Preoperative Biopsy Gleason Score Research Articles

Evaluation of four pre-operative models for prediction of biochemical recurrence after radical prostatectomy in localised prostate cancer.

Biochemical recurrence (BCR) can be seen in the early or late period after radical prostatectomy (RP). Various models have been developed to predict BCR. In our study, we evaluated the accuracy of four pre-operative models (GP score, PRIX, D'Amico risk classification, CAPRA) in predicting BCR after RP in Turkish patients. Age, preoperative total prostate-specific antigen (PSA) values, clinical stages, total number of cores taken in biopsy, number of positive cores, preoperative biopsy Gleason score (GS), follow-up time and presence of BCR after RP were recorded. BCR was defined as a total PSA value >0.2ng/dL twice consecutively after RP. Classifications or scoring was performed according to pre-operative models. The 1-, 3- and 5-year BCR-free rates of the patients were determined for each model. Also, the accuracy of four predictive models for predicting 1-, 3- and 5-year BCR was evaluated. For all pre-operative models there was a statistically significant difference between risk groups in BCR-free rates at 1-, 3- and 5-year after RP (P<.001). The Harrell's concordance index for 1-year BCR predictions was 0.802, 0.831, 0.773 and 0.745 for the GP score, PRIX, CAPRA and D'Amico, respectively. For 3-year BCR predictions, it was 0.798, 0.791, 0.723 and 0.714 for the GP score, PRIX, CAPRA and D'Amico and respectively. Finally, The Harrell's concordance index for 5-year BCR predictions was 0.778, 0.771, 0.702 and 0.693 for the GP score, PRIX, CAPRA and D'Amico, respectively. In the prediction of BCR, the accuracy of GP scoring and PRIX seems slightly higher than CAPRA and D'Amico risk classification. Surely our results should be supported by head to head comparisons within other larger cohorts.

Focal Therapy for Localized Prostate Cancer with Either High Intensity Focused Ultrasound or Cryoablation: A Single Institution Experience

We report oncologic outcomes in patients treated with focal therapy for prostate cancer. We retrospectively analyzed a single institution cohort of men with localized prostate cancer who received focal therapy using high intensity focused ultrasound or cryotherapy from 2009 to 2018. Focal therapy was offered for low or intermediate risk disease (prostate specific antigen less than 20 ng/ml, Gleason score 7 or less and clinical stage T2b or less). Patients with previous prostate cancer treatment or less than 6 months of followup were excluded from study. Failure was defined as local or systemic salvage treatment, a positive biopsy Gleason score of 7 or greater in-field or out-of-field in nontreated patients, prostate cancer metastasis or prostate cancer specific death. Cox regression analysis was done to identify independent predictors of failure after focal therapy. Of the 309 patients included in study 190 and 119 were treated with high intensity focused ultrasound and cryotherapy, respectively. Median followup was 45 months. At 1, 3 and 5 years the failure-free survival rate was 95%, 67% and 54%, and the radical treatment-free survival rate was 99%, 79% and 67%, respectively. The 5-year metastasis-free survival rate was 98% and no prostate cancer specific death was registered in this cohort. Before focal therapy a biopsy Gleason score of 7 (3 + 4) or greater (HR 2.4, p <0.001) and nadir prostate specific antigen (HR 2.2, p <0.001) were independently associated with failed focal therapy. In the salvage focal therapy setting in-field recurrence after primary focal therapy was associated with poorer failure-free survival (p=0.02). Almost half of the men were free of focal therapy failure 5 years after treatment. Still, a significant proportion experienced recurrence at the midterm followup. The preoperative biopsy Gleason score and nadir prostate specific antigen were significantly associated with treatment failure.

The oncologic results of cryoablation in prostate cancer patients with bone metastases

