Incidence of bladder cancer after radiation for prostate cancer as a function of time and radiation modality.

OBJECTIVES: To evaluate the risk of BlCa developing after radiation for PCa, stratified by ethnicity and follow-up duration. METHODS: The 1973-2011 surveillance, epidemiology and end results database was used to determine the observed and expected number of BlCa after PCa radiation. The adjusted relative risks (RRs) of developing BlCa were calculated for the various radiation modalities relative to no radiation, stratified by ethnicity and follow-up duration. BlCa characteristics were compared between patients with a history of prostate radiation and those without PCa. RESULTS: PCa was radiated in 346,429 men, 6401 of whom developed BlCa versus 2464 expected cases [SIR (95 % CI) of 2.60 (2.53-2.66)]. All radiation modalities were found to have an increased RR of developing BlCa after 10 years, with brachytherapy having a significantly higher RR than external beam radiation (EBRT) or combined EBRT and brachytherapy in Caucasian men and a significantly higher RR than EBRT in men of other/unknown ethnicity. Post-radiation BlCa, in particular that after brachytherapy, had higher grade (P = 0.0001) and lower stage (P = 0.0001) versus the general population. CONCLUSIONS: The increased risk of BlCa after prostate radiation occurs predominantly after 10 years, regardless of ethnicity. The RR of developing BlCa after 10 years is significantly higher following brachytherapy than after EBRT or EBRT and brachytherapy. Bladder cancers after prostate radiation, especially after brachytherapy, are generally lower stage but higher grade than those in patients without PCa.

Detection of prostate cancer in an ethnically diverse, disadvantaged population with multiple prostate specific antigen measurements before biopsy.

PURPOSE: We assessed the predictive effect of prostate specific antigen velocity for men with a minimum of 3 pre-biopsy prostate specific antigen measurements in a racially diverse population. MATERIALS AND METHODS: We identified 795 patients who underwent 3 or more prostate specific antigen tests before prostate biopsy. Prostate specific antigen velocity was calculated by linear regression and used to assess associations with the risk of prostate cancer overall and of high grade prostate cancer (Gleason score 7-10). We created ROC curves and determined the AUC for several models, including only prostate specific antigen velocity or the last prostate specific antigen measurement before biopsy, to predict prostate cancer and high grade prostate cancer. RESULTS: The risk of prostate cancer and high grade prostate cancer increased linearly with increasing prostate specific antigen velocity quartiles (each p trend<0.001). Older patients were more likely to be diagnosed with prostate cancer, given the same prostate specific antigen velocity. In black and Hispanic patients there were strong linear associations between increasing prostate specific antigen velocity and the risk of prostate cancer overall and high grade prostate cancer. ROC curves incorporating prostate specific antigen velocity to predict prostate cancer and high grade prostate cancer varied significantly by race. The AUC of models in black and Hispanic patients was significantly higher than in white patients (0.62 and 0.64, respectively, vs 0.47, p=0.03). CONCLUSIONS: Prostate specific antigen velocity is a significant predictor of prostate cancer and high grade prostate cancer in men with 3 or more prostate specific antigen tests before prostate biopsy. Black and Hispanic patients appear to be at increased risk for prostate cancer at higher prostate specific antigen velocity, as are men older than 60 years. Further studies should confirm these results and create age and race specific guidelines to assess prostate specific antigen velocity.

Recovery of urinary function after radical prostatectomy: predictors of urinary function on preoperative prostate magnetic resonance imaging.

