Age and baseline quality of life at radical prostatectomy--who has the most to lose?

PURPOSE: Although younger men have better health related quality of life scores after radical prostatectomy, many have higher baseline function with more to lose than older men. We examined the impact of age on sexual and urinary function and bother during the first 2 years after radical prostatectomy. MATERIALS AND METHODS: Participants enrolled in CaPSURE™ reported sexual and urinary scores before and after radical prostatectomy using UCLA-PCI. Repeated measures mixed models were used to compare the change in health related quality of life with time between men who were younger (age 60 years or less) and older (age greater than 60 years). Logistic regression models were used to assess associations between age and clinically meaningful health related quality of life decreases (worsening). Models were adjusted for clinical characteristics. RESULTS: Of 1,806 patients younger men reported higher sexual and urinary function scores at each time point and higher sexual function decrease rates at 1 year than older men (81% vs 75%, p<0.01). Younger men also had higher sexual bother decrease rates 1 year (74% vs 61%, p<0.01) and 2 years (62% vs 56%, p=0.02) after radical prostatectomy. On multivariate analysis age was associated with changes in sexual function and bother from baseline through 2 years (each p<0.01). Younger men had higher adjusted odds of sexual function decreases at 1 year (OR 1.15/5 years, 95% CI 1.01-1.30, p=0.03) but not at 2 years. Younger age was associated with lower odds of worsening sexual bother at 2 years (OR 0.79/5 years, 95% CI 0.67-0.94, p<0.01). Urinary function and bother decrease rates were similar by age. Secondary analyses of the age/health related quality of life interaction showed that men were at greater risk for health related quality of life decreases if baseline scores were above average regardless of age. CONCLUSIONS: Younger men reported higher sexual and urinary function overall, and experienced greater decreases in sexual function immediately after radical prostatectomy than older men. While the 2 groups experienced similar relative sexual function decreases at 2 years, younger men had worse interim decreases at 1 year. Providers should consider these findings when discussing treatment timing, particularly with younger men diagnosed with early stage, low grade disease.

The quantitative Gleason score improves prostate cancer risk assessment.

BACKGROUND: In the current study, the authors propose the quantitative Gleason score (qGS), a modification of the current Gleason grading system for prostate cancer, based on the weighted average of Gleason patterns present in the pathology specimen. They hypothesize that the qGS can improve prostate cancer risk stratification and help prevent the overtreatment of patients with clinically indolent tumors. METHODS: The qGS was applied to patients in the University of California San Francisco urologic oncology database with tumors determined to have a GS of 7 on prostate biopsy or final pathology after radical prostatectomy (RP). Using multivariable logistic regression, Cox proportional hazards regression, receiver operating characteristic (ROC), and decision curve analyses, the ability of qGS to predict pathological GS and the risk of disease recurrence after RP was assessed. RESULTS: A total of 225 men were included in the analysis of biopsy specimens and 618 men were included in the assessment of RP specimens. Compared with traditional Gleason scoring, the qGS improved concordance between biopsy and pathological GS on decision curve and ROC analyses (area under the curve ROC curve, 0.79 vs 0.71). On regression analysis, the qGS of biopsy specimens was found to be significantly associated with pathological grade after RP (hazard ratio [HR], 1.78; 95% confidence interval [95% CI], 1.49-2.12) and the qGS of RP specimens was significantly associated with the risk of biochemical disease recurrence after RP (HR, 1.13; 95% CI, 1.04-1.24). CONCLUSIONS: The qGS, a simple modification of the current Gleason system, appears to improve the correlation between biopsy and pathological GS, as well as the prediction of biochemical disease recurrence after RP. This scoring system may allow more men to pursue active surveillance, thereby avoiding the morbidity of prostate cancer treatment modalities.

Decreasing rates of lymph node dissection during radical nephrectomy for renal cell carcinoma.

