Do commonly used prostate medications alter prostate MRI and fusion biopsy performance?

AIMS: To determine whether phosphodiesterase inhibitors (PDEi) or α-antagonists (AA) were associated with differences in region of interest (ROI) characteristics or prostate cancer detection on fusion biopsy (FB). MATERIALS AND METHODS: Records from 847 consecutive patients undergoing FB at three separate institutions over a period of 2 years were retrospectively reviewed. Associations between medication use, Prostate Imaging Reporting & Data System (PIRADS) scores, and ROI locations were assessed with ordinal logistic regression. Associations with lesion size and International Society of Urologic Pathology (ISUP) grade group (GG) on biopsy were tested using multivariate regression. RESULTS: Medication use included PDEi in 14.2% and AA in 23.0%. PDEi use was associated with 19.3% smaller lesion diameter (-2.8 mm; CI from -4.8 to -0.7; p < 0.01) and lower PIRADS scores on MRI (OR 0.60; CI 0.40 - 1.00; p = 0.05). AA use was associated with higher PIRADS scores (OR 1.43; CI 0.97 - 2.11; p = 0.06), fewer positive fusion-directed biopsy cores (-28.6%, CI from -57.9 to 0.01%, p = 0.05), and downgrading on final pathology (-19%; CI from -40 to 2%; p = 0.06). CONCLUSION: For PIRADS scores ≥ 3, PDEi use is associated with smaller ROI and lower PIRADS scores, while AA use is associated with higher PIRADS scores. Neither medication was associated with differences in biopsy GG. Prospective studies are needed to investigate the discordance between multi-parametric magnetic resonance imaging (mpMRI) results and oncologic outcomes associated with PDEi and AA use.

Outcomes of MRI fusion-guided versus systematic standard prostate biopsies.

INTRODUCTION: The current utility of MRI-fusion targeted biopsy as either an adjunct to or replacement for systematic template biopsy for the detection of clinically significant prostate cancer is disputed. The purpose of this study is to assess the current effectiveness of MRI-targeted versus systematic template prostate biopsies at two institutions and to consider possible underlying factors that could impact variability between detection rates in our patient population compared to others. MATERIALS AND METHODS: A retrospective review from our prospectively maintained prostate cancer databases was conducted. Patients with prostate MRI lesions (PI-RADSv2) receiving concurrent systematic 12-core and MRI-fusion targeted biopsies were reviewed. Clinically significant cancer was considered to be Grade Group ≥ 2. RESULTS: A total of 457 patients were included in the analysis; 255 patients received their biopsy at Institution A and 202 at Institution B. Overall cancer detection rate was 68%; the clinically significant cancer detection rate was 34%. Both MRI-targeted and systematic biopsies identified unique cases of clinically significant prostate cancer that the other modality missed. Out of 157 cases of clinically significant prostate cancer, MRI-targeted biopsy identified 29/157 cases (18%) missed by systematic biopsy, while systematic biopsy identified 37/157 cases (24%) missed by MRI-targeted biopsy (p = .39). Individual biopsy performance was similar when stratified by active surveillance or prior biopsy status, PI-RADSv2 score, and institution. CONCLUSIONS: MRI-fusion targeted and systematic biopsy each identified unique cases of clinically significant prostate cancer. Both biopsy modalities should be utilized in order to provide the greatest sensitivity for the detection of clinically significant prostate cancer.

National Comprehensive Cancer Network® Favorable Intermediate Risk Prostate Cancer-Is Active Surveillance Appropriate?

