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.

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.

The influence of President Trump's micro-expressions during his COVID-19 national address on viewers' emotional response.

This preregistered study replicates and extends studies concerning emotional response to wartime rally speeches and applies it to U.S. President Donald Trump's first national address regarding the COVID-19 pandemic on March 11, 2020. We experimentally test the effect of a micro-expression (ME) by Trump associated with appraised threat on change in participant self-reported distress, sadness, anger, affinity, and reassurance while controlling for followership. We find that polarization is perpetuated in emotional response to the address which focused on portraying the COVID-19 threat as being of Chinese provenance. We also find a significant, albeit slight, effect by Trump's ME on self-reported sadness, suggesting that this facial behavior served did not diminish his speech, instead serving as a form of nonverbal punctuation. Further exploration of participant response using the Linguistic Inventory and Word Count software reinforces and extends these findings.

Trends in renal surgery: robotic technology is associated with increased use of partial nephrectomy.

PURPOSE: Underuse of partial vs radical nephrectomy for renal tumors was noted in recent population based analyses. An explanation is the learning curve associated with laparoscopic partial nephrectomy. We analyzed state trends in renal surgery and their relationship to the introduction of robotic technology. MATERIALS AND METHODS: We used the Maryland HSCRC (Health Services Cost Review Commission) database to identify patients who underwent radical or partial nephrectomy, or renal ablation from 2000 to 2011. Utilization trends, and associated patient and hospital factors were analyzed using multivariate logistic regression. ICD-9 robotic modifier codes were established in October 2008. RESULTS: Of the 14,260 patients included in analysis 11,271 (79.0%), 2,622 (18.4%) and 367 (2.6%) underwent radical and partial nephrectomy, and renal ablation, respectively. Partial nephrectomy increased from 8.6% in 2000 to 27% in 2011. Open radical nephrectomy decreased by 33%, while minimally invasive radical nephrectomy increased by 15%. Robot-assisted laparoscopic partial nephrectomy increased from 2008 to 2011, attaining a 14% rate at university and 10% at nonuniversity hospitals (p = 0.03). It was associated with increased partial nephrectomy (OR 9.67, p <0.001). Younger age, male gender and low patient complexity predicted partial nephrectomy on overall analysis, while higher hospital volume and university status were predictors only in earlier years. CONCLUSIONS: Partial nephrectomy use increased in Maryland from 2001 to 2011, which was facilitated by robotic technology. Associations with hospital factors decreased with time. These data suggest that robotic technology may enable surgeons across practice settings to more frequently perform nephron sparing surgery.

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.

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'.

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.

The impact of anatomical radical retropubic prostatectomy on cancer control: the 30-year anniversary.

PURPOSE: Radical prostatectomy has decreased prostate cancer specific mortality in men with clinically localized prostate cancer. We report oncological outcomes of the longest running series of nerve sparing radical retropubic prostatectomy on the 30th anniversary of the inaugural operation. MATERIALS AND METHODS: A total of 4,478 men underwent anatomical radical retropubic prostatectomy, as performed by a single surgeon (PCW), at the Johns Hopkins Medical Institutions from 1982 to 2011, without neoadjuvant or adjuvant therapy. During a median followup of 10 years (range 1 to 29), we examined progression-free, metastasis-free and cancer specific survival. RESULTS: The overall 25-year progression-free, metastasis-free and cancer specific survival rates were 68%, 84% and 86%, respectively, although there were significant differences in treatment outcomes between men treated in the pre-PSA and PSA eras. In each era, there were significant differences in progression-free, metastasis-free and cancer specific survival by D'Amico risk groups. In multivariable models considering prostatectomy features, pathological stage and grade were significantly associated with the risk of metastatic progression and disease specific mortality. CONCLUSIONS: Excellent prostate cancer specific survival was demonstrated up to 30 years after surgery. Clinical risk categories and pathological tumor features were significant predictors of long-term disease specific outcomes, supporting their ongoing use in risk stratification and management decisions. Anatomical radical retropubic prostatectomy continues to represent the gold standard in the surgical management of clinically localized prostate cancer to which alternate treatment options should be compared.

Radical prostatectomy outcome in men 65 years old or older with low risk prostate cancer.

