Impact of the Cell Cycle Progression Test on Physician and Patient Treatment Selection for Localized Prostate Cancer.

PURPOSE: The cell cycle progression test is a validated molecular assay that assesses prostate cancer specific disease progression and mortality risk when combined with clinicopathological parameters. We present the results from PROCEDE-1000, a large, prospective registry designed to evaluate the impact of the cell cycle progression test on shared treatment decision making for patients newly diagnosed with prostate cancer. MATERIALS AND METHODS: Untreated patients with newly diagnosed prostate adenocarcinoma were enrolled in the study and the cell cycle progression test was performed on the initial prostate biopsy tissue. A set of 4 sequential surveys tracked changes relative to initial therapy recommendations (before cell cycle progression) based on clinicopathological parameters following physician review of the cell cycle progression test result, physician/patient review of the cell cycle progression test results and a minimum of 3 months of clinical followup (actual treatment). RESULTS: Of the 1,596 patients enrolled in this registry 1,206 were eligible for analysis. There was a significant reduction in the treatment burden recorded at each successive evaluation (p <0.0001), with the mean number of treatments per patient decreasing from 1.72 before the cell cycle progression test to 1.16 in actual followup. The cell cycle progression test caused a change in actual treatment in 47.8% of patients. Of these changes 72.1% were reductions and 26.9% were increases in treatment. For each clinical risk category there was a significant change in treatment modality (intervention vs nonintervention) before vs after cell cycle progression testing (p=0.0002). CONCLUSIONS: The cell cycle progression test has a significant impact in assisting physicians and patients reach personalized treatment decisions.

Is there a proper pelvic size for an extraperitoneal robot-assisted radical prostatectomy?

BACKGROUND: A narrow pelvis can potentially complicate an extraperitoneal radical robot-assisted prostatectomy (RAP). We report our experience with RAP and evaluate whether a narrow pelvis can affect treatment outcomes after extraperitoneal RAP. MATERIALS AND METHODS: We prospectively evaluated 50 patients who underwent RAP during a 2-month period using the extraperitoneal approach. To approximate the relative size of the field available for working using the extraperitoneal approach, the arc length between the anterior superior iliac spines was estimated with the umbilicus as the center of the circle. Patients with an arc length measuring <33 cm were compared with those with an arc length > or =33 cm. Additional parameters evaluated included age, total operating time, estimated blood loss, prostate-specific antigen (PSA) level, pathological stage and Gleason grade, intraoperative and perioperative complications, surgical margin status, and continence at 3 months. RESULTS: Twenty-eight (56%) patients had an arc length <33 cm and twenty-two (44%) patients had an arc length > or =33 cm. When comparing the two groups, no statistically significant difference (P > 0.05) was noted in age, PSA level, blood loss (161 v 163 mL), operative time (174 v 176 min), and total positive margin rates (14% v 13.6%). The continence rate at 3 months was 66.6% and equal for both groups. CONCLUSION: In our experience, a narrow pelvis did not significantly affect operative outcome in patients undergoing an extraperitoneal radical RAP. Although this variable should be taken into account, it should not be a primary factor in deciding the route of access.

Randomized comparison of extraperitoneal and transperitoneal access for robot-assisted radical prostatectomy.

PURPOSE: Although extraperitoneal robot-assisted radical prostatectomy (RARP) is gaining popularity, the majority of these procedures are performed transperitoneally. The purpose of this study was to compare the transperitoneal and extraperitoneal approaches for RARP. PATIENTS AND METHODS: We randomized 62 consecutive patients undergoing RARP into two equal groups according to the route of access. The groups were evaluated for age, body mass index (BMI), preoperative serum prostate specific antigen (PSA) concentration, total operating time, estimated blood loss, specimen weight, pathologic Gleason score and stage, intraoperative and postoperative complications, and surgical-margin status. RESULTS: No significant differences were noted the extraperitoneal and transperitoneal groups with respect total operative time (181 v 191 minutes), blood loss (199 v 163 mL), pathologic Gleason score (6.6 v 6.7), specimen weight (53 v 48 g), or positive-margin status (0 v 1 patient). There were no significant differences in age (56 v 59 years) or PSA (7.8 v 6.1 ng/dL). However, the BMI was significantly higher in the extraperitoneal group (29.8 v 26.5 kg/m(2); P < 0.01). The only complication in the study was a urine leak, which occurred in the transperitoneal group and was managed conservatively. CONCLUSIONS: There were no significant differences in operative parameters in the two groups. Choice of access should be based on patient characteristics as well as surgeon preference. Patients who have had abdominal operations are best suited for the extraperitoneal route. Surgeons should be familiar with both approaches in order to provide patients with the best care.