Objective: To explore the role of whole gland cryoablation plus ADT in prostate cancer (PCa) with bone metastases compared with ADT treatment alone in metastatic PCa.Methods: A total of 30 patients with biopsy-proven PCa with bone metastases underwent cryoablation and ADT treatment. The control group consisted of 30 men who were initially treated with ADT only and who were followed until progression, development of castration resistant PCa or death. Patients were pair matched for age, PSA level, clinical stage, preoperative biopsy Gleason score and bone metastases. Time to clinical progression, time to CRPC, cancer-specific survival and overall survival were analysed using descriptive statistical analysis.Results: Age at diagnosis, baseline PSA, biopsy Gleason score and ECOG status were comparable between the two groups. Prostate cryoablation was well tolerated and no serious complications occurred. At the last follow-up, patients in the cryoablation and ADT treatment group had a lower median PSA nadir (0.4 ng/ml vs. 0.8 ng/ml, p < 0.01) and longer time to CRPC (33 ± 0.9 mo vs. 22 ± 0.8 mo, p < 0.01). Further analyses detected the statistically significant benefits of cryoablation treatment not only in PFS (41 ± 1.4 mo vs. 22 ± 0.8 mo, p < 0.01), but also in CSS (52 ± 1.9 mo vs. 32 ± 2.4 mo, p ± 0.01) and OS (41 ± 1.5 mo vs. 28 ± 1.7 mo, p < 0.01). Moreover, there were fewer palliative procedures for local progression in the cryoablation group than the controls.Conclusions: Cryoablation plus ADT might be a treatment option in the multimodality management of metastatic prostate cancer. Further investigations are warranted.

MP80-14 MRI PRIOR TO PROSTATECTOMY DOES NOT IMPROVE SURGICAL OUTCOMES

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy VII1 Apr 2016MP80-14 MRI PRIOR TO PROSTATECTOMY DOES NOT IMPROVE SURGICAL OUTCOMES Eric Kim, Niraj Badhiwala, Joel Vetter, Robert Grubb, and Gerald Andriole Eric KimEric Kim More articles by this author , Niraj BadhiwalaNiraj Badhiwala More articles by this author , Joel VetterJoel Vetter More articles by this author , Robert GrubbRobert Grubb More articles by this author , and Gerald AndrioleGerald Andriole More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2046AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Magnetic resonance imaging (MRI) of the prostate has been increasingly utilized in the diagnosis of prostate cancer (PCa). Multiple studies have demonstrated benefits in risk stratification of patients as well as biopsy outcomes with MRI. However, the added value of prostate MRI prior to surgical intervention is not well defined. We examined our institutional experience in order to evaluate for improvements in prostatectomy outcomes associated with preoperative MRI. METHODS We identified patients at our institution who underwent prostatectomy for PCa between January 2012 and June 2015 (n=465). Of these patients, 199 had received MRI prior to prostatectomy. Using propensity scoring analysis, patients who had received MRI prior to prostatectomy were matched 1:1 to patients who did not receive MRI, based on age, comorbidity, body-mass index (BMI), prostate-specific antigen (PSA), and biopsy Gleason score. The final matched cohort included 128 patients with preoperative MRI and 128 patients without. Multivariate logistic and linear regression analysis was performed on this cohort examining operative time, estimated blood loss (EBL), perioperative complication, lymph node yield, and positive surgical margin. RESULTS When controlling for all measured variables between the propensity matched cohorts, preoperative MRI was not predictive of operative time, EBL, complications, lymph node yield, or positive surgical margins. No measured variable was predictive of a perioperative complication in this cohort. Preoperative biopsy Gleason score 8 and 9 were predictive of lymph node yield (Estimate 3.2, p=0.02 and 4.8, p<0.01) on multivariate linear regression. Preoperative PSA was predictive of positive surgical margin (OR=1.06, p=0.03). The only predictive variable for EBL and operative time was surgeon. CONCLUSIONS Although prostate MRI has become increasingly utilized in the diagnosis of PCa, preoperative MRI does not improve technical prostatectomy outcomes in our institutional experience. At this time, for patients who are already diagnosed with PCa and planned to undergo prostatectomy, preoperative MRI should not be recommended. Future studies should examine the impact of preoperative MRI on patient self-reported outcomes of urinary continence and sexual function after prostatectomy. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e1048 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Eric Kim More articles by this author Niraj Badhiwala More articles by this author Joel Vetter More articles by this author Robert Grubb More articles by this author Gerald Andriole More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Impact of a preoperatively estimated prostate volume using transrectal ultrasonography on surgical and oncological outcomes in a single surgeon's experience with robot-assisted radical prostatectomy.

