Association of patients' sex with treatment outcomes after intravesical bacillus Calmette-Guérin immunotherapy for T1G3/HG bladder cancer.

PURPOSE: To investigate the association of patients' sex with recurrence and disease progression in patients treated with intravesical bacillus Calmette-Guérin (BCG) for T1G3/HG urinary bladder cancer (UBC). MATERIALS AND METHODS: We analyzed the data of 2635 patients treated with adjuvant intravesical BCG for T1 UBC between 1984 and 2019. We accounted for missing data using multiple imputations and adjusted for covariate imbalance between males and females using inverse probability weighting (IPW). Crude and IPW-adjusted Cox regression analyses were used to estimate the hazard ratios (HR) with their 95% confidence intervals (CI) for the association of patients' sex with HG-recurrence and disease progression. RESULTS: A total of 2170 (82%) males and 465 (18%) females were available for analysis. Overall, 1090 (50%) males and 244 (52%) females experienced recurrence, and 391 (18%) males and 104 (22%) females experienced disease progression. On IPW-adjusted Cox regression analyses, female sex was associated with disease progression (HR 1.25, 95%CI 1.01-1.56, p = 0.04) but not with recurrence (HR 1.06, 95%CI 0.92-1.22, p = 0.41). A total of 1056 patients were treated with adequate BCG. In these patients, on IPW-adjusted Cox regression analyses, patients' sex was not associated with recurrence (HR 0.99, 95%CI 0.80-1.24, p = 0.96), HG-recurrence (HR 1.00, 95%CI 0.78-1.29, p = 0.99) or disease progression (HR 1.12, 95%CI 0.78-1.60, p = 0.55). CONCLUSION: Our analysis generates the hypothesis of a differential response to BCG between males and females if not adequately treated. Further studies should focus on sex-based differences in innate and adaptive immune system and their association with BCG response.

Irreversible Electroporation for the Ablation of Prostate Cancer.

PURPOSE OF REVIEW: Although still considered experimental, focal irreversible electroporation (IRE) as a primary treatment for prostate cancer (PCa) is considered one of the most promising ablative technologies for focal therapy. This review provides a description of the principle of IRE for the treatment of PCa, combined with an overview of the recent research. RECENT FINDINGS: It has been almost a decade since the first human studies of focal IRE for PCa were trying to demonstrate its feasibility and safety, and recently new data are emerging regarding the functional and oncological outcomes. It was shown that the expected ablation efficacy of IRE is dependent on increased safety margins of > 9 mm and an uninterrupted IRE procedure, but these findings need further investigation in larger cohorts and randomized control trials (RCT). Recent data from larger cohorts with a longer follow-up of up to 12 months prove that focal IRE as primary treatment for localized PCa is indeed safe, has effective short-term oncological control in selected patients, and it has good functional outcomes by retaining urinary function and causing only mild erectile dysfunction.

Serum testosterone as a biomarker for second prostatic biopsy in men with negative first biopsy for prostatic cancer and PSA>4ng/mL, or with PIN biopsy result

Abstract Introduction: Data from animal, clinical and prevention studies support the role of androgens in prostate cancer growth, proliferation and progression. Results of serum based epidemiologic studies in humans, however, have been inconclusive. The present study aims to define whether serum testosterone can be used as a predictor of a positive second biopsy in males considered for re-biopsy. Material and Methods: The study included 320 men who underwent a prostatic biopsy in our department from October 2011 until June 2012. Total testosterone, free testosterone, bioavailable testosterone and prostate pathology were evaluated in all cases. Patients undergoing a second biopsy were identified and biopsy results were statistically analyzed. Results: Forty men (12.5%) were assessed with a second biopsy. The diagnosis of the second biopsy was High Grade Intraepithelial Neoplasia in 14 patients (35%) and Prostate Cancer in 12 patients (30%). The comparison of prostatic volume, total testosterone, sex hormone binding globulin, free testosterone, bioavailable testosterone and albumin showed that patients with cancer of the prostate had significantly greater levels of free testosterone (p=0.043) and bioavailable T (p=0.049). Conclusion: In our study, higher free testosterone and bioavailable testosterone levels were associated with a cancer diagnosis at re-biopsy. Our results indicate a possible role for free and bioavailable testosterone in predicting the presence of prostate cancer in patients considered for re-biopsy.

