Optimizing outcomes in men with prostate cancer: the cardiovascular event lowering (CaELo) pathways.

INTRODUCTION: Risk of cardiovascular disease is higher among men with prostate cancer than men without, and prostate cancer treatments (especially those that are hormonally based) are associated with increased cardiovascular risk. MATERIALS AND METHODS: An 11-member panel of urologic, medical, and radiation oncologists (along with a men's health specialist and an endocrinologist/preventive cardiologist) met to discuss current practices and challenges in the management of cardiovascular risk in prostate cancer patients who are taking androgen deprivation therapies (ADT) including LHRH analogues, alone and in combination with androgen-targeted therapies (ATTs). RESULTS: The panel developed an assessment algorithm to categorize patients by risk and deploy a risk-adapted management strategy, in collaboration with other healthcare providers (the patient's healthcare "village"), with the goal of preventing as well as reducing cardiovascular events. The panel also developed a patient questionnaire for cardiovascular risk as well as a checklist to ensure that all aspects of cardiovascular disease risk reduction are completed and monitored. CONCLUSIONS: Prostate cancer patients receiving ADT with or without ATT need to be more zealously assessed for prevention and aggressively managed to reduce cardiovascular events. This can and should include participation from the entire multidisciplinary healthcare team.

Are robots the future? A case for robotic pyeloplasty as the gold standard treatment in ureteropelvic junction obstruction.

PURPOSE OF REVIEW: Robotic pyeloplasty is still a relatively novel procedure. Clinically, early studies have shown high success rates, decreased complication rates, decreased length of hospital stay, and better cosmetic results. This goal of this article is to argue for the use of robotic pyeloplasty as the gold standard of ureteropelvic junction obstruction (UPJO) treatment. Results of studies that have compared robotic pyeloplasty with other procedures currently used are reviewed. RECENT FINDINGS: Our study, a comprehensive review of published outcomes of robotic pyeloplasty and alternative therapies, consisted of 666 pediatric patients and 653 adult patients. Our review coincided with the previously established studies that robotic pyeloplasty shows equivalent surgical success rates as previous standard of care treatments. Open pyeloplasty has fallen out of favor as standard of care due to the increased length of hospital stay, increased adverse events, and the undesirable aesthetics. SUMMARY: The use of robotic pyeloplasty has shown to have clinical outcomes that are consistent with other intervention for UPJO, with a potential decrease in length of stay and morbidity. More work has to be done to develop ways to decrease cost of the robot to help establish it as the gold standard for UPJO treatment.

Testosterone therapy in prostate cancer: is it still a controversy?

PURPOSE OF REVIEW: The benefits of testosterone therapy (TTh) in the hypogonadal male can be dramatic. Historically, TTh has been contraindicated in prostate cancer (PCa). Current evidence has redefined our understanding of the influence serum testosterone has on prostatic androgen activity. Increasing numbers of hypogonadal men with coexisting PCa emphasizes the importance of describing those who may safely receive TTh. This review aims to present literature that evaluates the efficacy and safety of TTh in men with coexisting PCa. RECENT FINDINGS: Our study, a comprehensive review of published literature regarding TTh in men with a history of PCa, consisted of studies conducted from the 1940s to 2022. Our review discusses evidence in accordance with previous studies that TTh has a role in patients with localized PCa as it has not been reported to increase rates of recurrence or progression of PCa. SUMMARY: The use of TTh in hypongonadal men with a localized PCa has been shown to have positive clinical outcomes without increasing the rate of disease progression or recurrence. Further research, in a randomized controlled setting, is warranted.

Optimizing the role of androgen deprivation therapy in advanced prostate cancer: Challenges beyond the guidelines.