To assess the impact of preoperatively estimated prostate volume (PV) using transrectal ultrasonography (TRUS) on surgical and oncological outcomes in robot-assisted radical prostatectomy (RARP). We analyzed the experience of a single surgeon at our hospital who performed 436 RARPs without neoadjuvant hormone therapy between August 2006 and December 2013. Patients were divided into three groups according to their preoperative PV calculated using TRUS (PV≤20cm(3): group 1, n=61; 20<PV<50cm(3): group 2, n=303; PV≥50cm(3): group 3, n=72). Blood loss was significantly higher in group 3 than in group 1 and group 2. In stage pT2 patients, the rate of positive surgical margin (PSM) was significantly lower in group 3 than in group 1. In addition, perioperative complications significantly increased with increasing PV, while the extraprostatic extension (EPE) rate significantly decreased with increasing PV. The preoperative biopsy Gleason score, prostate-specific antigen (PSA) density, and clinical T2 stage were inversely correlated with increasing PV. Biochemical recurrence-free survival after RARP was significantly lower in group 1 than in groups 2 and 3. A large prostate size was significantly associated with increased blood loss and a higher rate of perioperative complications. A small prostate size was associated with a higher PSM rate, PSA density, Gleason score, EPE rate, and biochemical recurrence rate. These results suggest that RARP was technically challenging in patients with large prostates, whereas small prostates were associated with unfavorable oncological outcomes.

1218 SALVAGE ROBOT-ASSISTED RADICAL PROSTATECTOMY FOR RECURRENT PROSTATE CANCER: SAFETY AND FEASIBILITY

INTRODUCTION AND OBJECTIVES: The safety and feasibility of salvage robot-assisted radical prostatectomy (sRARP) for recurrent prostate cancer is unclear. Herein we report short-term cancer control, functional, and perioperative outcomes in a multi-institutional cohort. METHODS: Between July 2007 and October 2011, 38 consecutive men underwent sRARP for recurrent prostate cancer at the University of Southern California (n 14) or Global Robotics Institute (n 24). Failed primary therapy was varied (external beam radiotherapy [EBRT; n 14]; interstitial brachytherapy [IBT; n 11]; EBRT IBT [n 5]; high-intensity focused ultrasound [n 3]; cryoablation [n 3]; other [n 2]). The main outcomes were immediate biochemical failure (IBF), positive surgical margins (PSM), urinary continence and erectile function at 3 months, and complications within 90 days of surgery. Immediate biochemical failure was defined as a PSA 0.2 ng/ml. Urinary continence was defined as the use of no pads and erectile function was defined as a SHIM score 21. Complications were classified and graded using the Clavien system. RESULTS: The median age was 68 years (50-83 years) and median preoperative PSA was 4.1 ng/ml (0.4-15.2 ng/ml). Preoperative biopsy Gleason score was 6 (n 7), 7 (n 18), and 8 (n 12). All procedures were completed without the need for open conversion. No patient experienced an intra-operative complication. Median estimated blood loss was 100 ml (30-300 ml) and operative time was 1.5 h (1-6h). Median length of hospital stay was 1 day (1-7 days). The median duration of urethral catheterization was 12 days (4-48 days). IBF occurred in 9 (29%) patients and PSM occurred in 7 (18%) patients. Urinary continence and erectile function occurred in 9 (34%) and 0 patients, respectively. One or more postoperative complications occurred in 12 (31%) patients. Low grade (I-II) and high grade (III-IV) complications occurred in 8 (21%) and 4 (10%) patients, respectively. No patient died. CONCLUSIONS: Salvage robot-assisted radical prostatectomy is safe and feasible. Short-term cancer control and perioperative morbidity were acceptable.

Safety and feasibility of salvage robot-assisted radical prostatectomy for recurrent prostate cancer.

