A 2-year prospective evaluation of the Prostate Health Index in guiding biopsy decisions in a large cohort.

OBJECTIVES: To prospectively evaluate how the Prostate Health Index (PHI) impacts on clinical decision in a real-life setting for men with a prostate-specific antigen (PSA) level between 4 and 10 ng/mL and normal digital rectal examination. PATIENTS AND METHODS: Since 2016, the PHI has been available at no cost to eligible men in all Hong Kong public hospitals. All eligible patients who received PHI testing in all public Urology units (n = 16) in Hong Kong between May 2016 and August 2017 were prospectively included and followed up. All included men had a PHI test, with its result and implications explained; the subsequent follow-up plan was then decided via shared decision-making with urologists. Patients were followed up for 2 years, with outcomes including prostate biopsy rates and biopsy findings analysed in relation to the initial PHI measurements. RESULTS: A total of 2828 patients were followed up for 2 years. The majority (82%) had PHI results in the lower risk range (score <35). Knowing the PHI findings, 83% of the patients with elevated PSA decided not to undergo biopsy. In all, 11% and 45% opted for biopsy in the PHI score <35 and ≥35 groups, respectively. The initial detection rate of International Society of Urological Pathology (ISUP) Grade Group (GG) ≥2 cancer was higher in the PHI score ≥35 group (23%) than in the PHI score <35 group (7.9%). Amongst patients with no initial positive biopsy findings, the subsequent positive biopsy rate for ISUP GG ≥2 cancer was higher in the PHI score ≥35 group (34%) than the PHI score <35 group (13%) with a median follow-up of 2.4 years. CONCLUSION: In a real-life setting, with the PHI incorporated into the routine clinical pathway, 83% of the patients with elevated PSA level decided not to undergo prostate biopsy. The PHI pathway also improved the high-grade prostate cancer detection rate when compared to PSA-driven strategies. Higher baseline PHI predicted subsequent biopsy outcome at 2 years. The PHI can serve as a tool to individualise biopsy decisions and frequency of follow-up visits.

Prostate Health Index and %p2PSA Predict Aggressive Prostate Cancer Pathology in Chinese Patients Undergoing Radical Prostatectomy.

PURPOSE: To investigate the performance of prostate health index (PHI) and percentage prostate-specific antigen (PSA) isoform [-2]proPSA (%p2PSA) in predicting pathologic outcomes at radical prostatectomy (RP) in a Chinese population. METHODS: We performed a prospective study of 135 prostate cancer patients with RP. The accuracy of preoperative %p2PSA (= p2PSA/free PSA) and PHI [= (p2PSA/free PSA) × âˆšPSA] in predicting pathologic outcomes of RP including pT3 disease, pathologic Gleason score (pGS) ≥7, Gleason score (GS) upgrade at RP, tumor volume >0.5 ml, and Epstein criteria for significant tumor were calculated using multivariate analyses and area under the curve. The base model in multivariate analysis included age, PSA, abnormal digital rectal examination, and biopsy GS. RESULTS: PHI was significantly higher in patients with pT3 or pGS ≥ 7 (p < 0.001), pT3 disease (p = 0.001), pGS ≥ 7 (p < 0.001), GS upgrade (p < 0.001), tumor volume >0.5 ml (p < 0.001), and Epstein criteria for significant tumor (p = 0.001). %p2PSA was also significantly higher in all the above outcomes. The risk of pT3 or pGS ≥ 7 was 16.1 % for PHI < 35 and 60.8 % for PHI > 35 (sensitivity 84.2 %, specificity of 60.3 %), and the risk of tumor volume >0.5 ml was 25.5 % for PHI < 35 and 72.6 % for PHI > 35 (sensitivity 79.1 %, specificity 67.2 %). In multivariate analysis, adding %p2PSA or PHI to the base model significantly improved the accuracy (area under the curve) in predicting pT3 or pGS ≥ 7 (by 7.2-7.9 %), tumor volume >0.5 ml (by 10.3-12.8 %), and Epstein criteria for significant tumor (by 13.9-15.9 %). Net clinical benefit was observed in decision curve analyses for prediction of both tumor volume >0.5 ml, and pT3 or pGS ≥ 7. CONCLUSIONS: Both PHI and %p2PSA predict aggressive and significant pathologies in RP in Chinese men. This enabled identification of nonaggressive cancers for better counseling on active surveillance or treatment.

