Cryoablation for locally advanced clinical stage T3 prostate cancer: a report from the Cryo-On-Line Database (COLD) Registry.

OBJECTIVE: To assess the oncological and functional outcomes of primary prostate cryoablation for men with clinical stage T3 (cT3) prostate cancer, as although radical prostatectomy (RP) or external beam radiotherapy (EBRT) are the standard treatments for locally advanced cT3 prostate cancer some patients opt for nonextirpative prostate cryoablation instead. PATIENTS AND METHODS: The Cryo-On-Line Database (COLD) Registry was queried to identify patients with cT3 prostate cancer treated with whole-gland cryoablation (366 patients). We assessed biochemical disease-free survival (bDFS) using the Phoenix definition and determined reported rates of urinary incontinence and retention, sexual activity, and rectourethral fistulisation after treatment. Patients were subsequently assessed according to whether they were administered neoadjuvant androgen-deprivation therapy or not (ADT; 115 patients, 31.4%). RESULTS: For the entire cohort, the 36- and 60-month bDFS rates were 65.3% and 51.9%, respectively. Patients who received neoadjuvant ADT had statistically nonsignificantly higher 36- and 60-month bDFS rates (68.0% and 55.4%, respectively) than patients who did not receive neoadjuvant ADT (55.3% and 36.9%, respectively). The after treatment urinary incontinence rate was 2.6%; urinary retention rate, 6.0%; sexual activity rate, 30.4%; and rectourethral fistulisation rate, 1.1%. CONCLUSIONS: Cryoablation for patients with cT3 prostate cancer leads to less favourable bDFS than that after RP or RT for the same group of men. The after treatment rectourethral fistulisation rates for patients with cT3 disease are higher than in those with organ-confined prostate cancer treated with cryoablation; however, urinary dysfunction and sexual activity rates are similar for men with cT3 to those reported from this same registry in men with cT2 disease. The addition of neoadjuvant ADT (though not studied prospectively here) should be strongly considered if a patient with cT3 prostate cancer is to be treated with cryoablation.

Peyronie's disease compromises the durability and component-malfunction rates in patients implanted with an inflatable penile prosthesis.

OBJECTIVE: To compare the durability and complication rates of surgery to implant an inflatable penile prosthesis (IPP) between patients with and without Peyronie's disease (PD). PATIENTS AND METHODS: We retrospectively reviewed all patients undergoing IPP surgery at one centre (Memphis) between July 1997 and May 2007. Variables included age at surgery, race, body mass index, presence of PD, brand/type of IPP (two vs three pieces), presence of diabetes mellitus (DM), active tobacco use, and complications. The result were assessed using t-tests, chi-square and regression analysis, with P < 0.05 considered to indicate significant differences. RESULTS: In all, 79 men were analysed (mean age 59.8 years, range 38.1-81.5). Nine (11%) patients had PD and had a IPP implanted, with penile modelling. Overall, 43 (54%) patients had pre-existing DM and 51 (65%) actively used tobacco. At a mean (range) follow-up of 19.6 (0.1-115.3) months, six (8%) patients had component malfunctions. Of these, three had DM and four actively smoked. Of the nine patients with PD, three developed component malfunctions, vs three (4%) who did not have PD (P= 0.002). Both groups had similar infection rates (P= 0.98). The mean (range) time to component malfunction was 4.3 (0.1-9.6) months, which was longer (but not significantly) in the PD group, with a mean (median, range) of 10.9 (6.3, 1.1-9.6) months, than the 3.0 (1.0, 0.2-7.9) months in the group without PD (P= 0.4). Groups were matched for rates of DM (P= 0.1) and tobacco use (P= 0.2). PD was a significant predictor of component malfunction on both univariate (P= 0.001) and multivariate analysis (P= 0.002) when adjusting for age (P= 0.2), body mass index (P= 0.7), DM (P= 0.3) and tobacco use (P= 0.8). CONCLUSION: Patients with PD implanted with a IPP, with penile modelling, had significantly higher component malfunction rates. Further, PD independently predicted component malfunction. These findings might be related to stress on the device at the time of surgery, during use, or both. Further study into this relationship is required.

Variation in the incidence of and risk factors for the development of nephrolithiasis after radical or partial nephrectomy.

