Pathological analysis of the prostatic anterior fat pad at radical prostatectomy: insights from a prospective series.

OBJECTIVE: To assess factors associated with lymphatic drainage and lymph node (LN) metastasis to the prostatic anterior fat pad (PAFP) in men with prostate cancer and the utility of routine PAFP analysis at the time of radical prostatectomy (RP). PATIENTS AND METHODS: Our institution began to prospectively collect PAFP tissue in 2010. The PAFP was removed at the time of RP and sent as a pathological specimen separate from the pelvic LNs and prostate. Consecutive RPs performed at our institution in which the PAFP was removed were reviewed to determine the rate of LNs in the PAFP, the rate of metastatic LNs in the PAFP, and the association of metastatic PAFP LN with clinical and pathological features. The impact on biochemical recurrence (BCR) was assessed with a Cox's proportional hazard model. RESULTS: In all, 2 413 PAFP specimens were available for analysis. LNs were found in the PAFP in 255 (10.6%) cases and metastatic LNs in the PAFPs were found in 14 (0.6%) cases. Metastatic PAFP LNs were associated with anterior tumours in 11 of the 14 cases (P = 0.01), and were present only in preoperative D'Amico intermediate- (six of 14) and high- (eight of 14) risk patients (P < 0.001). Metastatic PAFP LNs were associated with extraprostatic disease in 13 of the 14 cases, although concomitant pelvic LN involvement was present in only four of the 14 cases. With a mean follow-up of 1.5 years, three of the 14 patients with metastatic PAFP LN developed BCR. Positive LN involvement in either the pelvic LN or PAFP had worse BCR than LN-negative patients (P < 0.001); however, there was no difference in BCR between patients with positive pelvic LN and positive PAFP LN (P = 0.5). CONCLUSION: Metastatic PAFP LNs are rare and always occur in the presence of other adverse pathological features. The routine pathological analysis of PAFP as a separate specimen, especially in low-risk disease, may not be warranted.

Ultrasound Guided, Freehand Transperineal Prostate Biopsy: An Alternative to the Transrectal Approach.

INTRODUCTION: There is growing interest in the use of transperineal prostate biopsy due to the advantages of decreased infection risk and improved cancer detection rates. However, brachytherapy stepper units and templates may increase costs and operative time for the practicing urologist. We present the safety, feasibility and early outcomes of a single urologist's experience with ultrasound guided freehand transperineal prostate biopsy as an alternative to transrectal ultrasound guided biopsy. METHODS: A retrospective review of all prospectively performed ultrasound guided freehand transperineal prostate biopsies between January 1, 2012 and April 30, 2014 was performed. Primary outcome measurements were safety and feasibility. RESULTS: A total of 274 ultrasound guided freehand transperineal prostate biopsies were performed in 244 patients. Operative and total operating room use times were 7.9 and 17.5 minutes, respectively, with an average of 14.4 cores obtained during each procedure. The overall cancer detection rates for all procedures, those in biopsy naïve patients and those performed for active surveillance were 62.8%, 56.4% and 89%, respectively. New diagnoses of prostate cancer occurred in 41.2% of patients with 10% positive after a previous negative transrectal ultrasound guided biopsy. Complications (Clavien grade I or greater) including systemic infection, urinary retention and hematuria or pain requiring physician or hospital intervention did not occur. CONCLUSIONS: The use of ultrasound guided freehand transperineal prostate biopsy for the suspicion or surveillance of prostate cancer is feasible and safe. The results were encouraging with respect to the primary outcome measurements. Ultrasound guided freehand transperineal prostate biopsy with the patient under local anesthesia is currently under investigation. Large, prospective, randomized, multiple operator studies to evaluate the comparative effectiveness of freehand transperineal prostate biopsy and transrectal ultrasound guided biopsy techniques are recommended.

The effect of repair costs on the profitability of a ureteroscopy program.