PURPOSE: We determined whether pelvic soft tissue and bony dimensions on endorectal magnetic resonance imaging influence the recovery of continence after radical prostatectomy, and whether adding significant magnetic resonance imaging variables to a statistical model improves the prediction of continence recovery. MATERIALS AND METHODS: Between 2001 and 2004, 967 men undergoing radical prostatectomy underwent preoperative magnetic resonance imaging. Soft tissue and bony dimensions were retrospectively measured by 2 raters blinded to clinical and pathological data. Patients who received neoadjuvant therapy, who were preoperatively incontinent or had missing followup for continence were excluded from study, leaving 600 patients eligible for analysis. No pad use defined continent. Logistic regression was used to identify variables associated with continence recovery at 6 and 12 months. We evaluated whether the predictive accuracy of a base model was improved by adding independently significant magnetic resonance imaging variables. RESULTS: Urethral length and urethral volume were significantly associated with the recovery of continence at 6 and 12 months. Larger inner and outer levator distances were significantly associated with a decreased probability of regaining continence at 6 or 12 months, but they did not reach statistical significance for other points. Addition of these 4 magnetic resonance imaging variables to a base model including age, clinical stage, prostate specific antigen and comorbidities marginally improved the discrimination (12-month AUC improved from 0.587 to 0.634). CONCLUSIONS: Membranous urethral length, urethral volume, and an anatomically close relation between the levator muscle and membranous urethra on preoperative magnetic resonance imaging are independent predictors of continence recovery after radical prostatectomy. The addition of magnetic resonance imaging variables to a base model improved the predictive accuracy for continence recovery, but the predictive accuracy remains low.

Measuring erectile function after radical prostatectomy: comparing a single question with the International Index of Erectile Function.

OBJECTIVE: To present a single-question institutional erectile function scale, which was developed at Memorial Sloan-Kettering Cancer Center (MSKCC) before the availability of the International Index of Erectile Function (IIEF), and to compare its performance with the IIEF. Erectile function status assessment after radical prostatectomy is a significant challenge both for research purposes and in clinical practice. Recently, there has been a shift away from complex questionnaire use such as the IIEF and regression to single-item assessment of erectile function. PATIENTS AND METHODS: Our erectile function score, a single question 5-point score based on physician-patient interview, was applied to 276 patients with prostate cancer after radical prostatectomy. Based on the erectile function score, patients were grouped into five groups. The mean IIEF score and the mean score of questions 3 and 4 of the IIEF were calculated and compared across the groups. Each score group was compared with the preceding group and tested for significant difference. The erectile function domain of the IIEF and the institutional score were tested for correlation. RESULTS: The complete erectile function domain score from the IIEF was available for 170 patients and scores from questions 3 and 4 were available for 220 patients. The institutional erectile function score categorized the subjects into distinct groups based on erectile function status. The institutional erectile function score was highly correlated with the IIEF erectile function domain score (r=-0.692, P < 0.001) and with the questions 3 and 4 combined score (r=-0.678, P < 0.001). CONCLUSIONS: The MSKCC erectile function scale is a practical, readily administered method to assess erectile function in patients with prostate cancer after radical prostatectomy. The erectile function score, as determined by this scale, is highly correlated with the IIEF erectile function domain score.

Assessment of complication and functional outcome reporting in the minimally invasive prostatectomy literature from 2006 to the present.

To query the minimally invasive urological literature from 2006 to the middle of 2010, focusing on complications and functional outcome reporting in laparoscopic radical prostatectomy (LRP) and robot-assisted LRP (RALP), to see if there has been an improvement in the overall reporting of complications. We performed a Medline search using the Medical Subject Heading terms 'prostatectomy', 'laparoscopy', 'robotics', and 'minimally invasive'. We then applied the Martin criteria for complications reporting to the selected articles. We identified 51 studies for a total of 32,680 patients. When excluding functional outcomes the outpatient complications reporting was 20/51 (39.2%). In all, 35% and 43% of papers did not list any method for recording continence and potency, respectively. A complication grading system was only used in 30 studies (58.8%). Of the 16 papers using a grading scale in 2006-2007, only 31.3% used the Clavien system, compared with 69% from 2008 to the first half of 2010. In all, 27% of papers used some form of risk-factor analysis for complications. Multivariate analysis was used in 43% of papers, 29% looked at body mass index, while one looked at prostate weight, and another age. There has been an overall improvement in complications reporting in the minimally invasive RP literature since 2005. However, most studies still do not fulfil many of the criteria necessary for standardised complication reporting. Functional outcome reporting remains poor and unstandardised. Given our current reliance on observational studies, increased efforts should be made to standardise all complication outcomes reporting.

Prognostic factors in male urethral cancer.

