MRI - ultrasound fusion guided biopsy of the prostate: lesion volume as a predictor of cancer in patients with repeat biopsies.

INTRODUCTION: The objective was to analyze the diagnostic value of multiparametric magnetic resonance imaging (MRI) prostate lesion volume (PLV) and its correlation with the subsequent MRI-ultrasound (MRI-US) fusion biopsy results. MATERIALS AND METHODS: Between March 2014 and July 2016, 150 men underwent MRI-US fusion biopsies at our institution. All suspicious prostate lesions were graded according to the Prostate Imaging Reporting and Data System (PIRADS) and their volumes were measured. These lesions were subsequently biopsied. All data were prospectively collected and retrospectively analyzed. The PLV of all suspicious lesions was correlated with the presence of cancer on the final MRI-US fusion biopsy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. RESULTS: There were 206 suspicious lesions identified in 150 men. The overall cancer detection rate was 102/206 (49.5%). The mean PLV for benign lesions was 0.63 ± 0.94 cm3 versus 1.44 ± 1.76 cm3 for cancerous lesions (P < 0.01). There was a statistically significant difference between the PLV of PIRADS 5 lesions when compared to PIRADS 4, 3, and 2 lesions (P < 0.0001, < 0.0001, and 0.006, respectively). The area under the curve for volume in predicting prostate cancer (PCa) was 0.66. The optimal volume for predicting PCa was 0.26 cm3 with a sensitivity, specificity, PPV, and NPV of 80.7%, 42.7%, 41.2%, and 74.6%, respectively. CONCLUSION: PLV may serve as a useful measure to triage patients prior to MRI-US fusion biopsy and help better understand the limits of this technology for individual patients.

Robot-assisted retroperitoneal lymph node dissection: technique and initial case series of 18 patients.

OBJECTIVE: To evaluate outcomes of the first 18 patients treated with robot-assisted retroperitoneal lymph node dissection (RA-RPLND) for non-seminomatous germ cell tumours (NSGCT) and paratesticular rhabdomyosarcoma (RMS) at our institution. PATIENTS AND METHODS: Between March 2008 and May 2013, 17 patients underwent RA-RPLND for NSGCT and one for paratesticular RMS. Data were collected retrospectively on patient demographics, preoperative tumour characteristics, and perioperative outcomes including open conversion rate, lymph node (LN) yield, rate of positive LNs, operative time, estimated blood loss (EBL), and length of stay (LOS). Perioperative outcomes were compared between patients receiving primary RA-RPLND vs post-chemotherapy RA-RPLND. Medium-term outcomes of tumour recurrence rate and maintenance of antegrade ejaculation were recorded. RESULTS: RA-RPLND was completed robotically in 15 of 18 (83%) patients. LNs were positive in eight of 18 patients (44%). The mean LN yield was 22 LNs. For cases completed robotically, the mean operative time was 329 min, EBL was 103 mL, and LOS was 2.4 days. At a mean (range) follow-up of 22 (1-58) months, there were no retroperitoneal recurrences and two of 17 (12%) patients with NSGCT had pulmonary recurrences. Antegrade ejaculation was maintained in 91% of patients with a nerve-sparing approach. Patients receiving primary RA-RPLND had shorter operative times compared with those post-chemotherapy (311 vs 369 min, P = 0.03). There was no significant difference in LN yield (22 vs 18 LNs, P = 0.34), EBL (100 vs 313 mL, P = 0.13), or LOS (2.75 vs 2.2 days, P = 0.36). CONCLUSION: This initial selected case series of RA-RPLND shows that the procedure is safe, reproducible, and feasible for stage I-IIB NSGCT and RMS in the hands of experienced robotic surgeons. Larger studies are needed to confirm the diagnostic and therapeutic utility of this technique.

Massive renal size is not a contraindication to a laparoscopic approach for bilateral native nephrectomies in autosomal dominant polycystic kidney disease (ADPKD).