BACKGROUND AND PURPOSE: Ureteroscopy (URS) is a common treatment for patients with stone disease. One of the disadvantages of this approach is the great capital expense associated with the purchase and repair of endoscopic equipment. In some cases, these costs can outpace revenues and lead to an unprofitable and unsustainable enterprise. We sought to characterize the profitability of our URS program when accounting for endoscope maintenance and repair costs. MATERIALS AND METHODS: We identified all URS cases performed at a single hospital during fiscal year 2013 (FY2013). Charges, collection rates, and fixed and variable costs including annual equipment repair costs were obtained. The net margin and break-even point of URS were derived on a per-case basis. RESULTS: For 190 cases performed in FY2013, total endoscope repair costs totaled $115,000, resulting in an average repair cost of $605 per case. The vast majority of cases (94.2%) were conducted in the outpatient setting, which generated a net margin of $659 per case, while inpatient cases yielded a net loss of $455. URS was ultimately associated with a net positive margin approaching $600 per case. On break-even analysis, URS remained profitable until repair costs reached $1200 per case. CONCLUSIONS: Based on these findings, an established URS program can sustain profitability even with large equipment repair costs. Nonetheless, our findings serve to emphasize the importance of controlling costs, particularly in the current setting of decreasing reimbursement. A multifaceted approach, based on improving endoscope durability and exploring digital and disposable platforms, will be critical in maintaining the sustainability of URS.

Robotic surgery in urological oncology: patient care or market share?

Surgical robotic use has grown exponentially in spite of limited or uncertain benefits and large costs. In certain situations, adoption of robotic technology provides value to patients and society. In other cases, however, the robot provides little or no increase in surgical quality, with increased expense, and, therefore, does not add value to health care. The surgical robot is expensive to purchase, maintain and operate, and can contribute to increased consumerism in relation to surgical procedures, and increased reliance on the technology, thus driving future increases in health-care expenditure. Given the current need for budget constraints, the cost-effectiveness of specific procedures must be evaluated. The surgical robot should be used when cost-effective, but traditional open and laparoscopic techniques also need to be continually fostered.

Impact of hospital volume on perioperative outcomes and costs of radical cystectomy: analysis of the Maryland Health Services Cost Review Commission database.

INTRODUCTION: The objective of this study was to evaluate the impact of hospital case volume on perioperative outcomes and costs of radical cystectomy (RC) after controlling for differences in patient case mix. MATERIALS AND METHODS: The Maryland Health Services Cost Review Commission database was queried for patients who underwent an open RC between 2000 and 2011. Patients were divided into tertiles based on hospital case volume. Groups were compared for differences in length of intensive care unit (ICU) stay, length of total hospital stay, rate of in-hospital deaths and procedure-related costs. RESULTS: In total, 1620 patients underwent a RC during the study period. Of these patients, 457 (28.2%) underwent surgery at 37 low volume centers, 465 (28.7%) at six mid volume centers and 698 (43.1%) at a single high volume center. The mean case volume of each group was 1.1, 7.0 and 63.5 RC/center/year, respectively. After controlling for marked differences in patient case mix, having surgery at the single high-volume center was independently associated with a decrease in length of ICU stay (coefficient = -0.41 days, 95% CI -0.78--0.05, p = 0.03), in-hospital mortality (OR 0.18, 95% CI 0.04-0.80, p = 0.02) and total medical costs (coefficient = -2.91k USD, 95% CI -4.15--1.67, p < 0.001). Decreased total costs were driven by reductions in charges associated with the operating room, drugs, radiology tests, labs, supplies and physical/occupational therapy (all p < 0.001). CONCLUSIONS: Undergoing RC at a high volume medical center was associated with improved outcomes and reduced costs. These data support the centralization of RC to high volume centers.

Trends and outcomes of total and partial nephrectomy in children: a statewide analysis.