BACKGROUND: Male urethral cancer is a rare neoplasm, with the published literature consisting of small single-institution retrospective series. As such, there is no objective analysis of prognostic factors and treatment outcome. The author sought to use the population-based Surveillance, Epidemiology, and End Results (SEER) database to evaluate prognostic factors in male urethral cancer. METHODS: From 1988 to 2006, 2065 men were identified in the SEER database as having primary urethral cancer. Median follow-up was 2.5 years. Cancer-specific and overall survival was computed using the Kaplan-Meier method, and Cox proportional hazards analysis was used to evaluate patient age at diagnosis, year of diagnosis, race, histologic type, grade, T stage, nodal status, M stage, extent of surgery, and type of radiation as potential significant independent predictors of survival. RESULTS: Overall survival at 5 and 10 years was 46.2% (95% confidence interval [CI], 43.9-48.6%) and 29.3% (95% CI, 26.6-32.0%), respectively, whereas cancer-specific survival at 5 and 10 years was 68.0% (95% CI, 65.5-70.5%) and 60.1% (95% CI, 57.0-63.2%), respectively. Advanced age, higher grade, higher T stage, systemic metastases, other histology versus transitional cell carcinoma (TCC), and no surgery versus radical resection were predictors of death and death from disease, whereas adenocarcinoma was associated with a lower likelihood of death and death from disease as compared with TCC. In addition, nodal metastasis was a predictor of death. Surgery had a better outcome than radiation for stage T2 -T4 nonmetastatic disease. CONCLUSIONS: Age, grade, TNM stage, histology, and extent of surgery were predictive of overall and cancer-specific survival.

Age, obesity, medical comorbidities and surgical technique are predictive of symptomatic anastomotic strictures after contemporary radical prostatectomy.

PURPOSE: Anastomotic strictures are relatively common after radical prostatectomy and are associated with significant morbidity, often requiring multiple surgical interventions. There is controversy in the literature regarding which factors predict the development of anastomotic strictures. In this study we determined predictors of symptomatic anastomotic strictures following contemporary radical prostatectomy. MATERIALS AND METHODS: Between 1999 and 2007, 4,592 consecutive patients underwent radical prostatectomy without prior radiotherapy at our institution. Data were collected from prospective surgical and institutional morbidity databases, and retrospectively from inpatient and outpatient medical and billing records. Cases were assigned a Charlson score to account for comorbidities. Complications were graded according to the modified Clavien classification. RESULTS: Open radical prostatectomy was performed in 3,458 men (75%) and laparoscopic radical prostatectomy was performed in 1,134 (25%). The laparoscopic radical prostatectomy group included 97 robotic-assisted cases. Median patient age was 59.5 years (IQR 54.7, 64.2). Symptomatic anastomotic strictures developed in 198 patients (4%) after a median postoperative followup of 3.5 months (IQR 2.1, 6.1). On multivariate analysis significant predictors included patient age, body mass index, Charlson score, renal insufficiency, individual surgeon, surgical approach and the presence of postoperative urine leak or hematoma. CONCLUSIONS: Patient factors as well as technical factors influence the development of symptomatic anastomotic strictures following contemporary radical prostatectomy. The impact of these factors is influenced by the individual surgeon and the approach used.

Extending the indications and anatomical limits of pelvic lymph node dissection for prostate cancer: improved staging or increased morbidity?

OBJECTIVE: • To assess, in a risk/benefit analysis, the additional risk for complications and benefits of extending the indications and anatomical limits of pelvic lymph node dissection (PLND). PATIENTS AND METHODS: • In total, 971 consecutive patients with clinically localized prostate cancer underwent laparoscopic radical prostatectomy from 2003-2007. • Before 1 February 2005, patients with a nomogram probability of lymph node invasion (LNI) <2% did not undergo PLND (No PLND group), whereas those with a LNI ≥ 2% had a PLND limited to the external iliac nodal group (limited PLND group). • After 1 February 2005, all patients underwent a standard PLND including the external iliac, hypogastric and obturator fossa nodal groups (standard PLND group). • The risk parameters were PLND-related complications and operating time. Complications were graded using a modified Clavien classification. The benefit was the detection of nodal metastases. RESULTS: • In the subgroup of patients with a LNI ≥ 2%, standard PLND was a superior operation than the limited PLND in detecting nodal metastases (14.3% vs 4.5%, respectively; P = 0.003). • The risk/benefit of standard vs limited PLND would be one additional grade 3 complication per 20 additional patients with nodal metastases. In the subgroup of patients with LNI <2%, three patients (1.0%) had positive nodes after a standard PLND. • The risk/benefit of standard PLND vs no PLND would be one additional grade 3 complication per three or four additional patients with nodal metastasis. The no PLND group was associated with the lowest risk of grade 1, 2 and 3 complications compared to either the limited or standard PLND groups (P < 0.001). CONCLUSIONS: • In patients with LNI ≥ 2%, standard PLND detects more nodal metastasis. PLND is associated with higher but non-prohibitive complications rate. • The present study found no evidence that the incidence of complications would be reduced by a limited PLND.