OBJECTIVE: To determine if massive renal size should be a contraindication for attempting a laparoscopic approach to bilateral native nephrectomies in patients with autosomal dominant polycystic kidney disease (ADPKD). PATIENTS AND METHODS: We retrospectively reviewed all laparoscopic bilateral nephrectomies performed for ADPKD at our institution from 1 January 2000 to 31 December 2012. We stratified patients by kidney weight (with or without at least one kidney weighing >2500 g) and compared perioperative data, complications, and status of kidney allografts. Additionally, the subset of patients with at least one kidney weighing >3500 g was compared with the rest of the cohort. RESULTS: We identified 68 patients; mean (range) individual kidney weight was 1984 (197-5042) g. In all, 24 patients had at least one kidney weighing >2500 g, yet patients in this group were not significantly different from the rest of the cohort for complications, estimated blood loss, transfusion rate, or duration of hospitalisation. For those who underwent simultaneous renal allotransplantation, native kidney size was not associated with graft outcomes. Additionally, of the six patients with at least one kidney weighing >3500 g, only one required a blood transfusion, and the group had no intraoperative or postoperative Clavien grade ≥3 complications. None of the cohort required conversion to open surgery. CONCLUSION: Massive size of polycystic kidneys is not a contraindication to attempting a laparoscopic approach to bilateral nephrectomies in an experienced, high-volume centre.

Venous thromboembolism after urological surgery.

PURPOSE: We determined the rates of deep venous thromboembolism and pulmonary embolism after common urological procedures in the United States. MATERIALS AND METHODS: The NSQIP database was used to identify common urological procedures performed between January 1, 2005 and December 31, 2011. A total of 82,808 patients were included in the study. RESULTS: Overall 633 (0.76% of 82,808 subjects) deep venous thromboses occurred within 30 days of surgery in this cohort of patients treated with common urological procedures. Among procedures performed at least 500 times the rates of deep venous thrombosis were highest for cystectomy/urinary diversion (3.96% [71/1,792]), partial cystectomy (2.35% [17/722]) and open radical nephrectomy (1.67% [45/2,702]). The rates of deep venous thrombosis were lowest in patients undergoing laparoscopic colpopexy (0.00% [0/707]), placement of a female sling (0.08% [9/10,648]) and hydrocelectomy/spermatocelectomy/varicocelectomy (0.13% [3/2,333]). A total of 349 (0.42%) pulmonary embolisms occurred in this cohort, with cystectomy/urinary diversion having the highest rate overall (2.85% [51/1,792]). Multivariate logistic regression revealed that age greater than 60 years, functional status, history of disseminated cancer, congestive heart failure, anesthesia time greater than 120 minutes and chronic steroid use were independently associated with the formation of deep venous thrombosis/pulmonary embolism. A limitation of the study is that no data were available on thromboembolic prophylaxis. CONCLUSIONS: While deep venous thrombosis and pulmonary embolism are uncommon after urological surgery, this study is the first to our knowledge to provide a comprehensive comparison of deep venous thrombosis/pulmonary embolism rates across a full spectrum of various urological procedures in American patients. This study should give the reader a better understanding of the exact risk faced by the patient when undergoing common urological procedures.

Simultaneous kidney transplantation and bilateral native nephrectomy for polycystic kidney disease.