The efficacy of BCG TICE and BCG Connaught in a cohort of 2,099 patients with T1G3 non-muscle-invasive bladder cancer.

BACKGROUND: Potential differences in efficacy of different bacillus Calmette-Guérin (BCG) strains are of importance for daily practice, especially in the era of BCG shortage. OBJECTIVE: To retrospectively compare the outcome with BCG Connaught and BCG TICE in a large study cohort of pT1 high-grade non-muscle-invasive bladder cancer patients. DESIGN, SETTING, AND PARTICIPANTS: Individual patient data were collected for 2,451 patients with primary T1G3 tumors from 23 centers who were treated with BCG for the first time between 1990 and 2011. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Using Cox multivariable regression and adjusting for the most important prognostic factors in this nonrandomized comparison, BCG Connaught and TICE were compared for time to recurrence, progression, and the duration of cancer specific survival and overall survival. RESULTS AND LIMITATIONS: Information on the BCG strain was available for 2,099 patients: 957 on Connaught and 1,142 on TICE. Overall, 765 (36%) patients received some form of maintenance BCG, 560 (59%) on Connaught and 205 (18%) on TICE. Without maintenance, Connaught was more effective than TICE only for the time to first recurrence (hazard ratio [HR] = 1.48; 95% CI: 1.20-1.82; P<0.001). With maintenance, TICE was more effective than Connaught for the time to first recurrence (HR = 0.66; 95% CI: 0.47-0.93; P = 0.019) with a trend for cancer specific survival (HR = 0.36; 95% CI: 0.14-0.92; P = 0.033). For time to progression and overall survival, Connaught and TICE had a similar efficacy. Compared to no maintenance therapy, maintenance BCG significantly reduced the risk of recurrence, progression and death, both overall, and disease specific, for TICE, but not for Connaught. CONCLUSIONS: We found that BCG Connaught results in a lower recurrence rate as compared with BCG TICE when no maintenance is used. However, the opposite is true when maintenance is given. PATIENT SUMMARY: As there is currently a BCG shortage, information on the efficacy of different BCG strains is important. In this nonrandomized retrospective comparison in over 2,000 patients, we found that BCG Connaught reduces the recurrence rate compared to BCG TICE when no maintenance is used, but the opposite is true when maintenance is given.

Serum testosterone as a biomarker for second prostatic biopsy in men with negative first biopsy for prostatic cancer and PSA>4ng/mL, or with PIN biopsy result.

INTRODUCTION: Data from animal, clinical and prevention studies support the role of androgens in prostate cancer growth, proliferation and progression. Results of serum based epidemiologic studies in humans, however, have been inconclusive. The present study aims to define whether serum testosterone can be used as a predictor of a posi¬tive second biopsy in males considered for re-biopsy. MATERIAL AND METHODS: The study included 320 men who underwent a prostatic biopsy in our department from October 2011 until June 2012. Total testosterone, free testos¬terone, bioavailable testosterone and prostate pathology were evaluated in all cases. Patients undergoing a second biopsy were identified and biopsy results were statistically analyzed. RESULTS: Forty men (12.5%) were assessed with a second biopsy. The diagnosis of the second biopsy was High Grade Intraepithelial Neoplasia in 14 patients (35%) and Prostate Cancer in 12 patients (30%). The comparison of prostatic volume, total testosterone, sex hormone binding globulin, free testosterone, bioavailable testosterone and albumin showed that patients with cancer of the prostate had significantly greater levels of free testosterone (p=0.043) and bioavailable T (p=0.049). CONCLUSION: In our study, higher free testosterone and bioavailable testosterone levels were associated with a cancer diagnosis at re-biopsy. Our results indicate a possible role for free and bioavailable testosterone in predicting the presence of prostate cancer in patients considered for re-biopsy.

Prognostic factors and risk groups in T1G3 non-muscle-invasive bladder cancer patients initially treated with Bacillus Calmette-Guérin: results of a retrospective multicenter study of 2451 patients.