BACKGROUND: For specific clinical indications, androgen deprivation therapy (ADT) will induce disease prostate cancer (PC) regression, relieve symptoms and prolong survival; however, ADT has a well-described range of side effects, which may have a detrimental effect on the patient's quality of life, necessitating additional interventions or changes in PC treatment. The risk-benefit analysis for initiating ADT in PC patients throughout the PC disease continuum warrants review. METHODS: A 14-member panel comprised of urologic and medical oncologists were chosen for an expert review panel, to provide guidance on a more judicious use of ADT in advanced PC patients. Panel members were chosen based upon their academic and community experience and expertise in the management of PC patients. Four academic members of the panel served as group leaders; the remaining eight panel members were from Large Urology Group Practice Association practices with proven experience in leading their advanced PC clinics. The panel members were assigned to four separate working groups, and were tasked with addressing the role of ADT in specific PC settings. RESULTS: This article describes the practical recommendations of an expert panel for the use of ADT throughout the PC disease continuum, as well as an algorithm summarizing the key recommendations. The target for this publication is all providers (urologists, medical oncologists, radiation oncologists, or advanced practice providers) who evaluate and manage advanced PC patients, regardless of their practice setting. CONCLUSION: The panel has provided recommendations for monitoring PC patients while on ADT, recognizing that PC patients will progress despite testosterone suppression and, therefore, early identification of conversion from castrate-sensitive to castration resistance is critical. Also, the requirement to both identify and mitigate side effects of ADT as well as the importance of quality of life maintenance are essential to the optimization of patient care, especially as more combinatorial therapeutic strategies with ADT continue to emerge.

A randomized, double-blind, solifenacin succinate versus placebo control, phase 4, multicenter study evaluating urinary continence after robotic assisted radical prostatectomy.

PURPOSE: Bladder dysfunction influences recovery of urinary continence after radical prostatectomy. We performed a multicenter, randomized, double-blind study evaluating solifenacin vs placebo on return to continence in patients who were still incontinent 7 to 21 days after catheter removal after robot-assisted radical prostatectomy. MATERIALS AND METHODS: A wireless personal digital assistant was given to patients the day of catheter removal. Encrypted answers were transmitted daily to dedicated servers. After a 7 to 21-day treatment-free washout period, patients requiring 2 to 10 pads per day for 7 consecutive days were randomized (1:1) to 5 mg solifenacin daily or placebo. The primary end point was time from first dose to continence defined as 0 pads per day or a dry security pad for 3 consecutive days. Secondary end points included proportion of patients continent at end of study, average change in pads per day number and quality of life assessments. RESULTS: A total of 1,086 screened patients recorded personal digital assistant information. Overall 640 patients were randomized to solifenacin vs placebo and 17 failed to take medication. There was no difference in time to continence (p=0.17). Continence was achieved by study end in 91 of 313 (29%) vs 66 of 309 (21%), respectively (p=0.04). Pads per day change from baseline was -3.2 and -2.9, respectively (p=0.03). Dry mouth was the only common adverse event seen in 6.1% and 0.6%, respectively. Constipation rates were similar. The overall rate of continence in the entire population from screening to end of study was 73%. CONCLUSIONS: There was no effect on primary outcome but some secondary end points benefited the solifenacin arm. The study provides level 1B clinical evidence for continence outcomes after robot-assisted radical prostatectomy.

Effect of a genomic classifier test on clinical practice decisions for patients with high-risk prostate cancer after surgery.