PURPOSE: Bilateral native nephrectomy with simultaneous kidney transplantation is becoming more common for patients with polycystic kidney disease in the living donor nephrectomy era. Single center reports evaluating the short-term and long-term outcomes of simultaneous kidney transplantation have been published but are generally limited by small sample sizes. We examined population level data to broadly define the complications of simultaneous kidney transplantation. MATERIALS AND METHODS: The Nationwide Inpatient Sample (NIS) was used to acquire data on 2,368 patients with polycystic kidney disease treated with bilateral native nephrectomy between 1998 and 2010. We performed unadjusted, multivariable and propensity score adjusted analyses of postoperative outcomes. RESULTS: A total of 2,368 patients were included in this study. The 271 patients (11.4%) who underwent simultaneous kidney transplantation had higher rates of intraoperative hemorrhage, blood transfusion and urological complications (propensity score adjusted OR 3.3, p=0.01, OR 4.2, p<0.0001 and OR 5.5, p<0.0001, respectively) but a lower in-hospital mortality rate (15.8% vs 1.1%, propensity score adjusted OR 0.10, p<0.0001). Median hospitalization was also significantly higher in patients who underwent simultaneous kidney transplantation (6 vs 9 days, p<0.0001). For the top quartile of high volume hospitals the rates of intraoperative hemorrhage, blood transfusion and urological complications remained statistically higher in patients treated with simultaneous kidney transplantation but in-hospital mortality was similar on multivariable logistic regression (OR 0.2, p=0.17). CONCLUSIONS: Except for increased rates of intraoperative hemorrhage, blood transfusion and urological complications there were no significant differences in postoperative adverse outcomes in this large, population based study of patients who underwent simultaneous kidney transplantation compared to bilateral native nephrectomy alone.

Outcome and toxicity for patients treated with intensity modulated radiation therapy for localized prostate cancer.

PURPOSE: We evaluate long-term disease control and chronic toxicities observed in patients treated with intensity modulated radiation therapy for clinically localized prostate cancer. MATERIALS AND METHODS: A total of 302 patients with localized prostate cancer treated with image guided intensity modulated radiation therapy between July 2000 and May 2005 were retrospectively analyzed. Risk groups (low, intermediate and high) were designated based on National Comprehensive Cancer Network guidelines. Biochemical control was based on the American Society for Therapeutic Radiology and Oncology (Phoenix) consensus definition. Chronic toxicity was measured at peak symptoms and at last visit. Toxicity was scored based on Common Terminology Criteria for Adverse Events v4. RESULTS: The median radiation dose delivered was 75.6 Gy (range 70.2 to 77.4) and 35.4% of patients received androgen deprivation therapy. Patients were followed until death or from 6 to 138 months (median 91) for those alive at last evaluation. Local and distant recurrence rates were 5% and 8.6%, respectively. At 9 years biochemical control rates were 77.4% for low risk, 69.6% for intermediate risk and 53.3% for high risk cases (log rank p = 0.05). On multivariate analysis T stage and prostate specific antigen group were prognostic for biochemical control. At last followup only 0% and 0.7% of patients had persistent grade 3 or greater gastrointestinal and genitourinary toxicity, respectively. High risk group was associated with higher distant metastasis rate (p = 0.02) and death from prostate cancer (p = 0.0012). CONCLUSIONS: This study represents one of the longest experiences with intensity modulated radiation therapy for prostate cancer. With a median followup of 91 months, intensity modulated radiation therapy resulted in durable biochemical control rates with low chronic toxicity.

Athermal nerve sparing robot-assisted radical prostatectomy: initial experience with microporous polysaccharide hemospheres as a topical hemostatic agent.

PURPOSE: Microporous polysaccharide hemospheres (MPH) are hemostatic beads engineered from plant starch to accelerate the natural clotting cascade. The purpose of this report is to detail our initial experience with MPH as a topical hemostatic agent during robot-assisted radical prostatectomy (RARP). METHODS: We examined a single surgeon series of 30 consecutive RARP's dividing patients into MPH or non-MPH groups. The last ten procedures utilized the MPH, which were matched 1:2 to non-MPH procedures for comparison. Nerve-sparing procedures were performed when clinically indicated and all done athermally. All demographic data, length of operation, margin status, blood loss, change in hemoglobin, and need for blood transfusion were prospectively collected and analyzed. RESULTS: The baseline characteristics were the same. The post-operative decrease in hemoglobin was less in the MPH group (1.8 g/dL MPH group vs. 3.2 g/dL non-MPH). One patient in each group required a blood transfusion. CONCLUSIONS: These preliminary findings support the role for MPH as a potential hemostatic agent during athermal nerve-sparing RARP.

Marital status and prostate cancer outcomes.

