Health-related quality of life outcomes from a contemporary prostate cancer registry in a large diverse population.

OBJECTIVE: To assess the health-related quality of life (HRQoL) of patients with prostate cancer up to 24 months after treatment in a contemporary large diverse population. PATIENTS AND METHODS: Patients with newly diagnosed prostate cancer from March 2011 to January 2014 in our healthcare system were included. The Expanded Prostate Cancer Index Composite (EPIC-26) questionnaire was administered before treatment, and at 1, 3, 6, 12, 18, and 24 months after treatment up to November 2014 for all methods of treatment. The Kruskall-Wallis test was used to compare the distribution of each EPIC-26 domain score at each time point, and mixed models were used to assess the overall scores over the period after treatment. RESULTS: In all, 5 727 patients were included. There were data for 3 422, 2 329, 2 017, 1 922, 1 772, 1 260, and 837 patients before treatment, and at 1, 3, 6, 12, 18, and 24 months after treatment, respectively. At 1 month, bowel scores were the lowest for patients that had had radiation therapy, and urinary irritative symptoms were the lowest for those who had had brachytherapy. There were sexual function declines for all the treatment methods, with surgery having the steepest decline; open radical prostatectomy (ORP) had a greater decline than robot-assisted laparoscopic prostatectomy (RALP). Patients who underwent RALP had a better return of sexual function, approaching that of brachytherapy and radiation therapy at 24 months. Urinary incontinence (UI) also declined the most in surgical patients, with RALP patients improving slightly more than ORP patients at 12-24 months. CONCLUSIONS: Patients' HRQoL after prostate cancer treatment varies by treatment method. Notably, sexual function recovers most for RALP patients. UI remains worse at 24 months after surgery, compared to other methods of prostate cancer treatment.

Extracting data from electronic medical records: validation of a natural language processing program to assess prostate biopsy results.

OBJECTIVE: The extraction of specific data from electronic medical records (EMR) remains tedious and is often performed manually. Natural language processing (NLP) programs have been developed to identify and extract information within clinical narrative text. We performed a study to assess the validity of an NLP program to accurately identify patients with prostate cancer and to retrieve pertinent pathologic information from their EMR. MATERIALS AND METHODS: A retrospective review was performed of a prospectively collected database including patients from the Southern California Kaiser Permanente Medical Region that underwent prostate biopsies during a 2-week period. A NLP program was used to identify patients with prostate biopsies that were positive for prostatic adenocarcinoma from all pathology reports within this period. The application then processed 100 consecutive patients with prostate adenocarcinoma to extract 10 variables from their pathology reports. The extraction and retrieval of information by NLP was then compared to a blinded manual review. RESULTS: A consecutive series of 18,453 pathology reports were evaluated. NLP correctly detected 117 out of 118 patients (99.1%) with prostatic adenocarcinoma after TRUS-guided prostate biopsy. NLP had a positive predictive value of 99.1% with a 99.1% sensitivity and a 99.9% specificity to correctly identify patients with prostatic adenocarcinoma after biopsy. The overall ability of the NLP application to accurately extract variables from the pathology reports was 97.6%. CONCLUSIONS: Natural language processing is a reliable and accurate method to identify select patients and to extract relevant data from an existing EMR in order to establish a prospective clinical database.

Achieving proficiency with robot-assisted radical prostatectomy: Laparoscopic-trained versus robotics-trained surgeons.

BACKGROUND: Initiating a robotics program is complex, in regards to achieving favourable outcomes, effectively utilizing an expensive surgical tool, and granting console privileges to surgeons. We report the implementation of a community-based robotics program among minimally-invasive surgery (MIS) urologists with and without formal robotics training. METHODS: From August 2008 to December 2010 at Kaiser Permanente Southern California, 2 groups of urologists performing robot-assisted radical prostatectomy (RARP) were followed since the time of robot acquisition at a single institution. The robotics group included 4 surgeons with formal robotics training and the laparoscopic group with another 4 surgeons who were robot-naïve, but skilled in laparoscopy. The laparoscopic group underwent an initial 7-day mentorship period. Surgical proficiency was measured by various operative and pathological outcome variables. Data were evaluated using comparative statistics and multivariate analysis. RESULTS: A total of 420 and 549 RARPs were performed by the robotics and laparoscopic groups, respectively. Operative times were longer in the laparoscopic group (p = 0.002), but estimated blood loss was similar. The robotics group had a significantly better overall positive surgical margin rate of 19.9% compared to the laparoscopic group (27.8%) (p = 0.005). Both groups showed improvements in operative and pathological parameters as they accrued experience, and achieved similar results towards the end of the study. CONCLUSIONS: Robot-naïve laparoscopic surgeons may achieve similar outcomes to robotic surgeons relatively early after a graduated mentorship period. This study may apply to a community-based practice in which multiple urologists with varied training backgrounds are granted robot privileges.

Racial and ethnic differences in time to treatment for patients with localized prostate cancer.