BACKGROUND: The impact of prognostic factors in T1G3 non-muscle-invasive bladder cancer (BCa) patients is critical for proper treatment decision making. OBJECTIVE: To assess prognostic factors in patients who received bacillus Calmette-Guérin (BCG) as initial intravesical treatment of T1G3 tumors and to identify a subgroup of high-risk patients who should be considered for more aggressive treatment. DESIGN, SETTING, AND PARTICIPANTS: Individual patient data were collected for 2451 T1G3 patients from 23 centers who received BCG between 1990 and 2011. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Using Cox multivariable regression, the prognostic importance of several clinical variables was assessed for time to recurrence, progression, BCa-specific survival, and overall survival (OS). RESULTS AND LIMITATIONS: With a median follow-up of 5.2 yr, 465 patients (19%) progressed, 509 (21%) underwent cystectomy, and 221 (9%) died because of BCa. In multivariable analyses, the most important prognostic factors for progression were age, tumor size, and concomitant carcinoma in situ (CIS); the most important prognostic factors for BCa-specific survival and OS were age and tumor size. Patients were divided into four risk groups for progression according to the number of adverse factors among age ≥ 70 yr, size ≥ 3 cm, and presence of CIS. Progression rates at 10 yr ranged from 17% to 52%. BCa-specific death rates at 10 yr were 32% in patients ≥ 70 yr with tumor size ≥ 3 cm and 13% otherwise. CONCLUSIONS: T1G3 patients ≥ 70 yr with tumors ≥ 3 cm and concomitant CIS should be treated more aggressively because of the high risk of progression. PATIENT SUMMARY: Although the majority of T1G3 patients can be safely treated with intravesical bacillus Calmette-Guérin, there is a subgroup of T1G3 patients with age ≥ 70 yr, tumor size ≥ 3 cm, and concomitant CIS who have a high risk of progression and thus require aggressive treatment.

Bladder neck preservation during classic laparoscopic radical prostatectomy - point of technique and preliminary results.

INTRODUCTION: Stress urinary incontinence after radical prostatectomy for prostate cancer organ-confined patients can significantly affect quality of life. The article presents a technique of bladder neck preservation, because it is believed that this point is one of many crucial points responsible for fast recovery of continence after laparoscopic radical prostatectomy (LRP). MATERIAL AND METHODS: Laparoscopic radical prostatectomy with the intention of bladder neck preservation was performed in 194 patients of clinically organ-confined prostate cancer (cT2 ≤ N0M0). The working space was done by tissues-fingers dissections and insufflation of the cavity under full visual control, without the Gaur-balloon device. We insert two 10 mm trocars, three trocars of 5 mm and both 0° and 30° laparoscopes. The most important points of technique include: identification of landmarks of bladder neck and prostate base; dissection of muscle fibres of the very superficial bladder wall; mobilization of the posterior part of the urethra and simultaneous seminal vesicles release; neuro-vascular bundles preservation. This procedure resulted in a long bladder neck which can be easily anastomosed with the urethra. Tension-free and end-to-end (bladder neck-urethra) anastomosis are the results. RESULTS: In all cases radical prostatectomy was performed laparoscopically in the extraperitoneal space. There were no complications of bladder neck preservation during laparoscopic radical prostatectomy (LRP) apart from 22 cases with a large medium lobe. The mean time of operation was 150 min (110-210 min). The mean blood loss during LRP was 150 ml (110-350 ml). Blood transfusion was not necessary. There were no postoperative complications. Mean hospitalization time was 5 days. Pathological result of the postoperative specimens was pT2a in 30%, pT2b in 60%, pT3a in 6%, and pT3b in 4% of patients. In 7% of patients a positive surgical margin was affirmed, but the bladder neck was not affected in any case. Full continence after 3, 6, and 12 months was observed in 75%, 85%, and 92% of analysed patients, respectively. CONCLUSIONS: Bladder neck preservation during LRP is an effective, safe procedure that offers good functional results based on fast recovery of continence. Bladder neck preservation offers full tight anastomosis, especially in cases with no large median lobe of prostatic adenoma. Continence of patients who underwent bladder neck preservation was improved during short-term follow-up. Long-term results are still not conclusive. We think that this technique applied to laparoscopy will finally result in real progress of continence preservation after radical prostatectomy, but larger groups of patients have to be compared.

Minimally invasive approach in the management of upper- urinary-tract tumours.