OBJECTIVE: to examine incidence of and risk factors for the development of nephrolithiasis in patients treated with radical nephrectomy (RN) or partial nephrectomy (nephron-sparing surgery, NSS). PATIENTS AND METHODS: the study comprised a single-centre review of 749 patients treated with RN or NSS from August 1987 to June 2006. Demographics, medical and stone history, metabolic variables and postoperative stone events were recorded. Data were analysed within subgroups based on treatment (RN vs NSS). Multivariate analysis was used to identify risk factors for postoperative stone formation. RESULTS: in all, 499 patients had RN and 250 had NSS (mean age 57.9 years; mean follow-up 6.3 years). There were no significant differences in their demographic factors, but tumours were significantly larger in RN (P < 0.001). There was no significant difference in preoperative urinary pH < 6.0 or stone history. Significantly fewer patients after NSS than RN formed calculi (NSS 1.6% vs RN 8.4%, P < 0.001), developed hypobicarbonataemia (NSS 7.2% vs RN 12.8%, P= 0.020), and a urinary pH of <6.0 (NSS 11.2% vs RN 19.4%, P= 0.004). Multivariate analysis showed that RN (odds ratio 18.18), postoperative urinary pH < 6 (15.63), previous stone disease (13.7), age <60 years (7.33, all P < 0.001), body mass index ≥ 30 kg/m(2) (3.26, P= 0.033), male gender (2.67, P= 0.039), and hypobicarbonataemia (2.46, P= 0.034) were significantly associated with the development of postoperative calculi. CONCLUSIONS: patients undergoing RN have a significantly higher incidence of postoperative nephrolithiasis than a well-matched cohort undergoing NSS. In addition to RN, male sex, urinary pH < 6.0, hypobicarbonataemia, history of stone disease, obesity, and age <60 years were significantly associated with postoperative stone formation.

Feasibility and efficacy of neoadjuvant sunitinib before nephron-sparing surgery.

OBJECTIVE: To investigate efficacy of neoadjuvant tyrosine kinase-inhibitor therapy (TKI) before imperative nephron-sparing surgery (NSS), as NSS in patients with large locally advanced or centrally located tumours can be challenging, and TKI therapy might result in a reduction of primary tumour burden and increase the feasibility of NSS. PATIENTS AND METHODS: This was a multicentre retrospective review and prospective pilot study of patients undergoing neoadjuvant sunitinib before planned NSS from February 2006 to February 2009. All patients underwent confirmatory biopsy for clear cell renal cell carcinoma. Patients received two 28-day cycles of sunitinib before NSS. Demographics/tumour characteristics, tumour response (by the Response Evaluation Criteria In Solid Tumors), outcomes and complications were analysed. RESULTS: Twelve patients (seven men and five women; mean age 60.1 years, tumours on 14 renal units) were given TKI before NSS for imperative indications. The mean pretreatment tumour diameter was 7.1 cm; all patients had a decrease in size of the primary tumour after TKI, with a mean reduction in maximum diameter of 1.5 cm (21.1%). Four of 14 and 10 of 14 primary tumours had a partial response and stable disease after TKI. NSS was achievable in all 14 kidneys. Four patients had a concurrent metastasectomy. The mean warm ischaemia time was 22.5 min; postoperative dialysis was not required in any patients. Final pathology revealed negative tumour margins in all 14 tumours. The mean creatinine and estimated glomerular filtration rate (before/after NSS) were 1.34/1.40 mg/dL (P = 0.431) and 57.7/53.4 mL/min/1.73 m(2) (P = 0.475), respectively. At a mean follow-up of 23.9 months, 10 of the 12 patients were alive, one died from metastatic RCC and none required dialysis. Three of the 14 renal units developed delayed urinary leaks, all in patients who also received postoperative sunitinib. All leaks resolved with conservative measures. CONCLUSIONS: Neoadjuvant TKI followed by NSS is safe and feasible, with all patients achieving a reduction in maximum tumour diameter, and with NSS being achievable with negative margins and with no requirement for postoperative dialysis. Further investigation is required.

Comparison of rates and risk factors for developing chronic renal insufficiency, proteinuria and metabolic acidosis after radical or partial nephrectomy.