INTRODUCTION: To evaluate the influence of marriage on the survival outcomes of men diagnosed with prostate cancer. MATERIALS AND METHODS: We examined 115,922 prostate cancer cases reported to the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2003. Multivariate Cox regression techniques were used to study the relationship of marital status and prostate cancer-specific and overall mortality. RESULTS: Married men comprised 78% of the cohort (n = 91,490) while unmarried men (single, divorced, widowed, and separated) comprised 22% of the cohort (n = 24,432). Married men were younger (66.4 versus 67.8 years, p < 0.0001), more likely to be white (85% versus 76%, p < 0.0001), presented with lower tumor grades (68% are well or moderately differentiated versus 62%, p < 0.0001) and at earlier clinical stages (41% AJCC stage I/II versus 37%, p < 0.0001). Multivariate analysis revealed that unmarried men had a 40% increase in the relative risk of prostate cancer-specific mortality (HR 1.40; CI 1.35-1.44; p < 0.0001), and a 51% increase in overall mortality (HR 1.51; CI 1.48-1.54; p < 0.0001), even when controlling for age, AJCC stage, tumor grade, race and median household income. Furthermore, the 5 year disease-specific survival rates for married men was 89.1% compared to 80.5% for unmarried men (p < 0.0001). CONCLUSION: Marital status is an independent predictor of prostate cancer-specific mortality and overall mortality in men with prostate cancer. Unmarried men have a higher risk of prostate cancer-specific mortality compared to married men of similar age, race, stage, and tumor grade.

Laparoscopic bilateral native nephrectomies with simultaneous kidney transplantation.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? Extirpation of polycystic kidneys for various medical reasons has been performed using many different approaches in attempts to limit morbidity from such a large operation. In indicated patients, it has usually been offered in a staged approach with renal transplantation to avoid graft complications. We published the first case of simultaneous laparoscopic bilateral native nephrectomy with kidney transplant in 2008. The present study shows our continued experience with offering this minimally invasive, single surgery alternative. The results are comparable to a staged laparoscopic approach with significantly shorter total hospital stay and one recovery for the patient and his/her family. OBJECTIVE: • To analyse the perioperative outcomes of native bilateral laparoscopic nephrectomy (BLN) with simultaneous kidney transplantation. PATIENTS AND METHODS: • From November 2000 to April 2011, 37 patients were seen for renal failure secondary to autosomal-dominant polycystic kidney disease (ADPKD) and underwent renal transplant with native nephrectomies at a single tertiary academic centre. • In all, 15 patients underwent BLN for ADPKD followed by simultaneous kidney transplantation. • The other 22 patients underwent BLN for ADPKD with kidney transplant performed at a separate setting. • Demographic data, perioperative outcomes, complications regardless of need for intervention, and graft function were analysed in both groups. RESULTS: • The combined surgery was completed without intraoperative complication in all cases. • The median total operative duration was 372 min, estimated blood loss was 300 mL with two patients requiring transfusion, and the median (range) hospital stay was 5 (3-7) days. • All patients had immediate graft function with additional relief of compressive symptoms. • In comparison to our staged cohort, the simultaneous group had a significantly shorter total hospital stay. • All other outcomes and complication rates were comparable. CONCLUSION: • In ADPKD, a less invasive laparoscopic approach for native nephrectomies with simultaneous renal transplant offers comparable morbidity without graft compromise and the convenience of one operation and one recovery for the patient.

Ureteral stricture formation in laparoscopically procured living donor kidney transplantation.

