Clear cell adenocarcinoma of the prostatic urethra with metachronous prostate adenocarcinoma.

A 70-year-old male underwent a Transurethral Resection of Prostate for the management of obstructive voiding symptoms. On cystoscopy, papillary frond-like lesions up to 2cm in size were encountered, overlying the right side of the prostatic urethra. Histopathology from the resection revealed clear cell adenocarcinoma (CCA) of the prostatic urethra. Primary clear cell adenocarcinoma of the prostatic urethra is exceedingly rare, with as few as 9 cases reported. We review the literature for its oncogenesis, discuss the histopathological features for diagnosis and report on our surgical management and outcome.

Morphology of Proximal Ulna Bare Area: A Guide for Olecranon Osteotomy.

PURPOSE: Olecranon osteotomy is commonly used to obtain access to the distal humerus for fracture fixation. The goal of this study was to accurately describe the anatomy of the bare area to minimize articular cartilage damage while performing olecranon osteotomies. METHODS: Twenty cadaveric ulnae were denuded to expose the bare area. Laser surface mapping was used to create 3-dimensional models, and the nonarticular portions of the ulnae were digitally measured. RESULTS: The morphology of the bare area from all aspects of the proximal ulna was defined. The central bare area was consistent in its location, 4.9 ± 1.5 mm distal to the deepest portion of the trochlear notch and 23.2 ± 2.3 mm distal to the olecranon tip. The maximum chevron osteotomy apical angle to stay within the bare area averaged 110° ± 11.8°. However, there was little tolerance for error without the risk of violating the articular cartilage. With transverse osteotomy, averaging 18° ± 10.6° in the coronal plane, there is less risk of damaging the articular cartilage. CONCLUSIONS: Transverse osteotomy perpendicular to the posterior surface of the ulna aiming at the visible bare area on the medial and lateral sides of the greater sigmoid notch may reduce the chances of violating the nonvisible articular cartilage of the proximal ulna. Based on the findings of this study, if chevron osteotomy is used, a shallow apex distal angle of more than 110° is recommended. CLINICAL RELEVANCE: This study provides intraoperative landmarks to guide surgeons performing olecranon osteotomies to stay within the bare area.

Comparing internal fixation constructs for scapular spine insufficiency fractures following reverse shoulder arthroplasty.

INTRODUCTION: There is limited research on the surgical management techniques for scapular spine fractures after reverse shoulder arthroplasty (RTSA). As such, the purpose of this in vitro biomechanical study was to compare 4 fixation constructs to stabilize scapular spine insufficiency fractures. METHODS: Twelve paired fresh-frozen cadaveric scapulae (N = 24) were randomized into 4 fixation groups: subcutaneous border plating (± hook) and supraspinatus fossa plating (± hook). A Levy type II fracture was simulated. Each specimen was cyclically loaded incrementally up to 700 N in 50 N steps or until failure. Between 50 and 200 N construct stiffness was measured, and stability failure was defined as displacement greater than 2.5 mm. RESULTS: Seventy-nine percent (19 of 24) of the specimens failed before the maximum load of 700 N. The average survival force with subcutaneous border plating was 480 ± 80 N compared with 380 ± 30 N for supraspinatus fossa plating (P = .3). Fixation construct failure was significantly more likely with fossa plating over subcutaneous plating (P = .012). The presence of the lateral plate hook was beneficial in preventing failure of the lateral acromion (P = .016). CONCLUSION: When appropriately surgically indicated, a dorsally applied plate to the subcutaneous border of the scapular spine with a lateral inferior supporting hook may be advantageous for internal fixation of type II scapular spine insufficiency fractures after RTSA.

Focal irreversible electroporation as primary treatment for localized prostate cancer.