e15171 Background: The safety and feasibility of salvage robot-assisted radical prostatectomy (sRARP) for recurrent prostate cancer is unclear. Herein we report short-term cancer control, functional, and perioperative outcomes in a multi-institutional cohort. Methods: Between July 2007 and October 2011, 38 consecutive men underwent sRARP for recurrent prostate cancer at the University of Southern California (n=14) or Global Robotics Institute (n=24). Failed primary therapy was varied (external beam radiotherapy [EBRT; n=14]; interstitial brachytherapy [IBT; n=11]; EBRT + IBT [n=5]; high-intensity focused ultrasound [n=3]; cryoablation [n=3]; other [n=2]). The main outcomes were immediate biochemical failure (IBF), positive surgical margins (PSM), urinary continence and erectile function at 3 months, and complications within 90 days of surgery. Immediate biochemical failure was defined as a PSA &gt; 0.2 ng/ml. Urinary continence was defined as the use of no pads and erectile function was defined as a SHIM score &gt; 21. Complications were classified and graded using the Clavien system. Results: The median age was 68 years (50-83 years) and median preoperative PSA was 4.1 ng/ml (0.4-15.2 ng/ml). Preoperative biopsy Gleason score was ≤6 (n=7), 7 (n=18), and ≥8 (n=12). All procedures were completed without the need for open conversion. No patient experienced an intra-operative complication. Median estimated blood loss was 100 ml (30-300 ml) and operative time was 1.5 h (1-6h). Median length of hospital stay was 1 day (1-7 days). The median duration of urethral catheterization was 12 days (4-48 days). IBF occurred in 9 (29%) patients and PSM occurred in 7 (18%) patients. Urinary continence and erectile function occurred in 9 (34%) and 0 patients, respectively. One or more postoperative complications occurred in 12 (31%) patients. Low grade (I-II) and high grade (III-IV) complications occurred in 8 (21%) and 4 (10%) patients, respectively. No patient died. Conclusions: Salvage robot-assisted radical prostatectomy is safe and feasible. Short-term cancer control and perioperative morbidity were acceptable; however, functional recovery was poor. To date, this is the largest series worldwide.

1393 SHOULD ANTERIOR PROSTATIC FAT DURING RADICAL PROSTATECTOMY UNDERGO PATHOLOGICAL EXAMINATION?

You have accessJournal of UrologyTechnology & Instruments: Robotics - Malignant Disease & Benign Disease II1 Apr 20121393 SHOULD ANTERIOR PROSTATIC FAT DURING RADICAL PROSTATECTOMY UNDERGO PATHOLOGICAL EXAMINATION? Brooke Harnisch, Charlotte Caligiuri, Kevin Tomera, Alexander Perepletchikov, and Ingolf Tuerk Brooke HarnischBrooke Harnisch Boston, MA More articles by this author , Charlotte CaligiuriCharlotte Caligiuri Brighton, MA More articles by this author , Kevin TomeraKevin Tomera Brighton, MA More articles by this author , Alexander PerepletchikovAlexander Perepletchikov Brighton, MA More articles by this author , and Ingolf TuerkIngolf Tuerk Brighton, MA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1842AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Dissection of the anterior fat overlying the prostate allows for visualization during robotic assisted laparoscopic radical prostatectomy (RARP). Although not usually sent enbloc for pathological analysis, anterior prostatic fat (APF) can harbor lymph nodes involved with prostate cancer. The purpose of this study was to evaluate APF and the incidence for positive nodes. METHODS An IRB approved retrospective study was conducted between July 2010 and October 2011 on patients who underwent RARP with ± pelvic lymph node dissection and had APF sent for pathologic analysis. Clinical and pathological data was analyzed. RESULTS A total of 302 patients were identified. Perioperative patient characteristics are summarized in Table 1. Overall, 30/302 patients (10%) had APF lymph nodes (range 1-3) and 272 patients (90%) had no APF lymph nodes. Four of 302 patients (1.3%) had positive APF nodes. Two patients had concomitant positive pelvic lymph nodes (PLN). The pre-operative biopsy Gleason score and prostate specific antigen was 4+3 and 5.6 ng/ml for patient 1, 4+3 and 2.6 ng/ml for patient 2, 4+3 and 5.1 ng/ml for patient 3, 3+4 and 6.4 ng/ml for patient four. Pathological data is summarized in Table 2. Table 2. Perioperative patient characteristics APF nodes not present (n=272) APF nodes present (n=30) P value Patient age 60.7±6.7 59.4±10.9 0.35 BMI (kg/m2) 27.9±11.6 29.3±3.7 0.08 Pre-op PSA 6.8±10.8 6.9±6.8 0.99 Average Gleason biopsy score 7±0.8 6.7±0.8 0.89 OR time (minutes) 121±27 125±22 0.42 EBL (mls) 169±169 154±97 0.47 Table 2. Pathological data Seminal vesicle invasion Extraprostatic extension Perineural invasion Lymphovascular invasion Positive PLN Pathological staging Patient one (−) (−) (+) (−) No pT2aN1Mx Patient two (−) (−) (+) (+) No pT2cN1Mx Patient three (+) (+) (+) (+) Yes pT3bN1Mx Patient four (+) (+) (+) (+) Yes pT3bN1Mx CONCLUSIONS APF lymph nodes were present in 10% of patients with no clinical or pathological characteristics that could identify these men. Four of 302 patients (1.3%) had positive APF nodes. Pathological upstaging occurred in 2/304 patients (0.7%). Since lymph node involvement is a significant prognosticator for adjuvant treatment including radiation and hormone therapies, routine excision and pathologic analysis of the APF should be considered during RARP. Future studies with large cohorts of patients are needed to validate our findings. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e565-e566 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Brooke Harnisch Boston, MA More articles by this author Charlotte Caligiuri Brighton, MA More articles by this author Kevin Tomera Brighton, MA More articles by this author Alexander Perepletchikov Brighton, MA More articles by this author Ingolf Tuerk Brighton, MA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Radical salvage prostatectomy for locally recurrent prostate cancer after radiation therapy.