INTRODUCTION: To identify the incidence of and risk factors for ureteral stricture formation in laparoscopically procured living donor kidney transplantation (LLDKT). MATERIALS AND METHODS: An IRB approved retrospective review of our institution's living donor database was performed. Patients were divided into two cohorts, those with ureteral strictures requiring procedural intervention and those without evidence of ureteral strictures. Analysis was limited to those patients with at least 1 year of follow up. RESULTS: Of the 584 LLDKT's performed at our institution since June 1999, 510 had at least 1 year of follow up. Four hundred and ninety-six patients had no evidence of stricture disease (97.2%) while 14 (2.8%) developed clinically significant ureteral strictures. The incidence of delayed graft function was higher in the stricture group (21% versus 3%, p < 0.0001) while the intraoperative placement of a ureteral stent was associated with decreased incidence of ureteral strictures (21% of the stricture group received stents compared to 58% in the no stricture group, p = 0.006). In multivariable logistic regression models, delayed graft function was strongly associated with the development of clinically significant ureteral stricture disease (OR 19.3; 95% CI 3.59, 104.2; p = 0.001) while the placement of intraoperative ureteral stents was protective against ureteral stricture formation (OR 0.09; 95% CI: 0.02, 0.49; p = 0.005). CONCLUSION: Delayed graft function and nonuse of ureteral stents are associated with the development of ureteral strictures following LLDKT.

Natural orifice translumenal endoscopic radical prostatectomy (NOTES RP): the evolution of the technique.

Minimally invasive surgery is advancing to new frontiers that attempt to limit patient morbidities while providing excellent surgical outcomes. At the forefront of these efforts is natural orifice surgery, where surgical incisions can theoretically be eliminated. The purpose of this report is to describe the evolution of the clinical development of the natural orifice translumenal endoscopic radical prostatectomy (NOTES RP). It details the early experimental cadaver and animal work and the many challenges encountered to bring this procedure to clinical fruition. While the procedure remains in its infancy the clinical application to human patients shows its potential merit to positively impact the surgical control of prostate cancer. Early clinical experience does not allow the ability to draw definitive conclusions about the procedure at this time but the potential benefits for a new minimally invasive inexpensive treatment for prostate cancer patients is promising.

Lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

OBJECTIVE: To evaluate the incidence of, and predictors for, lymphadenectomy in patients undergoing robot-assisted radical cystectomy (RARC) for bladder cancer. PATIENTS AND METHODS: Utilizing the International Robotic Cystectomy Consortium (IRCC) database, 527 patients were identified who underwent RARC at 15 institutions from 2003 to 2009. After stratification by age group, sex, pathological T stage, nodal status, sequential case number, institutional volume and surgeon volume, logistic regression was used to correlate variables to the likelihood of undergoing lymphadenectomy (defined as ≥ 10 nodes removed). RESULTS: Of the 527 patients, 437 (82.9%) underwent lymphadenectomy. A mean of 17.8 (range 0-68) lymph nodes were examined. Tumour stage, sequential case number, institution volume and surgeon volume were significantly associated with the likelihood of undergoing lymphadenectomy. Surgeon volume was most significantly associated with lymphadenectomy on multivariate analysis. High-volume surgeons (> 20 cases) were almost three times more likely to perform lymphadenectomy than lower-volume surgeons, all other variables being constant [odds ratio (OR) = 2.37; 95% confidence interval (CI) = 1.39-4.05; P = 0.002]. CONCLUSION: The rates of lymphadenectomy at RARC for advanced bladder cancer are similar to those of open cystectomy series using a large, multi-institutional cohort. There does, however, appear to be a learning curve associated with the performance of lymphadenectomy at RARC.

Impact of margin status at 37 months after robot assisted radical prostatectomy.

INTRODUCTION: We evaluate the impact of margin length, location, and pathologic stage on biochemical recurrence (BCR) after robot assisted radical prostatectomy (RARP) at 37 months of follow up. MATERIALS AND METHODS: A total of 1420 patients underwent a robot assisted radical prostatectomy between March 2004 and May 2010. Patients who received adjuvant therapy, those who never achieved an undetectable prostate-specific antigen (PSA), and those who had less than 18 months of follow up were excluded. Patients were then divided and evaluated based on margin status. RESULTS: In total, 419 patients were included in the analysis. Eighty-three had a positive surgical margin (PSM) (19.8%), 336 had a negative surgical margin (NSM) (80.2%). The overall mean follow up was 37 months. On multivariate analysis the Gleason sum and PSM were independent predictors of BCR. Margin length and location had no significant difference on the rate of BCR. Patients with a PSM and pT2 disease had an increased rate of BCR compared to pT2 and NSM. The relative risk of BCR was 2.03 and 3.21 for patients who have a PSM versus a NSM, overall and in those with pT2 disease respectively. No different BCR is seen in pT2 PSM versus ≥ pT3 NSM; or ≥ pT3 PSM versus NSM. CONCLUSION: With 37 months follow up; positive surgical margin and postoperative Gleason sum impact the rate of BCR. Location and length of the PSM do not appear to have an impact on BCR. There was an increased risk of BCR with PSM, especially in pT2 disease.