OBJECTIVE: To report trends in surgical approach and associations with outcomes in children undergoing extirpative renal surgery in the state of Maryland over a 12-year period. METHODS: The Maryland Health Services Cost Review Commission (HSCRC) database was queried to identify children undergoing total or partial nephrectomy between 2000 and 2011. Demographic, clinical, hospital, and charge data were compared between children undergoing open and minimally invasive renal surgery. Multivariable logistic regression analysis was performed to identify independent predictors of prolonged length of hospital stay and 30-day readmission. Multivariable linear regression was performed to identify independent predictors of increased hospital charges. RESULTS: Of the 346 children undergoing extirpative renal surgery, 289 (83.5%) underwent total nephrectomy and 48 (13.9%) underwent minimally invasive surgery. Utilization of minimally invasive surgery for congenital urinary anomalies has steadily increased from 15% to 35% over the past decade. Children undergoing minimally invasive total nephrectomy were healthier, had shorter hospital stay, and were more likely to have surgery at a high-volume institution. No such differences were noted in patients undergoing open and minimally invasive partial nephrectomy. On multivariable regression analyses, high patient complexity was the main predictor of increased length of stay (OR 16.02, 95% CI 7.06-36.31), 30-day readmission (OR 3.04, 95% CI 1.38-6.70), and total hospital charge (p < 0.001). CONCLUSION: In Maryland hospitals, most extirpative renal surgeries in children are total nephrectomies performed using an open technique by high-volume surgeons. Although the overall proportion of minimally invasive surgeries has not increased over time, the utilization of MIS in congenital anomaly cases has. Patient complexity and not operative approach dictates postoperative morbidity and hospital charges.

High-resolution transrectal ultrasound: pilot study of a novel technique for imaging clinically localized prostate cancer.

OBJECTIVES: To determine how high-resolution transrectal ultrasound (HiTRUS) compares with conventional TRUS (LoTRUS) for the visualization of prostate cancer. METHODS AND MATERIALS: Twenty-five men with known prostate cancer scheduled for radical prostatectomy were preoperatively imaged with both LoTRUS (5MHz) and HiTRUS (21MHz). Dynamic cine loops and still images for each modality were saved and subjected to blinded review by a radiologist looking for hypoechoic foci ≥ 5 mm in each sextant of the prostate. Following prostatectomy, areas of prostate cancer ≥ 5 mm on pathologic review were anatomically correlated to LoTRUS and HiTRUS findings. The accuracy of LoTRUS and HiTRUS to visualize prostate cancer in each sextant of the prostate and to identify high-grade and locally advanced disease was assessed. The McNemar test was used to compare sensitivity and specificity and paired dichotomous outcomes between imaging modalities. RESULTS: Among 69 sextants with pathologically identified cancerous foci at radical prostatecomy, HiTRUS visualized 45 and missed 24, whereas LoTRUS visualized 26 and missed 43. Compared with LoTRUS, HiTRUS demonstrated improved sensitivity (65.2% vs. 37.7%) and specificity (71.6% vs. 65.4%). HiTRUS's agreement with pathologic findings was twice as high as LoTRUS (P = 0.006). HiTRUS provided a nonsignificant increase in visualization of high-grade lesions (84% vs. 60%, P = 0.11). CONCLUSIONS: HiTRUS appears promising for prostate cancer imaging. Our initial experience suggests superiority to LoTRUS for the visualization of cancerous foci, and supports proceeding with a clinical trial in the biopsy setting.

Multiparametric magnetic resonance imaging characterization of prostate lesions in the active surveillance population: incremental value of magnetic resonance imaging for prediction of disease reclassification.

OBJECTIVE: This study aimed to characterize prostate lesions by multiparametric magnetic resonance imaging (MRI) in active surveillance (AS) and examine the incremental predictive value of MRI in comparison with clinical parameters for disease reclassification. METHODS: Blinded imaging review of 3-T endorectal mMRI from 50 consecutive men was performed. Multiparametric MRI biomarkers and morphological parameters and the predictive value of a suspicious MR lesion of 10 mm or greater for clinical or histopathologic disease reclassification were assessed. RESULTS: Nine patients were reclassified as AS noneligible during follow-up. Morphological parameters, magnetic resonance spectroscopic imaging, and dynamic contrast-enhanced MRI were associated with disease reclassification. Multiparametric MRI best predicted disease reclassification in patients who did not meet clinical AS enrollment criteria and had a suspicious lesion 10 mm or greater, followed by patients with a suspicious lesion of 10 mm or greater. Not meeting enrollment criteria alone was not a significant predictor of disease reclassification. CONCLUSIONS: Multiparametric MRI demonstrates incremental predictive value when used in combination with clinical AS enrollment criteria and supports the assessment of eligibility for AS.