OBJECTIVE: To investigate the incidence of and risk factors for developing chronic renal insufficiency (CRI), proteinuria and metabolic acidosis (MA) in patients treated with radical nephrectomy (RN) or nephron-sparing surgery (NSS). PATIENTS AND METHODS: We retrospectively reviewed 749 patients (mean age 57.7 years; mean follow-up 6.4 years) who had RN or NSS for renal tumours between July 1987 and June 2006 at our institution. The demographics and outcomes were analysed and recorded. The primary outcome variable was the development of an estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m(2), with secondary outcomes being the development of a serum creatinine level of > or =2.0 mg/dL, MA (serum bicarbonate <22 mmol/L), and proteinuria (> or =1+ on dipstick testing). Multivariate logistic regression (MV) was used to identify risk factors for developing an eGFR of <60 mL/min/1.73 m(2), a creatinine level of > or =2.0 mg/dL and MA. RESULTS: Of the 749 patients, 499 had RN and 250 NSS; there were no significant demographic differences between the groups. After surgery a significantly greater proportion of the RN than the NSS group had a low eGFR (44.7% vs 16.0%, P < 0.001), MA (12.8% vs 7.2%, P = 0.02), proteinuria (22.2% vs 13.2%, P = 0.003) and elevated creatinine (14.2% vs 8.4%, P = 0.022). MV showed that diabetes mellitus (odds ratio 8.96, P = 0.002), RN (5.32, P < 0.001), hypertension (4.55, P = 0.003), a body mass index (BMI) of > or =30 kg/m(2) (3.51, P = 0.017), age > or =60 years (2.91, P = 0.015) and smoking (2.44, P = 0.014) were risk factors for developing a low eGFR; and that age > or =60 years (2.00, P = 0.019), diabetes mellitus (10, P < 0.001), hypertension (7.41, P = 0.002), smoking (5.29, P < 0.001) and RN (3.08, P < 0.001) were risk factors for developing an elevated creatinine level; and that being male (2.50, P = 0.019), age > or =60 years (3.13, P = 0.002), a BMI > or =30 (3.52, P < 0.001), RN (9.82, P < 0.001), preoperative eGFR <60 (9.71, P < 0.001) and elevated creatinine (5.9, P = 0.008) were risk factors for developing MA. CONCLUSIONS: Patients undergoing RN had significantly greater CRI, MA and proteinuria rates than a well-matched group undergoing NSS. In addition to RN, age > or =60 years, diabetes mellitus, hypertension and smoking were associated with progression to CRI after surgery.

Survival outcomes in men receiving androgen-deprivation therapy as primary or salvage treatment for localized or advanced prostate cancer: 20-year single-centre experience.

OBJECTIVES: To evaluate the overall survival (OS) and disease-specific survival (DSS) in men receiving primary androgen-deprivation therapy (PADT) or salvage medical ADT (SADT) for prostate cancer. PATIENTS AND METHODS: After Institutional Review Board approval, we retrospectively reviewed patients receiving ADT for prostate cancer between July 1987 and June 2007. Variables included age at diagnosis and ADT induction, race, PSA level before ADT, ADT schedule (continuous/intermittent), clinical/pathological stage, hormone-refractory prostate cancer (HRCP) status, PADT or SADT, and deaths. RESULTS: In all, 548 men were analysed. The mean age at diagnosis and ADT induction were 70.1 and 72.3 years, respectively, and 321 (58.6%) were African-American. The median PSA level before ADT was 16.3 ng/mL. ADT was administered continuously in 497 (90.7%) patients; 342 (62.4%) received PADT while 206 (37.6%) received SADT. At mean (range) follow-up of 81.8 (2.1-445) months, 98 (17.9%) deaths occurred; 31 (31.6%) were cancer-specific. The OS and DSS in the PADT and SADT groups were not significantly different (P = 0.36 and P = 0.81, respectively). Mortality rates/distributions were similar between groups (P = 0.68). Multivariate predictors of OS and DSS included age at diagnosis (P = 0.03) and ADT induction (P = 0.009), tumour stage (P < 0.001), and PSA level at ADT induction (P = 0.01). Progression to HRPC worsened OS and DSS (both P < 0.001). CONCLUSION: PADT and SADT prolong survival in men with prostate cancer. HRPC portends a poor DSS. Age at diagnosis and ADT induction, PSA level before ADT, and disease stage predict both OS and DSS in this population. However, most men died from causes unrelated to prostate cancer, thus questioning the true value of ADT in prolonging patient survival.

Adverse effects of androgen deprivation therapy in prostate cancer: Current management issues.

Prostate cancer (CaP) is the most common visceral malignancy and a leading cause of cancer death in men. Androgen deprivation therapy (ADT) is an established treatment for locally advanced and metastatic CaP, and often used as primary therapy in select patients. As ADT has continued to assume an important role in the treatment of CaP, a greater appreciation of potential adverse effects has been acknowledged in men receiving this therapy. Given that all treatments for CaP are frequently associated with some degree of morbidity and can have a negative impact on health-related quality of life (HRQOL), the potential benefits of any treatment, including ADT, must outweigh the risks, particularly in patients with asymptomatic disease. Once the choice to proceed with ADT is complete, it is imperative for the urologist to possess comprehensive knowledge of the potential adverse effects of ADT. This permits the urologist to properly monitor for, perhaps diminish, and to treat any linked morbidities. Patient complaints related to ADT such as a decrease in HRQOL, cognitive and sexual dysfunction, hot flashes, endocrine abnormalities, cardiovascular disease, and alterations in skeletal and body composition are commonly reported throughout the literature. Herein, we review the principal adverse effects linked with ADT in CaP patients and suggest various universal strategies that may diminish these potential adverse consequences associated with this therapy.

Patterns of sexual and erectile dysfunction and response to treatment in patients receiving androgen deprivation therapy for prostate cancer.

