The impact of financial interest in intensity-modulated radiation therapy on the utilization of radiation therapy for treatment of newly diagnosed prostate cancer: a single center experience.

Objective. As recent participants in an integrated prostate cancer (PCa) care center, we sought to evaluate whether financial investment in an intensity-modulated radiation therapy (IMRT) center resulted in an increased utilization of radiation therapy in our patients with newly diagnosed PCa. Materials & Methods. Following institutional review board approval, we retrospectively reviewed the records of all consecutive patients who were diagnosed with prostate cancer in the 12 months prior to and after investment in IMRT. Primary treatment modalities included active surveillance (AS), brachytherapy (BT), radiation therapy (XRT), radical prostatectomy (RP), and androgen deprivation therapy (ADT). Treatment data were available for all patients and were compared between the two groups. Results. A total of 344 patients with newly diagnosed PCa were evaluated over the designated time period. The pre-investment group totaled 198 patients, while 146 patients constituted the post-investment group. Among all patients evaluated, there was a similar rate in the use of XRT (20.71% versus 20.55%, P = 1.000) pre- and post-investment in IMRT. Conclusions. Financial interest in IMRT by urologists does not impact overall utilization rates among patients with newly diagnosed PCa at our center.

Do silver alloy-coated catheters increase risk of urethral strictures after robotic-assisted laparoscopic radical prostatectomy?

OBJECTIVES: To evaluate whether the use of silver-coated catheters increased the risk of developing urethral stricture disease after robotic-assisted laparoscopic radical prostatectomy (RALP). Recently, silver alloy-coated Foley catheters have been shown to decrease the risk of catheter-associated urinary tract infections. Other than the increased cost, no disadvantages to the use of these catheters have been reported. MATERIAL AND METHODS: We switched to routine use of the Bardex I.C. silver alloy-coated Foley catheters for all urologic procedures on November 1, 2008. After institutional review board approval, we retrospectively reviewed the records of all consecutive patients who had undergone RALP 12 months before and after the catheter change. The primary outcome was the rate of urethral strictures after RALP. RESULTS: A total of 188 RALPs were performed during the 12 months before the catheter change. No patients who underwent RALP in the months before the catheter change had developed a new postoperative urethral stricture. In the 12 months after the change to the silver-coated catheters, 217 RALPs were performed. Six patients after RALP using silver-coated catheters developed new strictures, at a rate of 2.8% (P = .03). CONCLUSIONS: Silver alloy-coated urinary catheters might increase the risk of developing urethral strictures after RALP compared with standard noncoated catheters. Additional evaluation by a large randomized prospective trial is warranted to elucidate the true risk of stricture formation.

The minimally invasive treatment of ureteropelvic junction obstruction: a review of our experience during the last decade.

PURPOSE: The minimally invasive treatment of ureteropelvic junction obstruction has evolved during the last decade from endoscopic to laparoscopic and robotic. We review our 10-year experience with ureteropelvic junction obstruction, and report on our experience and followup. MATERIALS AND METHODS: We reviewed all patients treated during the last 10 years. There were 294 procedures performed with complete records on 273 patients including 128 retrograde endopyelotomies, 116 laparoscopic pyeloplasties and 29 robotic pyeloplasties. Technique for each procedure is reviewed. Statistical analysis was performed on all results. Variables evaluated were gender, age (younger than 41 vs 41 years or older), side (right or left), presence of crossing vessels, presence of a high insertion, primary or secondary procedure and whether prior endopyelotomy or pyeloplasty had been performed. RESULTS: Mean followup for endopyelotomy, laparoscopic pyeloplasty and robotic pyeloplasty was 20, 20 and 19 months, respectively, with success rates of 60.2%, 88.8% and 100%, respectively. On univariable analysis only the presence of crossing vessels or a high insertion was significant for laparoscopic pyeloplasty. On multivariable analysis age was significant for endopyelotomy and the presence of crossing vessels was significant for pyeloplasty. On Kaplan-Meier analysis failures were noted to occur after 5 years in both groups. CONCLUSIONS: Laparoscopic pyeloplasty and robotic pyeloplasty are superior minimally invasive treatments for ureteropelvic junction obstruction. However, endopyelotomy can be used for select patients. Because of late failures patients who undergo either of these procedures should receive long-term followup.

Outcomes of hand-assisted laparoscopic nephrectomy in technically challenging cases.