PURPOSE: We compared pathological and biochemical outcomes after radical prostatectomy in patients at favorable intermediate risk who fulfilled current NCCN® (National Comprehensive Cancer Network®) Guidelines® for active surveillance criteria to outcomes in patients who met more traditional criteria for active surveillance. MATERIALS AND METHODS: We queried our institutional review board approved prostate cancer database for patients who met NCCN criteria for very low risk (T1c, Grade Group 1, 3 or fewer of 12 cores, 50% or less core volume and prostate specific antigen density less than 0.15 ng/ml), low risk (T1-T2a, Grade Group 1 and prostate specific antigen less than 10 ng/ml) or favorable intermediate risk (major pattern grade 3 and less than 50% positive biopsy cores) and who had 1 intermediate risk factor, including T2b/c, Grade Group 2 or prostate specific antigen 10 to 20 ng/ml. Men at intermediate risk who did not meet favorable criteria were labeled as being at unfavorable intermediate risk. Patients at favorable intermediate risk were compared to those at very low and low risk, and those at unfavorable intermediate risk to identify differences in rates of adverse pathological findings at radical prostatectomy, including Gleason score Grade Group 3-5, nonorgan confined disease or nodal involvement. Time to biochemical recurrence was compared among the groups using Cox regression. RESULTS: A total of 3,686 patients underwent radical prostatectomy between January 1, 2014 and December 31, 2015. Of these men 1,454, 250 and 1,362 fulfilled the criteria for low, favorable intermediate and unfavorable intermediate risk, respectively. The rate of adverse pathological findings in favorable intermediate risk cases was significantly higher than in low risk cases and significantly lower than in unfavorable intermediate risk cases (27.4% vs 14.8% and 48.5%, respectively, each p <0.001). Time to biochemical recurrence differed significantly among the risk groups (p <0.001). CONCLUSIONS: Relative to men at low risk those at favorable intermediate risk represent a distinct group. Care should be taken when selecting these patients for active surveillance and monitoring them once they are in an active surveillance program.

Prostate atypia: does repeat biopsy detect clinically significant prostate cancer?

BACKGROUND: While the treatment pathway in response to benign or malignant prostate biopsies is well established, there is uncertainty regarding the risk of subsequently diagnosing prostate cancer when an initial diagnosis of prostate atypia is made. As such, we investigated the likelihood of a repeat biopsy diagnosing prostate cancer (PCa) in patients in which an initial biopsy diagnosed prostate atypia. METHODS: We reviewed our prospectively maintained prostate biopsy database to identify patients who underwent a repeat prostate biopsy within one year of atypia (atypical small acinar proliferation; ASAP) diagnosis between November 1987 and March 2011. Patients with a history of PCa were excluded. Chart review identified patients who underwent radical prostatectomy (RP), radiotherapy (RT), or active surveillance (AS). For some analyses, patients were divided into two subgroups based on their date of service. RESULTS: Ten thousand seven hundred and twenty patients underwent 13,595 biopsies during November 1987-March 2011. Five hundred and sixty seven patients (5.3%) had ASAP on initial biopsy, and 287 (50.1%) of these patients underwent a repeat biopsy within one year. Of these, 122 (42.5%) were negative, 44 (15.3%) had atypia, 19 (6.6%) had prostatic intraepithelial neoplasia, and 102 (35.6%) contained PCa. Using modified Epstein's criteria, 27/53 (51%) patients with PCa on repeat biopsy were determined to have clinically significant tumors. 37 (36.3%) proceeded to RP, 25 (24.5%) underwent RT, and 40 (39.2%) received no immediate treatment. In patients who underwent surgery, Gleason grade on final pathology was upgraded in 11 (35.5%), and downgraded 1 (3.2%) patient. CONCLUSIONS: ASAP on initial biopsy was associated with a significant risk of PCa on repeat biopsy in patients who subsequently underwent definitive local therapy. Patients with ASAP should be counseled on the probability of harboring both clinically significant and insignificant prostate cancer.

Weighted Gleason scores do not outperform standard clinical Gleason scores.

INTRODUCTION: Predicting patient survival rates following radical prostatectomy remains an area of clinical interest. We compared the ability of standard clinical Gleason scores and alternative 'weighted' Gleason scores to predict pathology, margin status and recurrence in prostate cancer. MATERIALS AND METHODS: Patients who underwent robotic radical prostatectomy performed by a single surgeon between Jan 2007 - Dec 2008 were included. Tumor at the inked margin in pathologic samples was considered a positive margin. Recurrence was defined as PSA ≥ 0.2 or the institution of salvage therapy. Standard pathologic Gleason scores were recorded. The proportion of tumor in each core was used to calculate 'weighted' and 'rounded weighted ' Gleason scores. The ability of each Gleason score to predict pathology, margin status and recurrence were statistically compared. RESULTS: Of 433 cases, 281 with uniform Gleason 6 cores were excluded. One hundred and fifty-two cases had Gleason scores ≥ 7, of which complete data were unavailable for three patients. In the final cohort of 149 cases, 72 (48.3%) patients had uniformly scored biopsies, while 77 (51.7%) had biopsies with non-uniform Gleason scores. The positive margin rate and recurrence free rates were 30.2% and 77.2%, respectively. Analyses of the entire patient cohort, and patients with non-uniform cores, found no significant difference between the predictive capacities of each scoring system. The alternative algorithms were not shown to be better predictors of pathologic Gleason score, margin status or recurrence. CONCLUSIONS: Using the highest standard Gleason score of all cores to define a preoperative Gleason score remains an appropriate clinical practice.