47 Background: Radical salvage prostatectomy (SRP) is one local treatment option with curative intent in patients failing radiation therapy (RT) for localized prostate cancer (PCA). We compared the surgical, histological and functional outcome of a large cohort of patients who underwent SRP for locally recurrent PCA following LDR – brachytherapy (BRT). Methods: 66 consecutive patients with locally recurrent PCA after BRT underwent retropubic SRP and pelvic lymphadenectomy. Preoperative PSA, PSA doubling time, PSA prior to initial RT, biopsy Gleason score, number of positive biopsies, cT stage, neoadjuvant androgen deprivation were correlated with pathohistological stage, complications and functional outcome by uni- and multivariate analysis. Results: Mean preop. PSA was 5.6 (2-13.5) ng/ml; mean preoperative biopsy Gleason score was y5.6 (4-9). 1 patient (1.5%) experienced a rectal lesion, mean blood loss was 430 (200-900) ml, none of the patients received blood transfusions. Pathohistology demonstrated organ confined prostate cancer pT2a-2c in 38 (57.5%) patients, stage pT3a and stage pT3b was identified in 14 (21.1%) patients and in 14 (21.1%) patients, respectively. Positive surgical margins were diagnosed in 9 (13.6%) patients and 12 (15.1%) patients harboured lymph node metastases. Functional outcome was good with a continence rate of 82%; the mean time until recovery of continence was 8.4 (6-14) months. After a mean follow-up of 22.5 (1-72) months, 28% of the patients experienced a PSA relapse defined as any PSA increase &gt; 0.2 ng/ml validated by 2 consecutive measures. Conclusions: SRP can be performed safely and with a low morbidity in biopsy proven locally recurrent PCA following BRT. However, our data demonstrate an unfavourable histology with locally advanced disease in about 40% of the patients who all were diagnosed with low risk prostate cancer. These data question the quality of the selection process for patients being counselled for BRT and the data raise the possibility of both intrinsic radioresistance of prostate cancer or poorly performed BRT.

Learning Curve of Robotic-assisted Radical Prostatectomy With 60 Initial Cases by a Single Surgeon

We tracked various proficiency indicators for the learning curve as a single Taiwanese surgeon became familiar with robotic-assisted laparoscopic radical prostatectomy surgeries by performing 60 initial procedures. Between December 2005 and December 2007, 60 consecutive patients were classified into Group 1 (Cases 1-30) or Group 2 (Cases 31-60). Pre-operative clinical characteristics, operative parameters, and postoperative parameters were assessed. Pre-operative biopsy Gleason scores were significantly higher in Group 2 than in Group 1 (7.03 vs. 6.13, P < 0.01). The vesicourethral anastomosis time showed a statistically significant reduction from 46.38 minutes in Group 1 to 31 minutes in Group 2 (p < 0.01). The continence rate at 3 months in Group 2 was higher than that in Group 1 (97.6%vs. 76.7%, p = 0.052); the mean duration to continence was shorter in Group 2 than Group 1 (70.26 ± 67.37 days vs. 39.63 ± 36.48 days, p = 0.056). Group 2 had shorter postoperative stays (3.93 vs. 7.33) and longer durations of Foley catheter removal (9.0 vs. 7.7) than Group 1, representing a statistically significant difference (p < 0.01). After gaining experience by performing an initial 30 robotic-assisted laparoscopic radical prostatectomies, the subsequent 30 surgeries established proficiency as determined by vesicourethral anastomosis time and early continence rate.