OBJECTIVES: To evaluate the impact of a genomic classifier (GC) test for predicting metastasis risk after radical prostatectomy (RP) on urologists' decision-making about adjuvant treatment of patients with high-risk prostate cancer. SUBJECTS AND METHODS: Patient case history was extracted from the medical records of each of the 145 patients with pT3 disease or positive surgical margins (PSMs) after RP treated by six high-volume urologists, from five community practices. GC results were available for 122 (84%) of these patients. US board-certified urologists (n = 107) were invited to provide adjuvant treatment recommendations for 10 cases randomly drawn from the pool of patient case histories. For each case, the study participants were asked to make an adjuvant therapy recommendation without (clinical variables only) and with knowledge of the GC test results. Recommendations were made without knowledge of other participants' responses and the presentation of case histories was randomised to minimise recall bias. RESULTS: A total of 110 patient case histories were available for review by the study participants. The median patient age was 62 years, 71% of patients had pT3 disease and 63% had PSMs. The median (range) 5-year predicted probability of metastasis by the GC test for the cohort was 3.9 (1-33)% and the GC test classified 72% of patients as having low risk for metastasis. A total of 51 urologists consented to the study and provided 530 adjuvant treatment recommendations without, and 530 with knowledge of the GC test results. Study participants performed a mean of 130 RPs/year and 55% were from community-based practices. Without GC test result knowledge, observation was recommended for 57% (n = 303), adjuvant radiation therapy (ART) for 36% (n = 193) and other treatments for 7% (n = 34) of patients. Overall, 31% (95% CI: 27-35%) of treatment recommendations changed with knowledge of the GC test results. Of the ART recommendations without GC test result knowledge, 40% (n = 77) changed to observation (95% CI: 33-47%) with this knowledge. Of patients recommended for observation, 13% (n = 38 [95% CI: 9-17%]) were changed to ART with knowledge of the GC test result. Patients with low risk disease according to the GC test were recommended for observation 81% of the time (n = 276), while of those with high risk, 65% were recommended for treatment (n = 118; P < 0.001). Treatment intensity was strongly correlated with the GC-predicted probability of metastasis (P < 0.001) and the GC test was the dominant risk factor driving decisions in multivariable analysis (odds ratio 8.6, 95% CI: 5.3-14.3%; P < 0.001). CONCLUSIONS: Knowledge of GC test results had a direct effect on treatment strategies after surgery. Recommendations for observation increased by 20% for patients assessed by the GC test to be at low risk of metastasis, whereas recommendations for treatment increased by 16% for patients at high risk of metastasis. These results suggest that the implementation of genomic testing in clinical practice may lead to significant changes in adjuvant therapy decision-making for high-risk prostate cancer.

Oncologic outcomes in men with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institution international study.

BACKGROUND: The presence of lymph nodes (LN) within the prostatic anterior fat pad (PAFP) has been reported in several recent reports. These PAFP LNs rarely harbor metastatic disease, and the characteristics of patients with PAFP LN metastasis are not well-described in the literature. Our previous study suggested that metastatic disease to the PAFP LN was associated with less severe oncologic outcomes than those that involve the pelvic lymph node (PLN). Therefore, the objective of this study is to assess the oncologic outcome of prostate cancer (PCa) patients with PAFP LN metastasis in a larger patient population. METHODS: Data were analyzed on 8800 patients from eleven international centers in three countries. Eighty-eight patients were found to have metastatic disease to the PAFP LNs (PAFP+) and 206 men had isolated metastasis to the pelvic LNs (PLN+). Clinicopathologic features were compared using ANOVA and Chi square tests. The Kaplan-Meier method was used to calculate the time to biochemical recurrence (BCR). RESULTS: Of the eighty-eight patients with PAFP LN metastasis, sixty-three (71.6%) were up-staged based on the pathologic analysis of PAFP and eight (9.1%) had a low-risk disease. Patients with LNs present in the PAFP had a higher incidence of biopsy Gleason score (GS) 8-10, pathologic N1 disease, and positive surgical margin in prostatectomy specimens than those with no LNs detected in the PAFP. Men who were PAFP+ with or without PLN involvement had more aggressive pathologic features than those with PLN disease only. However, there was no significant difference in BCR-free survival regardless of adjuvant therapy. In 300 patients who underwent PAFP LN mapping, 65 LNs were detected. It was also found that 44 out of 65 (67.7%) nodes were located in the middle portion of the PAFP. CONCLUSIONS: There was no significant difference in the rate of BCR between the PAFP LN+ and PLN+ groups. The PAFP likely represents a landing zone that is different from the PLNs for PCa metastasis. Therefore, the removal and pathologic analysis of PAFP should be adopted as a standard procedure in all patients undergoing radical prostatectomy.

Telemedicine Utilization in the COVID-19 Era: Patterns of Care in Community Urology Practice.