BACKGROUND: The utility of lymph node dissection (LND) during radical nephrectomy for renal cell carcinoma (RCC) continues to be controversial, yet its use by urologists in the United States is unknown. We analyzed the incidence of and trends in LND from a large, nationally representative cancer registry. METHODS: Using the Surveillance, Epidemiology, and End Results registry we identified 37,279 patients with RCC who underwent radical nephrectomy from 1988 to 2005. LND was defined as a surgeon removing ≥5 nodes; however, sensitivity tests were performed using cutoffs of ≥3 and ≥1 nodes. We analyzed changes in LND rates over time and used multivariable logistic regression to predict those who underwent LND. RESULTS: Of the 37,279 patients with RCC, 2,463 (6.6 %) received a LND. There was a gradual decline in LND beginning in 1988 that accelerated after 1997, with the period of 1998-2005 having significantly decreased odds of LND compared with the period 1988-1997 (odds ratio [OR]: 0.65; 95 % confidence interval [95 % CI]: 0.59-0.71). This decline was driven primarily by a 63 % reduction in LND rates among localized tumors (p < .001). CONCLUSIONS: There has been a significant decline in LND rates during radical nephrectomy for localized kidney cancer over the past 7 years. In contrast to prior estimates, very few urologists in the United States are removing ≥5 nodes during lymph node dissection for RCC.

Effect of heating on the mechanical properties of insole materials.

BACKGROUND: The most common method of customizing shoe insoles to the shape and surface of the foot is to heat and then mold the materials. The effect of heating on the mechanical properties of these materials is unknown. METHODS: The properties of individual and common combinations of insole materials were tested before and after heating. Individual materials tested were soft Plastazote (SP), medium Plastazote (MP), Puff (F), and Nickelplast (N); combinations of materials that were tested were SP + F and MP + F, each with and without Poron (P). Three samples of each were tested five times. Materials were heated and then compressed with an MTS servohydraulic device. Load transmission and percent compression at maximal load were measured on single materials and their combinations. Stress-strain curves were measured. RESULTS: Compared to unheated material, the heated material transmitted higher forces. After heating, the combinations transmitted maximal load at a lower percentage of compression (i.e., became stiffer). Heating also changed the stress-strain curves of the three-material combinations, causing them to transmit maximal pressure at a lower strain. CONCLUSION: Heating insole materials changed their mechanical properties. The materials became stiffer and less effective in the attenuation of applied forces. CLINICAL RELEVANCE: The common practice of heating insole materials to improve their contact with the foot reduced the pressure-reducing properties of the materials, which may decrease their clinical effectiveness.

Endorectal magnetic resonance imaging has limited clinical ability to preoperatively predict pT3 prostate cancer.

OBJECTIVE: • To assess the clinical value of preoperative knowledge of the presence of extracapsular extension (ECE) or seminal vesicle invasion (SVI) in the planning for prostatectomy. MATERIALS AND METHODS: • An institutional database of 1161 robotic-assisted laparoscopic prostatectomies (RALP) performed by a single surgeon (D.B.S.) was queried for those who underwent endorectal coil magnetic resonance imaging (erMRI) before robotic-assisted laparoscopic prostatectomy. • erMRI reports were dichotomized into positive or negative and compared with the final histopathology. The erMRIs performed at academic centres were compared with those performed in non-academic settings. • A sub-group of high-risk patients was also analyzed for erMRI accuracy. RESULTS: • The 179 patients who underwent erMRI had significantly worse disease compared to the 982 patients without imaging. Of the 110 patients with histopathologically organ-confined disease, 81 (74%) were correctly diagnosed as such on erMRI, whereas 29 (26%) were felt to have cT3 disease and constituted false-positives. Among the 69 patients with pT3 disease, erMRI correctly predicted 30 (43%), whereas 39 (57%) were incorrectly considered organ-confined. • The overall sensitivity and specificity for diagnosing pT3 disease was 43% and 73%. • When stratified by pT3a and pT3b, the sensitivity and specificity of erMRI to accurately diagnose ECE is 33% and 81%, respectively. In evaluating SVI, erMRI has a sensitivity and specificity of 33% and 89%, respectively. The positive predictive value of erMRI to assess for ECE and SVI is 50% in both, with a negative predictive value of 61% and 63%, respectively. • erMRIs performed at academic centres compared to non-academic locations demonstrated similar rates of sensitivity at 67% vs 77% and specificity at 39% vs 54%, respectively (P = 0.33). CONCLUSIONS: • In the setting of the present study, which was designed to be more reflective of current practice patterns in the USA, erMRI has limited clinical value in preoperatively detecting ECE and SVI. • The accuracy of detecting T3 disease did not improve in academic centres or in high-risk patients.

High body mass index does not affect outcomes following robotic assisted laparoscopic prostatectomy.