OBJECTIVES: To evaluate the outcomes of hand-assisted laparoscopic nephrectomy in patients with significant complicating clinical factors. METHODS: We performed a retrospective review of 322 hand-assisted laparoscopic nephrectomy cases that were completed at a single institution from 1998 to 2004. Patients with a history of extensive abdominal surgery or prior procedures on the affected kidney, evidence of perirenal inflammation, renal lesions 10 cm or more in diameter, or level I renal vein thrombus were included. RESULTS: A total of 42 patients were included in this series. Of these, 16 patients had a lesion 10 cm or larger, 10 had a renal vein thrombus, and 10 had undergone prior major abdominal surgery. Many patients had more than one complicating factor. Another 6 patients had a history of prior renal procedures or chronic inflammatory processes involving the affected kidney. One Stage T4 renal tumor with paraspinous muscle invasion was successfully managed without conversion. The overall mean operative time and estimated blood loss was 235 minutes and 439 mL, respectively, with a mean hospital stay of 4 days. Four patients (9.5%) required open conversion (one renal hilar injury, two failure to progress, and one persistent bleeding from the renal fossa). Postoperative complications included pulmonary embolism in 1, ileus in 1, and chronic obstructive pulmonary disease exacerbation in 1 patient. One patient developed an incarcerated port site hernia requiring reoperation. CONCLUSIONS: Hand-assisted laparoscopic nephrectomy is an attractive minimally invasive option in the setting of significant complicating factors. This technique may facilitate the successful laparoscopic completion of these challenging cases with reasonable operative times, blood loss, and complication rates.

Hand-assisted laparoscopic cystoprostatectomy and urinary diversion.

PURPOSE: We report the first series of patients who have undergone hand-assisted laparoscopic cystoprostatectomy and diversion (HALCD). PATIENTS AND METHODS: Seven patients with muscle-invasive bladder cancer elected to have their surgery by hand-assisted laparoscopy. The bladder was excised using a hand-assisted laparoscopic technique, and the ileal conduit was constructed through the midline incision created for the hand. RESULTS: The operative time was relatively short (mean 7.6 hours), blood loss was low (420 mL), and the postoperative stay was short (4.6 days). Long-term follow-up is pending. CONCLUSION: Laparoscopic techniques for radical cystectomy are currently being explored at several major medical centers. Hand-assisted laparoscopy offers the distinct advantages of palpation, retraction, speed, and minimal morbidity.

Perioperative morbidity of laparoscopic radical prostatectomy compared with open radical retropubic prostatectomy.

The objective of the study was to compare the perioperative complication rates of our initial 60 laparoscopic radical prostatectomy (LRP) patients and our most recent 60 sequential open radical retropubic prostatectomy (RRP) patients. Sixty sequential LRP and 60 sequential RRP patients treated between March 2000 and March 2002 were retrospectively evaluated. Patients who received neo-adjuvant hormonal therapy or had metastatic disease and 3 LRP patients converted to open RRP were excluded. Estimated blood loss (EBL), transfusion rates, hemoglobin level, serum and drain fluid creatinine levels, hospital stay and complication rates were analyzed. There were 15 (25%) and 11 (18.3%) complications in the LRP and RRP cohorts, respectively. There were 3 (ulnar neuropathy, ureteral stricture, anastomotic leak with ureteral obstruction requiring reoperation), and 4 [2 bladder neck contractures (BNC) and 2 deep venous thromboses (DVT)] major complications, respectively. Minor complications included rectus hematoma, superficial wound infections, ileus and anastomotic urine leaks. A higher incidence of the latter (10 patients) was noted in the LRP cohort. One (1.7%) LRP and 31 (52%) RRP cohort patients received intraoperative or postoperative transfusions. The mean (median) EBL was 317 (250) and 1355 (1100) for the LRP and RRP cohorts, respectively. A transient, insignificant increase in serum creatinine from a median of 1.0 to 1.2 mg/dL was observed only in the LRP cohort. We concluded that our initial 60 LRP patients had a similar, but not improved, rate of perioperative complications when compared with 60 sequential open RRP patients of nearly identical age, preoperative PSA and prostate size. The types of complications differed between the LRP and RRP cohorts.

Retroperitoneal laparoscopic cryoablation of small renal tumors: intermediate results.