Do pelvic dimensions and prostate location contribute to the risk of experiencing complications after radical prostatectomy?

OBJECTIVE: To assess if pelvic size, such as a narrow, steep pelvis, as well as prostate location in relation to the pelvic anatomy might have an impact on the likelihood of experiencing complications after radical prostatectomy. PATIENTS AND METHODS: In a standardized manner, different bony and soft tissue dimensions on preoperative staging MRI were retrospectively measured in a study cohort of 934 patients undergoing radical prostatectomy. Measurements were defined aimed at assessing pelvic size and prostate location. Medical and surgical complications after radical prostatectomy were meticulously reviewed and grouped into subcategories to assess whether a narrow, steep pelvis and an anatomically deeply situated prostate (which is thought to be more surgically challenging) might be associated with a higher likelihood of postoperative complications. Multivariate Cox regression was performed to assess if dimensions have a significant impact on the likelihood of postoperative complications. RESULTS: While known parameters such as a higher preoperative PSA and presence of comorbidities were associated with an increased risk of experiencing complications after surgical treatment, none of the dimensions assessed on preoperative MRI had a significant impact on the development of any medical or surgical complication. CONCLUSION: We report the largest cohort of patients where pelvic dimensions were evaluated in a standardized manner on preoperative MRI aimed at assessing anatomic factors and their impact on complications after radical prostatectomy. None of the measurements could significantly predict the likelihood of developing medical or surgical complications.

Subjective characterization of nerve sparing predicts recovery of erectile function after radical prostatectomy: defining the utility of a nerve sparing grading system.

INTRODUCTION: Radical prostatectomy (RP) is a common technique for managing prostate cancer. Concern regarding functional outcomes in patients prompted the development of nerve sparing to improve recovery of erectile function. AIM: To assess if a cumulative nerve damage grading system is a more precise predictor of recovery of erectile function as compared to the current "all-or-none" grading system. METHODS: Baseline demographic, medical history, and International Index of Erectile Function (IIEF)-erectile function domain (EFD) scores were collected. At the time of RP, patients were assigned a nerve sparing score (NSS) by their surgeon for each neurovascular bundle (left and right) to assess the quality of intraoperative nerve sparing (1-complete preservation, 4-complete resection). Patients completed IIEF questionnaires at 24 months after RP. MAIN OUTCOME MEASURES: Group comparisons and multiple regression analyses were used to test the association between the NSS and IIEF-EFD scores for patients with preoperative EFD scores ≥ 24. RESULTS: A total of 173 patients were included in this analysis. Mean age for patients was 59, and 62% of patients had at least one comorbidity. Baseline EFD scores were comparable between all NSS assignments. At 24 months, EFD scores were reduced by 7.2, 11.6, 13.9, and 15.4 points for patients with NSS grades of 2, 3, 4, and 5-8, respectively (P < 0.01). Multivariate analysis demonstrated lower NSS predicted recovery of erectile function at 24 months (P = 0.001), as did age (P = 0.001) and baseline EFD score (P = 0.02). CONCLUSION: Our data support the adoption of a subjectively assigned NSS to more precisely predict erectile function outcomes and suggest that even minor nerve trauma significantly impairs the recovery of erectile function after procedures classically regarded as having achieved bilateral nerve sparing. Further studies are needed to identify the optimal NSS system.

Pelvimetric dimensions do not impact upon nerve sparing or erectile function recovery in patients undergoing radical retropubic prostatectomy.