OBJECTIVE: To investigate the incidence of patient-reported erectile (ED) and sexual dysfunction and response to treatment in men after the induction of androgen deprivation therapy (ADT) for prostate cancer, as ADT-induced changes in serum testosterone can result in changes in libido and sexual function. PATIENTS AND METHODS: We retrospectively reviewed patients receiving ADT for prostate cancer at our institution between January 1989 and July 2005; those receiving only neoadjuvant ADT were excluded. Variables included age, race, body mass index, prostate-specific antigen level before ADT, Gleason sum, clinical stage, ADT type (medical vs surgical) and schedule (continuous vs intermittent), previous treatment for prostate cancer, presence of pre-existing or new-onset diabetes mellitus (DM), and presence of ED before ADT. After ADT induction, charts were reviewed for reporting of ED, changes in libido, and initiation of ED therapy (medical or surgical). RESULTS: In all, 395 patients (mean age of 71.7 years; 59.0% African-American, 41.0% Caucasian/other, at initiation ADT) were analysed. At mean follow-up of 87.4 months, 57 (14.4%) patients reported ED; 40 of these (70%) reported new-onset ED, while 17 (30%) reported ED before ADT. Response rates were 33-80% with medical therapy, including 44% receiving phosphodiesterase-5 inhibitor monotherapy. On multivariate analysis, age <70 years (P < 0.001) and the absence of DM (P = 0.024) were associated with reporting ED after ADT. CONCLUSIONS: Patients receiving ADT for prostate cancer have variable degrees of ED. Successful outcomes are possible, particularly when implementing multimodal therapy. Younger patients and those with no DM are more likely to report ED after ADT induction.

Nonoperative management of blunt renal trauma: is routine early follow-up imaging necessary?

BACKGROUND: There is no consensus on the role of routine follow-up imaging during nonoperative management of blunt renal trauma. We reviewed our experience with nonoperative management of blunt renal injuries in order to evaluate the utility of routine early follow-up imaging. METHODS: We reviewed all cases of blunt renal injury admitted for nonoperative management at our institution between 1/2002 and 1/2006. Data were compiled from chart review, and clinical outcomes were correlated with CT imaging results. RESULTS: 207 patients were identified (210 renal units). American Association for the Surgery of Trauma (AAST) grades I, II, III, IV, and V were assigned to 35 (16%), 66 (31%), 81 (39%), 26 (13%), and 2 (1%) renal units, respectively. 177 (84%) renal units underwent routine follow-up imaging 24-48 hours after admission. In three cases of grade IV renal injury, a ureteral stent was placed after serial imaging demonstrated persistent extravasation. In no other cases did follow-up imaging independently alter clinical management. There were no urologic complications among cases for which follow-up imaging was not obtained. CONCLUSION: Routine follow-up imaging is unnecessary for blunt renal injuries of grades I-III. Grade IV renovascular injuries can be followed clinically without routine early follow-up imaging, but urine extravasation necessitates serial imaging to guide management decisions. The volume of grade V renal injuries in this study is not sufficient to support or contest the need for routine follow-up imaging.

Tubeless percutaneous nephrolithotomy for complex renal stone disease: single center experience.

OBJECTIVE: Tubeless percutaneous nephrolithotomy (PCNL) has become an option for treatment of renal stone disease, though no clearly defined algorithm exists for selection of patients suitable to tubeless PCNL. We investigated our experience with tubeless PCNL to evaluate its safety and efficacy for cases of complex renal calculi. PATIENTS AND METHODS: Retrospective review of all tubeless PCNLs performed for complex renal calculus disease (bilateral stones, partial/complete staghorn, infundibular stenosis/calyceal diverticulum, pre-existing renal insufficiency) between January 2001 and January 2006. All patients had a ureteral stent placed in an antegrade fashion following stone treatment, and a foley catheter remained in place overnight. No patient received nephrostomy tube (NT). Imaging (CT or KUB) was obtained at the first outpatient follow-up visit. Patient demographics, incidence of complications, clinical outcomes and stone-free rates were noted and analyzed. "Stone free" was defined as negative imaging (CT or KUB). RESULTS: Forty-two patients (47 renal units) were treated with tubeless PCNL for complex renal stone disease (5 bilateral, 25 total/partial staghorn, 12 renal insufficiency, and 10 infundibular stenosis or calyceal diverticulum). Mean age was 58.2+/-9.4 years. Mean length of hospital stay was 2.1 days. Mean preoperative and postoperative hematocrit were 40.5+/-4.5 and 37.2+/-5.8, respectively (p=0.001). Single-procedure stone free rate was 74.5%, and the two-procedure stone free rate was 91.5%. One patient (2.4%) required a blood transfusion and one patient (2.4%) developed urosepsis. CONCLUSIONS: Tubeless PCNL is safe and effective and can be utilized in cases of complex renal stone disease.

