The impact of serum testosterone level to reflect age-related multi-organ functions.

The aim of this study is to examine the correlation between aging, serum total testosterone and biomarkers of multiple organ functions in men. The participants consisted of 12,547 outpatients, whose serum testosterone level was measured. A multiple regression analysis was conducted to determine whether biomarkers including hemoglobin (Hb), hematocrit (Hct), luteinizing hormone (LH), follicle stimulating hormone (FSH), alkaline phosphatase (ALP), albumin (ALB), creatinine (Cre), aspartate aminotransferase (AST), alanine aminotransferase (ALT), glucose (Glu), C-reactive protein (CRP), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) values were associated with serum total testosterone concentration. Significant correlations (p < 0.05) were found between total testosterone and Hb, Hct, LH, FSH, ALP, ALB, TG, HDL-C, AST, ALT, Glu, and CRP. In addition, significant correlations (p < 0.05) were found between Hb, Hct, LH, FSH, ALP, ALB, TG and HDL-C associated with [age × testosterone]. This large-scale study provided new insights into correlations between serum testosterone and biomarkers associated with age-related diseases, suggesting that testosterone is especially important for maintaining homeostasis in aging males. Thus, hypogonadism in elderly patients may be associated with multiple organ dysfunctions.

Summary of the clinical practice manual for late-onset hypogonadism.

Testosterone plays an important role in maintaining both physical and mental function. Age-related testosterone depletion contributes to the development of angina, arteriosclerosis, obesity, metabolic syndrome, dementia, frailty, and a range of other conditions. A condition involving age-related testosterone depletion and the associated clinical symptoms is defined as late-onset hypogonadism (LOH). LOH is treated by testosterone replacement therapy. Indications for testosterone replacement therapy are determined by evaluating symptoms and signs.

Luteinizing Hormone Suppression Profiles in Men Treated With Exogenous Testosterone.

BACKGROUND: Due to the negative feedback mechanism involved in the hypothalamic-pituitary-gonadal axis, testosterone therapy (TTh) may result in suppression of luteinizing hormone (LH) secretion, but clinical experience demonstrates the level of LH suppression is variable. AIM: We sought to define the relationship between TTh and LH levels, specifically predictors of LH suppression in men on TTh. METHODS: We performed a retrospective analysis of a prospectively maintained database of patients with testosterone deficiency (TD) treated with TTh. Patient demographic and clinical data including vascular risk factor (VRF) status were collected. Serum total T and LH levels before TTh and after ≥3 months (m) were recorded. LH suppression was defined as serum LH level <1.0 IU/ml. MAIN OUTCOME MEASURES: Predictors of LH suppression were searched though a series of logistic regression models assessing suppression status at the final observation, and then a series of Cox proportional hazards models assessing time to first suppression were performed. RESULTS: A total of 227 patients with mean age of 58±14 years at time of TTh initiation were included in our analysis. Just under half of subjects received transdermal T as the only modality (n = 101, 44%), while one third (n = 77, 34%) received intramuscular only, and the remainder (n = 49, 22%) received both modalities during follow-up. The mean baseline LH level was 10 ± 12 IU/ml. The percent of men who had baseline LH level above 1 IU/ml and at any given point of TTh was 84% and 78%, respectively, thus 22% of men had suppressed LH levels on TTh considering the definition of LH <1 IU/ml. Most men (73%) had a suppressed LH level of <1 IU/ml at least once during follow-up. In the final adjusted model for LH suppression, intramuscular route (OR = 2.44), baseline LH (OR = 0.94), estradiol (OR = 1.05) remained significant. CLINICAL IMPLICATIONS: LH suppression profiles may be relevant for dose titration during TTh and perhaps to minimize testicular atrophy. STRENGTHS & LIMITATIONS: A strict definition for TD was applied using LCMS for T measurements and patients had long-term follow-up. CONCLUSION: While 73% of patients had at least one LH <1 IU/ml during TTh, only 22% maintained suppressed throughout the treatment. Miranda EP, Schofield E, Matsushita K, et al. Luteinizing Hormone Suppression Profiles in Men Treated With Exogenous Testosterone. J Sex Med 2022;19:1359-1365.

The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis.