INTRODUCTION: The acute phase of the COVID-19 pandemic disrupted ambulatory care in the US, and in response telemedicine was adopted rapidly but unevenly across specialties and time. This study examines the utilization of telemedicine in the specialty of urology across a 3-year period (before, during, and after the onset of the pandemic) with the objective of describing patterns, costs, and trends in telemedicine utilization in the specialty. METHODS: The study data were drawn from the adjudicated claims of 1726 providers in 41 independent (privately owned) practices across the US from March 2019 to February 2022. Encounters were indexed to providers to allow for comparisons of utilization across time. Telehealth adoption was defined as the percentage of encounters eligible for reimbursement by telehealth actually conducted by telehealth. RESULTS: A total of 3,630,474 individual patients and 16,130,444 unique encounters were included in our analysis. Telehealth-eligible (evaluation and management) encounters declined sharply from a prepandemic baseline of 262 per provider per month (pppm) to a nadir of 164 pppm in April 2020 (acute phase), but quickly rebounded to 264 pppm by June 2020 (postacute phase). Telehealth adoption among urology providers in this study was 0% prior to March 2020, peaked at 46% in April 2020, and then declined rapidly in the months afterward. CONCLUSIONS: Telehealth adoption in urology spiked abruptly during the acute phase of the pandemic before declining to a low but stable level above prepandemic baseline. These findings may have implications for the broader role of telemedicine in the delivery of urologic care.

Technical and ethical considerations in telesurgery.

Telesurgery, a cutting-edge field at the intersection of medicine and technology, holds immense promise for enhancing surgical capabilities, extending medical care, and improving patient outcomes. In this scenario, this article explores the landscape of technical and ethical considerations that highlight the advancement and adoption of telesurgery. Network considerations are crucial for ensuring seamless and low-latency communication between remote surgeons and robotic systems, while technical challenges encompass system reliability, latency reduction, and the integration of emerging technologies like artificial intelligence and 5G networks. Therefore, this article also explores the critical role of network infrastructure, highlighting the necessity for low-latency, high-bandwidth, secure and private connections to ensure patient safety and surgical precision. Moreover, ethical considerations in telesurgery include patient consent, data security, and the potential for remote surgical interventions to distance surgeons from their patients. Legal and regulatory frameworks require refinement to accommodate the unique aspects of telesurgery, including liability, licensure, and reimbursement. Our article presents a comprehensive analysis of the current state of telesurgery technology and its potential while critically examining the challenges that must be navigated for its widespread adoption.

Clinical applications of robotic surgery platforms: a comprehensive review.

Robotic surgery has expanded globally across various medical specialties since its inception more than 20 years ago. Accompanying this expansion were significant technological improvements, providing tremendous benefits to patients and allowing the surgeon to perform with more precision and accuracy. This review lists some of the different types of platforms available for use in various clinical applications. We performed a literature review of PubMed and Web of Science databases in May 2023, searching for all available articles describing surgical robotic platforms from January 2000 (the year of the first approved surgical robot, da Vinci® System, by Intuitive Surgical) until May 1st, 2023. All retrieved robotic platforms were then divided according to their clinical application into four distinct groups: soft tissue robotic platforms, orthopedic robotic platforms, neurosurgery and spine platforms, and endoluminal robotic platforms. Robotic surgical technology has undergone a rapid expansion over the last few years. Currently, multiple robotic platforms with specialty-specific applications are entering the market. Many of the fields of surgery are now embracing robotic surgical technology. We review some of the most important systems in clinical practice at this time.

Detailed analysis of patients with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institutional study.