Neoadjuvant Hormonal Therapy Preceding Radical Prostatectomy for Clinically Localized Prostate Cancer: Early Postoperative Complications and Biochemical Recurrence

PurposeThe effect of neoadjuvant hormonal therapy (NHT) on radical retropubic prostatectomy (RRP) for prostate cancer is various and remains a controversy for urologists. We conducted this study to comparatively evaluate whether NHT before RRP is indicated and beneficial in the aspects of postoperative complications, positive surgical margin, and biochemical recurrence.Materials and MethodsBetween September 2006 and December 2009, 69 men were scheduled for RRP as a treatment for clinically localized and locally advanced prostate cancer and were divided into two groups. Group 1 (n=31, 44.9%) was treated with RRP only, and group 2 (n=38, 55.1%) underwent RRP with preoperative NHT. We evaluated clinical parameters, surgical parameters, and the positive margin rate in surgical specimens and the biochemical recurrence rate.ResultsThere were no statistical differences in age, body mass index (BMI), preoperative biopsy Gleason score, initial serum prostate-specific antigen (PSA) levels, International Prostate Symptom Score (IPSS), or quality of life (QoL) between the two groups (p>0.05). We also observed no differences in the transfusion rate, mean catheterization time, or positive margin rate (p>0.05). However, the mean operative time was significantly higher in the RRP with preoperative NHT group than in the other group (p=0.034). There was no significant difference in the biochemical recurrence rate during the last follow-up according to NHT (p=0.102) or positive surgical margin (p=0.473).ConclusionsThese results suggest that there were no clinical benefits to the administration of NHT before RRP from the viewpoint of biochemical recurrence.

Optimizing Vesicourethral Anastomosis Healing After Robot-Assisted Laparoscopic Radical Prostatectomy: Lessons Learned from Three Techniques in 1900 Patients

Creation of an optimally apposed, tension-free, well-supported vesicourethral anastomosis remains the cornerstone for anastomotic healing after radical prostatectomy. We report the effect of three techniques of bladder neck reconstruction during robot-assisted radical prostatectomy on anastomotic leak, stricture formation, and continence recovery. Between January 2005 to September 2009, 1900 consecutive patients underwent robotic-assisted laparoscopic prostatectomy (RALP) by a single surgeon. Of these, the first 214 underwent vesicourethral conventional anastomosis (CA); the next 303 men underwent anterior reconstruction (AR) only; and last 1383 men underwent total anatomic restoration (TR). Data elements included patient age, body mass index, preoperative biopsy Gleason score and prostate-specific antigen level, prostate volume, total operative time, console time, time for performing vesicourethral anastomosis, estimated blood loss, tumor stage, and margin status on final pathologic findings. Primary end points were rates of clinically significant anastomotic leaks, bladder neck contractures, and time to return of continence. Chi-square and Fisher exact tests were used for analysis of categoric variables. The Cox proportional hazard model was used for both univariate and multivariate analysis. Clinically significant anastomotic leakage and bladder neck strictures were significantly fewer in the reconstructed groups (2.3% vs 1.0% vs 0.3% and 3.7% vs 1.3% vs 0.5% in the CA, AR, and TR groups, P < 0.01). Continence rates at 1, 6, 12, 26, and 52 weeks after RALP were also significantly better at all time points with AR and TR compared with CA alone (P < 0.001). TR of the continence mechanism optimizes vesicourethral anastomosis healing and hastens early continence return after RALP.

Robotic Laparoscopic Radical Prostatectomy for Biopsy Gleason 8 to 10: Prediction of Favorable Pathologic Outcome with Preoperative Parameters