BACKGROUND: The 3-piece inflatable penile prosthesis includes an easy-to-use pump and fluid filled reservoir which is placed in either the space of Retzius (SOR) or in an alternative ectopic location. Reservoir placement in the SOR is a blind procedure despite the SOR being surrounded by many critical structures. To date only a handful of cadaveric studies have described the relevant anatomy. AIM: To use magnetic resonance imaging (MRI) as an in-vivo model to study relevant retropubic anatomy critical for SOR reservoir placement. METHODS: The study population included men with elevated prostate specific antigen or biopsy proven prostate cancer who (i) underwent pelvic MRI, (ii) without prior pelvic or inguinal surgery, and (iii) without pelvic radiation therapy. All MRIs were completed with a 3-Tesla scanner and endorectal coil. Both T1 and T2 weighted images were captured in both axial and sagittal planes. All images were reviewed by 2 independent reviewers under the supervision of a dedicated body MRI radiologist. Bladder volume was calculated using an ellipsoid formula. OUTCOMES: Relevant measurements included (i) the distance between the external inguinal ring (EIR) at the level of the pubic tubercle to the external iliac vein (EIV), (ii) the distance from the EIR at the pubic tubercle to the bladder (accounting for bladder volume) and (iii) the distance from the midline pubic symphysis to the bladder (accounting for bladder volume). Pearson correlation was used to determine correlated measurements. RESULTS: A total of 24 patients were included. Median participant age was 63 years (interquartile range, 59-66). The mean EIR-EIV distance was 3.0 ± 0.4 cm, the mean EIR-bladder distance was 1.8 ± 1.0 cm and the mean distance from the superior pubic symphysis to bladder was 0.9 ± 0.3 cm. There was a weak correlation between bladder volume and distance between the EIR and bladder (r = -0.30, P = .16). CLINICAL IMPLICATIONS: The use of MRI as an in-vivo model is a high-fidelity tool to study real time unaltered anatomy and allows for surgical preparation, diagnosis of anatomic variants and acts as a valuable teaching tool. STRENGTHS & LIMITATIONS: This is the first in-vivo model to report relevant retropubic anatomy in penile implant surgery. Our study is limited by sample size and inclusion of participants with no history of prior pelvic intervention. CONCLUSION: We demonstrate the utility of MRI as an in-vivo model, as opposed to cadaveric models, for the understanding of relevant retropubic anatomy for implant surgeons. Punjani N, Monteiro L, Sullivan J F et al. The Anatomical Relationships in the Space of Retzius for Penile Implants: An MRI Analysis. J Sex Med 2021;18:1830-1834.

Climacturia After Radical Prostatectomy: MRI-Based Predictors.

BACKGROUND: After radical prostatectomy (RP), climacturia is a prevalent and distressing problem. To date, no specific predictors have been identified. AIM: In this analysis, we sought to find associated pelvic magnetic resonance imaging (MRI) parameters. METHODS: We identified all men in our departmental database who (i) had climacturia post-RP, ≥3 episodes; (ii) underwent a pre-RP endorectal MRI; (iii) had no radiation or androgen deprivation therapy (ADT). Soft tissue and bony dimensions were measured by 2 raters blinded to clinical and pathological data. OUTCOMES: MRI parameters included the following: maximum height, width, and depth of prostate, prostate volume, urethral width and length, lower conjugate of pelvis, bony femoral width, outer and inner levator distances and thickness. Point-biserial correlations were run on univariate associations. Logistic regression was used for the multivariable model. RESULTS: 194 consecutive pre-RP MRI studies were reviewed (56 men with and 138 without climacturia). Mean age was 60 ± 7 years, average time post-RP at assessment, 7 ± 7 months. Of MRI parameters, urethral width (r = 0.13, P = .03) and lower conjugate (r = 0.12, P = .05) were associated with presence of persistent climacturia. 2 others met criteria for multivariable analysis, prostate depth and outer levator distance. Of the non-MRI parameters, none were significantly related to climacturia and only body mass index (BMI) met criteria for multivariable analysis. On multivariable analysis, only urethral width was associated with climacturia (OR = 1.23, 95% CI: 1.01-1.49, P = .04); the wider the urethra, greater the chance of climacturia. CLINICAL IMPLICATIONS: Improved ability to predict the occurrence of orgasm-associated incontinence in the preoperative setting. STRENGTHS AND LIMITATIONS: Limitations include the fact that the MRI endorectal probe may have distorted pelvic tissues during imaging and that our study population size was small. However, prospective data collection, blinded measurements by 2 trained readers, and rigorous statistical analysis should be considered strengths. CONCLUSION: By identifying preoperative risk factors, such as urethral width on MRI, we may be able to better understand the pathophysiology of this condition and furthermore may permit us to better counsel men regarding this postoperative outcome. Sullivan JF, Ortega Y, Matsushita K, et al. Climacturia After Radical Prostatectomy: MRI-Based Predictors. J Sex Med 2020;17:1723-1728.