INTRODUCTION: Given the anatomic constraints of obese patients, concern exists as to whether robotic assisted laparoscopic prostatectomy (RALP) is appropriate in patients with higher body mass index (BMI). We reviewed a large RALP database to determine if clinical outcomes are related to BMI. METHODS: The records of patients who underwent a RALP from 2003-2009 were reviewed. BMI stratifications were concordant with the Centers for Disease Control (CDC) standards: > or = 30, > or = 25 and < 30, and < 25 were classified as obese, overweight, and normal weight, respectively. Baseline, perioperative, histopathologic, and functional outcome data were collected. RESULTS: A total of 1420 patients were identified and BMI information was available for 1112 patients. Median BMI in the three strata was 23.5 (n = 270), 27.3 (n = 600), and 32.1 (n = 242). There were no significant differences in preoperative prostate specific antigen (PSA), clinical staging, and preoperative Gleason scores. Operating time was 6 minutes longer in the obese (p < 0.001) and prostate weight was 8 g greater (p < 0.001). Other perioperative factors were similar, including: EBL, pathologic stage and Gleason score and rates of positive surgical margins. The overall incidence of postoperative complications was similar between the three groups. Biochemical recurrence rates were similar among all patients, although there was a trend toward increased recurrence in the obese (p = 0.09). Recovery of erectile function and continence was similar regardless of BMI. CONCLUSIONS: RALP is an effective approach to prostatectomy in obese patients as perioperative and functional outcomes are almost identical across BMI strata. This supports the continued utilization of RALP in obese and overweight men.

The CAPRA Score at 10 Years: Contemporary Perspectives and Analysis of Supporting Studies.

Tools that appraise oncologic risk are a critical component of research and clinical management of prostate cancer (PCa). We performed a PubMed/Medline search to review the concept, design, and clinical validation of the Cancer of the Prostate Risk Assessment (CAPRA) score and similar systems in the postsurgical (CAPRA-S) and primary androgen deprivation therapy (Japan CAPRA [J-CAPRA]) settings. We included reports addressing the CAPRA (n=13), CAPRA-S (n=4), and J-CAPRA (n=5) scores. External validation studies for the CAPRA score have yielded favorable clinical performance in both academic and community cohorts, with concordance index (c-index) for biochemical recurrence (BCR) after definitive treatment in the range of 0.66-0.81. Validation studies addressing the postsurgical CAPRA-S score have demonstrated favorable prediction of distant end points (c-index for BCR: 0.73-0.80; prostate cancer-specific mortality [PCSM]: 0.75-0.88). The J-CAPRA score was evaluated in 1378 men treated with primary ADT and demonstrated excellent discrimination (c-index for progression-free survival: 0.80-0.89; PCSM: 0.820-0.836; overall survival: 0.665-0.700). The CAPRA score and its derivatives have demonstrated robust clinical discrimination in a decade of validation studies. The CAPRA score and similar multivariable stratification systems are posed to replace prior older and less accurate risk group categories. PATIENT SUMMARY: We addressed the development of the Cancer of the Prostate Risk Assessment (CAPRA) score, its methodology, and its supporting studies. The CAPRA score and similarly designed tools have yielded strong performance in the prediction of numerous prostate cancer end points.

Clinicopathological, functional, and immediate oncologic outcome assessment in men aged≤50 years with prostate cancer after robotic prostatectomy.

BACKGROUND: To define the pathologic and functional outcomes of men 50 years of age and younger with prostate cancer in a contemporary robotic cohort, this study was designed. METHODS: Patients undergoing robotic-assisted laparoscopic prostatectomy from April 2002 to April 2012 (n = 2,495) formed the base population for the current analyses. The patients were dichotomized according to their age≤50 (n = 271) and>50-year-old (n = 2,224). Clinicopathological and health-related quality-of-life outcomes were recorded and analyzed for differences. Propensity score matching was used when assessing urinary and sexual function outcome. RESULTS: Baseline prostate-specific antigen and clinical stage were similar between men older than 50 years and those younger. Younger patients had less severe disease (D׳Amico risk and Gleason scores) and smaller prostates. Young men had higher rates of erectile function at all time points, including baseline (94% vs. 83% at 12mo, P <0.01). Continence was similar at all time points except for 6 months, where younger patients experienced a faster return than older patients and then remained constant, while older patients continued to improve (96% vs. 89%, P<0.01). After matching process, the difference in erectile function at 6-month follow-up was lost. CONCLUSION: Most men aged 50 years and younger who received robotic-assisted laparoscopic prostatectomy had clinically significant prostate cancer. Although histopathologic and short-term oncologic outcomes were nearly identical when compared to older patients, younger men had a more rapid and superior return of erectile function.