OBJECTIVES: To determine the safety, quality of life (QoL) and short-term oncological outcomes of primary focal irreversible electroporation (IRE) for the treatment of localized prostate cancer (PCa), and to identify potential risk factors for oncological failure. PATIENTS AND METHODS: Patients who met the consensus guidelines on patient criteria and selection methods for primary focal therapy were eligible for analysis. Focal IRE was performed for organ-confined clinically significant PCa, defined as high-volume disease with Gleason sum score 6 (International Society of Urological Pathology [ISUP] grade 1) or any Gleason sum score of 7 (ISUP grades 2-3). Oncological, adverse event (AE) and QoL outcome data, with a minimum of 6 months' follow-up, were analysed. Patient characteristics and peri-operative treatment variables were compared between patients with and without oncological failure on follow-up biopsy. Wilcoxon's signed rank test, Wilcoxon's rank sum test and the chi-squared test were used to assess statistically significant differences in paired continuous, unpaired continuous and categorical variables respectively. RESULTS: A total of 63 patients met all eligibility criteria and were included in the final analysis. No high-grade AEs occurred. QoL questionnaire analysis demonstrated no significant change from baseline in physical (P = 0.81), mental (P = 0.48), bowel (P = 0.25) or urinary QoL domains (P = 0.41 and P = 0.25), but there was a mild decrease in the sexual QoL domain (median score 66 at baseline vs 54 at 6 months; P < 0.001). Compared with baseline, a decline of 70% in prostate-specific antigen level (1.8 ng/mL, interquartile range 0.96-4.8 ng/mL) was seen at 6-12 months. A narrow safety margin (P = 0.047) and system errors (P = 0.010) were identified as potential early risk factors for in-field oncological failure. In-field and whole-gland oncological control on follow-up biopsies was 84% (38/45 patients) and 76% (34/45 patients); this increased to 97% (38/39 patients) and 87% (34/39 patients) when patients treated with a narrow safety margin and system errors were excluded. CONCLUSION: Our data support the safety and feasibility of focal IRE as a primary treatment for localized PCa with effective short-term oncological control in carefully selected men.

Feasibility and safety of focal irreversible electroporation as salvage treatment for localized radio-recurrent prostate cancer.

OBJECTIVES: To evaluate the feasibility, safety, early quality-of-life (QoL) and oncological outcomes of salvage focal irreversible electroporation (IRE) for radio-recurrent prostate cancer (PCa). PATIENTS AND METHODS: Patients with localized, radio-recurrent PCa without evidence of metastatic or nodal disease were offered focal IRE according to the consensus guidelines. Patients with a minimum follow-up of 6 months were eligible for analysis. Adverse events were monitored using the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE version 4.0). Patient-reported QoL data were collected at baseline, 6 weeks, 3, 6 and 12 months using the Expanded Prostate Cancer Index Composite (EPIC), the American Urological Association (AUA) symptom score and the 12-item short-from health survey (SF-12) physical and mental component summary questionnaires. Oncological control was evaluated according to serial prostate-specific antigen (PSA), 6-month multiparametric magnetic resonance imaging (mpMRI) and 12-month prostate biopsy. Wilcoxon's signed rank test was used to assess QoL differences over time in paired continuous variables. RESULTS: A total of 18 patients were included in the analysis. The median follow-up was 21 months. No high-grade adverse events (CTCAE >2) or recto-urethral fistulae occurred. No statistically significant declines were observed in QoL outcomes (n = 11) on the EPIC bowel domain (P = 0.29), AUA symptom score (P = 0.77), or the SF-12 physical (P = 0.17) or SF-12 mental component summary (P = 0.77) questionnaires. At 6 months, patients who had undergone salvage therapy experienced a decline in EPIC sexual domain score (median of 38-24; P = 0.028) and urinary domain (median of 96-92; P = 0.074). Pad-free continence and erections sufficient for intercourse were preserved in 8/11 patients and 2/6 patients at 6 months, respectively. The mpMRI was clear in 11/13 patients, with two single out-field lesions (true-positive and false-positive, respectively). The median (interquartile range) nadir PSA was 0.39 (0.04-0.43) µg/L. Three and four patients experienced biochemical failure using the Phoenix and Stuttgart definitions of biochemical failure, respectively. Eight out of 10 of the patients were clear of any PCa on follow-up biopsy, whereas two patients had significant PCa on follow-up biopsy (International Society of Urological Pathology grade 5). CONCLUSION: Our short-term safety, QoL and oncological control data show that focal IRE is a feasible salvage option for localized radio-recurrent PCa. A prospective multicentre study (FIRE trial) has been initiated that will provide further insight into the ability of focal IRE to obtain oncological control of radio-recurrent PCa with acceptable patient morbidity.