Do fibrin sealants impact negative outcomes after robot-assisted partial nephrectomy?

PURPOSE: Contemporary rates of postoperative hemorrhage after partial nephrectomy (PN) are low. Commercially available hemostatic agents are commonly used during this surgery to reduce this risk despite a paucity of data supporting the practice. We assessed the impact of fibrin sealant hemostatic agents, a costly addition to surgeries, during robot-assisted partial nephrectomy (RAPN). PATIENTS AND METHODS: Between 2007 and 2011, 114 consecutive patients underwent RAPN by a single surgeon (MEA). Evicel fibrin sealant was used in the first 74 patients during renorraphy. The last 40 patients had renorraphy performed without the use of any hemostatic agents. Clinicopathologic, operative, and complication data were compared between groups. Multivariate and univariate logistic regression analysis was performed to test the association between the use of fibrin sealants and operative outcomes. RESULTS: Patient demographic data and clinical tumor characteristics were similar between groups. The use of fibrin sealant did not increase operative time (166.3 vs 176.1 minutes, P=0.28), warm ischemia time (WIT) (14.4 vs 16.1 minutes, P=0.18), or length of hospital stay (2.6 vs 2.4 days, P=0.35). The omission of these agents did not increase estimated blood loss (116.6 vs 176.1 mL, P=0.8) or postoperative blood transfusion (0% vs 2.5%, P=0.17). Univariate analysis demonstrated no association between use of fibrin sealants and increased complications (P>0.05). Multivariable logistic regression showed no statistically significant predictive value of omission of hemostatic agents for perioperative outcomes (P>0.05). CONCLUSION: Perioperative hemorrhage and other major complications after contemporary RAPN are rare in experienced hands. In our study, the use of fibrin sealants during RAPN does not decrease the rate of complications, blood loss, or hospital stay. Furthermore, no impact is seen on operative time, WIT, or other negative outcomes. Omitting these agents during RAPN could be a safe, effective, cost-saving measure.

Trends in immediate perioperative morbidity and delay in discharge after open and minimally invasive radical prostatectomy (RP): a 20-year institutional experience.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Standard clinical care pathways to discharge have been established for a number of operations including radical prostatectomy (RP). The pathway after RP has changed dramatically over the past two decades due to improvements in surgical technique, anaesthesia and most recently, the introduction of minimally invasive RP (MIRP). This study adds evidence that the emergence of MIRP is associated with a decrease in LOS for all patients undergoing RP. In addition, it catalogues the development of the clinical care pathway over 20 years at a large, tertiary care hospital with extensive experience in RP. Finally, it defines the common reasons patients fall 'off-pathway' (ileus, urine leak, anaemia and re-exploration for bleeding) and defines the immediate perioperative morbidity profile of RP. Specifically, it addresses approach-specific morbidities and indicates that MIRP is associated with higher rates of 'off-pathway' discharge, most often due to ileus. OBJECTIVE: To investigate the development of the clinical care pathway to discharge after radical prostatectomy (RP) at a large, academic medical centre over the past 20 years, focusing on the rates and reasons for deviation. PATIENTS AND METHODS: In all, 18 049 men were identified from the Johns Hopkins RP database who had undergone surgery since 1991. Patients in whom the length of stay (LOS) was ≤95th percentile, defined the clinical care pathway to discharge and those in whom LOS was ≥98th percentile were termed 'off-pathway'. RESULTS: The mean LOS decreased from 7.7 days in 1991 to 1.6 days in 2010. Of 7126 patients undergoing RP since 2005, 1803(25.3%), 4881(68.5%) and 312 (4.4%) were discharged on postoperative day (POD) 1, 2 and 3, respectively; 126 (1.8%) patients, discharged on POD4-21 were 'off-pathway'. The most common reasons for delay of discharge were ileus (44, 0.615%), urine leak (12, 0.17%), anaemia requiring blood transfusion (nine, 0.126%) and bleeding requiring re-exploration (six, 0.08%). The proportion of patients 'off-pathway' was 1.20%, 1.06% and 4.01% for retropubic RP (RRP), laparoscopic RP (LRP) and robot-assisted laparoscopic RP (RALRP), respectively (P < 0.001). Ileus delayed discharge in 0.28%, 0.37% and 1.9% of patients undergoing RRP, LRP and RALRP, respectively (P < 0.001). CONCLUSIONS: The clinical care pathway to discharge after RP has changed dramatically at our institution over the past 20 years. RALRP appears to result in a higher proportion of 'off-pathway' patients, primarily due to ileus, compared with RRP and LRP. However, very few patients were discharged 'off-pathway'.