Ability of Surgical Residents to Impact Patient Tobacco Use in the Perioperative Setting.

INTRODUCTION: Tobacco use significantly impacts patient morbidity and mortality, and is particularly important to the surgical community as it has a negative impact on surgical recovery. Despite its relevance, most surgeons do not engage in smoking cessation counseling. METHODS: As part of the UCSF Medical Center quality improvement program, urology residents designed and led an initiative targeting urological patients undergoing surgery at UCSF between August 2013 and July 2014. Our primary objectives were to 1) elicit the smoking status of at least 80% of perioperative patients who stayed at least 1 night in the hospital and 2) obtain an inpatient smoking cessation consultation for patients who were active tobacco users. RESULTS: A total of 934 patients were assessed, of whom 8.5% were current tobacco users, 37% were past users and 55% had never used tobacco. Current smokers were more likely to be younger and female, and less likely to have a cancer diagnosis compared to past or never smokers (all p ≤0.001). The rate of tobacco status assessment improved significantly throughout the quality improvement period, at 59.0% in quarter 1, 85.5% in quarter 2, 92.9% in quarter 3 and 94.4% by quarter 4. Patients who underwent smoking cessation consults were more likely to be prescribed nicotine replacement therapy during their hospital stay and upon discharge home. CONCLUSIONS: Through our quality initiative program we demonstrated a fast, feasible and easily implemented approach to identify smokers, and obtain smoking cessation counseling and treatment. This practical approach represents a significant opportunity to effect change in smoking behavior at a teachable moment.

Correction: Endoscopic Gold Fiducial Marker Placement into the Bladder Wall to Optimize Radiotherapy Targeting for Bladder-Preserving Management of Muscle-Invasive Bladder Cancer: Feasibility and Initial Outcomes.

[This corrects the article DOI: 10.1371/journal.pone.0089754.].

Electronic Preconsultation as a Method of Quality Improvement for Urological Referrals.

INTRODUCTION: Preconsultation exchange is a method to promote expedited care among health care providers through communication between primary care providers and specialists before a clinic visit. We evaluated the efficacy of a preconsultation exchange in streamlining patient visits to the urology clinic with an emphasis on resource efficiency in a safety net hospital. METHODS: Between April 1, 2011 and March 31, 2012 there were 1,705 electronic referrals to our urology department. A random sample of 500 referrals was selected for evaluation, of whom 487 patients met study inclusion criteria. Scheduling outcome and preconsultation exchange were evaluated for each chief complaint. RESULTS: Patients with operative or procedural chief complaints, or potential oncologic diagnoses were most likely to be scheduled directly to the urology clinic. Of the 487 patients 36 (7.4%) were treated for benign urological conditions by primary care providers and did not need to be seen in the urology clinic. For 13.5% of patients recommended laboratory and radiological tests were obtained before the initial urology clinic visit as a result of preconsultation exchange. CONCLUSIONS: Electronic preconsultation exchange served as a method of quality improvement by promoting urology clinic efficiency. Unnecessary appointments were limited and the completeness of appropriate laboratory and imaging studies at the initial visit was increased. Health care was streamlined by increased access to urological care and by management of benign urological conditions without a formal clinic visit in appropriate cases.

Endoscopic gold fiducial marker placement into the bladder wall to optimize radiotherapy targeting for bladder-preserving management of muscle-invasive bladder cancer: feasibility and initial outcomes.