INTRODUCTION: The impact of unfavorable pelvic anatomy on the likelihood of having a nerve sparing radical retropubic prostatectomy (RRP) and the potential correlation between pelvic dimensions and recovery of erectile function (EF) after RRP have not been previously evaluated. AIM: To determine the impact of different pelvic bony and soft tissue dimensions as well as apical prostate depth on the likelihood of performing bilateral nerve sparing and on recovery of EF after RP. METHODS: Between November 2001 and June 2007, 644 potent men undergoing RRP had preoperative MRI where pelvimetry was performed with bilateral nerve sparing in 504 men. Outcomes including varying degrees of recovery of EF (level 1: normal; level 2: partial erections routinely sufficient for intercourse; level 3: partial erections occasionally sufficient for intercourse) were assessed. Median follow-up was 44.1 (interquartile range: 29.2, 65.3) months. We evaluated independent predictors of performing a bilateral nerve sparing procedure and of recovery of EF using multivariable Cox proportional hazards methods. MAIN OUTCOME MEASURES: Likelihood of performing bilateral nerve sparing as well as recovery of EF after RRP. RESULTS: Patients with higher clinical stage and biopsy Gleason score are less likely to undergo bilateral nerve sparing. Surgeon is also a factor in the likelihood of having bilateral nerve sparing RRP. On multivariate Cox regression analysis, factors predictive of recovery of EF were age, pretreatment erectile function, surgeon, and modified Charlson score. None of the pelvimetric dimensions were significant predictors of any degree of recovery of EF. However, the study is limited by its retrospective nature and by being based on MRI evaluations useful for cancer staging rather than anatomical evaluation of pelvimetric dimensions. CONCLUSIONS: We did not find unfavorable pelvic anatomy to impact the likelihood of performing a nerve sparing procedure or to be predictive of any degree of recovery of EF after RRP.

Predictors of symptomatic lymphocele after radical prostatectomy and bilateral pelvic lymph node dissection.

OBJECTIVES: Lymphocele is the most common complication of pelvic lymphadenectomy (PLND). We sought to determine predictors of symptomatic lymphocele after radical prostatectomy (RP) and PLND, and in particular, to determine if the number of drains placed represents an independent predictor. METHODS: Between January 1999 and June 2007, 4173 consecutive patients underwent bilateral PLND at the time of either open or laparoscopic RP. Lymphoceles were identified in patients undergoing imaging as a result of symptoms suspicious for lymphocele, such as fever, abdominal pain or lower extremity swelling. Routine postoperative imaging was not carried out. Cox proportional hazards analysis was carried out using forced variable entry to obtain maximum likelihood estimates of the hazard ratios and 95% confidence intervals using the number of drains placed, number of nodes removed, RP approach and use of prophylactic low-molecular-weight heparin (LMWH) as predictors of symptomatic lymphocele. RESULTS: There were 164 patients (4%) with a symptomatic lymphocele on follow up, with a median time to presentation of 19 days. The primary presenting complaints were fever in 47%, abdominal pain in 40%, lower extremity swelling in 37%, genital swelling in 25%, groin pain in 22%, abdominal swelling in 9%, and back and flank pain in 6% and 5%, respectively. Median lymphocele diameter was 5 cm. Significant predictors of symptomatic lymphocele on multivariate analysis included number of nodes removed and use of LMWH, but not number of drains placed. CONCLUSIONS: Use of prophylactic LMWH and a higher node count are predictive of a higher incidence of symptomatic lymphocele after RP and PLND.

Impact of prior prostate radiation on complications after radical prostatectomy.

PURPOSE: Salvage radical prostatectomy is associated with a higher complication rate than radical prostatectomy without prior radiotherapy but the magnitude of the increase is not well delineated. MATERIALS AND METHODS: A total of 3,458 consecutive patients underwent open radical prostatectomy and 98 underwent open salvage radical prostatectomy from January 1999 to June 2007. Data were collected from prospective surgical and institutional morbidity databases, and retrospectively from billing records and medical records. Medical and surgical complications were captured, graded by the modified Clavien classification and classified by time of onset. RESULTS: Median followup after salvage radical prostatectomy and radical prostatectomy was 34.5 and 45.5 months, respectively. Patients with salvage had significantly higher median age, modified Charlson comorbidity score, clinical and pathological stage, and Gleason score. They were less likely to have organ confined disease and more likely to have seminal vesicle invasion and nodal metastasis. There was no significant difference in median operative time, blood loss or transfusion rate. The salvage group had a higher adjusted probability of medical and surgical complications, including urinary tract infection, bladder neck contracture, urinary retention, urinary fistula, abscess and rectal injury. Only 1 of 4 potent patients with salvage prostatectomy who underwent bilateral nerve sparing recovered erection adequate for intercourse. The 3-year actuarial recovery of continence was 30% (95% CI 19-41). CONCLUSIONS: Medical and surgical complications of prostatectomy are significantly increased in the setting of prior radiotherapy. Understanding the magnitude of this increased risk is important for patient counseling.