Renal cell carcinoma seeding of a percutaneous biopsy tract.

We report the case of a 68-year-old male with extension of papillary renal cell carcinoma (Fuhrman grade III) along a percutanous biopsy tract detected at the time of partial nephrectomy. Biopsy was performed to a obtain tissue diagnosis of a complex renal cyst as the patient was unable to receive intravenous contrast for imaging due to a severe allergy. Although biopsy of indeterminate renal lesions can provide valuable diagnostic information, there are inherent risks associated with this procedure. The rare occurrence of tumour seeding should be considered when recommending percutaneous biopsy to a patient with a renal mass.

Increased intra-abdominal fat predicts perioperative complications following minimally invasive partial nephrectomy.

OBJECTIVE: To evaluate the anthropometric measurements of body mass index, outer-abdominal fat (OAF) and intra-abdominal fat (IAF) for their utility in predicting perioperative complications following minimally invasive partial nephrectomy. METHODS: We retrospectively reviewed the clinical data of patients who underwent a laparoscopic or robotic partial nephrectomy between August 2006 and July 2012 by a single surgeon. Measurements of OAF and IAF were obtained from preoperative cross-sectional imaging available through our institution's imaging archive. Preoperative clinical parameters, including BMI, OAF and IAF, were evaluated for associations with postoperative complications, operative time and length of hospital stay. RESULTS: In total, 257 patients underwent a minimally invasive partial nephrectomy during the study period. Of these patients, 195 (75.9%) had preoperative scans available for analysis of OAF and IAF. A total of 52 (26.7%) patients experienced a Clavien grade I-IV complication within 30 days of surgery, 18 (34.6%) of which were grade III-IV. No patient experienced a grade V complication. On multivariate analysis, only increasing IAF (OR 1.05 [95% CI 1.02-1.09], P = .005) was associated with grade I-IV complications, while IAF (OR 1.05 [95% CI 1.00-1.10], P = .04) and intermediate to high tumor complexity (OR 5.31 [95% CI 1.47-19.17], P = .01) were associated with grade III-IV complications. BMI, OAF and IAF were not found to be independently associated with operative time or length of hospital stay. CONCLUSION: IAF is independently associated with complications following minimally invasive partial nephrectomy. With further validation, this measurement may prove useful in the preoperative risk stratification of patients with small renal masses.

Multiphasic enhancement patterns of small renal masses (≤4 cm) on preoperative computed tomography: utility for distinguishing subtypes of renal cell carcinoma, angiomyolipoma, and oncocytoma.