PURPOSE: Lymph nodes in the prostatic anterior fat pad rarely harbor metastatic disease. Therefore, the characteristics of patients with prostatic anterior fat pad lymph node metastasis are not well described in the literature. We identified the perioperative characteristics and assessed the clinical outcomes of patients with prostatic anterior fat pad lymph node metastasis. MATERIALS AND METHODS: At 8 tertiary care centers a total of 4,261 patients underwent complete removal and pathological analysis of the prostatic anterior fat pad. We describe preoperative and pathological characteristics, and clinical management and outcomes in patients with metastatic disease to the prostatic anterior fat pad. RESULTS: Metastatic disease to the prostatic anterior fat pad lymph nodes was detected in 40 patients (0.94%), of whom 37 (92.5%) had intermediate or high risk features preoperatively. Most patients with prostatic anterior fat pad metastases underwent concomitant pelvic lymph node dissection, and adjuvant therapy with radiation, androgen ablation and/or chemotherapy. A total of 27 patients (67.5%) with prostatic anterior fat pad metastatic disease were up-staged as a result of prostatic anterior fat pad pathological analysis, of whom 14 (51.8%) remained free of biochemical recurrence with observation and/or definitive adjuvant/salvage therapy. CONCLUSIONS: Most patients with prostatic anterior fat pad metastatic disease had intermediate to high risk features preoperatively. In some patients with such lymph node metastasis removing these lymph nodes resulted in prolonged biochemical recurrence-free survival. Therefore, we recommend that the prostatic anterior fat pad be removed in all patients undergoing radical prostatectomy. However, pathological analysis of the prostatic anterior fat pad may be limited to patients with intermediate to high risk oncological features preoperatively.

Surgical Stone Treatment: Patterns May Predict Performance on Episode-based Cost Measure in the Quality Payment Program.

INTRODUCTION: The Renal or Ureteral Stone Surgical Treatment Episode-based Measure in the Quality Payment Program evaluates clinicians' cost to Medicare for beneficiaries who receive surgical treatment for stones. The measure score is calculated from Medicare claims according to a complex methodology. This paper seeks to describe the stone treatment patterns of urologists and establish benchmarks for 2 surrogate measures-preoperative stenting and postoperative infection-which may predict clinician performance on the episode cost-based measure. METHODS: The study data were drawn from the adjudicated claims of 960 providers who performed at least 30 surgical stone treatments between January 1, 2020, and June 30, 2022. To allow for the correlation of procedures performed by the same providers, generalized estimating equations logistic regression models were used to evaluate the rate of preoperative stenting and postoperative infection. RESULTS: A total of 185,076 surgical episodes (113,799 [61.5%] ureteroscopy, 63,931 [34.5%] extracorporeal shock wave lithotripsy, and 7,346 [4.0%] percutaneous nephrolithotripsy) were identified over the study period. Preoperative stenting was performed in 35,550 episodes (19.2%) and postoperative infection was documented in 13,114 episodes (7.1%). Preoperative stenting and postoperative infection were significantly more common in patients who were female (adjusted OR 1.42, 1.38), in those undergoing ureteroscopy vs extracorporeal shock wave lithotripsy (adjusted OR 3.24, 1.66), and in patients on Medicare vs commercial insurance (adjusted OR 1.19, 1.17). CONCLUSIONS: This large study of surgical stone treatments documents rates of events and associated attributes of patients that may increase episode cost and be relevant to urologists participating in the Quality Payment Program.

Pretreatment expectations of patients undergoing robotic assisted laparoscopic or open retropubic radical prostatectomy.