OBJECTIVE: To investigate the racial/ethnic differences in the time to treatment among patients with prostate cancer. MATERIALS AND METHODS: All 3448 men diagnosed with localized prostate cancer at Kaiser Permanente Southern California from 2006 to 2007 were identified. The patients were passively followed up through their electronic health records until definitive treatment, defined as the first treatment given with curative intent within 1 year of diagnosis. Cox proportional hazard models, with PROC SURVEYPHREG procedures, were used to account for the variability in time to the different treatments within multiple medical centers. RESULTS: The overall median time to treatment was 102 days, with modest differences for whites (100 days), blacks (104 days), and Hispanics (99 days). In the adjusted model, black men had a significantly longer time to surgery (adjusted hazard ratio 0.74, 95% confidence interval 0.56-0.91) compared with white men. Hispanic men (adjusted hazard ratio 1.44, 95% confidence interval 1.07-1.74) experienced significantly shorter times to radiotherapy compared with white men. No difference was found in the time to radiotherapy or brachytherapy for black men relative to white men. CONCLUSION: These data suggest that minimal racial/ethnic differences exist in the time to treatment after the diagnosis of prostate cancer in this equal-access setting. This is encouraging, but does not mean that all men were satisfied with their treatment choice.

Impact of median lobe anatomy: does its presence affect surgical margin rates during robot-assisted laparoscopic prostatectomy?

PURPOSE: To measure and describe the impact of median lobe anatomy on surgical margin status after robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: We prospectively collected median lobe status, surgical margin status, and other perioperative data on 791 patients who underwent RALP at our institution by 12 surgeons between August 2008 and December 2010. We performed univariable and multivariable analysis to measure the association between median lobe status and positive surgical margin rates, including site. RESULTS: Compared with patients without a median lobe (n=672), patients with a median lobe (n=119) were less likely to have a positive surgical margin (16% vs 24.4%). They had a higher prostate-specific antigen (PSA) level (6.1 ng/dL vs 5.4 ng/dL), lower Gleason scores (<7, 58.1% vs 42.1%), lower pathologic stages (T(2), 87.4% vs 75.4%), and larger prostates (64 g vs 48 g) (all P<0.05). In our multivariable model, the effect of median lobe anatomy on surgical margin status, after adjusting for these factors, was not statistically significant (relative risk 0.97, 95% confidence interval, 0.64-1.47, P=0.88). Lower PSA level, Gleason score, and pathologic stage and larger prostates, however, predicted decreased positive surgical margin rates (P<0.01). CONCLUSION: Although presence of median lobe anatomy is not an independent predictor of positive surgical margins in RALP, it is associated with favorable pathologic characteristics that are known to predict decreased positive surgical margins.

Association of hematuria on microscopic urinalysis and risk of urinary tract cancer.

PURPOSE: We determined the incidence of urinary tract cancer in patients with hematuria, stratified risk by age, gender and hematuria degree, and examined current best policy recommendations. MATERIALS AND METHODS: We performed a large, retrospective population based cohort study of patients who underwent microscopic urinalysis during 2004 and 2005 in a large managed care organization. Patients were followed for 3 years for urinary tract cancer. RESULTS: We identified 772,002 patients who underwent urinalysis during the study period. After exclusions due to previous hematuria, age less than 18 years, pregnancy, urinary tract infection, inpatient status and prior urinary tract cancer 309,402 patients were available for analysis, of whom 156,691 had hematuria. The overall 3-year incidence of urinary tract cancer in those with hematuria was 0.68%. Older age (greater than 40 years OR 17.0, 95% CI 11.2-25.7), greater hematuria (greater than 25 red blood cells per high power field OR 4.0, 95% CI 3.5-4.5) and male gender (OR 4.8, 95% CI 4.2-5.6) were associated with a higher risk of cancer. The American Urological Association definition of microhematuria had 50% sensitivity, 84% specificity and 1.3% positive predictive value. CONCLUSIONS: The incidence of urinary tract cancer is low even in individuals with microhematuria. Thus, current best policy recommendations do not perform well. Since older age, male gender and greater hematuria are associated with a higher risk of cancer, future studies should evaluate strategies that target these populations.

Regular nonsteroidal anti-inflammatory drug use and erectile dysfunction.

PURPOSE: Previous data suggest a potential relationship between inflammation and erectile dysfunction. If it is causal, nonsteroidal anti-inflammatory drug use should be inversely associated with erectile dysfunction. To this end we examined the association between nonsteroidal anti-inflammatory drug use and erectile dysfunction in a large, ethnically diverse cohort of men enrolled in the California Men's Health Study. MATERIALS AND METHODS: This prospective cohort study enrolled male members of the Kaiser Permanente managed care plans who were 45 to 69 years old beginning in 2002. Erectile dysfunction was assessed by questionnaire. Nonsteroidal anti-inflammatory drug exposure was determined by automated pharmacy data and self-reported use. RESULTS: Of the 80,966 men in this study 47.4% were considered nonsteroidal anti-inflammatory drug users based on the definitions used and 29.3% reported moderate or severe erectile dysfunction. Nonsteroidal anti-inflammatory drug use and erectile dysfunction strongly correlated with age with regular drug use increasing from 34.5% in men at ages 45 to 49 years to 54.7% in men 60 to 69 years old with erectile dysfunction increasing from 13% to 42%. The unadjusted OR for the association of nonsteroidal anti-inflammatory drugs and erectile dysfunction was 2.40 (95% CI 2.27, 2.53). With adjustment for age, race/ethnicity, smoking status, diabetes mellitus, hypertension, hyperlipidemia, peripheral vascular disease, coronary artery disease and body mass index, a positive association persisted (adjusted OR 1.38). The association persisted when using a stricter definition of nonsteroidal anti-inflammatory drug exposure. CONCLUSIONS: These data suggest that regular nonsteroidal anti-inflammatory drug use is associated with erectile dysfunction beyond what would be expected due to age and comorbidity.