PURPOSE: A recent update of the Scandinavian Prostate Cancer Group Study-4 concluded that men older than 65 years treated with radical prostatectomy had no survival advantage compared to men treated with watchful waiting. We examined the proportion and outcomes of men 65 years old or older with low risk disease who underwent radical prostatectomy at our institution. MATERIALS AND METHODS: Our institutional radical prostatectomy database with more than 19,000 patients was queried for men 65 years old or older with low risk prostate cancer. Pathological and survival outcomes were assessed. Subanalysis was done on men 70 years old or older to determine whether outcomes among older men differed by age. RESULTS: A total of 1,560 men (8.1%) 65 years old or older with low risk prostate cancer underwent radical prostatectomy between 1983 and 2010. After radical prostatectomy 38.3% of the men had evidence of more aggressive cancer, including Gleason score 7 or greater, or extraprostatic extension. After radical prostatectomy actuarial 5, 10 and 15-year biochemical recurrence-free survival was 93.2%, 89.2% and 82.2%, prostate cancer specific survival was 99.7%, 98.4% and 97.2%, and overall survival was 96.1%, 83.5% and 60.2%, respectively. CONCLUSIONS: Fewer than 10% of men treated with radical prostatectomy at our institution were 65 years old or older with low risk prostate cancer. Despite a high prevalence of aggressive disease discovered at surgery these men experienced excellent long-term survival. Treatment recommendations in older men with low risk prostate cancer should be made after careful consideration of life expectancy based on comorbidities and potential adverse outcomes of treatment.

Tumor complexity predicts malignant disease for small renal masses.

PURPOSE: Approximately 20% to 30% of suspicious small renal tumors are benign. A significant proportion of malignant tumors are low grade and potentially indolent. We evaluated whether preoperative patient and tumor characteristics are associated with adverse pathological features. MATERIALS AND METHODS: A total of 886 patients underwent robot-assisted partial nephrectomy, as done by 1 of 5 high volume surgeons. Demographic and clinical data were compared between patients with benign/malignant disease, clear cell/nonclear cell renal cell carcinoma and high/low grade tumors. Tumor complexity was quantified by R.E.N.A.L. (radius, exophytic/endophytic, nearness of tumor to collecting system or sinus, anterior/posterior, hilar and location relative to polar lines) nephrometry score and described as low--4 to 6, intermediate--7 to 9 or high--10 or greater. Logistic regression analyses were performed to test the association between tumor and patient characteristics, and high grade renal cell carcinoma. Subanalyses were done for patients with renal tumors 4 cm or less. RESULTS: High grade renal cell carcinoma was larger and more likely to develop in men. Patients with malignant tumors and with clear cell histology were more likely to have intermediate or high complexity tumors. Increasing tumor complexity independently predicted malignancy, high grade malignancy and clear cell histology on multivariate regression analysis (each p <0.05). Male gender was independently associated with malignancy and high grade renal cell carcinoma. When considering tumors 4 cm or less, tumor complexity predicted malignancy but not tumor grade. CONCLUSIONS: High R.E.N.A.L nephrometry score and male gender are associated with an increased risk of malignancy and high grade malignancy in tumors treated with partial nephrectomy.

Lymphangiography with sclerotherapy: a novel therapy for refractory chylous ascites.

INTRODUCTION: We report the outcomes of a small series of patients with refractory chylous ascites following urologic surgery treated with lymphangiography +/- sclerotherapy. MATERIALS AND METHODS: Retrospective review revealed three patients who underwent lymphangiography for prolonged lymphatic leak following urological surgery. Contrast material is injected slowly into a lymphatic vessel on the dorsum of the foot and serial imaging is used to capture the location and degree of lymphatic leak in order to guide definitive treatment. Demographic and clinical details were collected and are reported. RESULTS: Three patients were identified from 2005-2008 (one following donor nephrectomy and two following retroperitoneal lymph node dissection). All patients presented with abdominal distension within 30 days of surgery. Traditional conservative measures failed in all patients. Lymphangiography localized all leaks (renal hilum, paraspinal, and retrocaval). One patient elected for successful surgical repair after localization. The remaining two patients resolved immediately following lymphangiography; one of these patients underwent percutaneous doxycycline sclerosis. With over 1 year of follow up there have been no recurrences or long term sequelae. CONCLUSIONS: Lymphangiography is a valuable management option for the rare patient with chylous ascites refractory to conservative therapy. Prompt resolution of prolonged chylous ascites following lymphangiography should encourage its use in such difficult cases.