Impact of indocyanine green-guided extended pelvic lymph node dissection during robot-assisted radical prostatectomy.

OBJECTIVES: To evaluate the effectiveness of indocyanine green-guided extended pelvic lymph node dissection during robot-assisted radical prostatectomy for intermediate- to high-risk prostate cancer. MATERIALS AND METHODS: After institutional review board approval, between July 2017 and December 2018, we carried out 100 indocyanine green-guided extended pelvic lymph node dissections in patients with localized intermediate- and high-risk prostate cancer, using the Firefly (Novadaq Technologies, Mississauga, ON, Canada) and da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Indocyanine green was injected transrectally using ultrasound sonography before each surgery. Then, lymphatic drainage patterns and pathological findings were recorded. RESULTS: Lymphatic drainage routes were successfully determined in 91 right-sided and 90 left-sided cases. Five main lymphatic pathways and sites were identified: (i) an internal route (57%); (ii) a lateral route (50%); (iii) a presacral route (20%); (iv) a paravesical artery site (20%); and (v) a pre-prostatic site (5%). Lymph node metastasis was positive in 15 patients, with 44 pathologically confirmed metastatic lymph nodes. Metastatic fluorescent lymph nodes were found in 15 out of 44 lymph nodes (34.1%). For sentinel lymph node identification, the 34% sensitivity and 64.8% specificity rates were detected in regard to identification of lymph node metastasis. CONCLUSIONS: Lymphatic drainage patterns from the prostate can be identified and classified using indocyanine green-guided extended pelvic lymph node dissections. Although the direct role of fluorescent lymph nodes in sentinel lymph node identification appears to be limited, the identification of lymphatic pathways could contribute to high-quality extended pelvic lymph node dissection during robot-assisted radical prostatectomy.

Testosterone Levels Are Not Associated With Magnitude of Deformity in Men With Peyronie's Disease.

INTRODUCTION: There are some data suggesting that there is a relationship between the magnitude of Peyronie's disease (PD)-associated penile curvature and low serum testosterone. AIM: To evaluate the relationship between PD associated penile deformity and total testosterone (TT) and free testosterone (FT) levels. METHODS: We identified patients diagnosed with PD who had early morning TT measurements. Because laboratories have different reference values, we analyzed testosterone values 2 ways, as raw values and as standardized values (TT and FT values converted into z-scores for each laboratory). Deformity assessment was conducted during an intracavernosal injection-induced rigid erection. The association between T levels and magnitude of penile curvature was analyzed in a number of ways. First, an independent measure t-test tested differences in curvature degree by TT groups (low T: <300 ng/dL; normal T: ≥300 ng/dL). Second, an association was sought between T levels based on quartiles of the normal range (<300, 300-450, 450-600, and >600 ng/dL). These analyses were conducted for both TT and FT levels and using both raw and standardized T values. Third, multivariable analysis using multiple linear regression was performed in an attempt to define predictors of the degree of penile curvature. Factors entered into the model included: TT level, FT level, patient age, race (white vs other), number of co-morbidities, body mass index, presence of erectile dysfunction, duration of PD, and prostatectomy (yes vs no). MAIN OUTCOME MEASURES: The relationship between T levels and the magnitude of penile curvature. RESULTS: 184 subjects met all study criteria. Average age was 54 ± 12 years. Mean TT level was 425 ± 176 ng/dL, and mean curvature magnitude was 35° ± 19°. The percent of subjects in the first through fourth TT quartiles was 26%, 34%, 24%, and 16%. As a continuous variable, there was no association between TT levels (r = -0.01, P = .95) or FT levels (r = -0.08, P = .30) and the curvature magnitude. When examining TT groups, there was no difference in mean curvature between the low TT group and the normal TT group (35.4° ± 17° vs 34° ± 20°, P = .70). When analyzing the TT and FT levels standardized into z-scores, there was no association between degree of curvature and TT z-scores (r = -0.003, P = .95) and FT z-scores (r = -0.08, P = .43). There was also no association between testosterone levels and degree of curvature in the multivariable model. CONCLUSIONS: There does not appear to be any association between testosterone levels and the magnitude of PD-associated penile deformity. Mulhall JP, Matsushita K, Nelson CJ. Testosterone Levels Are Not Associated With Magnitude of Deformity in Men With Peyronie's Disease. J Sex Med 2019;16:1283-1289.