OBJECTIVE: Nephroureterectomy with bladder cuff excision has been the gold standard treatment for upper tract transitional cell carcinoma (UTTCC) for more than 60 years. However, endoscopic treatment of urothelial tumours of renal pelvis and ureter is gaining acceptance as a conservative treatment modality. MATERIAL AND METHODS: A review in the English language of the Medline and Pub Med databases was performed using the keywords upper urinary tract transitional cell carcinoma and endoscopic management. There was a particular emphasis on treatment outcomes from published series. RESULTS: Endoscopic treatment of UTTCC alone for high-grade tumours is not advised owing to high rates of both local recurrence and disease progression, while many authors do not recommend primary endoscopic management of UTTCC in elective situations if pathological analysis and tumour grade cannot be obtained. CONCLUSION: Endourological management of UTTCC has become an accepted treatment option in highly selected patients, provided long-term close surveillance to detect and treat recurrences is ensured.

Endoscopic treatment of urothelial tumours of the renal pelvis and ureter.

Endoscopic treatment of urothelial tumors of renal pelvis and ureter is gaining acceptance as a conservative treatment modality. Technological advances have increased its applicability. Ureteroscopic and percutaneous tumor ablation have become reasonable treatment options for patients with imperative indications, such as bilateral disease, renal insufficiency or solitary kidney. However, endoscopic tumor ablation is being utilized more frequently for patients with UTTCC even in the setting low grade disease and a normal contralateral kidney, provided long-term close surveillance to detect and treat recurrences is ensured. This paper reviews the current role of endoscopic management of UTTCC.

Xanthogranulomatous pyelonephritis: presentation and management in the era of laparoscopy.

OBJECTIVE: To report a contemporary series of patients with xanthogranulomatous pyelonephritis (XGP, an inflammatory condition of the kidney that has traditionally been treated with open nephrectomy, ON), managed with either ON or laparoscopic nephrectomy (LN), as early reports suggest that the benefits of LN do not extend to patients with XGP. PATIENTS AND METHODS: The medical and procedural records of patients with pathologically confirmed XGP between December 1993 to February 2004 were reviewed retrospectively. During this period, 26 patients (mean age 43.5 years, range 17-85) had surgical management of XGP; information on the mode of presentation, surgical management, hospital course and complications were analysed. RESULTS: Twelve (46%) and 14 (54%) patients had ON and LN, respectively. The LN group had significantly lower blood loss (P = 0.002), transfusion rates (P = 0.02), time to resumption of oral intake (P = 0.002) and length of hospital stay (P = 0.002) than the ON group. One (7%) LN was converted to ON due to failure to progress. The overall complication rates between the ON and LN groups were not significantly different (P = 0.95). CONCLUSIONS: LN in the setting of XGP is often difficult and requires advanced laparoscopic skills. In highly selected patients this approach can be offered, with acceptable morbidity, allowing for lower blood loss and shorter convalesce times.

Case report: laparoscopic ureteropyelostomy and distal ureterectomy for management of duplication with ectopia.

PURPOSE: To evaluate the role of laparoscopic ureteropyelostomy and subtotal ureterectomy for management of an ectopic ureter to the prostatic urethra. CASE REPORT: A 54-year-old man presented with complaints of paravertebral pain and recurrent prostatitis with elevation of the serum prostate specific antigen concentration. Diagnostic evaluation revealed right renal duplication with an ectopic ureter to the prostatic urethra. Using a four-port transperitoneal laparoscopic technique, a laparoscopic ureteropyelostomy and subtotal ureterectomy were performed. Diagnostic follow-up documented successful treatment with the minimally invasive technique. CONCLUSIONS: Laparoscopic ureteropyelostomy and subtotal ureterectomy provide effective treatment for this rare condition. The minimally invasive technique may also have clinical applications in the pediatric population.

Complete daVinci versus laparoscopic pyeloplasty: cost analysis.