OBJECTIVE: To analyze the enhancement patterns of small renal masses (SRMs) during 4-phase computed tomography (CT) imaging to predict histology. METHODS: One-hundred consecutive patients with SRMs and 4-phase preoperative CT imaging, who underwent extirpative surgery with a pathologic diagnosis of renal cell carcinoma (RCC), angiomyolipoma (AML), or oncocytoma, were identified from a single institution. An expert radiologist, blinded to histologic results, retrospectively recorded tumor size, RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor, and the location relative to polar lines) nephrometry score, tumor attenuation, and the renal cortex on all 4 acquisitions (precontrast, corticomedullary, nephrogenic, and delayed density). RESULTS: Pathologic diagnoses included 48 clear-cell RCCs (ccRCCs), 22 papillary RCCs, 10 chromophobe RCCs, 13 oncocytomas, and 7 AMLs. There was no significant difference in median tumor size (P = .8), nephrometry score (P = .98), or anatomic location (P >.2) among histologies. Significant differences were noted in peak enhancement (P <.001) and phase-specific enhancement (P <.007) by histology. Papillary RCCs demonstrated a distinct enhancement pattern, with a peak Hounsfield unit (HU) of 56, and greatest enhancement during the NG and delayed phases. The highest peak HU were demonstrated by ccRCC (117 HU) and oncocytoma (125 HU); ccRCC more often peaked in the corticomedullary phase, whereas oncocytoma peaked in the nephrogenic phase. CONCLUSION: In a series of patients with SRMs undergoing 4-phase CT, tumor histologies demonstrated distinct enhancement patterns. Thus, preoperative 4-phase CT imaging may provide useful information regarding pathologic diagnosis in patients undergoing extirpative surgery.

Perioperative complications of robot-assisted partial nephrectomy: analysis of 886 patients at 5 United States centers.

OBJECTIVE: To review complications of robot-assisted partial nephrectomy (RAPN) at 5 centers, as classified by the Clavien system. MATERIALS AND METHODS: A multi-institutional analysis of prospectively maintained databases assessed RAPN complications. From June 2007 to November 2011, 886 patients at 5 United States centers underwent RAPN. Patient demographics, perioperative outcomes, and complications data were collected. Complication severity was classified by Clavien grade. RESULTS: Mean (standard deviation) data were patient age, 59.4 (11.4) years; age-adjusted Charlson Comorbidity Index, 3.0 (1.9); radiographic tumor size, 3.0 (1.6) cm; nephrometry score, 6.9 (2.0); and warm ischemia time, 18.8 (9.0) minutes. Median blood loss was 100 mL (interquartile range, 100-250 mL). Of the 886 patients, intraoperative complications occurred in 23 patients (2.6%) and 139 postoperative complications occurred in 115 patients (13.0%) for a total complication rate of 15.6%. Among the 139 postoperative complications, 43 (30.9%) were classified as Clavien 1, 64 (46.0%) were Clavien 2, 21 (15.1%) were Clavien 3, and 11 (7.9%) were Clavien 4. No complication-related deaths occurred. Intraoperative hemorrhage occurred in 9 patients (1.0%) and postoperative hemorrhage in 51 (5.8%). Forty-one patients (4.6%) required a perioperative blood transfusion, 10 (1.1%) required angioembolization, and 2 (0.2%) required surgical reexploration for postoperative hemorrhage. Urine leaks developed in 10 patients (1.1%): 3 (0.3%) required ureteral stenting, and 2 (0.2%) required percutaneous drainage. Acute postoperative renal insufficiency or renal failure developed in 7 patients (0.8%), 2 of whom required hemodialysis. The RENAL (radius, exophytic/endophytic properties of the tumor, nearness of tumor deepest portion to the collecting system or sinus, anterior/posterior descriptor and the location relative to polar lines) nephrometry scoring system accurately predicted RAPN complication rates. CONCLUSION: Complication rates in this large multicenter series of RAPN appear to be acceptable and comparable with other nephron-sparing modalities. Most complications (77.0%) are Clavien 1 and 2 and can be managed conservatively.