Incidence, Risk Factors and a Novel Prevention Technique for Inguinal Hernia after Robot-Assisted Radical Prostatectomy.

INTRODUCTION: To evaluate the incidence and risk factors for postoperative inguinal hernia (IH) after robot-assisted radical prostatectomy (RARP) and to assess whether a newly developed prevention technique reduces the incidence of IH after RARP. METHODS: We included 161 consecutive patients (322 groins) who underwent RARP between September 2011 and October 2013. The prevention technique was as follows: (1) sufficient incision of peritoneum around the internal inguinal ring; (2) separation of spermatic vessels; (3) dissection of vas deferens. RESULTS: Postoperative IH occurred in 14 cases (19.4%) occurring in the observation group compared to 2 cases (2.2%) in the prevention group. Patent processus vaginalis (PPV) was the only risk factor. Time-to-event analysis demonstrated a significant decrease in IH incidence in the IH prevention group (p = 0.005). CONCLUSION: Our data reveal a higher incidence of IH after RARP, with the existence of PPV as the only identified risk factor. Our simple IH-prevention technique, which does not involve the use of artificial materials, appears safe and effective.

Preoperative predictive model of recovery of urinary continence after radical prostatectomy.

OBJECTIVE: To build a predictive model of urinary continence recovery after radical prostatectomy (RP) that incorporates magnetic resonance imaging (MRI) parameters and clinical data. PATIENTS AND METHODS: We conducted a retrospective review of data from 2,849 patients who underwent pelvic staging MRI before RP from November 2001 to June 2010. We used logistic regression to evaluate the association between each MRI variable and continence at 6 or 12 months, adjusting for age, body mass index (BMI) and American Society of Anesthesiologists (ASA) score, and then used multivariable logistic regression to create our model. A nomogram was constructed using the multivariable logistic regression models. RESULTS: In all, 68% (1,742/2,559) and 82% (2,205/2,689) regained function at 6 and 12 months, respectively. In the base model, age, BMI and ASA score were significant predictors of continence at 6 or 12 months on univariate analysis (P < 0.005). Among the preoperative MRI measurements, membranous urethral length, which showed great significance, was incorporated into the base model to create the full model. For continence recovery at 6 months, the addition of membranous urethral length increased the area under the curve (AUC) to 0.664 for the validation set, an increase of 0.064 over the base model. For continence recovery at 12 months, the AUC was 0.674, an increase of 0.085 over the base model. CONCLUSION: Using our model, the likelihood of continence recovery increases with membranous urethral length and decreases with age, BMI and ASA score. This model could be used for patient counselling and for the identification of patients at high risk for urinary incontinence in whom to study changes in operative technique that improve urinary function after RP.

Concordance between patient and physician assessment of the magnitude of Peyronie's disease curvature.

INTRODUCTION: The magnitude of penile deformity is a critically important factor in Peyronie's disease, as it is associated with increased difficulty in penetrative sexual intercourse and in turn with negative psychosocial consequences. Deformity magnitude also influences treatment choice when surgical correction is indicated. AIM: To determine the concordance between patient and physician assessment of magnitude of penile curvature in men with Peyronie's disease. METHODS: Patient assessment of curvature was obtained at initial interview. Physician assessment was performed using intracavernosal injection-assisted erection using a goniometer applied during excellent penile rigidity. MAIN OUTCOME MEASURES: Patient and physician assessments of penile curvature. RESULTS: The sample consisted of 192 men with a mean age of 54 ± 12 years old. Mean curvature on patient and physician assessment was 33 ± 17 and 36 ± 18 degrees, respectively. Only 49% of patients (94) correctly assessed their curvature, whereas 35% underestimated and 16% overestimated it. CONCLUSIONS: Only half of PD patients accurately assess their penile curvature, with more than twice as many patients underestimating it than overestimating it. These data suggest that patient self-reporting of penile curvature should not be used as a clinical marker or end point in Peyronie's disease trials.