Ureteral stents placed at the time of urinary diversion decreases postoperative morbidity.

OBJECTIVE: To determine the impact of stenting ureteroenteric anastomoses on postoperative stricture rate and gastrointestinal recovery in continent and noncontinent urinary diversions (UDs). PATIENTS AND METHODS: We retrospectively reviewed the clinical and pathologic data on 192 consecutive patients who underwent a radical cystectomy and UD. Patients received either a continent or noncontinent UD with or without stent placement through the ureteroenteric anastomoses. Stricture rate, gastrointestinal recovery, length of hospital stay, and stricture characteristics were analyzed. Study endpoints were compared between four groups--stented and nonstented continent and stented and nonstented noncontinent UDs. RESULTS: 36% of patients were stented and 64% were nonstented at the time of UD. Total ureteral stricture rate was 9.9%. There was no statistically significant difference in stricture rate (p = 0.11) or length of hospital stay (p = 0.081) in stented compared to nonstented patients. There was a significantly (p = 0.014) greater rate of ileus in patients who were nonstented in both continent and noncontinent UDs. CONCLUSION: Stenting of ureteroenteric anastomoses in both continent and noncontinent UD has no effect on postoperative stricture rate, but is associated with lower rates of postoperative ileus.

Laparoendoscopic single-site surgery of the kidney: an initial experience.

INTRODUCTION: Laparoendoscopic single-site surgery (LESS) has emerged as a natural progression from standard laparoscopy toward minimization of surgical morbidity. We present our initial experience with LESS renal surgery in order to assess safety, feasibility, and early postoperative outcomes. MATERIALS AND METHODS: Patients undergoing LESS renal surgery by a single surgeon from November 2008 to June 2010 were retrospectively identified. Safety, feasibility, and early outcomes were analyzed. Pain parameters were assessed using morphine equivalents used and visual analog pain scores (VAPS). RESULTS: LESS procedures included 13 radical nephrectomy (1 bilateral), 5 simple nephrectomy (1 bilateral), 2 partial nephrectomy, 2 renal biopsy, and 1 renal cryoablation. Of 17 renal tumors, 15 were renal cell carcinoma and 2 had known renal vein involvement. Mean patient age was 55.4 years and mean BMI was 25.5 kg/m2. Mean operative time was 131 minutes (38-230), median estimated blood loss was 50 mL, and median length of stay was 2 days. There was one intraoperative transfusion and one conversion to conventional laparoscopy. The postoperative complication rate was 12% with two Clavien grade > 2 complications. Mean morphine equivalent dose of intravenous narcotics was 21.7 mg, and mean VAPS scores were 4.3, 3.5, and 2.9/10 on POD#0, #1, and day of discharge, respectively. CONCLUSIONS: LESS surgery is safe and feasible for a wide variety of renal surgeries. Despite the selection bias of this early experience, postoperative outcomes and pain scores appear comparable to those reported for standard laparoscopy. Prospective studies comparing LESS to standard laparoscopic renal surgery are needed for definitive assessment.

Pelvic node dissection in prostate cancer: extended, limited, or not at all?

PURPOSE OF REVIEW: Pelvic lymph node dissection in patients with clinically localized prostate cancer has long been an established part of radical prostatectomy that provides prognostic information in men with locally metastatic disease. However, given downward stage migration over the last 25 years, it is no longer clear that pelvic lymphadenectomy is pertinent for most men diagnosed today. In men in whom it is pertinent, it is unclear how extensive a lymphadenectomy should be performed. RECENT FINDINGS: Computed tomography and magnetic resonance imaging alone are not accurate for detecting nodal metastases, but new modalities such as magnetic resonance lymphography have great apparent potential. Until these become widely available, pelvic lymph node dissection remains the modality of choice for detecting lymph node metastasis. A variety of predictive nomograms exists to predict lymph node involvement. As a pelvic lymphadenectomy has complications that generally increase with extent of dissection, lymphadenectomy should be limited to patients at an increased risk of nodal metastasis. SUMMARY: There is good evidence that a pelvic lymph node dissection limited to the external iliac vein nodes is unnecessary in men with low-risk prostate cancer. A standard external iliac and obturator lymph node dissection, with or without extension to hypogastric nodes, makes sense in cases of intermediate and high risk. Harvesting a greater number of lymph nodes adds prognostic and even therapeutic benefit in many cases, including in some men with no obvious nodal metastases.

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.

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.