Multiparametric magnetic resonance imaging findings in men with low-risk prostate cancer followed using active surveillance.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Up to 35% of men on active surveillance (AS) for clinically localized prostate cancer will experience biopsy reclassification during follow-up. Currently, annual prostate biopsy is recommended in AS programmes. Multiparametric MRI has shown promise in identifying men at risk for immediate reclassification at the time of entry into AS; however, the MRI characteristics of men already enrolled in AS who may be at low risk for disease reclassification have not been fully described. In the present study, we describe the MRI findings of a cohort of men enrolled within AS, with extended follow-up. Among these men, multiparametric MRI demonstrated excellent specificity (0.974) and negative predictive value (0.897) for the detection of pathological index lesions (determined on serial biopsies). These results suggest that men enrolled in AS with a non-suspicious MRI are unlikely to harbour an index cancerous lesion. OBJECTIVE: To assess the performance of multiparametric magnetic resonance imaging (MRI) in identifying pathological-index (path-index) lesions, defined as cancer present in the same prostate sextant in two separate surveillance biopsies, in men followed within an active surveillance (AS) programme for low-risk prostate cancer (CaP) with extended follow-up. MATERIALS AND METHODS: A total of 50 men, representing >215 person-years of follow-up in an AS programme, who were referred for prostate MRI were randomly chosen to have their images reviewed by a radiologist with expertise in prostate MRI, who was blinded to biopsy results. Index lesions on MRI were defined as a single suspicious lesion ≥10 mm or >2 lesions in a given prostate sextant. Lesions on MRI were considered suspicious if ≥2 abnormal parameters co-registered anatomically. Path-index lesions were defined as cancer present in a given prostate sextant on two separate biopsy sessions. Sensitivity and specificity were calculated to test the performance of MRI for identifying path-index lesions. Clinical and pathological features were compared between men with and without a MRI-index lesion. RESULTS: A total of 31 path-index and 13 MRI-index lesions were detected in 22 and 10 patients, respectively. Multiparametric MRI demonstrated excellent specificity and negative predictive value (0.974 and 0.897, respectively) for the detection of path-index lesions. Sensitivity (0.19) and positive predictive value (0.46) were considerably lower. Patients with an index lesion on MRI were younger and less likely to have met the 'Epstein' criteria for very low-risk CaP. Compared with men without an MRI lesion, a significant increase in biopsy reclassification was noted for men with a MRI lesion (40 vs 12.5%, P = 0.04). CONCLUSIONS: A non-suspicious MRI was highly correlated with a lack of path-index lesions in an AS population. Multiparametric MRI may be useful in both the selection and monitoring of patients undergoing AS.

Contemporaneous comparison of open vs minimally-invasive radical prostatectomy for high-risk prostate cancer.

OBJECTIVES: To analyze pathological and short-term oncological outcomes in men undergoing open and minimally-invasive radical prostatectomy (MIRP) for high-risk prostate cancer (HRPC; prostate-specific antigen level [PSA] >20 ng/mL, ≥ cT2c, Gleason score 8-10) in a contemporaneous series. PATIENTS AND METHODS: In total, 913 patients with HRPC were identified in the Johns Hopkins Radical Prostatectomy Database subsequent to the inception of MIRP at this institution (2002-2011) Of these, 743 (81.4%) underwent open radical retropubic prostatectomy (ORRP), 105 (11.5%) underwent robot-assisted laparoscopic radical prostatectomy (RALRP) and 65 (7.1%) underwent laparoscopic radical prostatectomy (LRP) for HRPC. Appropriate comparative tests were used to evaluate patient and prostate cancer characteristics. Proportional hazards regression models were used to predict biochemical recurrence. RESULTS: Age, race, body mass index, preoperative PSA level, clinical stage, number of positive cores and Gleason score at final pathology were similar between ORRP and MIRP. On average, men undergoing MIRP had smaller prostates and more organ-confined (pT2) disease (P = 0.02). The number of surgeons and surgeon experience were greatest for the ORRP cohort. Overall surgical margin rate was 29.4%, 34.3% and 27.7% (P = 0.52) and 1.9%, 2.9% and 6.2% (P = 0.39) for pT2 disease in men undergoing ORRP, RALRP and LRP, respectively. Biochemical recurrence-free survival among ORRP, RALRP and LRP was 56.3%, 67.8% and 41.1%, respectively, at 3 years (P = 0.6) and the approach employed did not predict biochemical recurrence in regression models. CONCLUSIONS: At an experienced centre, MIRP is comparable to open radical prostatectomy for HRPC with respect to surgical margin status and biochemical recurrence.