Initial Prostate Health Index (phi) and phi density predicts future risk of clinically significant prostate cancer in men with initial negative prostate biopsy: a 6-year follow-up study.

BACKGROUND: Men with elevated prostate-specific antigen (PSA) and initial negative prostate biopsy may have risk of prostate cancer (PCa) in the future. The role of Prostate Health Index (phi) in determining future PCa risk has not been studied before. This study aims to investigate the role of initial phi and phi density in predicting future PCa risk in men with initial negative biopsy. METHODS: Five hundred sixty nine men with PSA 4-10 ng/mL were recruited between 2008 and 2015 for prostate biopsy with prior phi. Electronic clinical record of men with initial negative biopsy was reviewed. Patients and follow-up doctors were blinded to phi. Kaplan-Meier curves were used to analyze the PCa-free survival in different baseline phi and phi density groups. RESULTS: Four hundred sixty-one men with complete follow-up data were included. Median follow-up is 77 months. PCa and HGPCa was diagnosed in 8.2% (38/461) and 4.8% (22/461) of cohort respectively. A higher baseline phi value was associated with PCa (p = 0.003) and HGPCa (p < 0.001). HGPCa was diagnosed in 0.6% (1/163) of phi < 25, 4.6% (9/195) of phi 25-34.9, and 11.7% (12/103) of phi ≥ 35 (p < 0.001). HGPCa was diagnosed in 0% (0/109) and 21.0% (13/62) with phi density of <0.4 and ≥1.2, respectively, (p < 0.001). Kaplan-Meier curves showed phi and phi density predicted PCa and HGPCa diagnoses (log-rank test, all p ≤ 0.002). CONCLUSIONS: Initial phi or phi density predicted 6-year risk of PCa in men with initial negative prostate biopsy. Men with higher phi (≥35) or phi density (≥1.2) need closer follow-up and repeated investigation, while men with lower phi (<25) or phi density (<0.4) could have less frequent follow-up.

High-Intensity Focused Ultrasound (HIFU) Focal Therapy for Localized Prostate Cancer with MRI-US Fusion Platform.

OBJECTIVE: The study aimed at investigating the outcome of prostate HIFU focal therapy using the MRI-US fusion platform for treatment localization and delivery. METHODS: It is a prospectively designed case series of HIFU focal therapy for localized prostate cancer. The inclusion criteria include clinical tumor stage ≤T2, visible index lesion on multiparametric MRI less than 20 mm in diameter, absence of Gleason 5 pattern on prostate biopsy, and PSA ≤ 20 ng/ml. HIFU focal therapy was performed in the conventional manner in the beginning 50% of the series, whereas the subsequent cases were performed with MRI-US fusion platform. The primary outcome was treatment failure rate which is defined by the need of salvage therapy. Secondary outcomes included tumor recurrence in follow-up biopsy, PSA change, perioperative complications, and postoperative functional outcomes. RESULTS: Twenty patients underwent HIFU focal ablation. HIFU on an MRI-US fusion platform had a trend of a longer total operative time than the conventional counterpart (124.2 min vs. 107.1 min, p=0.066). There was no difference in the mean ablation volume to lesion volume ratio between the two. The mean PSA percentage change from baseline to 6-month is more significant in the conventional group (63.3% vs. 44.6%, p=0.035). No suspicious lesion was seen at 6-month mpMRI in all 20 patients. Two patients, one from each group, eventually underwent radical treatment because of the presence of clinically significant prostate cancer in the form of out-of-field recurrences during follow-up biopsy. No significant difference was observed before and after HIFU concerning uroflowmetry, SF-12 score, and EPIC-26 score. It was observed that energy used per volume was positively correlated with PSA density of the patient (r = 0.6364, p=0.014). CONCLUSION: In conclusion, HIFU with conventional or MRI-US fusion platform provided similar oncological and functional outcomes.

Sectoral cancer detection and tolerability of freehand transperineal prostate biopsy under local anaesthesia.