Incidental prostate cancer revisited: early outcomes after holmium laser enucleation of the prostate.

Incidental prostate cancer (PCa) after treatment of benign prostate hyperplasia (BPH) is becoming less common. This is a result of the changing patterns of BPH treatment. The purpose of the present research was to re-examine the clinical outcomes and importance of cT1a and cT1b PCa in a contemporary cohort after holmium laser enucleation of the prostate (HoLEP). All patients with newly diagnosed PCa after HoLEP were retrospectively identified. Pre- and postoperative prostate-specific antigen (PSA), biopsy history, pathological features and disease progression were examined. Patients were matched to a control group with benign pathology for outcome comparisons. The database consisted of 240 consecutive patients, aged 52-90 years with prostate sizes from 25 to 375 cm(3) . A total of 28 patients were identified with incidental PCa (14 cT1a and 14 cT1b). Median follow up was 11 months and 13 months for cT1a and cT1b, respectively. Hospitalization time, catheterization time, complications and functional outcomes were similar. Three patients with cT1b required additional treatment as a result of PSA progression. All other cancers are being closely followed. The functional benefits of HoLEP are well established. The incidental PCa detection rate of 11.7% shows the potential benefit of pathological analysis. Just 10.7% of these patients received additional treatment, but this might be significant as these patients would otherwise go untreated. The impact on disease-specific survival and progression requires a longer follow up.

Surgical margin status after robot assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.

PURPOSE: Positive surgical margins at radical cystectomy confer a poor prognosis. We evaluated the incidence and predictors of positive surgical margins in patients who underwent robot assisted radical cystectomy for bladder cancer. MATERIALS AND METHODS: Using the International Robotic Cystectomy Consortium database we identified 513 patients who underwent robot assisted radical cystectomy, as done by a total of 22 surgeons at 15 institutions from 2003 to 2009. After stratification by age group, gender, pathological T stage, nodal status, sequential case number and institutional volume logistic regression was used to correlate variables with the likelihood of a positive surgical margin. RESULTS: Of the 513 patients 35 (6.8%) had a positive surgical margin. Increasing 10-year age group, lymph node positivity and higher pathological T stage were significantly associated with an increased likelihood of a positive margin (p = 0.010, <0.001 and p <0.001, respectively). Gender, sequential case number and institutional volume were not significantly associated with margin positivity. The rate of margin positive disease at cystectomy was 1.5% for pT2 or less, 8.8% for pT3 and 39% for pT4 disease. CONCLUSIONS: Positive surgical margin rates at robot assisted radical cystectomy for advanced bladder cancer were similar to those in open cystectomy series in a large, multi-institutional, prospective cohort. Sequential case number, a surrogate for the learning curve and institutional volume were not significantly associated with positive margins at robot assisted radical cystectomy.

Robot-assisted radical cystectomy: intermediate survival results at a mean follow-up of 25 months.