BACKGROUND AND PURPOSE: Computer-assisted pyeloplasty with the daVinci system is an emerging technique to treat ureteropelvic junction (UPJ) obstruction. A relative cost analysis was performed assessing this technology in comparison with purely laparoscopic pyeloplasty. PATIENTS AND METHODS: Eight patients underwent computer-assisted (daVinci) dismembered pyeloplasty (CP) via a transperitoneal four-port approach. They were compared with 13 patients who underwent purely laparoscopic pyeloplasty (LP). All patients had a primary UPJ obstruction and were matched for age, sex, and body mass index. The cost of equipment and capital depreciation for both procedures, as well as assessment of room set-up time, takedown time, and personnel were analyzed. Surgeons and nursing staff for both groups were experienced in both laparoscopy and daVinci procedures. One- and two-way financial analysis was performed to assess relative costs. RESULTS: The mean set-up and takedown time was 71 minutes for CP and 49 minutes for LP. The mean length of stay was 2.3 days for CP and 2.5 days for LP. The mean operating room (OR) times for CP and LP were 176 and 210 minutes, respectively. There were no complications in either group. One-way cost analysis with an economic model showed that LP is more cost effective than CP at our hospital if LP OR time is <338 minutes. With adjustment to a volume of 500 daVinci cases/year, CP is still not as cost effective as LP. Two-way sensitivity analysis shows that in-room time must still be <130 minutes and yearly cases must be >500 to obtain cost equivalence for CP. CONCLUSIONS: Perioperative parameters for CP are encouraging. However, the costs are a clear disadvantage. In our hospital, it is more cost effective to teach and perform LP than to perform CP.

Laparoscopic retroperitoneal lymph node dissection: duplication of open technique.

Laparoscopic retroperitoneal lymph node dissection has been used to stage germ cell testicular cancer. Since its initial description, this minimally invasive procedure has evolved into a therapeutic operation that adheres to established strict oncologic principles. A modified template dissection that fully duplicates the open technique is now routinely performed at our institution. We describe and show in the accompanying video segments a laparoscopic modified template dissection.

Evaluation of urinary extravasation and results after continence-preserving radical retropubic prostatectomy.

OBJECTIVE: To evaluate the feasibility of urinary catheter removal 10 days after a radical retropubic prostatectomy (RRP) by assessing the incidence of urinary extravasation and its effect on postoperative stricture and continence rates. PATIENTS AND METHODS: During a 4.5-year period, 619 patients undergoing RRP were evaluated. If no extravasation was detected on gravity cystography, the urinary catheter was removed 10 days after RRP. In patients with significant extravasation the catheter was left in place for 3 weeks. Overall stricture and continence rates were recorded in patients at 3, 6 and 12 months after surgery. RESULTS: There was extravasation during cystography in 29 patients (4.6%). At 3, 6 and 12 months, continence rates after catheter removal at 10 days were 74.9%, 87.9%, and 93.6%, respectively, while in the late-removal group they were 72.4%, 84.6% and 90.9%, respectively, with no significant difference between the groups. At 3 months the overall continence rate was 74.8% and at 12 months up to 93.5%. There was no difference in stricture rates between the groups, with an overall stricture rate of 0.7%. CONCLUSIONS: Catheter removal 10 days after RRP is feasible, giving excellent early and late continence rates, with low anastomotic stricture rates obtained using good surgical technique. Extravasation at 10 days was rare and with proper management did not influence the final results.

Modified S-pouch neobladder vs ileal conduit and a matched control population: a quality-of-life survey.

OBJECTIVES: To measure the quality-of-life (QoL) outcome and urinary and sexual function and bother after radical cystectomy and different types of urinary tract reconstruction (Bricker vs modified S-pouch neobladder), also assessing differences between them and a normal population. PATIENTS, SUBJECTS AND METHODS: Two groups of patients with bladder cancer were assessed; group 1 comprised 58 (mean age 65 years, mean follow-up 28 months) with an ileal conduit diversion, and group 2, 50 (mean age 61 years, mean follow-up 26 months) with a modified S-pouch neobladder. All were disease-free. Group 3 comprised 54 healthy subjects (a control population) of similar age, gender and comorbidities other than bladder cancer. A QoL questionnaire was used to study changes in QoL, and a specific questionnaire for urinary and sexual function and bother was also constructed. RESULTS: There were no differences in the QoL scores among the three groups; group 3 (control) tended to have a better QoL for all domains except emotional functioning. Urinary function was seriously affected in group 1, with more daytime leakage than in groups 2 and 3 (37.8% vs 10%, P = 0.005, and 9.3%, P = 0.01), night loss of urine (39.5% vs 28%, P = 0.07, and 3.7%, P = 0.002) and urine odour (58.6% vs 4%, and 5.5%, both P = 0.001). Patients in group 2 differed from healthy individuals only in night loss of urine. Consequently urinary bother was more pronounced in group 1, as fewer were satisfied (68.9% vs 86% and 83.2%, both P = 0.03). Sexual function was seriously and similarly affected in groups 1 and 2; the erection rate was 28.9% for group 1, 35.5% for group 2 (P = 0.1) and 83.3% in group 3 (P = 0.003), while firm erections were present at 17.7%, 22.2% (P = 0.2) and 83.3% (P = 0.002). Women reported equivalent dysfunction in all three groups (15.4%, 20% and 16.6%, P = 0.3). Sexual desire was also equal in all groups (48.2%, 50% and 48.1). Patients in group 1 expressed more bother, while those in group 2 seemed more satisfied by their sexual life (84.4%, 68% and 68.5%, P = 0.04). CONCLUSIONS: Radical cystectomy does not affect QoL whichever urinary reconstruction is used, and this implies a determination by the patients to live and adjust to their new conditions. On the contrary, urinary and sexual function are affected and related to the method used to reconstruct the urinary system.