BACKGROUND: To investigate the feasibility of a freehand transperineal (TP) systematic prostate biopsy protocol under local anaesthesia (LA) and the value of different sectors in diagnosing prostate cancer (PCa). METHODS: A total of 611 consecutive freehand TP biopsies under LA in 2 hospitals were prospectively evaluated. Cancer detection rate in each of the four different sectors (anterior, mid, posterior, basal) was recorded to evaluate the value of each sector. Procedure tolerability was assessed by pain score and complications were documented. RESULTS: Systematic biopsies were performed in 556 out of 611 men with a median of 20 (IQR 12-24) biopsy cores taken. The median PSA was 9.9 (Inter-quartile range[IQR] 6.4-16.2) ng/mL, and 89.0% were first biopsies. All PCa and ISUP grade group (GG) ≥ 2 PCa (HGPCa) were diagnosed in 41.4% (230/556) and 28.2% (157/556) biopsies respectively. 77.0% HGPCa was diagnosed in ≥2 sectors. Single-sector HGPCa was predominantly found in anterior or posterior sector. Omitting base sector would have missed 1.5% (1/65) HGPCa out of the 219 cases with ≥24-core biopsies performed. Further omission of mid sector would have missed 3.1% (2/65) HGPCa and 7.4% (7/94) ISUP GG1 PCa (in which 3/7 involved 2 sectors). LA TP biopsy was well tolerated and the mean pain scores of the different steps of the procedure were between 1.9-3.1 (out of 10). Post-biopsy fever occurred in 0.3% of patients (2/611) and no sepsis was reported. The risk of urinary retention in men with ≥20 cores in ≥60 ml prostate was 7.8% (14/179), compared with 1.7% (7/423) in other groups (p < 0.001). CONCLUSIONS: TP sectoral prostate biopsy under LA was well tolerated with minimal sepsis risk. Basal sector biopsies had minimal additional value to HGPCa detection and its omission can be considered.

Novel approach of laparoscopic transperitoneal en bloc resection of urachal tumor and umbilectomy with a comparison of various techniques.

Urachal carcinoma is a rare cancer that accounts for less than 1% of all bladder cancers. Surgical resection remains the mainstay of treatment. With partial cystectomy, long-term survival is possible following complete resection of the tumor. In this paper, we describe a novel approach of laparoscopic en bloc partial cystectomy and umbilectomy. We emphasize the importance of complete resection of the tumor and umbilicus and prevention of tumor spillage during the procedure. The literature is also reviewed for the comparison of various laparoscopic techniques.

Effect of vardenafil on blood pressure profile of patients with erectile dysfunction concomitantly treated with doxazosin gastrointestinal therapeutic system for benign prostatic hyperplasia.

PURPOSE: We investigated the effect of the combination of the doxazosin gastrointestinal therapeutic system and 10 mg vardenafil on the hemodynamic status of patients with benign prostatic hyperplasia and erectile dysfunction. MATERIALS AND METHODS: This was a double-blinded, randomized, placebo controlled crossover trial. Patients with benign prostatic hyperplasia and erectile dysfunction treated with the doxazosin gastrointestinal therapeutic system on a regular basis, with no other antihypertensive events, were recruited. Subjects took 10 mg vardenafil or placebo in a randomized crossover fashion with a washout period of at least 7 days between each treatment. The supine and standing blood pressure of the subjects was recorded from 1 hour before to 6 hours after the administration of vardenafil or placebo. The primary outcome of the study was the maximal change in standing systolic blood pressure of the subjects from 1 half hour before to 6 hours after the administration of drugs. RESULTS: A total of 37 patients, 25 (67.6%) and 12 (32.4%) on the doxazosin gastrointestinal therapeutic system at 4 mg and 8 mg, respectively, completed the trial. The combination drug therapy resulted in a maximal decrease in standing systolic blood pressure of 6.18 mm Hg (95% CI -12.02, -0.33; p = 0.039). Only 1 patient had an asymptomatic standing systolic blood pressure of less than 85 mm Hg. Otherwise no symptomatic hypotension or clinically significant adverse cardiovascular event was observed during the study. CONCLUSIONS: In patients on the doxazosin gastrointestinal therapeutic system for benign prostatic hyperplasia a single 10 mg dose of vardenafil had no symptomatic hemodynamic effects.