A multiparametric magnetic resonance imaging-based risk model to determine the risk of significant prostate cancer prior to biopsy.

OBJECTIVE: To develop and externally validate a predictive model for detection of significant prostate cancer. PATIENTS AND METHODS: Development of the model was based on a prospective cohort including 393 men who underwent multiparametric magnetic resonance imaging (mpMRI) before biopsy. External validity of the model was then examined retrospectively in 198 men from a separate institution whom underwent mpMRI followed by biopsy for abnormal prostate-specific antigen (PSA) level or digital rectal examination (DRE). A model was developed with age, PSA level, DRE, prostate volume, previous biopsy, and Prostate Imaging Reporting and Data System (PIRADS) score, as predictors for significant prostate cancer (Gleason 7 with >5% grade 4, ≥20% cores positive or ≥7 mm of cancer in any core). Probability was studied via logistic regression. Discriminatory performance was quantified by concordance statistics and internally validated with bootstrap resampling. RESULTS: In all, 393 men had complete data and 149 (37.9%) had significant prostate cancer. While the variable model had good accuracy in predicting significant prostate cancer, area under the curve (AUC) of 0.80, the advanced model (incorporating mpMRI) had a significantly higher AUC of 0.88 (P < 0.001). The model was well calibrated in internal and external validation. Decision analysis showed that use of the advanced model in practice would improve biopsy outcome predictions. Clinical application of the model would reduce 28% of biopsies, whilst missing 2.6% significant prostate cancer. CONCLUSIONS: Individualised risk assessment of significant prostate cancer using a predictive model that incorporates mpMRI PIRADS score and clinical data allows a considerable reduction in unnecessary biopsies and reduction of the risk of over-detection of insignificant prostate cancer at the cost of a very small increase in the number of significant cancers missed.

Prospective evaluation of 68Gallium-prostate-specific membrane antigen positron emission tomography/computed tomography for preoperative lymph node staging in prostate cancer.

OBJECTIVES: To assess the accuracy of 68Gallium-prostate-specific membrane antigen (68Ga-PSMA) positron emission tomography/computed tomography (PET/CT) for lymph node (LN) staging in intermediate- and high-risk prostate cancer (PCa). MATERIALS AND METHODS: From April to October 2015, 30 patients with intermediate- (n = 3) or high-risk (n = 27) PCa were prospectively enrolled. Patients underwent preoperative 68Ga-PSMA PET/CT. Both visual and semi-quantitative analyses were undertaken. Subsequently, all patients underwent radical prostatectomy (RP) with an extended pelvic lymph node dissection. The sensitivity, specificity, and positive (PPV) and negative predictive value (NPV) for LN status of 68Ga-PSMA were calculated using histopathology as reference. RESULTS: Eleven patients (37%) had lymph node metastases (LNMs); 26 LNMs were identified in the 11 patients. Patient analysis showed that 68Ga-PSMA PET/CT had a sensitivity of 64% for the detection of LNMs, its specificity was 95%, the PPV was 88%, and the NPV was 82%. In total, 180 LN fields were analysed. In the LN-region-based analysis, the sensitivity of 68Ga-PSMA PET/CT for detection of LNMs was 56%, the specificity was 98%, the PPV was 90% and the NPV was 94%. The mean size of missed LNMs was 2.7 mm. Receiver-operating characteristic curve analysis showed a high accuracy of maximum standardized uptake value (SUVmax ) for the detection of LNMs, with an area under the curve of 0.915 (95% confidence interval 0.847-0.983); the optimum SUVmax was 2.0. CONCLUSIONS: In patients with intermediate- to high-risk PCa, 68Ga-PSMA PET/CT had a high specificity and a moderate sensitivity for LNM detection. 68Ga-PSMA PET/CT had the potential to replace current imaging for LN staging of patients with PCa scheduled for RP.