Impact of prostate size in robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE: A large prostate can complicate an extraperitoneal robot-assisted radical prostatectomy (RARP). We report our experience with RARP and evaluate the effects of prostate size on treatment outcomes after extraperitoneal RARP. PATIENTS AND METHODS: Information on 355 consecutive patients undergoing extraperitoneal RARP was gathered, and patients with prostate weight <75 g (N = 319) were compared with those having glands >or=75 g (N = 36). The factors considered were age, body mass index, total operating time, estimated blood loss, serum prostate specific antigen (PSA) concentration, pathologic stage and Gleason grade, intraoperative and peri-operative complications, margin status, and continence. RESULTS: A statistically significant difference (P < 0.05) was noted in age (59 v 64 years), PSA concentration (6.07 v 8.9 ng/dL), and blood loss (175 v 226 mL) between patients with smaller v larger prostates. No difference was seen in Gleason score (6 v 6), clinical T stage, operative time (217 v 225 minutes), or total positive-margin rate (13% v 19%). A higher positive-margin rate was seen in patients with stage T(3) disease and larger prostates. The 6-month continence rate in patients with a prostate volume < 75 g was 97% v 84% in patients with larger prostate volumes ( P < 0.05). CONCLUSION: Although a large prostate volume is associated with a slight increase in short-term urinary complications postoperatively, it should not be considered a contraindication for the experienced surgeon. This higher risk raises the question of a possible need for longer catheterization in this subset of patients.

Transrectal sonography in prostate evaluation.

Prostate cancer is the most prevalent newly diagnosed noncutaneous malignancy in men. With the continued use of prostate-specific antigen screening, there has been a dramatic rise in the number of prostate biopsied performed. Transrectal ultrasonography (TRUS) is an essential tool used for detecting prostate pathology and performing prostate biopsies. This article review the indications and principles of TRUS of the prostate, the technique of TRUS, and controversies pertaining to prostate core biopsy.

Robot-assisted radical prostatectomy in obese patients.

OBJECTIVES: Few centers perform extraperitoneal robot assisted radical prostatectomy. The average patient weight is increasing to the mildly obese. Little is known as to the difficulty-impact, obesity may have on robot-assisted extraperitoneal prostatectomy (RAP). We assess our own experience with obese patients undergoing RAP. MATERIALS AND METHODS: Information on 375 consecutive patients undergoing robot-assisted extraperitoneal prostatectomy by a single surgeon was gathered. Obesity is defined as having a body mass index (BMI) greater than 30 kg/m2. Patients with BMI >/= 30 were compared to those with BMI < 30. Specific comparators between the groups were: age, total operating time, estimated blood loss, total prostate specific antigen (PSA), specimen weight, pathological stage, grade and margin, complications, and functional outcomes. RESULTS: Sixty-seven men were identified as obese. When comparing the two groups, no statistically significant difference (p > .05) was noted in operative time (229 versus 217 min), blood loss (205 versus 175 ml), PSA, clinical and pathologic stages, specimen weight, and complications. 15% of non-obese patients had a positive margin compared to 12% of obese patients (p > .05). The 6-month continence rate in patients with a BMI >/= 30 was 92% versus 97% in patients with a BMI < 30. CONCLUSIONS: The extraperitoneal approach to performing a robot-assisted prostatectomy is not associated with increased morbidity in the obese patient. There were no statistically significant differences noted in oncological or functional outcomes between the two groups.

Combined ureterorenoscopy and shockwave lithotripsy for large renal stone burden: an alternative to percutaneous nephrolithotomy?