Bladder injury mimicking acute renal failure after cesarean section: a diagnostic challenge and minimally invasive management.

The reported incidence of bladder injury after cesarean section ranges from 0.14% to 0.94%. Most of the injuries were found intraoperatively. Delayed presentation is rare. We report a patient with bladder perforation presented with 'acute renal failure' and ascites 14 days after an uneventful cesarean section. Her clinical picture and initial presentation mimicked those of ureteric injury. Conventional cystography failed to demonstrate the bladder perforation. Computed tomography cystography clarified the diagnosis. Subsequent laparoscopic bladder repair resulted in quick and smooth recovery. This case highlights the pitfall of conventional cystography and the successful use of laparoscopy in management of this urologic condition. Literature was reviewed for this condition and its management.

Laparoscopic adrenalectomy: Comparison of lateral transperitoneal and lateral retroperitoneal approaches.

Laparoscopic adrenalectomy has become the method of choice of removal of most of adrenal lesions. This study investigated and compared the results of 2 different approaches of laparoscopic adrenalectomy, through retrospective review of 40 patients. Within this study period between 1995 and 2004, there were 20 lateral retroperitoneal and 20 lateral transperitoneal laparoscopic adrenalectomies performed. There was no significant difference in demographic variables between the 2 groups. Operative time, days to diet and ambulation, hospital stay, rate of conversion and complication did not differ significantly between the 2 approaches. No recurrence was detected upon mean follow-up period of 15.9 months. Learning curves showed gradual decrease in operation time in both approaches, reflecting maturation of techniques. In conclusion, both lateral transperitoneal and lateral retroperitoneal laparoscopic adrenalectomy are safe and effective. There is no difference in outcome between 2 approaches.

Prostate health index (PHI) and prostate-specific antigen (PSA) predictive models for prostate cancer in the Chinese population and the role of digital rectal examination-estimated prostate volume.

PURPOSE: To investigate PSA- and PHI (prostate health index)-based models for prediction of prostate cancer (PCa) and the feasibility of using DRE-estimated prostate volume (DRE-PV) in the models. METHODS: This study included 569 Chinese men with PSA 4-10 ng/mL and non-suspicious DRE with transrectal ultrasound (TRUS) 10-core prostate biopsies performed between April 2008 and July 2015. DRE-PV was estimated using 3 pre-defined classes: 25, 40, or 60 ml. The performance of PSA-based and PHI-based predictive models including age, DRE-PV, and TRUS prostate volume (TRUS-PV) was analyzed using logistic regression and area under the receiver operating curves (AUC), in both the whole cohort and the screening age group of 55-75. RESULTS: PCa and high-grade PCa (HGPCa) was diagnosed in 10.9 % (62/569) and 2.8 % (16/569) men, respectively. The performance of DRE-PV-based models was similar to TRUS-PV-based models. In the age group 55-75, the AUCs for PCa of PSA alone, PSA with DRE-PV and age, PHI alone, PHI with DRE-PV and age, and PHI with TRUS-PV and age were 0.54, 0.71, 0.76, 0.78, and 0.78, respectively. The corresponding AUCs for HGPCa were higher (0.60, 0.70, 0.85, 0.83, and 0.83). At 10 and 20 % risk threshold for PCa, 38.4 and 55.4 % biopsies could be avoided in the PHI-based model, respectively. CONCLUSIONS: PHI had better performance over PSA-based models and could reduce unnecessary biopsies. A DRE-assessed PV can replace TRUS-assessed PV in multivariate prediction models to facilitate clinical use.

Extended use of Prostate Health Index and percentage of [-2]pro-prostate-specific antigen in Chinese men with prostate specific antigen 10-20 ng/mL and normal digital rectal examination.