PURPOSE: We previously found that patients undergoing robotic assisted laparoscopic radical prostatectomy vs radical retropubic prostatectomy had a higher likelihood of not being satisfied, independent of side effect profile. We hypothesized that differential preoperative expectations might contribute to this finding. In the current study we compared expectations of patients undergoing robotic assisted laparoscopic radical prostatectomy vs radical retropubic prostatectomy. MATERIALS AND METHODS: A questionnaire on expectations regarding recovery was administered to 171 patients electing to undergo robotic assisted laparoscopic radical prostatectomy or radical retropubic prostatectomy from 2008 to 2010. We prospectively collected data on patient expectations before surgery. Differences between patients undergoing robotic assisted laparoscopic radical prostatectomy vs radical retropubic prostatectomy were assessed with adjusted proportional odds models. RESULTS: Patients who underwent robotic assisted laparoscopic radical prostatectomy (97) did not differ significantly from those treated with radical retropubic prostatectomy (74) in age, race, income, time between survey and surgery, and prostate specific antigen (p ≥0.4). Patients who underwent radical retropubic prostatectomy had significantly higher clinical stage and Gleason grade disease (p ≤0.007). After adjusting for socioeconomic factors, clinical stage and grade on multivariate analysis, patients who underwent robotic assisted laparoscopic radical prostatectomy expected a significantly shorter length of stay (OR 0.07, p <0.001) and earlier return to physical activity (OR 0.36, p = 0.005). The choice of robotic assisted laparoscopic radical prostatectomy (OR 0.41, p = 0.012), younger age (OR 0.49, p = 0.001) and higher preoperative International Index of Erectile Function-5-item version score (OR 0.60, p = 0.017) were independently associated with the expectation of earlier return of erections but not of continence on multivariate analysis. CONCLUSIONS: The body of evidence surrounding robotic assisted laparoscopic radical prostatectomy supports shorter hospitalization but there is no conclusive evidence that the robotic approach results in earlier return to physical activity or improved disease specific outcomes. Nonetheless we found that patients who underwent robotic assisted laparoscopic radical prostatectomy had higher expectations regarding these outcomes, particularly that of erectile function recovery, than did their radical retropubic prostatectomy counterparts.

Developing a successful robotics program.

PURPOSE OF REVIEW: Advancements in the robotic surgical technology have revolutionized the standard of care for many surgical procedures. The purpose of this review is to evaluate the important considerations in developing a new robotics program at a given healthcare institution. RECENT FINDINGS: Patients' interest in robotic-assisted surgery has and continues to grow because of improved outcomes and decreased periods of hospitalization. Resulting market forces have created a solid foundation for the implementation of robotic surgery into surgical practice. Given proper surgeon experience and an efficient system, robotic-assisted procedures have been cost comparable to open surgical alternatives. Surgeon training and experience is closely linked to the efficiency of a new robotics program. Formally trained robotic surgeons have better patient outcomes and shorter operative times. Training in robotics has shown no negative impact on patient outcomes or mentor learning curves. SUMMARY: Individual economic factors of local healthcare settings must be evaluated when planning for a new robotics program. The high cost of the robotic surgical platform is best offset with a large surgical volume. A mature, experienced surgeon is integral to the success of a new robotics program.

Positive surgical margins after robotic assisted radical prostatectomy: a multi-institutional study.

PURPOSE: Positive surgical margins are an independent predictive factor for biochemical recurrence after radical prostatectomy. We analyzed the incidence of and associative factors for positive surgical margins in a multi-institutional series of 8,418 robotic assisted radical prostatectomies. MATERIALS AND METHODS: We analyzed the records of 8,418 patients who underwent robotic assisted radical prostatectomy at 7 institutions. Of the patients 323 had missing data on margin status. Positive surgical margins were categorized into 4 groups, including apex, bladder neck, posterolateral and multifocal. The records of 6,169 patients were available for multivariate analysis. The variables entered into the logistic regression models were age, body mass index, preoperative prostate specific antigen, biopsy Gleason score, prostate weight and pathological stage. A second model was built to identify predictive factors for positive surgical margins in the subset of patients with organ confined disease (pT2). RESULTS: The overall positive surgical margin rate was 15.7% (1,272 of 8,095 patients). The positive surgical margin rate for pT2 and pT3 disease was 9.45% and 37.2%, respectively. On multivariate analysis pathological stage (pT2 vs pT3 OR 4.588, p<0.001) and preoperative prostate specific antigen (4 or less vs greater than 10 ng/ml OR 2.918, p<0.001) were the most important independent predictive factors for positive surgical margins after robotic assisted radical prostatectomy. Increasing prostate weight was associated with a lower risk of positive surgical margins after robotic assisted radical prostatectomy (OR 0.984, p<0.001) and a higher body mass index was associated with a higher risk of positive surgical margins (OR 1.032, p<0.001). For organ confined disease preoperative prostate specific antigen was the most important factor that independently correlated with positive surgical margins (4 or less vs greater than 10 ng/ml OR 3.8, p<0.001). CONCLUSIONS: The prostatic apex followed by a posterolateral site was the most common location of positive surgical margins after robotic assisted radical prostatectomy. Factors that correlated with cancer aggressiveness, such as pathological stage and preoperative prostate specific antigen, were the most important factors independently associated with an increased risk of positive surgical margins after robotic assisted radical prostatectomy.