Impact of active surveillance on pathology and nerve sparing status.

INTRODUCTION: We assessed whether, in comparison to immediate surgery, a time delay in performing radical prostatectomy (RP) in patients electing to undergo a period of active surveillance (AS) of low grade prostate cancer, is associated with adverse pathologic features, biochemical recurrence and the ability to perform effective nerve sparing surgery. MATERIALS AND METHODS: From our RP database of 2769 patients, we identified 41 men under AS who subsequently underwent RP. This study group was compared to control group A (164 patients who chose RP rather than AS), matched for prostate-specific antigen (PSA) and initial diagnostic biopsy characteristics. With time, PSA and biopsy characteristics in the AS study group changed, prompting these men to undergo RP. These changes were matched to create a separate control group B (123 patients most of whom did not meet AS criteria). The incidence of nerve sparing surgery, pathologic features, and biochemical recurrence were compared. Outcome variables were compared using Chi-square tests of proportions. Fisher's Exact test was used for recurrence rates due to the low expected frequencies in some cells. RESULTS: Compared with control group A, the AS patients experienced higher rates of Gleason score upgrading (33/41; 81.1% versus 76/164; 46.3%, p < 0.001), biochemical recurrence (5/41; 11.4% versus 2/164; 1.3%, p = 0.012) and lower rates of bilateral nerve sparing surgery (31/41; 75.6% versus 154/164; 93.9%, p < 0.001). Control group B and active surveillance group were comparable across all indices measured. CONCLUSIONS: Delaying RP, through undergoing a period of AS, had a significant negative impact on the incidence of bilateral nerve sparing surgery and adverse pathologic features when compared to patients with similar parameters at the time of diagnosis. Close monitoring and surveillance biopsies did not improve pathologic outcomes compared to patients from whom a single diagnostic biopsy was obtained (and were not candidates for AS), and who subsequently underwent immediate surgery.

The Association of a Peritoneal Interposition Flap With Lymphocele Formation After Pelvic Lymph Node Dissection During Robotic-assisted Laparoscopic Radical Prostatectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis to evaluate the association of a peritoneal interposition flap (PIF) with lymphocele formation following robotic-assisted laparoscopic radical prostatectomy (RALP) with pelvic lymph node dissection. METHODS: We conducted a systematic search of MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials through August 30, 2023, to identify randomized and nonrandomized studies comparing RALP with pelvic lymph node dissection with and without PIF. A random effects meta-analysis was then performed to evaluate the associations of PIF with 90-day postoperative outcomes. RESULTS: Five randomized controlled trials (RCTs) and four observational studies, including a total of 2941 patients, were included. The use of PIF was associated with a reduced risk of 90-day symptomatic lymphocele formation after RALP when examining only RCTs (pooled odds ratios [OR] 0.44, 95% CI 0.28-0.69; I2 =3%) and both RCTs and observational studies (OR 0.35, 95% CI 0.22-0.56; I2 =17%). Similarly, use of PIF was associated with a reduced risk of 90-day any lymphocele formation (OR 0.40, 95% CI 0.28-0.56, I2 =39%). There were no statistically significant differences in postoperative complications between the two groups (OR 0.89; 95% CI 0.69-1.14; I2 =20%). CONCLUSION: Use of the PIF is associated with an approximately 50% reduced risk of symptomatic and any lymphocele formation within 90-days of surgery, and it is not associated with an increase in postoperative complications.