PURPOSE: We investigated the extended use of Prostate Health Index (PHI) and percentage of [-2]pro-prostate-specific antigen (%p2PSA) in Chinese men with prostate-specific antigen (PSA) 10-20 ng/mL and normal digital rectal examination (DRE). MATERIALS AND METHODS: All consecutive Chinese men with PSA 10-20 ng/mL and normal DRE who agreed for transrectal ultrasound (TRUS)-guided 10-core prostate biopsy were recruited. Blood samples were taken immediately before TRUS-guided prostate biopsy. The performances of total PSA (tPSA), %free-to-total PSA (%fPSA), %p2PSA, and PHI were compared using logistic regression, receiver operating characteristic, and decision curve analyses (DCA). RESULTS: From 2008 to 2015, 312 consecutive Chinese men were included. Among them, 53 out of 312 (17.0%) men were diagnosed to have prostate cancer on biopsy. The proportions of men with positive biopsies were 6.7% in PHI<35, 22.8% in PHI 35-55, and 54.5% in PHI>55 (chi-square test, p<0.001). The area under curves (AUC) of the base model including age, tPSA and status of initial/repeated biopsy was 0.64. Adding %p2PSA and PHI to the base model improved the AUC to 0.79 (p<0.001) and 0.78 (p<0.001), respectively, and provided net clinical benefit in DCA. The positive biopsy rates of Gleason 7 or above prostate cancers were 2.2% for PHI<35, 7.9% for PHI 35-55, and 36.4% for PHI>55 (chi-square test, p<0.001). By utilizing the PHI cutoff of 35 to men with PSA 10-20 ng/mL and normal DRE, 57.1% (178 of 312) biopsies could be avoided. CONCLUSIONS: Both PHI and %p2PSA performed well in predicting prostate cancer and high grade prostate cancer. The use of PHI and %p2PSA should be extended to Chinese men with PSA 10-20 ng/mL and normal DRE.

Secondary hemorrhage after bipolar transurethral resection and vaporization of prostate.

INTRODUCTION: We evaluated the factors associated with secondary hemorrhage after bipolar transurethral resection of prostate (TURP) and vaporization of prostate. MATERIALS AND METHODS: The perioperative data of patients undergoing endoscopic surgery for benign prostatic hyperplasia (BPH) were prospectively collected. Procedures involved included bipolar TURP, bipolar vaporization of prostate, and hybrid bipolar TURP/vaporization of prostate. Secondary hemorrhage was defined as bleeding between 48 h and 30 days postsurgery requiring hospital attendance with or without admission. Risk factors for secondary hemorrhage were analyzed. RESULTS: From 2010 to 2013, 316 patients underwent bipolar surgery for BPH. Bipolar TURP accounted for 48.1% of the procedures, bipolar vaporization accounted for 20.3% of the procedures, and the rest were hybrid TURP/vaporization of prostate. Among this cohort of patients, fifty patients had secondary hemorrhage with hospital attendance. Consumption of platelet aggregation inhibitors (PAIs) was found to be associated with secondary hemorrhage (P < 0.0005). Age, prostate volume, operation type, the use of 5-alpha reductase inhibitors, and being with a urethral catheter before operation were not found to be statistically significant risk factors for secondary hemorrhage. CONCLUSIONS: Secondary hemorrhage after bipolar surgery for BPH is a common event. Consumption of PAI is a risk factor for such complication.

Robot-assisted radical cystectomy using a side-docking technique.

PURPOSE: Robot-assisted radical cystectomy (RARC) was first introduced in 2003. Although there have been modifications to the surgical techniques over the years, in every published RARC series the surgical robot is invariably docked between the patient's legs. We evaluated the use of a side-docking approach in RARC. PATIENTS AND METHODS: Ten RARCs using a side-docking technique were performed at a single institute between February 2013 and February 2014. The patients' clinical notes and operative findings were reviewed. The results were compared with results from RARCs using the conventional central-docking method from our historical cohort. RESULTS: There were no significant arm collisions in the side-docking RARC procedures. The perineum was readily accessible in all cases that used the side-docking method. A simultaneous urethrectomy was performed in 1 case with a side-docking approach. The median operative times were 417.5 minutes (range, 345-515 minutes) and 405.0 minutes (range, 330-500 minutes) in the central-docking and side-docking groups, respectively. There were no statistically significant differences in operation time, transfusion rate, complication rate, or hospital stay between the two groups. CONCLUSIONS: A side-docking approach in RARC provides better perineal access with the advantage of allowing simultaneous urethrectomy and transvaginal retrieval of the specimen without compromising the dexterity and precision of the robotic surgical system.