Clinical predictors of renal mass pathological features.

OBJECTIVE: • To evaluate the influence of radiographic tumour size and other preoperative variables on the pathological characteristics of the lesion to determine the distribution of pathological features and assess preoperative risk factors for potentially aggressive versus probably indolent renal lesions. PATIENTS AND METHODS: • Retrospective review of records for 768 patients who underwent surgery for single, sporadic renal mass between 2000 and 2008 in a tertiary academic institution. • Demographic, radiographic and pathological variables were recorded and analysed with regression analyses for risk factors for potentially aggressive pathological features (malignant pathology, high Fuhrman grade, lymphovascular invasion and extracapsular extension). RESULTS: • Malignancy was pathologically confirmed in 628 (81.8%) specimens. • Radiographic size was significantly associated with malignancy (versus benign pathology; OR = 1.13, P= 0.001), high Fuhrman grade (OR = 1.21, P < 0.0001), vascular invasion (OR = 1.19, P < 0.0001) and extracapsular extension (OR = 1.23, P < 0.0001). • Age, symptomatic presentation, solid appearance and radiographic size were independent predictors of potentially aggressive disease, whereas for male gender (OR = 1.43, P= 0.062) a trend toward statistical significance was noted. CONCLUSIONS: • Age, male gender, radiographic size and appearance, as well as symptomatic presentation, are associated with an increased risk of malignant, potentially aggressive disease. • These factors should be considered when evaluating management options for a solitary enhancing renal mass.

Predictors of prolonged operative time during robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: To determine risk factors for prolonged operative time (OT) during robot-assisted laparoscopic radical prostatectomy (RALP). Being able to predict prolonged OT is of pivotal importance both to the physician for patient counseling and to the hospital management. PATIENTS AND METHODS: Retrospective review of patient records undergoing RALP between 2003 and 2009 at a tertiary academic center with a structured teaching program. The following variables were recorded: age, race, body-mass index (BMI), previous abdominal surgery (yes/no), nerve-sparing technique (yes/no), lymph nodes dissection (yes/no), pathological stage (organ-confined versus non), cumulative surgical experience with RALP (expressed as number of years since introduction of RALP at our center), prostate weight and OT calculated skin-to-skin by the anesthesiologists. Prolonged OT was defined as the upper quintile (20%) according to the distribution. Multivariate regression model was generated to assess potential predictors of prolonged OT. RESULTS: A total of 523 records were retrieved. Caucasians accounted for 77.8% of the cohort. Median age was 60.3 years (interquartile range, IQR, 55.0-64.6 years), median BMI 28.1 (25.8-30.7 kg/m²), prostate weight 46.0 g (37.0-57.8 g). Eighty-six (16.4%) patients had previous abdominal surgery, lymph nodes dissection was performed in 341 (65.2%) and nerve-sparing technique was done in 310 (59.3%) cases. Median OT was 175 min (IQR 146-220 min). Prolonged OT was set at > 230 min, thereby 105 (20.1%) records were classified as such. On multivariate analysis, cumulative surgical experience with RALP (P < 0.001), nerve sparing (P = 0.023) and prostate weight (P < 0.001) were independent predictors of prolonged OT. CONCLUSIONS: Larger prostates are associated with longer OT and this effect is maintained independently of cumulative robotic experience that represents another independent factor in determining OT.

A comprehensive review of topical hemostatic agents: efficacy and recommendations for use.