Assessment of the Performance of Magnetic Resonance Imaging/Ultrasound Fusion Guided Prostate Biopsy against a Combined Targeted Plus Systematic Biopsy Approach Using 24-Core Transperineal Template Saturation Mapping Prostate Biopsy.

Objective. To compare the performance of multiparametric resonance imaging/ultrasound fusion targeted biopsy (MRI/US-TBx) to a combined biopsy strategy (MRI/US-TBx plus 24-core transperineal template saturation mapping biopsy (TTMB)). Methods. Between May 2012 and October 2015, all patients undergoing MRI/US-TBx at our institution were included for analysis. Patients underwent MRI/US-TBx of suspicious lesions detected on multiparametric MRI +/- simultaneous TTMB. Subgroup analysis was performed on patients undergoing simultaneous MRI/US-TBx + TTMB. Primary outcome was PCa detection. Significant PCa was defined as ≥Gleason score (GS) 3 + 4 = 7 PCa. McNemar's test was used to compare detection rates between MRI/US-TBx and the combined biopsy strategy. Results. 148 patients underwent MRI/US-TBx and 80 patients underwent MRI/US-TBx + TTMB. In the MRI/US-TBx versus combined biopsy strategy subgroup analysis (n = 80), there were 55 PCa and 38 significant PCa. The detection rate for the combined biopsy strategy versus MRI/US-TBx for significant PCa was 49% versus 40% (p = 0.02) and for insignificant PCa was 20% versus 10% (p = 0.04), respectively. Eleven cases (14%) of significant PCa were detected exclusively on MRI/US-TBx and 7 cases (8.7%) of significant PCa were detected exclusively on TTMB. Conclusions. A combined biopsy approach (MRI/US-TBx + TTMB) detects more significant PCa than MRI/US-TBx alone; however, it will double the detection rate of insignificant PCa.

Predicting Low-Risk Prostate Cancer from Transperineal Saturation Biopsies.

Introduction. To assess the performance of five previously described clinicopathological definitions of low-risk prostate cancer (PC). Materials and Methods. Men who underwent radical prostatectomy (RP) for clinical stage ≤T2, PSA <10 ng/mL, Gleason score <8 PC, diagnosed by transperineal template-guided saturation biopsy were included. The performance of five previously described criteria (i.e., criteria 1-5, criterion 1 stringent (Gleason score 6 + ≤5 mm total max core length PC + ≤3 mm max per core length PC) up to criterion 5 less stringent (Gleason score 6-7 with ≤5% Gleason grade 4) was analysed to assess ability of each to predict insignificant disease in RP specimens (defined as Gleason score ≤6 and total tumour volume <2.5 mL, or Gleason score 7 with ≤5% grade 4 and total tumour volume <0.7 mL). Results. 994 men who underwent RP were included. Criterion 4 (Gleason score 6) performed best with area under the curve of receiver operating characteristics 0.792. At decision curve analysis, criterion 4 was deemed clinically the best performing transperineal saturation biopsy-based definition for low-risk PC. Conclusions. Gleason score 6 disease demonstrated a superior trade-off between sensitivity and specificity for clarifying low-risk PC that can guide treatment and be used as reference test in diagnostic studies.