Prevalence and predictive factors for the development of de novo psychiatric illness in patients receiving androgen deprivation therapy for prostate cancer.

OBJECTIVE: Androgen deprivation therapy (ADT) remains a widely utilized modality for treatment of localized and advanced prostate cancer. While ADT-induced alterations in testosterone have demonstrated impacts on quality of life, the effects on mental health remain ill-defined. We investigated the prevalence of de novo psychiatric illness and predictive factors following ADT induction for prostate cancer. MATERIALS AND METHODS: We retrospectively reviewed patients receiving ADT for prostate cancer at our institution between 1/1989-7/2005, excluding men receiving only neoadjuvant ADT. Variables included age, race, body mass index, prostate-specific antigen (PSA), Gleason sum, clinical stage, ADT type (medical/surgical) and schedule (continuous/intermittent), and presence of pre-ADT and newly diagnosed psychiatric illness. The cohort was divided into three groups for analysis: pre-ADT psychiatric illness, de novo psychiatric illness, and no psychiatric illness. Data analysis utilized statistical software with p < 0.05 considered significant. RESULTS: Three-hundred and ninety-five patients with a mean age of 71.7 years at ADT initiation were analyzed. Thirty-four men (8.6%) were diagnosed with pre-ADT psychiatric illness. At mean follow-up of 87.4 months, 101 (27.9%) men were diagnosed with de novo psychiatric illness, most commonly including: depression (n = 57; 56.4%), dementia (n = 14; 13.9%), and anxiety (n = 9; 8.9%). On multivariate analysis, increasing pre-ADT PSA was predictive of post-ADT anxiety (p = 0.01). Overall and disease-specific survival outcomes were similar between groups. CONCLUSIONS: De novo psychiatric illness was identified in 27.9% of men. While no predictive factors were identified for de novo psychiatric illness, increasing PSA was associated with de novo anxiety. Prospective investigation using validated instruments is requisite to further delineate the relationship between ADT and psychiatric health.

Contemporary analysis of erectile, voiding, and oncologic outcomes following primary targeted cryoablation of the prostate for clinically localized prostate cancer.

PURPOSE: To evaluate erectile function (EF) and voiding function following primary targeted cryoablation of the prostate (TCAP) for clinically localized prostate cancer (CaP) in a contemporary cohort. MATERIALS AND METHODS: We retrospectively reviewed all patients treated between 2/2000-5/2006 with primary TCAP. Variables included age, Gleason sum, pre-TCAP prostate specific antigen (PSA), prostate volume, clinical stage, pre-TCAP hormonal ablation, pre-TCAP EF and American Urologic Association Symptom Score (AUASS). EF was recorded as follows: 1 = potent; 2 = sufficient for intercourse; 3 = partial/insufficient; 4 = minimal/insufficient; 5 = none. Voiding function was analyzed by comparing pre/post-TCAP AUASS. Statistical analysis utilized SAS software with p < 0.05 considered significant. RESULTS: After exclusions, 78 consecutive patients were analyzed with a mean age of 69.2 years and follow-up 39.8 months. Thirty-five (44.9%) men reported pre-TCAP EF level of 1-2. Post-TCAP, 9 of 35 (25.7%) regained EF of level 1-2 while 1 (2.9%) achieved level 3 EF. Median pre-TCAP AUASS was 8.75 versus 7.50 postoperatively (p = 0.39). Six patients (7.7%) experienced post-TCAP urinary incontinence. Lower pre-TCAP PSA (p = 0.008) and higher Gleason sum (p = 0.002) were associated with higher post-TCAP AUASS while prostate volume demonstrated a trend (p = 0.07). Post-TCAP EF and stable AUASS were not associated with increased disease-recurrence (p = 0.24 and p = 0.67, respectively). CONCLUSIONS: Stable voiding function was observed post-TCAP, with an overall incontinence rate of 7.7%. Further, though erectile dysfunction is common following TCAP, 25.7% of previously potent patients demonstrated erections suitable for intercourse. While long-term data is requisite, consideration should be made for prospective evaluation of penile rehabilitation following primary TCAP.

Osteoporosis and fractures after androgen deprivation initiation for prostate cancer.