Since ancient times we have attempted to facilitate hemostasis by application of topical agents. In the last decade, the number of different effective hemostatic agents has increased drastically. In order for the modern surgeon to successfully choose the right agent at the right time, it is essential to understand the mechanism of action, efficacy and possible adverse events as they relate to each agent. In this article we provide a comprehensive review of the most commonly used hemostatic agents, subcategorized as physical agents, absorbable agents, biologic agents, and synthetic agents. We also evaluate novel hemostatic dressings and their application in the current era. Furthermore, wholesale acquisition prices for hospitals in the United States are provided to aid in cost analysis. We conclude with an expert opinion on which agent to use under different scenarios.

Tumor percent involvement predicts prostate specific antigen recurrence after radical prostatectomy only in men with smaller prostate.

PURPOSE: We determined the predictive power of tumor percent involvement on prostate specific antigen recurrence in patients when stratified by prostate weight. MATERIALS AND METHODS: Data on 3,057 patients who underwent radical prostatectomy between 1988 and 2008 was retrieved from our institutional prostate cancer database. Patients with data on tumor percent involvement, prostate volume and prostate specific antigen recurrence were included in analysis. Patients were divided into 3 groups based on prostate volume less than 35, 35 to 45 and greater than 45 cc. The variables tumor percent involvement, age at surgery, race, prostate specific antigen, pathological Gleason score, positive surgical margins, extraprostatic extension, seminal vesicle invasion and surgery year were analyzed using the chi-square and Mann-Whitney tests to determine individual effects on prostate specific antigen recurrence. Tumor percent involvement and prostate specific antigen were evaluated as continuous variables. Significant variables on univariate analysis were included in multivariate Cox regression analysis to compare their effects on prostate specific antigen recurrence. RESULTS: Tumor percent involvement significantly predicted prostate specific antigen recurrence in men with a small prostate (p = 0.006) but not in those with a prostate of greater than 35 cc. Black race was a marginally significant predictor of prostate specific antigen recurrence in men with a medium prostate (p = 0.055). Age at surgery was a predictor of prostate specific antigen recurrence in men with a larger prostate (p = 0.003). Prostate specific antigen, positive surgical margins, seminal vesicle invasion and pathological Gleason score 7 or greater predicted prostate specific antigen recurrence in men with all prostate sizes. CONCLUSIONS: In men with a prostate of less than 35 cc tumor percent involvement is an important variable when assessing the risk of prostate specific antigen recurrence. Tumor percent involvement and prostate volume should be considered when counseling patients and determining who may benefit from heightened surveillance after radical prostatectomy.

Initial prostate specific antigen 1.5 ng/ml or greater in men 50 years old or younger predicts higher prostate cancer risk.

PURPOSE: Studies show that initial prostate specific antigen higher than the median in young men predicts a subsequent higher risk of prostate cancer. To our knowledge this relationship has not been studied in patients stratified by race. MATERIALS AND METHODS: A cohort of 3,530 black and 6,118 white men 50 years or younger with prostate specific antigen 4 ng/ml or less at the first prostate specific antigen screening was retrieved from the prostate center database at our institution. Patients were divided into groups based on initial prostate specific antigen 0.1 to 0.6, 0.7 to 1.4, 1.5 to 2.4 and 2.5 to 4.0 ng/ml. Univariate and age adjusted multivariate logistic regression was done to estimate the cancer RR in these prostate specific antigen groups. We calculated the prostate cancer rate at subsequent followups. RESULTS: Median prostate specific antigen in black and white men was 0.7 ng/ml at age 50 years or less. The prostate cancer rate was not significantly different in the groups with prostate specific antigen less than 0.6 and 0.7 to 1.4 ng/ml in black or white men. Black and white men with initial prostate specific antigen in the 1.5 to 2.4 ng/ml range had a 9.3 and 6.7-fold increase in the age adjusted prostate cancer RR, respectively. At up to 9 years of followup initial prostate specific antigen 1.5 ng/ml or greater was associated with gradually increased detection at followup in black and white men. CONCLUSIONS: An initial prostate specific antigen cutoff of 1.5 ng/ml may be better than median prostate specific antigen 0.7 ng/ml to determine the risk of prostate cancer in black and white men 50 years old or younger.