Step-by-Step Technique for Irreversible Electroporation of Focal Prostate Cancer: An Instructional Video Guide.

Focal therapy has emerged as a tissue-sparing treatment modality for selected men with low to intermediate volume, localized prostate cancer with the advantage of reducing treatment morbidity because of preservation of untreated prostate tissue and surrounding structures. Irreversible electroporation is an emerging interventional focal therapy modality that uses high voltage electrical fields to induce cell death. This instructional video guide (Fig) serves as an easy-to-understand, comprehensive educational tool so that a broader audience can gain an understanding of the techniques involved in this treatment modality.

Isolated Grade 5 Renal Trauma in a Hemodynamically Stable Patient.

Isolated grade 5 renal trauma in a hemodynamically stable patient is rare. It is therefore unsurprising there are conflicting recommendations on management of these injuries from authorities including the AUA, EAU and SIU. We present a 26-year-old male with flank pain following a 3-m fall whilst bicycle riding off a ramp, who was found to have an isolated grade 5 renal injury (shattered kidney). He was managed with early angio-embolization and subsequent nephrectomy due to ongoing bleeding. Further reports of clinician experience with this type of renal injury are needed to clarify best practice in management.

(68) Ga-PSMA has a high detection rate of prostate cancer recurrence outside the prostatic fossa in patients being considered for salvage radiation treatment.

OBJECTIVES: To examine the detection rates of (68) Ga-PSMA-positron emission tomography (PET)/computed tomography (CT) in patients with biochemical recurrence (BCR) after radical prostatectomy (RP), and also the impact on their management. MATERIALS AND METHODS: A total of 300 consecutive patients with prostate cancer (PCa) who underwent (68) Ga-PSMA-PET/CT between February and July 2015 were prospectively included in the Prostate Cancer Imaging (ProCan-I) database. For the present analysis, we included patients with BCR (prostate-specific antigen [PSA] level ≥0.05 and <1.0 ng/mL) after RP, who were being considered for salvage radiation therapy (RT) according to the Faculty of Radiation Oncology Genito-Urinary Group (FROGG) guidelines. Two readers assessed each (68) Ga-PSMA-PET/CT, and all positive lesions were assigned to an anatomical location. For each patient, the clinical and pathological features were recorded, their association with pathological (68) Ga-PSMA uptake was investigated, and detection rates were determined according to PSA level. RESULTS: A total of 70 patients were included, and 53 positive (68) Ga-PSMA lesions were detected in 38 (54%) patients. Among patients with PSA levels 0.05-0.09 ng/mL, 8% were definitely positive; the corresponding percentages for the other PSA ranges were as follows: PSA 0.1-0.19 ng/mL, 23%; PSA 0.2-0.29 ng/mL, 58%; PSA 0.3-0.49 ng/mL, 36%; and PSA 0.5-0.99 ng/mL, 57%. Eighteen of 70 patients (27%) had pathological (68) Ga-PSMA uptake in the prostatic fossa, 11 (14.3%) in the pelvic nodes, and five (4.3%) in both the fossa and pelvic lymph nodes. Finally, there was uptake outside the pelvis with or without a lesion in the fossa or pelvic lymph nodes in four cases (8.6%). As a result of the (68) Ga-PSMA findings there was a major management change in 20 (28.6%) patients. CONCLUSIONS: (68) Ga-PSMA appears to be useful for re-staging of PCa in patients with rising PSA levels who are being considered for salvage RT even at PSA levels <0.5 ng/mL. These results underline the need for further prospective trials to evaluate the changes in RT volume or management attributable to (68) Ga-PSMA findings.

Tumor volume in insignificant prostate cancer: Increasing the threshold is a safe approach to reduce over-treatment.

