PSA kinetics.

Long-term results of adjuvant versus early salvage postprostatectomy radiation: A large single-institutional experience.

PURPOSE: The purpose of this study was to evaluate freedom from biochemical failure (FFBF), freedom from androgen deprivation therapy (FFADT), freedom from distant metastases (FFDM), and overall survival (OS) after adjuvant radiation therapy (ART) versus early salvage radiation therapy (ESRT) in men with prostate cancer and adverse pathologic features (pT3 and/or positive surgical margins). METHODS AND MATERIALS: Of 718 patients consecutively treated with postoperative radiation therapy (RT) for prostate cancer between 1992 and 2013, we retrospectively identified 171 men receiving ART and 230 receiving ESRT (RT delivered at a prostate-specific antigen level ≤0.5 ng/mL) who had adverse pathologic features. Postirradiation FFBF (BF was defined as prostate-specific antigen level rise to ≥0.2 ng/mL), FFADT, FFDM, and OS were compared using Kaplan-Meier and Cox regression methods. Propensity score (PS)-matching was performed to estimate treatment effects while accounting for covariates predicting treatment allocation. RESULTS: Median follow-up was 7.4 and 8.0 years for patients treated with ART and ESRT, respectively. Ten-year FFBF (69% vs 56%, P = .003) and 10-year FFADT (88% vs 81%, P = .046) rates were higher after ART; however, FFDM and OS did not significantly differ. After PS-matching, ART was associated with improved FFBF (P < .0001), FFADT (P = .0001), and FFDM (P = .02). Findings were confirmed in multivariable analyses in unmatched and PS-matched cohorts. Sensitivity analyses showed that FFBF benefit associated with ART lost statistical significance only after 38% of ART patients were assumed to have been cured by surgery and excluded from the model. This corresponds to the upper bound of patients with adverse pathologic features who did not recur after observation in prior randomized trials. CONCLUSIONS: Postoperative RT confers excellent long-term cancer control. These results suggest ART may be associated with improved FFBF, FFADT, and FFDM, but comparable OS. Given the retrospective study design, these findings should be interpreted with caution. Optimal timing of postoperative RT further awaits results of ongoing trials.

Patient-reported Functional Outcomes Following Open, Laparoscopic, and Robotic Assisted Radical Prostatectomy Performed by High-volume Surgeons at High-volume Hospitals.

BACKGROUND: Functional outcomes following radical prostatectomy (RP) have received increased focus with dissemination of minimally invasive approaches. OBJECTIVE: To examine contemporary patient-reported functional outcomes following open RP. (ORP), laparoscopic RP, (LRP), and robotic assisted RP (RARP) performed by high-volume surgeons at high-volume hospitals. DESIGN, SETTINGS, AND PARTICIPANTS: This was a retrospective cohort study of 1686 men with cT1-cT2 prostate cancer treated with ORP (n=441), LRP (n=156), or RARP (n=1089) by high-volume surgeons (annual volume ≥25 cases) at two academic centers from 2009 to 2012. Surveys containing the Expanded Prostate Cancer Index Composite urinary and sexual domains were administered at a median of 30.5 mo postoperatively. INTERVENTIONS: ORP, LRP, and RARP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Bother with overall urinary and sexual function was examined and stratified by surgical technique. Logistic regression models evaluated the associations of clinicopathologic features with survey responses. RESULTS AND LIMITATIONS: In total, 6.4% of men reported a moderate or big problem with overall urinary function (ORP 5.8%, LRP 5.1%, RARP 6.8%; p=0.62), whereas 37.3% reported a moderate or big problem with overall sexual function (ORP 37.2%, LRP 36.1%, RARP 37.5%; p=0.95). On multivariable analysis, older age at surgery (odds ratio [OR]: 1.08; p<0.0001) was associated with overall urinary bother, whereas older age at surgery (OR: 1.03; p=0.005), preoperative erectile dysfunction treatment (OR: 2.22; p<0.0001), greater prostate volume (OR: 1.01; p=0.02), and RP Gleason score (7 vs 6: OR: 0.96; p=0.004; 8-10 vs 6: OR: 2.25; p=0.0006) were associated with overall sexual bother. Surgical technique was not associated with either functional outcome. Limitations included selection bias and a retrospective design. CONCLUSIONS: In this study of high-volume surgeons at high-volume hospitals, patients reported excellent functional outcomes independent of surgical technique. These results have implications for patient counseling. PATIENT SUMMARY: In this study of high-volume surgeons at high-volume hospitals, patients reported excellent outcomes for urinary and sexual function following radical prostatectomy regardless of surgical technique.