PURPOSE: To investigate the feasibility and initial outcomes of a combination of ureterorenoscopy (URS) using holmium laser lithotripsy and extracorporeal shockwave lithotripsy (SWL) in a single outpatient session for the treatment of large renal stone burdens in patients refusing or unsuitable for percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Fourteen patients with a mean age of 52.7 years (range 34-81 years) having a mean stone burden of 847 mm2 (range 58 mm2-1850 mm2) were treated with combined URS laser lithotripsy and SWL as an alternative to PCNL. The SWL (mean 2800 shockwaves) was performed using the Storz Modulith SL-X, and flexible URS with holmium laser lithotripsy was performed either during or following SWL. RESULTS: Ninety-three percent of the patients (13/14) were treated successfully on an outpatient basis. Two patients were rendered stone free after the initial procedure alone (14%). Overall, including secondary outpatient treatment with a second session of URS alone (N = 7) URS and SWL (N = 1), SWL (N = 1), or oral alkalinization therapy (N = 1), the stone-free rate was 76.9% (10/13). One patient was excluded secondary to death from unrelated causes after the initial procedure, and the success rate (residual fragments <4 mm) was 84.6% (11/13). The two treatment failures included one patient who required a third URS procedure and one patient who developed urosepsis necessitating nephrostomy-tube placement who underwent subsequent PCNL. CONCLUSIONS: In comparison with traditional approaches using PCNL and second-look nephroscopy, single-session combined URS and SWL with a second outpatient procedure may offer equivalent results with decreased morbidity in carefully selected patients.

Robot-assisted extraperitoneal radical prostatectomy in a patient with a pelvic kidney.

With the increasing popularity of the robotic approach for performing radical prostatectomy, the awareness of potential genitourinary anomalies is a necessity. The ectopic position of a pelvic kidney can present a unique challenge to the success of robot-assisted radical prostatectomy while preserving function in the kidney. We describe our experience of performing extraperitoneal robot-assisted radical prostatectomy in a patient with a pelvic kidney.

Comparison of operative and functional outcomes of laparoscopic radical prostatectomy and radical retropubic prostatectomy: single surgeon experience.

OBJECTIVES: To compare radical retropubic prostatectomy (RRP) and laparoscopic radical prostatectomy (LRP) outcomes in a contemporary series. METHODS: A total of 70 LRP patients operated on between 2001 and 2002 with at least 18 months of follow-up were selected. These patients were compared with a matched cohort of 70 patients who had undergone RRP by the same surgeon from 1999 to 2001. The baseline patient characteristics, perioperative and histologic parameters, recovery time, complications, and 18-month functional data were compared. RESULTS: No significant differences were found in the preoperative characteristics. The mean operative time was 181.8 +/- 18.7 minutes for RRP and 246.4 +/- 46.1 minutes for LRP (P <0.0001). The mean estimated blood loss was 563.2 mL for RRP and 275.8 mL for LRP (P <0.0001). The positive margin rate was 20% and 15.7% for the RRP and LRP groups, respectively (P = NS). The mean pain score on postoperative day 1 was 4.5 in the LRP group and 7.8 in the RRP group on an analog pain score of 0 to 10 (P = 0.02). Full recovery was achieved at 33 +/- 17 days and 45 +/- 20 days for the LRP and RRP groups, respectively (P <0.001). The total perioperative complication rate for LRP and RRP was comparable at 18.5% and 15.7%, respectively. The diurnal continence rate (no pads) for the LRP and RRP groups was 70%, 90%, and 92.8% and 71.4%, 87.6%, and 92% at 6, 12, and 18 months, respectively (P = NS). The potency rate after bilateral neurovascular preservation with or without sildenafil for the LRP and RRP group was 55%, 72.6%, and 79.5% and 43%, 58%, and 72.4% at 6, 12, and 18 months, respectively (P = NS). CONCLUSIONS: LRP is well tolerated and provides short-term oncologic and functional results comparable to those of RRP.

Evaluation of two techniques of partial urethral obstruction in the male rat model of bladder outlet obstruction.