Laparoscopic partial nephrectomy in patients with neoplasia in a solitary kidney.

OBJECTIVES: To assess the renal function and describe our operative experience with laparoscopic partial nephrectomy (LPN) in patients with solitary kidneys. METHODS: The medical records were analyzed to find patients with a solitary kidney and renal neoplasms who underwent LPN. Demographic, operative, pathologic, and follow-up data were obtained. RESULTS: Four patients were identified with solitary kidneys who had undergone LPN. The mean operative time was 251 minutes, mean warm ischemic time 15 minutes, mean estimated blood loss 395 mL, and mean hospitalization stay 3 days. The mean preoperative creatinine was 1.5 mg/dL and the mean peak creatinine 2.0 mg/dL. All patients returned to their baseline creatinine levels in the follow-up period. The final pathologic finding was Stage pT1 in 1, pT3a in 2, and angiomyolipoma in 1 patient. All surgical margins were negative. No cancer recurrence developed in the patients, with a mean follow-up of 17 months (range 3 to 35). CONCLUSIONS: LPN in patients with a solitary kidney is feasible and a reasonable treatment alternative to open partial nephrectomy.

Laparoscopic-assisted renal autotransplantation.

OBJECTIVES: To report our experience with laparoscopic nephrectomy and autotransplantation for the management of a variety of conditions with significant loss of healthy ureteral tissue or ureteral length. Renal autotransplantation has been described as an effective method for addressing this problem, avoiding the need for nephrectomy or complex ureteral replacement. In an effort to decrease the morbidity associated with traditional autotransplantation we elected to perform laparoscopic procurement of the kidney. METHODS: Four patients underwent laparoscopic nephrectomy using a transperitoneal four-port technique and subsequent autotransplantation into the iliac fossa for the treatment of proximal ureteral avulsion (2 patients), ureteral malignancy, and ureteral stricture. All patients had less than 5 cm of viable ureter. RESULTS: All procedures were performed without intraoperative complications. All renal scans on postoperative day 1 demonstrated good perfusion. None of the patients had a postoperative rise in serum creatinine. On postoperative day 1, the mean creatinine value was 0.95 mg/dL. Three patients had an uneventful postoperative course. One patient, however, had loss of the graft because of renal vein thrombosis on postoperative day 7. She was later found to have an undiagnosed thrombophilic disorder (decreased levels of antithrombin III) and to have a recent history of oral contraceptive use. CONCLUSIONS: Laparoscopic nephrectomy with renal autotransplantation is a feasible minimally invasive alternative to treat patients who have significant ureteral loss. This approach avoids the need for an upper abdominal or flank incision, resulting in decreased morbidity. The initial follow-up studies indicated stable renal function. Additional long-term observation is currently under way.

Evaluation of water jet morcellation as an alternative to hand morcellation of renal tissue ablation during laparoscopic nephrectomy: an in vitro study.