Modified anterior approach to the bladder neck: simple and reproducible procedure for anterior bladder neck transection during robot-assisted radical prostatectomy.

To evaluate the feasibility and reproducibility of a simple technique for identifying the initial cutting point of the bladder neck during robot-assisted radical prostatectomy. To precisely identify the prostatovesical junction, we first pulled the anterior bladder wall in an upward direction with the second arm to identify the precise location of the prostatovesical junction where anterior bladder neck dissection is initiated. After one experienced surgeon had established this technique, three surgeons who were less experienced in robot-assisted radical prostatectomy utilized this method for 50 consecutive robot-assisted radical prostatectomy cases. The pathological results and the time required to transect the anterior bladder wall were evaluated. There were no cases of positive resection margin on the site of bladder neck. The mean resection time was not significantly different when comparing less experienced surgeons with the experienced surgeon (P = 0.29). In conclusion, this method is a simple and reproducible way to identify the bladder neck during robot-assisted radical prostatectomy. This technique is also useful (for laparoscopic or open radical prostatectomy) even in difficult scenarios, such as post-transurethral resection of prostate cases.

Pathological response to neoadjuvant chemotherapy for muscle-invasive micropapillary bladder cancer.

OBJECTIVE: To describe the pathological outcomes of patients with muscle-invasive micropapillary bladder cancer who have undergone neoadjuvant chemotherapy. PATIENTS AND METHODS: A total of 82 patients with muscle-invasive micropapillary bladder cancer were treated between 1997 and 2010. After excluding those with metastatic disease, micropapillary histology only at radical cystectomy (RC), and chemo-radiation as primary treatment, 44 patients remained. All patients had ≥cT2 disease before chemotherapy/surgery. The median follow-up after RC was 28 months. Neoadjuvant chemotherapy was initiated in 29 (66%) patients and all patients underwent RC (93%) or partial cystectomy (7%). RESULTS: Micropapillary histology was diagnosed at first transurethral resection in 37 (84%) patients. Final RC pathology revealed pT0 in 15 (34%) patients and positive lymph nodes in 13 (31%) patients. Down-staging to pT0 occurred in 13 (45%) of those who received neoadjuvant chemotherapy compared with two (13%) of those who did not (P = 0.049). Patients with pT0 disease with micropapillary histology had higher overall survival rates (25 vs. 92%) and lower rates of bladder cancer recurrence (21 vs. 79%) at the 24-month follow-up. CONCLUSIONS: Almost half of the patients responded completely to neoadjuvant chemotherapy with a pT0 rate of 45%; therefore, patients with the micropapillary variant of urothelial carcinoma should not be excluded from consideration for neoadjuvant chemotherapy.

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.

The evolution of orgasmic pain (dysorgasmia) following radical prostatectomy.

INTRODUCTION: It is recognized that some patients experience painful orgasms known as dysorgasmia after radical prostatectomy (RP). This problem poses a barrier to satisfactory sexual relations for some couples. However, the natural history of this condition remains unknown. AIM: To assess the evolution of dysorgasmia in patients who underwent RP. METHODS: The study population included men who had been seen initially within 6 months after RP and complained of postoperative dysorgasmia and opted for no medical therapy with postoperative follow-up at least 24 months, and were seen at least twice over 2 years. MAIN OUTCOME MEASURES: A proprietary dysorgasmia frequency scale and visual analog scale (VAS) for pain were used at each visit. RESULTS: Data from 702 patients who had RP and presented for sexual function evaluation between 2002 and 2008 were prospectively collected and analyzed at Memorial Sloan-Kettering Cancer Center. Of the 702 patients, 84 (12%) complained of dysorgasmia. Mean patient age was 64 ± 16 years. Mean time interval since RP to initial sexual medicine interview was 2.2 ± 3.2 months. Mean number of visits was 4 ± 1.4. For the 84 patients who had dysorgasmia, mean dysorgasmia frequency and VAS score for pain at initial interview were 3.9 and 4.1, respectively. At 24 months, a statistically significant decrease in symptoms occurred, with 72%, 26%, and 7% of patients still complaining of pain at 12, 18, and 24 months, respectively. At 6 months, 26% of patients had a VAS score ≥6/10 and at 24 months this figure was 16%. CONCLUSIONS: Our data provide evidence that dysorgasmia decreases in frequency and degree over time after RP. These data are in support of a surveillance strategy for all but the most bothered patients with dysorgasmia after RP.