Impact of Peritoneal Interposition Flap on Patients Undergoing Robot-assisted Radical Prostatectomy and Pelvic Lymph Node Dissection: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

CONTEXT: Symptomatic lymphocele (sLC) occurs at a frequency of 2-10% after robot-assisted radical prostatectomy (RARP) with pelvic lymph node dissection (PLND). Construction of bilateral peritoneal interposition flaps (PIFs) subsequent to completion of RARP + PLND has been introduced to reduce the risk of lymphocele, and was initially evaluated on the basis of retrospective studies. OBJECTIVE: To conduct a systematic review and meta-analysis of only randomized controlled trials (RCTs) evaluating the impact of PIF on the rate of sLC (primary endpoint) and of overall lymphocele (oLC) and Clavien-Dindo grade ≥3 complications (secondary endpoints) to provide the best available evidence. EVIDENCE ACQUISITION: In accordance with the Preferred Reporting Items for Meta-Analyses statement for observational studies in epidemiology, a systematic literature search using the MEDLINE (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), and EMBASE databases up to February 3, 2023 was performed to identify RCTs. The risk of bias (RoB) was assessed using the revised Cochrane RoB tool for randomized trials. Meta-analysis used random-effect models to examine the impact of PIF on the primary and secondary endpoints. EVIDENCE SYNTHESIS: Four RCTs comparing outcomes for patients undergoing RARP + PLND with or without PIF were identified: PIANOFORTE, PerFix, ProLy, and PLUS. PIF was associated with odds ratios of 0.46 (95% confidence interval [CI] 0.23-0.93) for sLC, 0.51 (95% CI 0.38-0.68) for oLC, and 0.41 (95% CI 0.21-0.83) for Clavien-Dindo grade ≥3 complications. Functional impairment resulting from PIF construction was not observed. Heterogeneity was low to moderate, and RoB was low. CONCLUSIONS: PIF should be performed in patients undergoing RARP and simultaneous PLND to prevent or reduce postoperative sLC. PATIENT SUMMARY: A significant proportion of patients undergoing prostate cancer surgery have regional lymph nodes removed. This part of the surgery is associated with a risk of postoperative lymph collections (lymphocele). The risk of lymphocele can be halved via a complication-free surgical modification called a peritoneal interposition flap.

Prostate cancer biochemical recurrence rates after robotic-assisted laparoscopic radical prostatectomy.

BACKGROUND AND OBJECTIVES: To determine prostate cancer biochemical recurrence rates with respect to surgical margin (SM) status for patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP). METHODS: IRB-approved radical prostatectomy database was queried. Patients were stratified as low, intermediate, and high risk according to D'Amico's risk classification. Postoperative prostate-specific antigen (PSA) values were obtained every 3 mo for the first year, then biannually and annually thereafter. Biochemical recurrence was defined as ≥0.2ng/mL. Patients receiving adjuvant or salvage treatment were included. Positive surgical margin was defined as presence of cancer cells at inked resection margin in the final specimen. Margin presence (negative/positive), margin multiplicity (single/multiple), and margin length (≤ 3mm focal and >3mm extensive) were noted. Kaplan-Meier curves of biochemical recurrence-free survival (BRFS) as a function of SM were generated. Forward stepwise multivariate Cox regression was performed, with preoperative PSA, Gleason score, pathologic stage, prostate gland weight, and SM as covariates. RESULTS: At our institution, 1437 patients underwent RALP (2003-2009). Of these, 1159 had sufficient data and were included in our analysis. Mean follow-up was 16 mo. Kaplan-Meier curves demonstrated significant increase in BRFS in low-risk and intermediate-risk groups with negative SM. Overall BRFS at 5 y was 72%. Gleason score, pathologic stage, and SM status were significant prognostic factors in multivariate analysis. CONCLUSIONS: Negative surgical margins resulted in lower biochemical recurrence rates for low-risk and intermediate-risk groups. Multifocal and longer positive margins were associated with higher biochemical recurrence rates compared with unifocal and shorter positive margins. Documenting biochemical recurrence rates for RALP is important, because this treatment for localized prostate cancer is validated.

Robot-assisted laparoscopic distal ureteral surgery.