OBJECTIVES: To evaluate the feasibility and safety of morcellation with a new prototype device that uses high-pressure water flow as a cutting/ablating tool and compare it with standard manual morcellation. METHODS: Ten porcine kidneys were morcellated with the new water jet device and ten with conventional manual morcellation. Morcellation in all cases was performed in commercially available entrapment bags. The two groups were evaluated for morcellation time, fragment size, and perforation rates (macroscopic and microscopic). RESULTS: The kidney size in both groups was similar. Morcellation was significantly (P <0.0001) faster in the water jet morcellator group than in the hand morcellation group (5.6 versus 11.9 minutes). The macroscopic evaluation after filling the entrapment bags with normal saline revealed 4 (40%) and 2 (20%) pinhole perforations in the water jet and hand morcellation groups, respectively. The microscopic evaluation revealed an 80% perforation rate in the water jet group and a 20% rate in the hand morcellator group. The size of the resulting fragments in the water jet group was not available, because the morcellated kidney was transformed in a semiliquid form. Therefore, cytology evaluation of the tissue was not possible. CONCLUSIONS: Water jet technology can be used to morcellate renal porcine tissue effectively. It is faster, but the problems of safety and histologic evaluation must be solved before this promising technology can be used in a clinical setting.

Complication rate of transrectal ultrasound guided prostate biopsy: a comparison among 3 protocols with 6, 10 and 15 cores.

PURPOSE: We assessed the complication rate of ultrasound guided prostate biopsies performed at a single center in a screening population. Moreover the impact of different biopsy protocols comprising varying numbers of biopsy cores on the complication rate was evaluated. MATERIALS AND METHODS: A total of 5957 biopsies performed in 4303 clinically healthy men between January 1993 and August 2002 was evaluated retrospectively. Due to changes in the biopsy protocol, the number of biopsies obtained increased with time from 6 cores (January 1993 to October 1995) to 10 (November 1995 to March 2000) to 15 cores (March 2000 to August 2002). RESULTS: Minor complications such as hematospermia (36.3%), hematuria (14.5%) and rectal bleeding persisting for up to 2 days (2.3%) were noted frequently, while major complications requiring further treatment were far less common. Post-biopsy fever was seen in 48 patients (0.8%), rectal bleeding requiring surgical intervention or persisting for more than 2 days occurred in 36 patients (0.6%) and urinary retention was observed in 12 patients (0.2%). The increase in biopsy cores with time did not result in increased post-biopsy morbidity. Prostate cancer at biopsy was not associated with a higher complication rate. CONCLUSIONS: Prostate specific antigen screening has led to an increase in the number of patients undergoing prostate biopsy which, in turn, has increased the incidence of post-biopsy complications. However, most of the complications are minor and self-limiting. In this large study population the increased number of biopsy cores did not result in an increased incidence of major post-biopsy complications.

Radical retropubic prostatectomy in men younger than 45 years diagnosed during early prostate cancer detection program.

OBJECTIVES: To evaluate the incidence and outcome of prostate cancer in men younger than 45 years of age treated with radical retropubic prostatectomy after screening in an early prostate cancer detection program. METHODS: Our study group comprised 19,302 men younger than 45 years old who participated in this program. The indications for prostate biopsy were a prostate-specific antigen (PSA) level of 1.25 ng/mL or greater and a percent-free PSA value of 18% or less. Patients with prostate cancer underwent nerve-sparing radical retropubic prostatectomy. Intraoperative and early postoperative complications, clinical and pathologic stage, Gleason score, and surgical margins were reviewed retrospectively. In addition, potency, continence, and biochemical recurrence were assessed at the last follow-up visit. RESULTS: Of the study population eligible for prostate biopsy (1027 patients), only 175 (17%) consented to undergo the procedure (mean PSA 3.8 ng/mL). Twenty-eight men were diagnosed with prostate cancer, corresponding to 0.14% of the screened population and 16% of the biopsied patients. Twenty-six patients agreed to undergo radical retropubic prostatectomy. Pathologic examination revealed organ-confined disease in 22 (84.6%) and extraprostatic extension in 4 (15.4%). Positive surgical margins were seen in 2 patients (7.7%). The Gleason score was 7 or greater in 11 (42.3%) and 6 or less in 15 patients (57.7%). During a mean follow-up period of 15.8 months (range 3 to 36), all patients were continent, and 13 of the 16 patients with a follow-up of 12 months or longer were potent. CONCLUSIONS: In a large screening population younger than 45 years old, 16% of biopsied patients were positive for prostate cancer. These tumors were clinically significant but of a low stage and therefore potentially curable by surgery.