BACKGROUND AND PURPOSE: Bladder radiotherapy is a management option for carefully selected patients with muscle-invasive bladder cancer. However, the inability to visualize the tumor site during treatment and normal bladder movement limits targeting accuracy and increases collateral radiation. A means to accurately and reliably target the bladder during radiotherapy is needed. MATERIALS AND METHODS: Eighteen consecutive patients with muscle-invasive bladder cancer (T1-T4) elected bladder-preserving treatment with maximal transurethral resection (TUR), radiation and concurrent chemotherapy. All underwent endoscopic placement of 24-K gold fiducial markers modified with micro-tines (70 [2.9×0.9 mm.]; 19 [2.1×0.7 mm.) into healthy submucosa 5-10 mm. from the resection margin, using custom-made coaxial needles. Marker migration was assessed for with intra-op bladder-filling cystogram and measurement of distance between markers. Set-up error and marker retention through completion of radiotherapy was confirmed by on-table portal imaging. RESULTS: Between 1/2007 and 7/2012, a total of 89 markers (3-5 per tumor site) were placed into 18 patients of mean age 73.6 years. Two patients elected cystectomy before starting treatment; 16/18 completed chemo-radiotherapy. All (100%) markers were visible with all on-table (portal, cone-beam CT), fluoroscopy, plain-film, and CT-scan imaging. In two patients, 1 of 4 markers placed at the tumor site fell-out (voided) during the second half of radiotherapy. All other markers (80/82, 98%) were present through the end of radio-therapy. No intraoperative (e.g. uncontrolled bleeding, collateral injury) or post-operative complications (e.g. stone formation, urinary tract infection, post-TUR hematuria >48 hours) occurred. Use of micro-tined fiducial tumor-site markers afforded a 2 to 6-fold reduction in bladder-area targeted with high-dose radiation. DISCUSSION: Placement of the micro-tined fiducial markers into the bladder was feasible and associated with excellent retention-rate and no complications. All markers were well-visualized during radiotherapy with all imaging modalities. Bladder fiducial markers improve targeting accuracy, and may increase treatment efficacy and reduce morbidity from collateral radiation.

Candidacy for active surveillance may be associated with improved functional outcomes after prostatectomy.

OBJECTIVE: In an effort to curb overtreatment, active surveillance (AS) has grown in popularity as an option for men with low-risk prostate cancer. We evaluated the histopathologic and functional outcomes of patients who qualified for AS, but opted for robotic-assisted laparoscopic prostatectomy (RALP), and compared them to non-AS candidates. METHODS: An institutional database of 1,477 RALP performed by a single surgeon was queried for AS candidates, defined as PSA <10 ng/mL, biopsy Gleason score ≤6 with a minimum of 10 biopsy cores, <3 positive cores with <50% tumor volume in a single core and clinical stage ≤T2a. RESULTS: Of the 352 patients who would have qualified for AS, 159 (45%) were upgraded: 143 (41%) to Gl 3 + 4, 16 (4.5%) to 4 + 3, zero to Gleason 8 or higher. Seventeen (4.8%) patients were upstaged to pT3. AS candidates were younger and had more favorable tumor characteristics, but similar preoperative functional status. Bilateral nerve sparing was performed on 96% of AS candidates vs. 86% of non-AS candidates (P < 0.001). After 12 months of follow-up in patients who received bilateral nerve sparing, continence was higher in the AS cohort (98% vs. 92%, P < 0.001) but potency was equivalent (87% in each, P = 0.89). On multivariable analysis, candidacy for AS was independently associated with improved continence, but not potency. CONCLUSIONS: In addition to having the expected favorable histopathologic features, AS candidates who desire definitive therapy have a high likelihood of achieving excellent functional outcomes, perhaps superior to non-AS candidates, following RALP.

Nerve-sparing robotic prostatectomy in preoperatively high-risk patients is safe and efficacious.

OBJECTIVE: Given the higher likelihood of extraprostatic extension in high-risk patients, many urologists will sacrifice the neurovascular bundles in such patients in an attempt to decrease the risk of positive surgical margins. In contrast, we frequently perform nerve-sparing in high-risk patients. We analyzed our outcomes in patients with preoperatively high-risk prostate cancer according to the D'Amico risk group classification, and stratified by nerve-sparing status. MATERIALS AND METHODS: An institutional database of 1,503 robotic-assisted laparoscopic prostatectomies (RALP) was queried for patients presenting with PSA > 20 ng/ml, Gleason 8 or higher on biopsy, or clinical stage T2c or higher. Interfascial nerve-sparing was performed whenever oncologically feasible. Validated questionnaires were used to assess baseline and postoperative functional outcomes. RESULTS: Adequate follow-up was available in 123 high-risk patients. Mean serum PSA was 10.8. Bilateral, unilateral, and non-nerve-sparing was performed on 58%, 15%, and 27%, respectively. On final histopathology, 42% were organ confined; 55 patients had extraprostatic extension, and 35 had seminal vesicle invasion. Positive surgical margins occurred in 31%: 15% focal and 16% extensive. Favorable pathologic outcomes (organ-confined and negative surgical margins) were observed in 40%. Biochemical recurrence occurred in 20%. Nerve-sparing was associated with more favorable pathologic features, possibly due to selection bias. When controlling for adverse pathologic features, nerve-sparing was not associated with higher rates of positive surgical margins or biochemical recurrence. At a median follow-up of 13 months, 78% were continent and 56% were potent. The "trifecta" of continence, potency, and freedom from recurrence was achieved in 28 patients (23%). CONCLUSIONS: Nerve-sparing robotic-assisted laparoscopic prostatectomy can be safely performed in patients with preoperatively high risk prostate cancer. Histopathologic and short-term oncologic outcomes at 13-month median follow-up are comparable to those in open surgical series from similar cohorts.