INTRODUCTION: Androgen deprivation therapy (ADT) is widely utilized for treatment of localized and advanced prostate cancer (CaP). ADT is associated with increased rates of osteoporosis; however, its impact on fracture risk is not completely understood. We investigated incidence and predisposing factors for osteoporosis and fractures in a large, contemporary, single institution series of patients treated with ADT for CaP. METHODS: We retrospectively reviewed medical records of all patients who received ADT for CaP between 1/1989 and 7/2005. Primary endpoints of investigation were osteoporosis and non-pathologic fractures. Independent variables included age, race, body mass index (BMI), pretreatment serum PSA, Gleason sum, clinical stage, ADT type (medical versus surgical) and schedule (continuous versus intermittent), and receipt of calcium, vitamin D or bisphosphonate supplementation. Data were analyzed by Chi-square test, Student's t-test, Linear Regression, and Logistic Regression (p < 0.05 significant). RESULTS: A total of 395 patients were analyzed (mean age 71.7 years, 59% African American, 41% Caucasian/other). At mean follow-up of 66.1 months, 92 (23%) patients developed osteoporosis and 27 (7%) patients developed non-pathologic fractures. On univariate analysis, age, race, BMI, and ADT duration were significantly associated with osteoporosis development, while BMI, ADT duration, and presence of osteoporosis were significantly associated with fracture incidence. Regression analysis revealed that age > 70 at ADT initiation, continuous ADT, and increased treatment duration predicted osteoporosis development, while only osteoporosis was independently predictive of fracture development. CONCLUSIONS: Patients receiving continuous ADT for CaP are at increased risk for developing osteoporosis which may lead to fractures, with an incidence of 7% in our study population.

Postoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy.

PURPOSE: A postoperative nomogram for prostate cancer recurrence after radical prostatectomy (RP) has been independently validated as accurate and discriminating. We have updated the nomogram by extending the predictions to 10 years after RP and have enabled the nomogram predictions to be adjusted for the disease-free interval that a patient has maintained after RP. METHODS: Cox regression analysis was used to model the clinical information for 1,881 patients who underwent RP for clinically-localized prostate cancer by two high-volume surgeons. The model was externally validated separately on two independent cohorts of 1,782 patients and 1,357 patients, respectively. Disease progression was defined as a rising prostate-specific antigen (PSA) level, clinical progression, radiotherapy more than 12 months postoperatively, or initiation of systemic therapy. RESULTS: The 10-year progression-free probability for the modeling set was 79% (95% CI, 75% to 82%). Significant variables in the multivariable model included PSA (P = .002), primary (P < .0001) and secondary Gleason grade (P = .0006), extracapsular extension (P < .0001), positive surgical margins (P = .028), seminal vesicle invasion (P < .0001), lymph node involvement (P = .030), treatment year (P = .008), and adjuvant radiotherapy (P = .046). The concordance index of the nomogram when applied to the independent validation sets was 0.81 and 0.79. CONCLUSION: We have developed and validated as a robust predictive model an enhanced postoperative nomogram for prostate cancer recurrence after RP. Unique to predictive models, the nomogram predictions can be adjusted for the disease-free interval that a patient has achieved after RP.

Long-term oncologic results of salvage radical prostatectomy for locally recurrent prostate cancer after radiotherapy.

PURPOSE: Salvage radical prostatectomy (RP) may potentially cure patients who have isolated local prostate cancer recurrence after radiotherapy (RT). We report the long-term cancer control associated with salvage RP in a consecutive cohort of patients and identify the variables associated with disease progression and cancer survival. METHODS AND MATERIALS: A total of 100 consecutive patients underwent salvage RP with curative intent for biopsy-confirmed, locally recurrent, prostate cancer after RT. Disease progression after salvage RP was defined as a prostate-specific antigen (PSA) level of > or =0.2 ng/mL or by initiation of androgen deprivation therapy. Cancer-specific mortality was defined as active clinical disease progression despite castration. Cox regression analysis was used to evaluate these endpoints. The median follow-up from RT was 10 years (range, 3-27 years) and from salvage RP was 5 years (range, 1-20 years). RESULTS: Overall, the 5-year progression-free probability was 55% (95% confidence interval, 46-64%), and the median progression-free interval was 6.4 years. The preoperative PSA level was the only significant pretreatment predictor of disease progression in the multivariate analysis (p = 0.01). The 5-year progression-free probability for patients with a preoperative PSA level of <4, 4-10, and >10 ng/mL was 86%, 55%, and 37%, respectively. The 10-year and 15-year cancer-specific mortality after salvage RP was 27% and 40%, respectively. The median time from disease progression to cancer-specific death was 10.3 years (95% confidence interval, 7.6-12.9). After multivariate analysis, the preoperative serum PSA level and seminal vesicle or lymph node status correlated independently with disease progression. CONCLUSIONS: Greater preoperative PSA levels are associated with disease progression and cancer-specific death. Long-term control of locally recurrent prostate cancer after definitive RT is possible when salvage RP is performed early in the course of recurrent disease.

Nomogram to predict prostate cancer diagnosis on primary transrectal ultrasound-guided prostate biopsy in a contemporary series.