BACKGROUND: The use of robotic assistance in adult genitourinary surgery has been successful in many operations, leading surgeons to test its use in other applications as well. METHODS: Based on our use during prostatectomy, we have applied robotic surgery to complex distal ureteral surgeries since 2004 with successful outcomes. RESULTS: A series of 11 patients who underwent robot-assisted laparoscopic distal ureteral surgery is presented. These surgeries include distal ureterectomy for ureteral cancer with reimplantation, as well as reimplantation with and without Boari flap or psoas hitch for benign conditions. CONCLUSIONS: Robot-assisted laparoscopic surgery can be successfully applied to patients requiring distal ureteral surgery. Maintenance of the principles of open surgery is paramount.

Robot-assisted laparoscopic ileal ureter.

BACKGROUND AND OBJECTIVES: A patient with a solitary kidney, cysteine stones, and recurrent ureteral strictures underwent robot-assisted laparoscopic ureterectomy with ileal ureter formation. METHODS: Using a transperitoneal, 4-port robotic approach, we removed the strictured ureter and created an ileal ureter. The ileal-pyelo and ileal-vesical anastomoses were performed using the robotic system. An extracorporeal bowel anastomosis was performed using stapling devices. Operative time was 9 hours with negligible blood loss, and the patient was discharged after 5 days. RESULTS: A cystogram at 10 days demonstrated patent anastomoses without extravasation. The patient continues to do well 48 months later. CONCLUSION: Robot-assisted laparoscopic ileal ureter replacement is feasible with excellent long-term outcome.

Robotic assisted laparoscopic bladder diverticulectomy.

PURPOSE: Surgical management for bladder diverticuli includes open, endoscopic and standard laparoscopic techniques. To our knowledge we report the first series of robotic assisted laparoscopic bladder diverticulectomies. MATERIALS AND METHODS: Five patients underwent robotic assisted laparoscopic bladder diverticulectomy between December 2004 and December 2006, as performed by a single surgeon using the da Vinci robotic system for symptomatic diverticuli. The records were reviewed, the surgical technique is described and a review of the literature was performed. RESULTS: All patients underwent cystoscopy, ureteral stent placement and placement of an angiographic catheter to distend the diverticulum. The diverticulum was approached transperitoneally, mobilized and transected at its neck, and the bladder was closed in 2 layers. One patient underwent ureteral reimplantation for a Hutch diverticulum. Median total operative time was 178 minutes (range 163 to 235) and robotic operative time was 83 minutes (range 63 to 143). Length of stay was 3 days (range 1 to 6). Two patients who underwent transurethral prostate resection before diverticulum resection did well. Two patients in whom medical management failed ultimately underwent transurethral prostate resection and 1 patient continued on medical therapy with regular followup. CONCLUSIONS: Robotic assisted laparoscopic bladder diverticulectomy is safe and effective for patients with a large bladder diverticulum and small prostate. Perioperative surgical outcomes rival those of previously reported open, endoscopic and laparoscopic diverticulectomies.

Vesicovaginal fistula repair without intentional cystotomy using the laparoscopic robotic approach: a case report.

BACKGROUND AND OBJECTIVES: Fistulas inaccessible from the vagina may require abdominal repair; we sought to evaluate the robotic-assisted laparoscopic approach for this procedure. METHODS: A 41-year-old nulliparous woman presented with urinary incontinence following an abdominal hysterectomy, and office evaluation identified a vesicovaginal fistula. After discussion with the patient regarding the surgical options, the robotic approach was chosen to facilitate precise dissection, fine visualization, and suturing. A stent was placed from the bladder into the vagina, and no intentional cystotomy was made. The bladder was dissected away from the anterior vaginal wall at the fistula site, and the defects were closed independently with interposition of a fatty epiploica from the sigmoid colon. Total operative time was approximately 4 hours, and robotic time was about 2.5 hours. RESULTS: At 3 months after surgery, the patient had no recurrent symptoms. CONCLUSIONS: The robotic-assisted laparoscopic approach is a viable option for successful repair of a vesicovaginal fistula in a patient in whom a vaginal approach is not indicated.

Experienced Open vs Early Robotic-assisted Laparoscopic Radical Prostatectomy: A 10-year Prospective and Retrospective Comparison.