Efficacy and Safety of 5-Aminolevulinic Acid for Patients with Symptoms of Late-Onset Hypogonadism: A Preliminary Study.

PURPOSE: As the concept of late-onset hypogonadism (LOH) has gained increased attention, the treatment of eugonadal patients with LOH symptom has become a clinical problem. Previous studies have shown the possible benefits of 5-aminolevulinic acid (5-ALA) on the somatic, psychological and sexual functions. We therefore conducted this randomized, double-blind, placebo-controlled study to confirm the efficacy and safety of 5-ALA for LOH symptoms. MATERIALS AND METHODS: Thirty-two eugonadal subjects with LOH symptoms were randomly divided into a 5-ALA group (n=15) and a placebo group (n=17). Treatment was continued for 8 weeks. The change of the Aging Males' Symptoms (AMS) scale score and several biochemical and endocrinological variables during treatment were compared between the groups. RESULTS: After treatment, the change in the total AMS in the 5-ALA group was significantly greater than that in the placebo group (-7.4±4.7 vs. -4.9±4.9, p=0.029). However, the differences between the groups in the change of the somatic, psychological, and sexual sub-scores of the AMS did not reach the statistical significance, although these changes in the 5-ALA group were greater than those in the placebo group. Furthermore, the change in the biochemical and endocrinological variables in the two groups did not differ to a statistically significant extent. During the 8-week treatment period, no patients discontinued 5-ALA due to treatment-emergent adverse events (TEAEs). CONCLUSIONS: The intake of 5-ALA for 8 weeks was beneficial for eugonadal patients with symptoms of LOH and no severe TEAEs was experienced. 5-ALA should be considered as an option for those patients.

Role of prostate specific antigen and immediate confirmatory biopsy in predicting progression during active surveillance for low risk prostate cancer.

PURPOSE: We evaluated predictors of progression after starting active surveillance, especially the role of prostate specific antigen and immediate confirmatory prostate biopsy. MATERIALS AND METHODS: A total of 238 men with prostate cancer met active surveillance eligibility criteria and were analyzed for progression with time. Cox proportional hazards regression was used to evaluate predictors of progression. Progression was evaluated using 2 definitions, including no longer meeting 1) full and 2) modified criteria, excluding prostate specific antigen greater than 10 ng/ml as a criterion. RESULTS: Using full criteria 61 patients progressed during followup. The 2 and 5-year progression-free probability was 80% and 60%, respectively. With prostate specific antigen included in progression criteria prostate specific antigen at confirmatory biopsy (HR 1.29, 95% CI 1.14-1.46, p <0.0005) and positive confirmatory biopsy (HR 1.75, 95% CI 1.01-3.04, p = 0.047) were independent predictors of progression. Of the 61 cases 34 failed due to increased prostate specific antigen, including only 5 with subsequent progression by biopsy criteria. When prostate specific antigen was excluded from progression criteria, only 32 cases progressed, and 2 and 5-year progression-free probability was 91% and 76%, respectively. Using modified criteria as an end point positive confirmatory biopsy was the only independent predictor of progression (HR 3.16, 95% CI 1.41-7.09, p = 0.005). CONCLUSIONS: Active surveillance is feasible in patients with low risk prostate cancer and most patients show little evidence of progression within 5 years. There is no clear justification for treating patients in whom prostate specific antigen increases above 10 ng/ml in the absence of other indications of tumor progression. Patients considering active surveillance should undergo confirmatory biopsy to better assess the risk of progression.

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.