OBJECTIVES: To perform a comparison to determine which of two methods of partial urethral ligation produces the most consistent outcome and fewest side effects. Such a study has not been previously reported. Partial urethral ligation is a means of causing reproducible bladder outlet obstruction. In the male rat model, partial urethral obstruction can be performed either by perineal incision and bulbous urethral ligation or retropubic incision and midprostatic obstruction. METHODS: Fifteen male Sprague-Dawley rats were studied. Five were selected for bulbous urethral obstruction through a perineal incision, five for midprostatic obstruction using a retropubic approach, and five for a sham operation through a perineal incision. RESULTS: The operative time was shorter and morbidity lower with the perineal approach compared with the retropubic approach. Inflammation or infection, or both, were seen in the prostate, bladder, proximal urethra, ureters, and kidneys in the rats in which a midprostatic obstruction was performed. The proximal urethra and prostate were mildly inflamed in those rats that underwent bulbous obstruction. Sham-operated rats exhibited mild prostatitis only. CONCLUSIONS: The perineal approach to the bulbous urethra is the method of choice for creating a partial urethral obstruction model of bladder outlet obstruction in the male rat.

Trypanosoma cruzi infection induced changes in the innervation, structure and function of the murine bladder.

PURPOSE: The involvement of the lower urinary tract in chronic Chagas' disease has received little attention. Therefore, we investigated pathology and functional alterations in the bladder of Trypanosoma cruzi infected mice. MATERIALS AND METHODS: CD1 mice were infected with 5 x 10 T. cruzi trypomastigotes of the Brazil strain of T. cruzi. At day 100 after infection bladder structure and function were examined by pathological evaluation, magnetic resonance imaging and cystometric studies. RESULTS: The bladder in infected mice weighed more and were large, dilated, deformed, friable and thin walled compared with control mice. Magnetic resonance imaging confirmed these observations. Inflammation, fibrosis and ganglionitis was observed. Cystometric studies revealed that baseline, threshold and micturition pressures were increased in infected mice. Bladder overactivity and decreased bladder compliance were also noted in infected mice. There were no detectable differences in bladder capacity, micturition volume or residual volume between infected and uninfected mice. CONCLUSIONS: Bladder abnormalities may be a more common clinical sequelae of T. cruzi infection than previously appreciated.

Radical perineal prostatectomy in obese patients.

OBJECTIVES: To evaluate the efficacy of radical perineal prostatectomy in obese patients. No study has ever been published providing evidence of success of any type of prostatectomy specifically in patients with significant truncal obesity. METHODS: A retrospective review of 103 patients who underwent radical perineal prostatectomy between 1996 and 2002 was performed. Obesity is defined as having a body mass index greater than 30 kg/m(2). Seven obese patients were found. The operative time, blood loss, hospital length of stay, perioperative complications, urinary continence, and quality of specimen were assessed. RESULTS: The mean age was 61 years (range 56 to 67). The body mass index ranged between 30.21 and 47.9 (average 39.27). The average operative time and blood loss was 142 minutes and 542 mL, respectively. No complications occurred and no blood transfusions were needed perioperatively. Two specimens had a positive surgical margin. Six (85.7%) of the 7 patients went home on postoperative day 2; the remaining patient left on day 3. The 1-year continence rate was 66%. CONCLUSIONS: Radical perineal prostatectomy remains an excellent option for obese patients. It remains to be seen if this is the case with radical retropubic prostatectomy.

Critical surgical techniques for radical perineal prostatectomy.

PURPOSE: Radical perineal prostatectomy was historically the surgical treatment of choice for localized adenocarcinoma of the prostate until the 1980s when radical retropubic prostatectomy began to gain popularity. Nevertheless, the perineal approach possesses advantages that prompt resurgence in the interest of this classic operation. We review the relevant anatomy and our modified technique of performing a successful radical perineal prostatectomy. MATERIALS AND METHODS: The English literature pertaining to the different surgical approaches to radical perineal prostatectomy was reviewed through PubMed. Attention was paid to its indications, anatomical significance and various surgical techniques. RESULTS: Studies demonstrate no difference in the incidence of positive surgical margins and biochemical recurrence between radical retropubic and perineal prostatectomies. Furthermore, the perineal approach avoids the dorsal venous complex and better facilitates the vesicourethral anastomosis in the face of minimal pain and requirement for transfusion. We use a modified Belt approach, aiming to yield the most optimal outcome with minimal morbidity. A meticulous anatomical approach is warranted if complications such as rectal injury, incontinence and erectile dysfunction are to be minimized. CONCLUSIONS: With careful preoperative evaluation, selected patients should benefit from radical perineal prostatectomy for the management of localized prostate cancer. Familiarity with this specialized technique should be an immeasurable addition to any armamentarium in the therapy of prostatic diseases.