OBJECTIVES: To present our experience with laparoscopic renal cryoablation with up to 3 years of follow-up. Laparoscopic renal cryoablation remains a viable option for the treatment of small peripheral renal masses in patients with significant comorbidities. Although partial nephrectomy has been shown to be a safe and reliable method of renal parenchymal preservation, laparoscopic cryoablation still requires longer term data to prove its efficacy. METHODS: Twenty patients with small renal masses (1.4 to 4.5 cm) underwent laparoscopic renal cryosurgery at our institution. A retroperitoneal laparoscopic approach was used to expose the kidney. Intraoperative ultrasound guidance was used to localize the lesions and monitor iceball formation. A double-freeze technique was used. Needle biopsies of solid masses were performed intraoperatively. RESULTS: Renal biopsies revealed renal cell carcinoma in 11 of the 20 patients. Of these 11 patients, none had evidence of recurrent disease at last follow-up, and follow-up scans showed no enhancement of any lesions. Of the 8 patients with follow-up of 2 years or greater, 4 had complete resolution of the renal lesions. The remainder had lesions that were reduced and stable in size. Complications included surgical re-exploration to evaluate pancreatic injury in 1 patient and failure to ablate a lesion in another. CONCLUSIONS: Laparoscopic renal cryoablation appears to be an effective tool for ablation of small renal lesions. A moderate length of follow-up continues to demonstrate efficacy because no patients had growth of treated pathologic lesions or developed metastasis to date. Continued maturation of data is necessary to determine the long-term efficacy.

Expression of cell-cycle-regulated proteins pRb2/p130, p107, p27(kip1), p53, mdm-2, and Ki-67 (MIB-1) in prostatic gland adenocarcinoma.

PURPOSE: The quest for prognostic molecular markers in prostatic carcinoma is still in progress. Many proteins have already been screened by immunohistochemistry with the aim to find the most reliable indicator of progressive disease. In this study, we evaluated the expression of pRb2/p130, p107, p27(kip1), p53, mdm-2, and Ki-67 (MIB-1) by immunohistochemistry in 24 prostate carcinomas compared with the paired expression of normal prostates. EXPERIMENTAL DESIGN: Expression of the different proteins in normal and pathological specimens was evaluated by the Wilcoxon test. A matrix of correlation (Spearman coefficient) was used to evaluate the possible association in expression among the different proteins. Logistic regression analysis was used to test the multivariable prognostic value of the levels of protein expression for the probability of disease development. RESULTS: p53 and Ki-67 (MIB-1) showed a higher expression in cancer than in normal tissue (P = 0.006 and <0.001, respectively). pRb2/p130, p107, and p27(kip1) showed an overall lower expression in cancer, but the difference between cytoplasmic and nuclear expression was always higher for cancer (Ps, from <0.001 to 0.016). mdm-2 expression was lower in cancer, but the difference between cytoplasmic and nuclear expression was not significant (P = 0.571) when compared with that in normal tissue. A positive correlation between p27 and pRb2/p130 levels expressed, in normal and cancer counterparts in the same sample, as the difference between cytoplasmic and nuclear protein concentrations (P = 0.045) was found. Additionally, p107 expression showed an inverse correlation with Ki-67 (MIB-1) expression in the most aggressive tumors (P = 0.046). Logistic regression output showed that Ki-67 (MIB-1) and pRb2/p130 (expressed as differences between cytoplasmic and nuclear concentrations) were the variables associated with a higher risk of cancer. The highest value was reported for Ki-67 (MIB-1) (odds ratio, 2.11), followed by pRb2/p130 (odds ratio, 1.01). pRb2/p130 alone was associated with a sensitivity (rate of cases having a posterior probability of disease >/=0.5) of 61% with a false positive rate of 22%. Ki-67 (MIB-1) alone yielded a sensitivity of 69% and a false positive rate of 14%. The combined model (Ki-67 + pRb2/p130) yielded a sensitivity of 83% with a false positive rate of 17%. Interestingly, one specimen in which we also found a high-grade prostatic intraepithelial neoplasia showed the progressive loss of pRb2/p130 from normal prostatic cells to prostatic intraepithelial neoplasia cells, suggesting that in prostatic cancer, lack of expression of the tumor suppressor gene pRb2/p130 could be involved in the progression of the disease, from an early stage. CONCLUSIONS: This study showed that all of the proteins but mdm-2 were expressed at a different rate in normal and pathological prostate specimens. Multivariate analysis showed that pRb2/p130 and p107 may be involved in the pathogenesis and progression of prostate cancers, and that the expression of the retinoblastoma-related protein pRb2/p130 along with Ki-67 (MIB-1), expressed as differences between cytoplasmic and nuclear concentrations, could be considered new parameters to be evaluated in discriminating patients at a higher risk for prostate cancer.