Long-term follow-up of 3-month neoadjuvant hormone therapy before radical prostatectomy in a randomized trial.

OBJECTIVE: To report our long-term follow-up of an institutional randomized prospective trial of radical prostatectomy (RP) with or without a 3-month course of neoadjuvant hormone therapy (NHT), which results in pathological downstaging, but generally no reduction in biochemical recurrence (BCR) on early follow-up (at 3 years). PATIENTS AND METHODS: From December 1992 to June 1996, 148 patients with clinically localized prostate cancer were randomized to RP only or 3 months of goserelin acetate and flutamide before RP. BCR was defined as a detectable serum prostate specific antigen level (>0.1 ng/mL) at least 6 weeks after surgery, with a confirmatory increase. RESULTS: The median follow-up for BCR-free patients was 8 years. There was no significant difference in BCR-free probabilities between groups (P = 0.7). The BCR-free probability at 7 years was 78% for patients undergoing RP only and 80% for patients undergoing NHT and RP (difference of 2%; 95% confidence interval, CI, 12-16%). A Cox regression showed no significant relationship between NHT and BCR (hazard ratio 1.16; 95% CI, 0.56-2.39, P = 0.7). Overall, two patients had local recurrence and six developed metastases, and were evenly distributed among the RP only and NHT groups. CONCLUSION: Although our study was not originally powered to detect differences in BCR, there was no overall benefit in BCR-free probability, local recurrence or metastasis with 3 months of NHT at 8 years of follow-up. Pending evidence of improvement in patient outcomes, NHT before RP appears to be unjustified outside of clinical trials.

The depth of the prostatic apex is an independent predictor of positive apical margins at radical prostatectomy.

OBJECTIVE: To determine the effect of a deep and narrow pelvis on apical positive surgical margins (PSM) at radical prostatectomy (RP), controlling for other clinical and pathological variables and surgical approach, i.e. open retropubic (RRP) vs laparoscopic (LRP), as apical dissection is expected to be more challenging at RP with a prostate situated deep in a narrow pelvis. PATIENTS AND METHODS: From July 2003 to January 2005, 512 consecutive patients with preoperative prostate magnetic resonance imaging (MRI) underwent RRP or LRP with no previous radio- or hormonal therapy. An additional 74 patients with preoperative MRI undergoing RP from December 2001 to June 2007 who had an apical PSM were also included, with 586 patients comprising the study population. Bony and soft-tissue pelvic dimensions, including interspinous distance (ISD), bony (BFW) and soft tissue (SW) pelvic width, apical prostate depth (AD) and symphysis pubis angle, were measured on preoperative MRI. The pelvic dimension index (PDI), bony width index (BWI) and soft-tissue width index (SWI) were defined as ISD/AD, BFW/AD and SW/AD, respectively. Multivariate logistic regression was used to assess the effect of pelvic dimensions on apical PSM, controlling for surgical approach and clinical and pathological variables. RESULTS: There was no significant difference in ISD, BFW, SW or symphysis angle between patients with and without apical PSM. The AD was significantly greater in men with an apical PSM and consequently PDI, BWI and SWI were significantly lower in men with an apical PSM. Each of PDI, AD, BWI and SWI was a significant independent predictor of apical PSM, independent of surgical approach, and other clinicopathological variables. The main limitations of the study were that it was retrospective, and the relatively few patients with apical PSM. CONCLUSIONS: Apical prostate depth is an independent risk factor for apical PSM at RP. MRI pelvimetry might allow for preoperative planning of the approach to RP.