Monitoring validated quality of life outcomes after prostatectomy: initial description of novel online questionnaire.

OBJECTIVES: To describe a novel, low-cost, online health-related quality of life (HRQOL) survey that allows for automated follow-up and convenient access for patients in geographically diverse locations. Clinicians and investigators have been encouraged to use validated HRQOL instruments when reporting outcomes after radical prostatectomy. METHODS: The institutional review board approved our protocol and the use of a secure web site (http://www.SurveyMonkey.com) to send patients a collection of validated postprostatectomy HRQOL instruments by electronic mail. To assess compliance with the electronic mail format, a pilot study of cross-sectional surveys was sent to patients who presented for follow-up after robotic-assisted laparoscopic prostatectomy. The response data were transmitted in secure fashion in compliance with the Health Insurance Portability and Accountability Act. RESULTS: After providing written informed consent, 514 patients who presented for follow-up after robotic-assisted laparoscopic prostatectomy from March 2010 to February 2011 were sent the online survey. A total of 293 patients (57%) responded, with an average age of 60 years and a median interval from surgery of 12 months. Of the respondents, 75% completed the survey within 4 days of receiving the electronic mail, with a median completion time of 15 minutes. The total survey administration costs were limited to the web site's $200 annual fee-for-service. CONCLUSIONS: An online survey can be a low-cost, efficient, and confidential modality for assessing validated HRQOL outcomes in patients who undergo treatment of localized prostate cancer. This method could be especially useful for those who cannot return for follow-up because of geographic reasons.

Unnecessary imaging for the staging of low-risk prostate cancer is common.

OBJECTIVE: To quantify the rate of overuse of preoperative imaging procedures in a referral cohort of low-risk patients. International evidence-based best practice guidelines discourage routine imaging for staging purposes in low-risk patients with newly diagnosed prostate cancer. MATERIAL AND METHODS: An institutional database comprised of all patients undergoing robotic-assisted laparoscopic prostatectomy was queried for "low-risk" patients between May 2005 and January 2010. "Low-risk" was defined by the most inclusive criteria for imaging recommendations: prostate-specific antigen ≤10 ng/mL and Gleason score ≤6. We defined staging imaging as a bone scan, computed tomography (CT) of the pelvis or endorectal magnetic resonance imaging performed after the diagnosis of prostate cancer and before prostatectomy for the indication of "prostate cancer." Six-hundred seventy-seven patients were identified as having low-risk disease and comprised our study population. RESULTS: Of the 677 patients identified as low risk, 328 (48%) underwent at least one preoperative imaging procedure despite the guideline recommendations. Two-hundred two of 677 (30%) patients were administered at least 2 of the 3 modalities, and 18/677 (3%) patients received all 3 imaging examinations before prostatectomy. Suspicious results from the CT (7/265%, 2.7%) or bone scan (21/241%, 8.7%) resulted in 27 patients undergoing additional radiographic imaging, none of which resulted in suspicious lesions requiring intervention or biopsy. CONCLUSIONS: Despite international evidence-based guidelines for the staging of newly diagnosed prostate cancer patients, many urologists continue to refer low-risk patients for unnecessary imaging studies. This may place the patient at increased risk from radiation or contrast exposure and places an unnecessary financial burden on the patient and health care system.

Simple, age-based formula for predicting renal length in children.