OBJECTIVE: To undertake a prospective/retrospective comparison of longer-term oncologic and quality of life outcomes in open radical prostatectomy (ORP) or robotic-assisted laparoscopic radical prostatectomy (RALP) patients. MATERIALS AND METHODS: The clinical progression of ORP and RALP patients who underwent surgery during 2004 was followed over an extended (10 year) period. Pre- and perioperative parameters, oncologic outcomes, recurrence, mortality, and quality of life were compared between surgical modalities. Follow-up time was calculated from the time of surgery to the latest contact. Postoperative quality of life data were obtained from Expanded Prostate Cancer Index Composite survey questionnaires. Recurrence rates, times to recurrence, surgical time, length of stay, hematocrit, follow-up time, and sexual and urinary bother scores were compared between surgical groups. Multivariate analyses were used to predict positive surgical margins and biochemical recurrence. RESULTS: 63 ORP and 116 RALP patients were included (mean age of 60.4 ± 6.4 and 58.6 ± 5.8 years; P = .067), with follow-up times of 10.3 and 10.1 years (P = .191). RALP patients had longer operative times (P < .001), shorter hospital stays (P < .001), and higher discharge hematocrits (P < .001). With prostate-specific antigen, Gleason score, and T-stage as covariates, time to recurrence (P = .365) and positive margin rate (P = .230) were not statistically different between groups. Ninety-five percent of RALP patients were continent and 48.0% were potent vs 92.6% and 41.5% of ORP patients (P = .720; .497). Urinary and sexual bother were not significantly different between groups (P = .392; .985). CONCLUSION: Our longer-term follow-up data suggest that ORP and RALP patients have comparable oncologic and quality of life outcomes.

Seminal vesicle cyst with ipsilateral renal agenesis and ectopic ureter (Zinner syndrome).

The symptomatic presentation of seminal vesicle cysts with ipsilateral renal agenesis and ectopic ureter (Zinner syndrome) is rare. Patients are typically diagnosed at the third or the fourth decade of life and often present with infertility. Although the diagnosis can generally be made with magnetic resonance imaging, cystography can also be useful in indeterminate cases. We report on the unusual case of an 18-year-old man who presented with pelvic pain that was intensified by ejaculation. Computed tomography and magnetic resonance imaging revealed a cystic structure in the area of the right seminal vesicle that was successfully excised robotically without complications.

Urinary Bother as a Predictor of Postsurgical Changes in Urinary Function After Robotic Radical Prostatectomy.

OBJECTIVE: To characterize changes in indices of urinary function in prostatectomy patients with presurgical voiding symptoms. METHODS: A retrospective analysis of our prostate cancer database identified robot-assisted radical prostatectomy patients between April 2007 and December 2011 who completed pre- and postsurgical (24 months) Expanded Prostate Cancer Index Composite-26 surveys. Gleason score, margins, D'Amico risk, prostate-specific antigen, radiotherapy, and nerve-sparing status were tabulated. Survey questions addressed urinary irritation/obstruction, incontinence, and overall bother. Responses were averaged to calculate a urinary sum (US) score. Patients were stratified according to the severity of their baseline urinary bother (UB), and changes in urinary indices determined at 24 months. RESULTS: A total of 737 patients were included. Postsurgical improvement in urinary obstruction, bother, and sum score was related to baseline UB (P <.001). Men with severe baseline bother had the greatest improvement in US (+9.3), whereas those with asymptomatic baseline UB experienced a decline in US (-2.8). All patients experienced a decline in urinary incontinence of 6.3-8.3 that was independent of baseline bother (P = .507). Patients with severe UB experienced positive outcomes, whereas those at asymptomatic baseline experienced negative US outcomes. Negative urinary incontinence outcomes were unrelated to baseline UB. Age, radiotherapy, and nerve-sparing status were not associated with improved UB (P = .029). However, baseline UB was significantly associated with improvement in postsurgical UB (P = .001). CONCLUSION: Baseline UB is a predictor of postsurgical improvement in urinary function. These data are helpful when counseling a subset of robot-assisted laparoscopic radical prostatectomy patients with severe preoperative urinary symptoms.

Radical prostatectomy: size of the prostate gland and its relationship with acute perioperative complications.