Time course of recovery of erectile function after radical retropubic prostatectomy: does anyone recover after 2 years?

INTRODUCTION: Given the paucity of literature on the time course of recovery of erectile function (EF) after radical prostatectomy (RP), many publications have led patients and clinicians to believe that erections are unlikely to recover beyond 2 years after RP. AIMS: We sought to determine the time course of recovery of EF beyond 2 years after bilateral nerve sparing (BNS) RP and to determine factors predictive of continued improved recovery beyond 2 years. METHODS: EF was assessed prospectively on a 5-point scale: (i) full erections; (ii) diminished erections routinely sufficient for intercourse; (iii) partial erections occasionally satisfactory for intercourse; (iv) partial erections unsatisfactory for intercourse; and (v) no erections. From 01/1999 to 01/2007, 136 preoperatively potent (levels 1-2) men who underwent BNS RP without prior treatment and who had not recovered consistently functional erections (levels 1-2) at 24 months had further follow-up regarding EF. Median follow-up after the 2-year visit was 36.0 months. MAIN OUTCOME MEASURES: Recovery of improved erections at a later date: recovery of EF level 1-2 in those with level 3 EF at 2 years and recovery of EF level 1-3 in those with level 4-5 EF at 2 years. RESULTS: The actuarial rates of further improved recovery of EF to level 1-2 in those with level 3 EF at 2 years and to level 1-3 in those with level 4-5 EF at 2 years were 8%, 20%, and 23% at 3, 4, and 5 years postoperatively, and 5%, 17%, and 21% at 3, 4, and 5 years postoperatively, respectively. Younger age was predictive of greater likelihood of recovery beyond 2 years. CONCLUSION: There is continued improvement in EF beyond 2 years after BNS RP. Discussion of this prolonged time course of recovery may allow patients to have a more realistic expectation.

Predictors of recovery of erectile function after unilateral cavernous nerve graft reconstruction at radical retropubic prostatectomy.

INTRODUCTION: Although studies have reported a benefit to bilateral cavernous nerve graft (NG) interposition, the role of unilateral NG interposition in recovery of erectile function (EF) after radical prostatectomy (RP) with unilateral neurovascular bundle (NVB) resection is more controversial. AIM: To determine the probability and predictors of EF recovery after unilateral cavernous NG at RP with unilateral NVB resection. METHODS: We retrospectively reviewed the records of preoperatively potent men who underwent RP with unilateral NVB resection and ipsilateral NG without prior radiation or hormonal therapy from 1999 to 2007. Postoperative EF was defined in two ways: (i) physician interview-based assessment (level 3: erections sometimes sufficient for intercourse; level 2: erections routinely sufficient for intercourse; level 1: normal erections; all with or without oral phosphodiesterase-5 inhibitor use); and (ii) according to the sum Q3 + Q4 on the International Index of Erectile Function (IIEF) questionnaire. MAIN OUTCOME MEASURES: EF recovery based on physician interview-based scale and IIEF questionnaire. RESULTS: In all, 131 men underwent unilateral NG. Median follow-up was 37.3 months. The 5-year actuarial probability of EF recovery was 46, 30, and 12% for levels 3, 2, and 1, respectively, and 40, 34, and 22% for IIEF Q3 + Q4 sum > or =6, > or =8, and = 10, respectively. On multivariate analysis, patient age, specimen weight, and plastic surgeon were predictive of EF recovery based on physician-interview whereas patient age, ethnicity, and plastic surgeon were predictive of EF recovery based on the IIEF questionnaire. CONCLUSIONS: The impact of plastic surgeon on EF recovery with unilateral NG would suggest that technical factors play a role in EF recovery after unilateral NG. Meticulous surgical technique with proper identification of proximal and distal recipient nerve endings may improve the chance of EF recovery. The variation in recovery rate among plastic surgeons would imply that there is a benefit to unilateral NG in EF recovery.

Role of short-term antibiotic therapy at the moment of catheter removal after laparoscopic radical prostatectomy.