BACKGROUND: There are conflicting results in the literature regarding the tumor volume (TV) threshold that defines insignificant prostate cancer (PCa). In this study, we retrospectively evaluate the association of an increasing TV with biochemical recurrence (BCR) following radical prostatectomy (RP) in order to provide further clarification surrounding the TV threshold definition for insignificant PCa. METHODS: RP patients were recruited from January 2004 to December 2009. Inclusion criteria were localized (stage ≤pT2c, negative surgical margins) Gleason 6 PCa with a total TV of ≤2.50 cm(3) . BCR was the primary outcome and defined as a PSA of ≥0.1. All cases with BCR were re-evaluated by the pathologist with reassessment of tumor grade, pathological stage and surgical margin status. RESULTS: From 1,636 patients, 178 men (10.9%) met all inclusion criteria. Ninety-six patients (53.9%) had a TV <0.5 cm(3) and 82 patients (46.1%) had a TV 0.5-2.5 cm(3) . Three out of 178 patients (1.7%) presented with BCR during follow-up. One of these had TV <0.5 cm(3) and two had TV 0.5-2.5 cm(3) . These three cases of BCR underwent re-review of pathology; one patient was found to have a positive surgical margin and one patient was upgraded to Gleason 3 + 4 = 7. The third patient was re-reported as having positive margins for a benign hyperplastic nodule (incomplete RP specimen). Subsequently, these three cases were excluded from final analysis as they did not fit inclusion criteria. Median follow-up duration was 84 months (IQR 70-102 months). On final analysis, there were no patients with BCR, corresponding with a final BCR rate of 0% for both patients with a TV of <0.5 cm(3) and 0.5-2.5 cm(3) . CONCLUSIONS: Our results have shown that, with a median follow-up of 84 (IQR 70-102) months, patients in our cohort with localized Gleason 6 PCa with a total TV 0.5-2.5 cm(3) have a BCR rate of 0%. We would support a more liberal total TV threshold of 2.5 cm(3) for the further development of algorithms to identify patients suitable for active surveillance.

Early Experience in Da Vinci Robot-Assisted Partial Nephrectomy: An Australian Single Centre Series.

Introduction and Objectives. To demonstrate the safety and efficacy of the robot-assisted partial nephrectomy (RAPN) technique in an Australian setting. Methods. Between November 2010 and July 2014, a total of 76 patients underwent 77 RAPN procedures using the Da Vinci Surgical System© at our institution. 58 of these procedures were performed primarily by the senior author (PB) and are described in this case series. Results. Median operative time was 4 hours (range 1.5-6) and median warm ischaemic time (WIT) was 8 minutes (range 0-30) including 11 cases with zero ischaemic time. All surgical margins were clear with the exception of one patient who had egress of intravascular microscopic tumour outside the capsule to the point of the resection margin. Complications were identified in 9 patients (15.8%). Major complications included conversion to open surgery due to significant venous bleeding (n = 1), reperfusion injury (n = 1), gluteal compartment syndrome (n = 1), DVT/PE (n = 1), and readmission for haematuria (n = 1). Conclusion. This series demonstrates the safety and efficacy of the RAPN technique in an Australian setting when performed by experienced laparoscopic surgeons in a dedicated high volume robotic centre.

Acute pancreatitis secondary to diabetic ketoacidosis induced hypertriglyceridemia in a young adult with undiagnosed type 2 diabetes.

CONTEXT: The triad of acute pancreatitis, hypertriglyceridemia and diabetes is a rare occurrence. CASE REPORT: A previously well 19-year-old male presented to the emergency department with 24-hour history of epigastric pain, associated with polyuria and nausea. Biochemical markers showed the presence of hyperglycemia (blood sugar level 15 mmol/L) and ketonemia (5.3 mmol/L). Further investigation revealed severe hypertriglyceridemia (4,009 mg/dL) and elevated lipase (1,714 U/L). Abdominal ultrasound confirmed the diagnosis of acute pancreatitis. He was transferred to intensive care, where he received i.v. hydration, insulin and dextrose infusion. His metabolic derangements gradually resolved. His glycosylated hemoglobin was 13%, indicating the presence of chronically elevated blood sugars. CONCLUSION: The possible pathophysiology and management of this unusual triad: diabetic ketoacidosis, hypertriglyceridemia and acute pancreatitis, are explored in this paper.