OBJECTIVE: To determine if there is correlation between the size of radical prostatectomy specimens and perioperative complications including intraoperative blood loss. METHODS: One hundred twenty consecutive retropubic radical prostatectomy cases were retrospectively reviewed. Perioperative complications, intraoperative blood loss, pathologic stage, and size of the prostatectomy specimen were recorded. Logistic regression was used to determine whether variables such as age, PSA, and prostate weight are significant predictors of perioperative complications and intraoperative blood loss. RESULTS: The final analysis included a total of 117 cases. Significant complications were seen in 10 patients (8.5%). The median weight of the prostatectomy specimen in the group with major complications was 44.5 g (range 24-219) which was significantly higher than the median weight of 39.9 g (range 13-124) for the group without any complications (p = 0.034). The size of the prostate gland predicted the likelihood of a perioperative complication better than chance. A prostate size greater than 37 g was 10 times more likely to encounter major complications. Our analysis also indicated a statistically significant positive correlation between the weight of the prostatectomy specimen and intraoperative blood loss (p = 0.046). CONCLUSIONS: Prostate size correlates with a higher risk of major perioperative complications and higher intraoperative blood loss.

Laparoscopic adrenalectomy for isolated adrenal metastasis.

BACKGROUND: Laparoscopic adrenalectomy is accepted by many as the standard of care for the majority of adrenal masses less than 8 cm. The question exists whether laparoscopic removal of metastatic lesions to the adrenal is more difficult than laparoscopic removal of primary adrenal lesions. METHODS: We performed a retrospective analysis of all laparoscopic adrenalectomies performed at a single institution from 1998 to 2001, comparing laparoscopic adrenalectomies for primary lesions of the adrenal gland versus isolated metastatic lesions to the adrenal gland. RESULTS: Fourteen laparoscopic adrenalectomies were attempted, 10 for primary disease and 4 for metastatic disease. All 10 laparoscopic procedures were completed successfully for primary disease (average operative time=218 minutes, average tumor size=4 cm, median hospital stay=2 days). Only one of the 4 laparoscopic adrenalectomies for metastatic disease was completed successfully (average operative time=332 minutes, average tumor size=7.3 cm, median hospital stay=2 days). No major complications occurred in either group. CONCLUSIONS: We feel laparoscopic adrenalectomy is the preferred approach for primary adrenal masses less than 8 cm. Based on our experience and a review of the literature, isolated metastatic lesions to the adrenal gland appear less amenable to laparoscopic removal than do primary lesions of the same size.

Was a Change to a Urologist Owned Pathology Laboratory Associated with a Change in Prostate Biopsy Use?

INTRODUCTION: We assessed the impact of self-referral to urologist owned pathology facilities on prostate biopsy practice patterns, clinical decision making and pathology service use. METHODS: We reviewed a transrectal ultrasound guided prostate biopsy database during 2 periods, including 1) August 5, 2008 to April 10, 2010 (613 days) when pathology samples were sent to an independent service laboratory, and 2) June 11, 2010 to February 13, 2012 (613 days) when samples were assessed at a urologist owned pathology laboratory. We also examined data on 3 additional preceding equal length periods before urologist ownership to determine baseline biopsy rates. Billing databases were used to identify the number of new patient visits for increased prostate specific antigen and/or abnormal digital rectal examination. The Student t-test, and Wilcoxon rank sum and chi-square tests were used for statistical comparisons. RESULTS: All biopsies were obtained using a standard transrectal ultrasound guided prostate biopsy protocol. The biopsy rate in patients with increased or abnormal digital rectal examination was 39% during the urologist owned pathology laboratory era, and 35%, 40%, 35% and 40% during the 4 preceding independent service laboratory periods of equal length. There was no statistically significant difference in patient age, rate of abnormal digital rectal examination or indications for repeat transrectal ultrasound guided prostate biopsy among the periods. The prostate cancer detection rate was 45% in the independent service laboratory era and 46% in the urologist owned pathology laboratory era. CONCLUSIONS: Self-referral of transrectal ultrasound guided prostate biopsy specimens to urologist owned pathology facilities was not associated with a significant variation in the biopsy rate, the repeat biopsy rate, indications triggering repeat biopsy or the cancer detection rate.