OBJECTIVE: To determine a simple, age based formula for predicting ideal renal length in children. Renal size is a valuable marker in the evaluation of children with urological disorders. Although many authors have described complex nomograms and multivariate formulas for determining renal size, we propose a simple and accurate formula. MATERIAL AND METHODS: All renal ultrasound (US) studies performed over a 9-year period in patients <18 years of age were retrospectively evaluated, excluding patients with a history of urinary tract disease or with abnormal renal US findings. RESULTS: Ultrasounds were performed in 778 children <18 years who met inclusion criteria. Sixty-one percent of the patient population was ≥1 year of age at the time of the US. Forty-four percent of the children were male. In children 1 year of age or older, the formula was length (cm) = age (years) × 0.3 + 6, R(2) = .81. In infants younger than 1 year, renal length was poorly estimated by a simple age-based formula. CONCLUSION: Our proposed formula can be used to predict renal length in children older than 1 year.

Does size matter? The significance of prostate size on pathologic and functional outcomes in patients undergoing robotic prostatectomy.

BACKGROUND: We examined the effect of prostate weight on perioperative data, and the pathological and functional outcomes of robotic-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Data were available from 716 consecutive patients before, during and after undergoing RALP at one institution. Prostate size was arbitrarily stratified by recorded prostate weight into <50, 50-80 and >80 g, corresponding to small, moderate and large glands, respectively. Perioperative data and the histopathological and functional outcomes were compared across these groups by both univariable and multivariable-adjusted analyses. RESULTS: Increased prostate size was associated with increased age, preoperative prostate-specific antigen levels, body mass index, operative duration, blood loss, lower biopsy and pathological Gleason scores, and lower pathological staging (P < 0.05). The incidence of extensive positive surgical margins was 14.8%, 9.7%, and 5.3% in small, moderate and large prostates, respectively (P < 0.001). However, after multivariable adjustment, only Gleason score and pathological stage were significantly associated with the incidence of positive margins (P < 0.05); prostate weight was not significantly associated. Overall, 78% and 92% of patients were potent and continent at 12 months, respectively, which was not affected by prostate size. CONCLUSION: Patients with larger prostates had favourable pathological outcomes after RALP. When controlling for pathological stage, prostate size was not associated with margin positivity. Functionally, neither continence nor potency at 12 months was affected by prostate size.

Continuing robotically? The completion of a robot-assisted radical prostatectomy after laparotomy.

The laparoscopic management of difficult adhesions can be quite challenging for even the most experienced of laparoscopic surgeons. We describe a case of managing a suspected enterotomy with a laparotomy during a robot-assisted radical prostatectomy and the surgical options after repair. The case was complicated by a Meckel's diverticulum fused and continuous with a urachal cyst, itself a rare occurrence. After the excision of the Meckel's diverticulum­urachal complex, the laparotomy incision was closed, and the prostatectomy was performed robotically. We discuss the controversies regarding continuation of a planned robotic procedure after a midline laparotomy.

Improvements in robot-assisted prostatectomy: the effect of surgeon experience and technical changes on oncologic and functional outcomes.

PURPOSE: To assess the effect of surgeon experience and technical modifications on functional and oncologic outcomes after robot-assisted laparoscopic prostatectomy (RALP). PATIENTS AND METHODS: Data were available for 1181 of 1420 consecutive patients undergoing RALP by a single surgeon (DBS). Three techniques were evaluated. The "initial" technique included incision of the lateral endopelvic fascia, suture ligation of the dorsal venous complex (DVC), and anterior tennis-racquet bladder neck reconstruction (n = 590 procedures). The "intermediate" technique included a modified "curtain" nerve-sparing technique and incision of the DVC without previous ligation (n = 170). The "current" technique uses a posterior tennis-racquet bladder neck reconstruction (n = 421). Outcomes included continence and potency recovery and the presence of pT(2) surgical margins assessed in continuous fashion. Validated questionnaires were used to assess baseline and postoperative functional outcomes. RESULTS: Continence rates improved between techniques at all evaluated time points, with 1-year continence rates of 88%, 93%, and 96% in the initial, intermediate, and current technique groups, respectively (Ptrend <0.001). One-year potency rates, however, remained similar among the groups, with rates of 77%, 84%, and 79%, respectively (P = 0.58). pT(2) margin rates decreased continuously during the initial technique period, followed by a transient worsening of margin rates during the intermediate time period and a subsequent decrease during the period when the current technique was used. CONCLUSIONS: Increased experience with robot-assisted prostatectomy resulted in improvements in oncologic and functional outcomes. Modifications to robot-assisted prostatectomy techniques may aid in this improvement but are also associated with transient worsening of outcomes during the learning curve of the new technique.