OBJECTIVE: To assess the role of short-term antibiotic therapy (ABT) in preventing urinary tract infection (UTI) after catheter removal following laparoscopic radical prostatectomy (LRP). METHODS: 729 consecutive patients underwent LRP by one of two surgeons. One surgeon systematically prescribed a 3-day course of ABT (ciprofloxacin) starting the day before catheter removal; the other surgeon did not. The groups were compared for the incidence of symptomatic UTI occurring within 6 weeks after catheter removal. RESULTS: ABT was given to 261 of 713 patients (37%), while the remaining 452 patients (63%) did not receive ABT. After catheter removal, UTI was observed less frequently among patients receiving ABT: 3.1 vs. 7.3% in those not receiving ABT (p = 0.019). A number needed to treat to prevent 1 UTI is 24. Hospital readmission for febrile UTI was observed only in patients who did not receive ABT (n = 5, 1.1 vs. 0%, p = 0.16). One would need to prescribe ABT for 91 LRP patients to prevent 1 case of febrile UTI. CONCLUSIONS: ABT at the time of catheter removal reduced the risk of postoperative UTI after LRP. One would need to prescribe ABT to 24 patients to prevent 1 case of UTI.

Accuracy of the extent of bladder cancer nodal metastases found at pelvic lymphadenectomy at the time of cystectomy: relation to primary tumor stage.

OBJECTIVES: To determine the minimum number of nodes (n(min)) that need to be removed to ascertain N(0) status with 90/95% certainty, and to determine the maximum number of nodes theoretically involved for a given number 'm' of involved nodes reported out of a total of 'n' nodes examined. METHODS: 2,025 patients underwent cystectomy and pelvic lymphadenectomy, with pathologic stage < or =pT(2) in 1,132 (55.9%) and > or =pT(3) in 893 (44.1%). A mathematical model was utilized, using incidences derived from those having > or =10 nodes retrieved. RESULTS: For stage < or =pT(2) and 0, 1, or 2 positive nodes reported, n(min) are 2, 27, and 28, respectively, for 90% accuracy and 12, 29, and 29, respectively, for 95% accuracy. For stage > or =pT(3) and 0, 1, or 2 positive nodes reported, n(min) are 19, 28, and 29, respectively, for 90% accuracy and 24, 29, and 30, respectively, for 95% accuracy. CONCLUSIONS: Accuracy of the extent of nodal involvement depends on the number of positive nodes reported, total number of nodes retrieved, and pathologic stage. This model allows clinicians to assess potential underestimation of the 'true' number of involved nodes for a given number of positive nodes out of a total number reported.

Prostate size is associated with surgical difficulty but not functional outcome at 1 year after radical prostatectomy.

PURPOSE: We assessed the impact of prostate size on operative difficulty as measured by estimated blood loss, operating room time and positive surgical margins. In addition, we assessed the impact on biochemical recurrence and the functional outcomes of potency and continence at 1 year after radical prostatectomy as well as postoperative bladder neck contracture. MATERIALS AND METHODS: From 1998 to 2007, 3,067 men underwent radical prostatectomy by 1 of 5 dedicated prostate surgeons with no neoadjuvant or adjuvant therapy. Pathological specimen weight was used as a measure of prostate size. Cox proportional hazards and logistic regression analysis was used to study the association between specimen weight, and biochemical recurrence and surgical margin status, respectively, controlling for adverse pathological features. Continence and potency were analyzed controlling for age, nerve sparing status and surgical approach. RESULTS: With increasing prostate size there was increased estimated blood loss (p = 0.013) and operative time (p = 0.004), and a decrease in positive surgical margins (84 of 632 [14%] for 40 gm or less, 99 of 862 [12%] for 41 to 50 gm, 78 of 842 [10%] for 51 to 65 gm, 68 of 731 [10%] for more than 65 gm, p <0.001). Biochemical recurrence was observed in 186 of 2,882 patients followed postoperatively and was not significantly associated with specimen weight (p = 0.3). Complete continence was observed in 1,165 of 1,422 patients (82%) and potency in 425 of 827 (51%) at 1 year. Specimen weight was not significantly associated with potency (p = 0.8), continence (p = 0.08) or bladder neck contracture (p = 0.22). CONCLUSIONS: Prostate size does not appear to affect biochemical recurrence or 1-year functional results. However, estimated blood loss and operative time increased with larger prostate size, and positive surgical margins are more often observed in smaller glands.