OBJECTIVE: Transrectal ultrasound-guided biopsy (TRUSB) remains the mainstay for prostate cancer (CaP) diagnosis. Numerous variables have shown associations with development of CaP. We present a nomogram that predicts the probability of detecting CaP on TRUSB. METHODS: After obtaining institutional review board approval, all patients undergoing primary TRUSB for CaP detection at a single center at our institution between 2/2000 and 9/2007 were reviewed. Patients undergoing repeat biopsies were excluded, and only the first biopsy was included in the analysis. Variables included age at biopsy, race, clinical stage, prostate specific antigen (PSA), number of cores removed, TRUS prostate volume (TRUSPV), body mass index, family history of CaP, and pathology results. S-PLUS 2000 statistical software was utilized with p < 0.05 considered significant. Cox proportional hazards regression models with restricted cubic splines were utilized to construct the nomogram. Validation utilized bootstrapping, and the concordance index was calculated based on these predictions. RESULTS: A total of 1,542 consecutive patients underwent primary TRUSB with a median age of 64.2 years (range 34.9-89.2 years), PSA of 5.7 ng/ml (range 0.3-3,900 ng/ml), number of cores removed of 8.0 (range 1- 22) and TRUSPV of 36.4 cm(3) (range 9.6-212.0 cm(3)). CaP was diagnosed in 561 (36.4%) patients. A nomogram was constructed incorporating age at biopsy, race, PSA, body mass index, clinical stage, TRUSPV, number of cores removed, and family history of CaP. The concordance index when validated internally was 0.802. CONCLUSIONS: We have developed and internally validated a model predicting cancer detection in men undergoing TRUSB in a contemporary series. This model may assist clinicians in risk-stratifying potential candidates for TRUSB, potentially avoiding unnecessary or low-probability TRUSB.

Sutureless laparoscopic heminephrectomy: safety and efficacy in physiologic and chronically obstructed porcine kidney.

We sought to develop and examine the feasibility and efficacy of a streamlined sutureless system of repairing parenchymal and collecting system defects using BioGlue (bovine albumin-glutaraldehyde adhesive) and ProPatch (bovine pericardial patch) in swine under physiological conditions and mechanical stress imposed by chronic ureteral obstruction caused by complete ureteral transaction. Five pigs (10 kidneys) underwent left-side transperitoneal laparoscopic heminephrectomy, followed 2 weeks later by right-sided heminephrectomy with complete ureteral transaction (between clips) to provide a mechanical stressor on the repair, followed 2 weeks later by euthanasia. In each case, after hilar clamping, the lower pole was removed with a bipolar dissector. Hemostasis was obtained with argon beam coagulator and FloSeal (thrombin-gelatin matrix), followed by sutureless repair (ProPatch-BioGlue "sandwich"). At euthanasia, harvested kidneys underwent ex vivo retrograde-pyelography and pathological examination to rule out urinoma/perinephric fluid collection and determine collecting system/parenchymal healing. Mean operative time was 77.8 minutes. Mean warm ischemia time was 12.3+/-5.6 minutes. Estimated blood loss was 49.5+/-39.0 mL. All animals demonstrated immediate hemostasis on hilar clamp release. Pyelography failed to demonstrate any collecting system leakage, and closure and healing was confirmed in all. Four of 5 pigs had intact renal function at euthanasia. Two pigs were euthanized for causes unrelated to procedures 4 days prior to study end. This study provides proof of principle that sutureless laparoscopic heminephrectomy is effective in physiological and chronic obstruction conditions in the porcine model. The procedure is reproducible, and resection/renorrhaphy was completed on average with approximately 12 minutes warm ischemia time.

Single center comparison of laparoscopic cryoablation and CT-guided percutaneous cryoablation for renal tumors.