OBJECTIVE: To assess the overall and disease-specific survival rates of patients undergoing robot-assisted radical cystectomy (RARC) compared with historical open cystectomy. PATIENTS AND METHODS: Survival, pathological and demographic data were collected on all patients undergoing RARC for bladder cancer from both Tulane University Medical Center and Mayo Clinic Arizona. Of a total of 80 RARCs we only included those with a follow-up of > or =6 months from surgery. Survival curves were compared with those from historical series of open cystectomy. RESULTS: Of the 80 patients 59 were identified as having a follow-up of > or =6 months from the date of surgery. The mean (range) follow-up was 25 (6-49) months. Overall survival rates at 12 and 36 months were 82% and 69%, respectively, and disease-specific survival rates were 82% and 72% at 12 and 36 months, respectively. These results are comparable to survival rates from open cystectomy. As expected, patients with lymph node-positive disease fared worse than those with lymph node-negative disease. Patients with extravesical lymph node-negative disease (pT3, pT4) fared worse than patients with organ-confined lymph node-negative disease. Also, patients with lymph node-positive disease fared worse than those with extravesical lymph node-negative disease, which is consistent with historical results of open cystectomy. CONCLUSIONS: RARC has a comparable survival rate to open cystectomy in the intermediate follow-up. Further study with a longer follow-up and more patients is necessary to determine any long-term survival benefits.

Accuracy of ultrasound in estimation of prostate weight: comparison of urologists and radiologists.

INTRODUCTION: Measurements of prostate size are obtained to contribute in the diagnosis and follow up of patients with a variety of diseases. Since its introduction, transrectal ultrasonography (TRUS) of the prostate has become the most common method for assessment of prostate volumes. Ultrasonography, in general, has been associated with concerns of operator dependent variability. Herein, we analyze the accuracy of urologists and radiologists performing TRUS. MATERIAL AND METHODS: The accuracy of preoperative TRUS prostate volume estimation was evaluated by comparing it to gross specimen prostate weight following robot-assisted radical prostatectomy (RARP) performed from August 2004 to March 2008 in Mayo Clinic Arizona. A total of 800 RARPs were evaluated retrospectively with 302 patients having a prostate volume measurement with TRUS at our institution followed by RARP being performed within 30 days. The TRUS measurements were divided into two groups: those TRUS measurements performed by urologists (group 1), and those performed by radiologists (group 2). The accuracy of the two groups were compared using a Pearson correlation analysis. RESULTS: The estimated weight by TRUS in the total cohort of patients correlated with the pathological specimen weight at 0.802 with a standard error of 0.90. Group 1 performed a total of 114 ultrasounds with a correlation of 0.835 and a standard error of 1.27. Group 2 performed a total of 188 with a correlation of 0.786 and a standard error of 0.88. CONCLUSIONS: Urologists and radiologists are both consistently within 17%-22% of the estimated prostate specimen weight. Urologists appeared to have a slightly higher accuracy in estimation but a higher range of error for the whole group when compared to radiologists. Transrectal ultrasonography is a reliable technique to estimate prostate weight and accuracy to within 20% of the pathological weight. Urologists and radiologists are essentially equally proficient in estimating prostate weight with TRUS. These findings are particularly important with respect to specialty certification and competency/proficiency evaluation, as health care increasingly moves towards outcomes based reimbursement.

The effect of urinary diversion on long-term kidney function after cystectomy.

OBJECTIVES: Cystectomy with urinary diversion is associated with decreased long-term kidney function due to several factors. One factor that has been debated is the type of urinary diversion used: ileal conduit (IC) vs. neobladder (NB). We tested the hypothesis that long-term kidney function will not vary by type of urinary diversion. METHODS AND MATERIALS: We retrospectively identified all patients who underwent cystectomy with urinary diversion at our institution from January 1, 2007, to January 1, 2018. Data were collected on patient demographics, comorbid conditions, perioperative radiotherapy, and complications. Creatinine values were measured at several time points up to 120 months after surgery. Glomerular filtration rate (GFR) (ml/min per 1.73 m2) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed model with inverse probability of treatment weighting (IPTW) was used to compare GFR between the IC and NB cohorts over time. Multiple sensitivity analyses were performed based on 2 different calculations of GFR (Chronic Kidney Disease Epidemiology Collaboration equation vs. Modification of Diet in Renal Disease), with and without excluding patients with preoperative GFR less than 40 ml/min per 1.73 m2. RESULTS: Among 563 patients who underwent cystectomy with urinary diversion, a NB was used for 72 (12.8%) individuals. Patients who had a NB were significantly younger, had a lower American Society of Anesthesiologists score, greater baseline GFR, better Eastern Cooperative Oncology Group performance status, lower median Charlson comorbidity index, and were less likely to have received preoperative abdominal radiation (all P < 0.05). Both NB and IC patients had decreased kidney function over time, with mean GFR losses at 5 years of 17% and 14% of baseline values, respectively. The IPTW-adjusted linear mixed model revealed that IC patients had slightly more deterioration in kidney function over time, but this was not statistically significant (estimate, 0.12; P = 0.06). The sensitivity analyses yielded a similar trend, in that GFR decrease appeared to be greater in the IC cohort. This trend was statistically significant when using Modification of Diet in Renal Disease (P = 0.04). CONCLUSIONS: Among highly selected patients with an NB, deterioration of kidney function may potentially be lower over time than among IC patients. However, the statistical significance varied between analyses and we cautiously attribute these observed differences to patient selection.