Role of PSA density in diagnosis of prostate cancer in obese men.

PURPOSE: To compare the performance of prostate-specific antigen (PSA) density in the diagnosis of prostate cancer in obese and non-obese Chinese men. METHODS: The results of transrectal ultrasound-guided (TRUS) prostate biopsies of Chinese men with PSA <20 ng/mL were reviewed. Parameters including age, body mass index (BMI), TRUS prostate volume, and TRUS biopsy results were recorded. The diagnostic yields of PSA density (>0.15 ng/mL as positive) in obese and non-obese men with PSA <20 ng/mL were compared. Obesity was defined as BMI ≥ 27 kg/m(2) according to WHO recommendation for Hong Kong Chinese. RESULTS: TRUS biopsy, BMI, and PSA density data were available for 854 men (mean age 65.9 ± 7.3). The mean PSA values for the obese and non-obese patients were 7.9 ± 3.7 and 8.2 ± 4.1 ng/mL, respectively (p = 0.416). TRUS volumes in obese and non-obese men were 63.2 ml and 51.6 ml, respectively (t test, p < 0.001), and PSA density was significantly lower in obese men (0.145 vs. 0.188, p < 0.001). For obese men, positive PSA density was associated with four times (41.1 vs. 9.5 %, p < 0.001) the risk of prostate cancer, compared to only twice the risk (18.8 vs. 9.7 %, p = 0.001) in non-obese men. The specificity and area under the curve of PSA density were 74.2 % and 0.731, respectively, for obese men, and 51.4 % and 0.653, respectively, for non-obese men. Among patients with a diagnosis of prostate cancer, the obese patient group had a significantly higher proportion of patients with Gleason 7-10 prostate cancer than the non-obese patient group (48.9 vs. 32.7 %, Chi-square test, p = 0.035), and a trend toward a higher proportion of bilateral lobe involvement. CONCLUSION: PSA density had better performance in obese men. Positive PSA density in obese men was associated with four times the risk of prostate cancer.

Side-docking technique for robot-assisted urologic pelvic surgery.

OBJECTIVE: To investigate the feasibility of side-docking techniques in robot-assisted urologic pelvic surgery. MATERIALS AND METHODS: Six consecutive patients undergoing robot-assisted pelvic surgery participated in the study: 3 undergoing radical cystectomy for muscle-invasive bladder cancer, 1 patient undergoing ureteroneocystostomy for ureteric stricture, 1 patient undergoing partial cystectomy for urothelial cancer in a bladder diverticulum, and 1 undergoing transvesical simple prostatectomy. Each patient was placed in the lithotomy-Trendelenburg position, with the robot docked over the patient's right side. RESULTS: All the procedures were completed without the need for redocking. Simultaneous cystourethroscopy was performed in 1 case to localize a bladder diverticular tumor during a partial cystectomy. Manipulation of the uterus and perineum was possible by the second assistant sitting between the patients' legs. No significant collision between the robotic arms occurred. There was no Clavien-Dindo III-V complication in any case. CONCLUSION: Side docking for robot-assisted urologic pelvic surgery is a viable positioning alternative with the advantage of enhanced access to the perineum and urethra. This modified approach will be useful in robot-assisted radical cystectomy and other reconstructive urologic procedures.

Randomized controlled trial of antibiotic prophylaxis regimens for transrectal ultrasound-guided prostate biopsy.

BACKGROUND: A prior study showed significant antibiotic resistance to quinolone in our population. In this study we aimed to evaluate and compare the efficacy of a single versus a combined prophylactic antibiotic regimen before transrectal ultrasound-guided prostate biopsy (TRUGPB). METHODS: A prospective randomized study was conducted at a university hospital. Patients undergoing TRUGPB were randomized into an amoxicillin-clavulanate alone (1 mg; one dose before and two doses after biopsy) or an amoxicillin-clavulanate + ciprofloxacin group (250 mg; one dose before and two doses after biopsy). Patients were surveyed for infection symptoms by phone on days 3 and 30 after TRUGPB. We defined an infective complication as the occurrence of symptoms including fever, chills or rigor within 30 days after prostate biopsy, requiring medical treatment or hospitalization, aided by a territory-wide electronic medical record system. RESULTS: Between November 2007 and July 2009, 367 patients were randomized to either amoxicillin-clavulanate alone or amoxicillin-clavulanate + ciprofloxacin group. The infection rates after TRUGPB were 3.91% in the former group (7 out of 179 patients) versus 0.53% (1 out of 188 patients) in the latter. Sixty-three percent (5/8) of patients with infective complications needed hospitalization. There was no intensive care unit admission or mortality during the study period. CONCLUSIONS: Combining prophylactic antibiotics with amoxicillin-clavulanate + ciprofloxacin significantly reduced the incidence of infective complications after TRUGPB. We recommended a combination regimen, especially in centre with high incidence of post-TRUGPB infection.