Impact of robotic training on surgical and pathologic outcomes during robot-assisted laparoscopic radical prostatectomy.

OBJECTIVES: To prospectively compare outcomes during robotic prostatectomy between surgeons with formal training in either robotic prostatectomy (RALP) or laparoscopic prostatectomy (LRP). METHODS: A total of 286 robotic prostatectomies were performed by 12 urologists between August 2008 and March 2009 as part of a new robotic surgery program at one of the largest health maintenance organizations in the United States. Four surgeons had formal training in RALP and 8 had formal training in LRP. We prospectively compared surgical and pathologic outcomes between these 2 groups of surgeons. RESULTS: The 4 RALP surgeons performed 121 RALPs and the 8 LRP surgeons performed 165 RALPs. Patient demographics were similar between groups. The robot-naive group had significantly more clinical stage T1c than the robot-trained group (87.9% vs 74.4%, P = .003). Prostatectomy parameters were similar between the 2 groups of surgeons in terms of prostate size, Gleason score, pathologic stage, and estimated blood loss. The robot-trained surgeons had significantly lower overall positive margin rates (24% vs 34.6%, P = .05) and lower margin rates in T3 tumors (38.5% vs 61.8%, P = .07), which were approximately statistically significant. There was no difference in margin rates in T2 tumors. The robot-trained surgeons had significantly lower apical margin rates (8.3% vs 21.2%, P = .003) and lateral margin rates (1.7% vs 7.3%, P = .05). The robot-trained surgeons had 10%-15% shorter procedure times. There was no difference in complication rates. CONCLUSIONS: Formal RALP training may be beneficial for surgical and pathologic outcomes of RALP compared with formal LRP training during the initial implementation of a new robotics program.

Rapid implementation of a robot-assisted prostatectomy program in a large health maintenance organization setting.

PURPOSE: We present the rapid implementation of a robot-assisted surgery program by one of the largest health maintenance organizations (HMOs) in the United States. MATERIALS AND METHODS: A core group of 10 urologists were offered access to a new da Vinci S surgical system. A core group of five ancillary staff was assembled and trained at an Intuitive Surgical-designated training site. An experienced robotic surgeon acted as a proctor. Data regarding patient demographics, preoperative parameters, operative times, pathologic outcomes, and EPIC-26 quality-of-life questionnaires were collected prospectively and reviewed. All procedures were recorded on digital video disc as part of a quality assurance protocol. The core group reviewed complications monthly and received feedback on surgical techniques and pathologic outcomes. RESULTS: A total of 100 robot-assisted laparoscopic radical prostatectomies were performed from August to October 2008. The patient demographics, preoperative parameters, operative times, and pathologic outcomes of these first 100 procedures are outlined. CONCLUSIONS: We demonstrate the rapid implementation of an efficient multisurgeon HMO-based robot-assisted prostatectomy program with promising initial outcomes.

Factors predicting successful microsurgical vasectomy reversal.

A man who desires restoration of fertility after vasectomy has two main treatment options for having his genetic child: vasectomy reversal or sperm extraction with subsequent in vitro fertilization with intracytoplasmic sperm injection. Microsurgical reconstructive techniques and their widespread availability have made vasectomy reversal a realistic option for many couples; however, vasectomy reversal outcomes are varied because there are many factors that alter the chance of success. Some of these factors become known preoperatively, whereas others can only be ascertained at the time of surgery. Intraoperatively, the urologist must identify factors and understand how they will affect the decision to proceed. This article systematically reviews each of these phases of decision-making and management.

Adenovirus-mediated angiopoietin-1 gene therapy enhances skin flap survival.

This experimental study investigates the feasibility of pretreating the abdominal skin of a rat with subdermal injections of adenovirus encoding angiopoietin-1 in order to improve postoperative survival of the skin flap. An epigastric skin flap was used as the model in this study. Rats received subdermal injections of adenovirus encoding either angiopoietin-1 (treatment group) or green fluorescent protein (treatment control), or they received no treatment (control group). Subdermal injections were made 2 days prior to surgery, and skin flap survival was assessed 7 days afterwards as a percentage of necrotic area over total skin flap area. The treatment group which received adenovirus-mediated angiopoietin-1 had a median percent necrotic area of 11.01%, a significant decrease from the control group, which had a median percent necrotic area of 32.24% (P < 0.001). The results of this study suggest the possibility of using adenovirus-mediated angiopoietin-1 gene therapy to promote therapeutic angiogenesis in patients who undergo reconstructive procedures.