Does a history of previous surgery or radiation to the prostate affect outcomes of robot-assisted radical prostatectomy?

OBJECTIVE: To evaluate retrospectively whether or not previous treatment to the prostate alters the perioperative outcomes from robot-assisted radical prostatectomy (RARP) after the initial 'learning curve', as there are conflicting data on outcomes of RP in patients with previous treatment to the prostate. PATIENTS AND METHODS: We retrospectively reviewed the charts of patients who had RARP between March 2005 and August 2007, and analysed demographic, perioperative variables and pathological data. In all, 510 patient charts were reviewed, identifying 24 patients with a history of previous treatment to the prostate including transurethral resection or incision of the prostate, transurethral microwave therapy, transurethral needle ablation, photoselective vaporization, simple prostatectomy, external beam radiotherapy, brachytherapy, and open bladder neck reconstruction (group 1) and 486 with no previous treatment (group 2). RESULTS: There was no significant difference between the groups in body mass index, clinical stage, grade or prostate volume, but the patients in group 1 were older (70 vs 65 years, P = 0.001). Outcome analysis comparing groups 1 and 2 showed an estimated blood loss of 155 vs 137 mL, length of hospital stay of 2.2 vs 1.5 days, operative duration of 200 vs 186 min and catheter time of 12 vs 8 days, respectively; only the last was statistically significant (P = 0.03). There was an 8.3% and 6.8% complication rate in groups 1 and 2, respectively, and the respective overall positive margin rate was 20.8% and 22.6%. CONCLUSIONS: A history of previous treatment of the prostate does not appear to compromise the perioperative outcomes of RARP.

Interval from prostate biopsy to robot-assisted radical prostatectomy: effects on perioperative outcomes.

OBJECTIVE: To determine whether shorter intervals (<4 and 6 weeks) between prostate biopsy and robot-assisted radical prostatectomy (RARP) have a detrimental effect on perioperative outcomes, as recent studies showed that open RP shortly after prostate biopsy does not adversely influence surgical difficulty or efficacy, but RARP relies solely on visual cues rather than tactile sensation to determine posterior surgical planes of dissection. PATIENTS AND METHODS: A series of 559 patients undergoing RARP from March 2004 to July 2007 was retrospectively reviewed. The interval between prostate biopsy and RARP was determined and patients with intervals of 4 weeks. Patient characteristics and perioperative outcomes were analysed to determine statistically significant differences between the groups. This comparison was then repeated with a 6-week interval, and examined with a multivariate logistic regression analysis. RESULTS: In the 4-week group (509 patients), there was a significantly (P < 0.05) higher rate of complications (18.5% vs 6.9%). In the 6-week group (455 patients) there was a smaller but still significantly higher rate of complications (13.6% vs 6.4%). These results were still significant when controlling for patient and disease characteristics and the 'learning curve'. There was also a significantly higher rate of transfusion in the 6-week group (0.7%). CONCLUSIONS: Our data suggest that RARP should be delayed after prostate biopsy; RARP within 6 weeks of biopsy was associated with a greater risk of complications even when controlling for disease and patient characteristics.