Robot-assisted radical prostatectomy in Hong Kong: a review of 235 cases.

OBJECTIVES: To report the outcome of all robot-assisted laparoscopic radical prostatectomy (RALP) in the public health care system in Hong Kong. PATIENTS AND METHODS: All patients who underwent RALP in the public health care system with at least 1 year of follow-up were evaluated. Data analysis included age, body mass index, preoperative prostate-specific antigen (PSA) level, D'Amico risk category, operative details, pathologic stage, follow-up continence, potency, and biochemical recurrence. RESULTS: Between 2005 and 2009, 235 patients underwent RALP, with a mean age of 66.4±5.9 years and a mean preoperative PSA level of 11.0±10.5 ng/mL. Complications were 16 (7%) in total. There were 176 (74.9%) patients with pT(2) disease and 55 (23.4%) patients with pT(3) disease. The overall rate of positive surgical margins (PSM) was 20.7%. At postoperative 12 months, 72.5% of the patients were pad free. For those 83 preoperative potent patients having nerve-sparing surgery, the overall trifecta rate at 12 months was 37.3%. Multivariate analysis identified that pathologic T staging was significantly associated with PSM, with an odds ratio (OR) of 7.884 (95% confidence interval [CI]: 3.576-17.379; P<0.001) for the pT(3) group compared with the pT(2) group. When comparing D'Amico medium- and high-risk categories with low-risk categories, they were found to be significantly associated with biochemical failure (medium- compared with low-risk: OR=3.536, 95% CI: 1.253-10.173, P=0.016; high- compared with low-risk: OR=10.214, 95% CI: 2.958-35.274, P<0.001). CONCLUSIONS: Our data demonstrate the feasibility, safety, and efficacy of RALP in low-to-intermediate volume centers. Our early oncologic outcomes were significantly correlated with pathologic stage and D'Amico risk stratification.

Using urine microscopy and cytology for early detection of bladder cancer in male patients with lower urinary tract symptoms.

OBJECTIVES: Irritative urinary symptoms and micro-hematuria are the common findings in bladder cancer patients. In this study, we investigated the use of urine microscopy and cytological examination for early detection of bladder cancer in patients with lower urinary tract symptoms (LUTS). METHODS: Male patients presented with LUTS to urology clinic were enrolled. Voiding symptoms were evaluated with international prostate symptoms score, and urine samples were collected for microscopy and cytological examination. Cystoscopy was performed in patients with microscopic hematuria, suspicious/malignant cells in urine or at the time of transurethral resection of prostate. Subjects, who had no indication and did not receive cystoscopy, were followed up in clinic for progress of symptoms, including gross hematuria and occurrence of bladder cancer. RESULTS: Nine hundred and eighty-eight patients were enrolled during the period of 2005-2007. Fifty-two (5.26%) urine samples were documented as atypical, and 936 (94.7%) were negative. There was no suspicious or malignant cytology result in this series. Micro-hematuria was noticed in six patients (0.61%). The mean follow-up time was 29.1 ± 12.5 months. One (0.10%) patient had bladder cancer 44 months after the first visit in the cohort, who had micro-hematuria, atypical urine cytology, but normal cystoscopy before diagnosis. CONCLUSION: The prevalence rate of bladder cancer in male patients with LUTS is low. This study adds to information that microscopy and cytological examination are not useful to detect bladder cancer. Due to the economic concerns and burden of unnecessary investigations, the routine use of these tests is in doubt.