BACKGROUND AND PURPOSE: Cryoablation has demonstrated therapeutic effectiveness for selected renal tumors. We compared our perioperative and short-term outcomes of laparoscopic (LAP) v percutaneous (PERC) renal cryoablation. PATIENTS AND METHODS: Thirty-four patients (18 men/16 women) underwent a LAP and 26 patients (19 men/7 women) underwent a PERC procedure between September1998 and January 2007. LAP cryoablation was performed transperitoneally with ultrasonographic monitoring. PERC cryoablation was performed with CT guidance. Follow-up imaging was obtained at regular intervals. RESULTS: Mean follow-up was 25 months. Average age (years) was 67.0 for the LAP and 69.7 for the PERC procedure (P = 0.307). Mean body mass index (kg/m(2)) was 29.8 for those undergoing LAP and 28.7 for those undergoing PERC procedures (P = 0.543). Mean tumor size (cm) was 2.9 for LAP patients and 3.1 for PERC patients (P = 0.432). Anterior tumors comprised 61.7% of LAP and 15.4% of PERC procedures (P < 0.001). Posterior tumors comprised 32.4% of LAP and 65.4% of PERC procedures (P = 0.01). Mean procedure time (minutes) was 165.7 for LAP and 106.6 for PERC procedures (P < 0.001). Hospital stay (days) was 2.6 for those undergoing LAP and 1.8 for those undergoing PERC procedures (P < 0.001). Both LAP patients (82.4%) and PERC patients (19.2%) needed postoperative narcotics (P < 0.001). Atelectasis developed in 70.6% of LAP patients and 34.6% of PERC patients (P = 0.005). Residual enhancement was seen in 11.5% of PERC patients and 2.9% of LAP patients (P = 0.192). Complications developed in 14.7% of LAP patients and 26.9% of PERC patients (P = 0.248). 1-year, 2-year, and 3-year disease-specific survival for the two groups was 100%. Tumor size > 4 cm and endophytic location were significantly associated with residual enhancement. CONCLUSIONS: LAP and PERC renal cryoablation have similar short-term outcomes. Significantly more anterior tumors were approached laparoscopically and significantly more posterior tumors were approached percutaneously. The PERC approach may offer advantages regarding hospital stay, narcotic need, and development of atelectasis. Longer-term data are needed to establish success of this approach.

Risk of new-onset diabetes mellitus and worsening glycaemic variables for established diabetes in men undergoing androgen-deprivation therapy for prostate cancer.

OBJECTIVE To investigate the incidence of new-onset diabetes mellitus (NODM) and of worsening glycaemic control in established DM after starting androgen-deprivation therapy (ADT) for prostate cancer, as ADT is associated with altered body composition, potentially influencing insulin sensitivity. PATIENTS AND METHODS We retrospectively reviewed patients receiving ADT for prostate cancer at our institution between January 1989 and July 2005; those with incomplete information and those receiving only neoadjuvant ADT were excluded. Variables examined included age, race, body mass index (BMI), pretreatment prostate-specific antigen, Gleason sum, clinical stage, ADT type (medical vs surgical) and schedule (continuous vs intermittent), presence of pre-existing DM, serum glucose and glycosylated haemoglobin (HbA1c) levels before and after ADT, and receipt of vitamin D or bisphosphonate supplementation. Data were analysed statistically and P < 0.05 considered to indicate significance. RESULTS In all, 396 patients (median age 73.2 years; median BMI of 26.7 kg/m(2) at ADT initiation) were analysed. Of these, 59.1% were African-American and 40.9% were Caucasian/other. At a median follow-up of 60.1 months, 36 (11.3%) patients developed NODM. In 77 patients with pre-existing DM, there was an increase of >/=10% in serum HbA1c or fasting glucose levels in 15 (19.5%) and 22 (28.6%), respectively. On multivariate analysis, a BMI of >/=30 kg/m(2) was associated with an increased risk of developing NODM (odds ratio 4.65, P = 0.031). Receipt of vitamin D had a protective effect (odds ratio 5.75, P = 0.017). CONCLUSIONS Patients receiving ADT for prostate cancer with or with no history of DM should have routine surveillance of glycaemic control, particularly when their BMI is >/= 30 kg/m(2), with appropriate preventive and treatment measures.

Mini-flank supra-11th rib incision for open partial or radical nephrectomy.

OBJECTIVE: To report our approach to partial (PN) or radical nephrectomy (RN) using a supra-11th mini-flank incision, as the widespread availability of advanced imaging has increased the detection of incidental, lower-stage renal tumours that are generally amenable to resection using smaller incisions. PATIENTS AND METHODS: The study included 167 consecutive patients undergoing PN/RN for renal tumours treated between February 2000 and March 2003 using the supra-11th rib mini-flank approach. Variables analysed were age, gender, nephrectomy type (PN vs RN), operative duration, estimated blood loss (EBL), hospital stay, tumour size and location, pathological stage and histology, perioperative transfusions, and complications. Patients undergoing PN were examined for ischaemia type (cold, warm, none) and duration of renal artery clamping. The interval after surgery to initiate solid diet and discontinue patient-controlled analgesia, and overall pain control, were analysed and compared between PN and RN. RESULTS: In all, 133 patients (80%) underwent PN and 34 (20%) RN, at a median age of 61.7 years. The median operative duration was 2.9 h, the EBL 400 mL, tumour size 3.2 cm and median hospital stay 5 days. At a median follow-up of 18.2 months, there were seven (4%) late complications: six patients had a flank bulge and one had a reducible hernia. Surgical margins were negative in 164 (98%) patients. CONCLUSIONS: The supra-11th rib mini-flank incision offers a practical alternative to traditional open or laparoscopic PN or RN. Using a small (8 cm) incision with no rib resection, this approach affords optimum exposure without compromising cancer control, with excellent cosmetic results and a lower risk of late complications at the wound site.