Delayed amplatzer occluder device closure of postinfarction ventricular septal defect: a case report.

Postinfarction ventricular septal defect (VSD) is a rare complication after acute myocardial infarction, with an incidence rate of 1-2% of all myocardial infarcts (Hutchins, 1979). It is a medical emergency with sobering survival numbers, having a mortality rate of 70-80% within two weeks of the incident event (Bouchart et al., 1998). Cardiac surgery is considered the gold standard in the management of these defects; however, its main limitation is that it carries a high risk of perioperative mortality and postoperative sequelae. Percutaneous transcatheter closure of VSD is a relatively new method of repair. Due to scarcity of reports in the literature, there is limited data regarding survival data; however, noninferiority to surgery has been demonstrated in one case series (Papalexopoulou et al., 2013). Long-term follow-up studies are lacking, and thus long-term mortality has yet to be discerned. We present a case of an 87-year-old female who, following postmyocardial infarction VSD, developed clinically significant heart failure. The patient was reluctant to undergo open repair given her age and comorbidities and she underwent successful percutaneous repair of her VSD using a 16 mm Amplatzer occluder device 18 months after her initial presentation.

Urological vignette: Satellite lesion in the bladder from urachal enteric adenocarcinoma.

INTRODUCTION: We present, to the best of our knowledge, the first published case report of a satellite lesion within the bladder from enteric type urachal adenocarcinoma (UA). PRESENTATION OF CASE: Our case report involves a 38-year-old man from the Solomon Islands who underwent open partial cystectomy for UA. However, resection margins were positive due to the novel finding of a satellite lesion on histopathological assessment. Salvage cystectomy was subsequently performed and the patient had an uncomplicated post-operative recovery. DISCUSSION: This case highlights the importance of achieving negative soft tissue and bladder margins on initial resection of UA, as the consequences of incomplete resection can place significant additional morbidity on the patient. CONCLUSION: We aim to highlight the possibility of satellite lesions within the bladder in UA and suggest that further studies looking at this phenomenon are required to establish its incidence and overall impact on management of UA.

Perforation tolerance of glenoid implants to abnormal glenoid retroversion, anteversion, and medialization.

BACKGROUND: Loosening of the glenoid implant is a common complication of total shoulder arthroplasty. To prevent this, we need to ensure the glenoid vault is not perforated during insertion of the glenoid implant to allow for cement containment and maximum pressurization. Factors affecting perforation potential include glenoid implant design and alignment. This study looks at the perforation tolerance of 15 commercially available glenoid implants to increased retroversion, increased anteversion, and medialization. MATERIALS AND METHODS: Accurate 3-dimensional models of the 15 glenoid implants were created from exact dimensions obtained from the manufacturers and virtually implanted into 3-dimensional reconstructed models of 40 nonarthritic scapulae. Perforation tolerances of each implant to increased retroversion, increased anteversion, and medialization were determined through computer simulation to represent asymmetrical arthritic posterior wear, anterior wear, and eccentric corrective reaming, respectively. RESULTS: In all 15 glenoid implants, the overall mean increased retroversion tolerated before perforation was 19°, increased anteversion was 16°, and abnormal version fully corrected by eccentric reaming was 17°. Each glenoid implant was evaluated individually to allow for direct comparison and, finally, size-matched and downsized glenoid implants in relation to the size of the humeral head. CONCLUSION: The results from this study help surgeons, when faced with a severely arthritic glenoid, to choose the appropriate glenoid implant to minimize perforation potential, and provide guidance on how much abnormal version and how much corrective reaming can be tolerated before perforation occurs and fixation is compromised. These results can also help with future implant designs.