Preoperative characteristics of men with unfavorable high-Gleason prostate cancer at radical prostatectomy.

INTRODUCTION: Some men with Gleason sum 8-10 prostate cancer (PC) at RP have favorable outcomes: Biochemical recurrence free (BFS) and prostate cancer-specific survival (CSS) are improved for such men with pT2 or pT3a disease compared with pT3b or N1 disease at radical prostatectomy (RP). We examine biopsy characteristics of men with high-grade PC at RP to better select those who may benefit from surgery. MATERIALS AND METHODS: A total of 1,174 men from our Institutional Database (1982-2010) had Gleason 8-10 cancer at RP. Their demographic and prostate biopsy characteristics were compared among those with disease defined as favorable (pT2 or pT3a) vs. unfavorable (pT3b or N1). Logistic regression was used to determine predictors of unfavorable disease. Kaplan-Meier analysis was used to determine survival outcomes. RESULTS: Biopsy data were available for 1,157 men (median cores 12 [2-20]); 779 (66.4%) favorable, 394 (33.6%) unfavorable; 102 (8.7%), 515 (44.1%), and 552 (47.2%) were low, intermediate, and high-risk. For favorable and unfavorable cases, 10-year BFS was 40.0% and 5.7% (P < 0.001) and CSS was 84.9% and 60.3% (P < 0.001). Multivariate logistic regression revealed that PSA ≥ 20 and perineural invasion (PNI) at biopsy increased the likelihood of unfavorable, high-grade disease. Considering PSA ≥ 20 and PNI as adverse features, 23.7%, 40.1%, and 71.4% of patients with none, 1, or 2 adverse features had unfavorable, high-Gleason PC (P < 0.001). CONCLUSIONS: High-Gleason PC was not uniformly associated with poor outcomes after RP, though men with unfavorable (pT3b/N1) disease fared poorly. Preoperative predictors of high-Gleason, unfavorable disease in a cohort of predominantly intermediate and high-risk patients were PSA ≥ 20 and PNI.

Impact of robotic technique and surgical volume on the cost of radical prostatectomy.

BACKGROUND AND PURPOSE: Our present understanding of the effect of robotic surgery and surgical volume on the cost of radical prostatectomy (RP) is limited. Given the increasing pressures placed on healthcare resource utilization, such determinations of healthcare value are becoming increasingly important. Therefore, we performed a study to define the effect of robotic technology and surgical volume on the cost of RP. METHODS: The state of Maryland mandates that all acute-care hospitals report encounter-level and hospital discharge data to the Health Service Cost Review Commission (HSCRC). The HSCRC was queried for men undergoing RP between 2008 and 2011 (the period during which robot-assisted laparoscopic radical prostatectomy [RALRP] was coded separately). High-volume hospitals were defined as >60 cases per year, and high-volume surgeons were defined as >40 cases per year. Multivariate regression analysis was performed to evaluate whether robotic technique and high surgical volume impacted the cost of RP. RESULTS: There were 1499 patients who underwent RALRP and 2565 who underwent radical retropubic prostatectomy (RRP) during the study period. The total cost for RALRP was higher than for RRP ($14,000 vs 10,100; P<0.001) based primarily on operating room charges and supply charges. Multivariate regression demonstrated that RALRP was associated with a significantly higher cost (ß coeff 4.1; P<0.001), even within high-volume hospitals (ß coeff 3.3; P<0.001). High-volume surgeons and high-volume hospitals, however, were associated with a significantly lower cost for RP overall. High surgeon volume was associated with lower cost for RALRP and RRP, while high institutional volume was associated with lower cost for RALRP only. CONCLUSIONS: High surgical volume was associated with lower cost of RP. Even at high surgical volume, however, the cost of RALRP still exceeded that of RRP. As robotic surgery has come to dominate the healthcare marketplace, strategies to increase the role of high-volume providers may be needed to improve the cost-effectiveness of prostate cancer surgical therapy.