We sought to evaluate the pathologic results and postoperative outcomes for men undergoing robot-assisted laparoscopic radical prostatectomy (RLRP) for biopsy Gleason score (GS) 8 to 10 disease. Stratification of these patients according to preoperative variables was also performed in an attempt to predict organ-confined cancer. A prospective RLRP database identified all patients with preoperative biopsy GS 8 to 10. Variables, including prostate-specific antigen (PSA), percent positive biopsy cores (%PBC), maximal percentage of cancer in biopsy core (%MCB), clinical stage, pathologic stage, pathologic GS, surgical margins status, lymph node status, time to biochemical recurrence, and recurrence rate, were evaluated. Preoperative variables were treated as continuous and categorical using PSA, %PBC and %MCB cutoffs of 10 ng/mL, 50%, and 30%, respectively. Between February 2003 and September 2007, a total of 1225 RLRPs were performed at the University of Chicago Medical Center. Seventy-two (5.9%) patients had preoperative biopsy GS 8 to 10. Two patients received neoadjuvant hormonal therapy and were excluded. Among 70 patients evaluated, 33 (47%) had organconfined (pT(2)N0) disease. Forty (60.6%) patients had pathologic downgrading to GS <or=7. Overall positive surgical margin (PSM) rate was found to be 24.2%. pT(2)- and pT(3)-PSM rate was 6% and 42.3%, respectively. In multivariate logistic regression analysis, PSA <or=10 ng/mL (P = 0.04) and %MCB <or=30% (P = 0.001) were found to be statistically significant predictors of pT(2)N0 disease. Preoperative biopsy GS 8 to 10 predicts a significant likelihood of finding non-organ-confined prostate cancer on the final pathology report. Preoperative PSA <or=10 ng/mL and %MCB <or=30% may be used to predict favorable pathologic outcome for these patients during surgical counseling.

Laparoscopic extended pelvic lymph node dissection for high-risk prostate cancer

Introduction Recently, some controversy has arisen as to whether pelvic lymphadenectomy is still necessary for patients with prostate cancer who are undergoing radical prostatectomy. We prospectively evaluated the results and morbidity of laparoscopic extended pelvic lymph node dissection in patients with high-risk prostate cancer defined as a serum prostate-specific antigen (PSA) level greater than 10 ng/mL or preoperative biopsy Gleason score of 7 or more. Technical Considerations In 123 consecutive patients with clinically organ-confined high-risk prostate cancer, laparoscopic extended pelvic lymphadenectomy was performed before laparoscopic radical prostatectomy. The boundaries of the pelvic lymph node dissection were the bifurcation of the common iliac artery superiorly, the node of Cloquet inferiorly, the external iliac vein laterally, and the bladder wall medially. Preparation was done with bipolar forceps and scissors, with meticulous coagulation of all lymphatic tissue. The mean PSA level was 14.8 ng/mL (range 1.5 to 43.4). The mean number of lymph nodes removed was 21 (range 9 to 55). A total of 21 patients (17%) had lymph node metastases. The overall complication rate was 4%. Conclusions Laparoscopic extended pelvic lymph node dissection is safe and effective. The results and morbidity are equivalent to those of open surgery, with the advantage of a minimally invasive operative technique.

Utility of preoperative serumprostate-specific antigen concentration and biopsy Gleason score in predicting risk of pelvic lymph node metastases in prostate cancer

Objectives. To determine the accuracy of the preoperative serum concentrationof prostate-specific antigen (PSA) plus the Gleason pathology score of biopsy specimens in predicting the presence of disease in the pelvic lymph nodes in patients with prostate cancer. Methods. The medical records of all patients treated for prostate cancer at eight medicalcenters from January 1988 to June 1993 were reviewed. There were 932 patients with newly diagnosed prostate cancer for whom all relevant data were available who had undergone pelvic lymphadenectomy with (n = 912) or without (n = 20) radical prostatectomy. The rate of false-negative predictions of metastases based on combined preoperative biopsy Gleason score and serum PSA concentration was analyzed. A multivariate logistic regression analysis was performed to assess the value of preoperative serum PSA and biopsy Gleason scores individually and in combination in predicting pelvic lymph node metastases. Results. The false-negative rate of metastases was 0% for preoperative PSA concentrations≤6 ng/mL and biopsy Gleason scores ≤5 (n = 142) and 1.0% for PSA concentrations ≤10 ng/mL and Gleason scores ≤6 (n = 388). The 95% upper confidence limit for the rate of false negativity at this PSA cut-off level was 2.0%. A combination of preoperative serum PSA levels and biopsy Gleason scores provided the best prediction for the false-negative rates. Conclusions. For patients with newly diagnosed prostate cancer who have biopsy Gleason scores ≤6 and preoperative PSA concentrations ≤10 ng/mL (42% of our series), a staging pelvic lymphadenectomy appears to be unnecessary. The substantial cost associated with both cross-sectional imaging and staging lymphadenectomy may therefore be avoidable in this group of patients.