Oncological and functional outcomes following open radical prostatectomy: how patients may achieve the "trifecta"?

PURPOSE: The desirable outcomes after open radical prostatectomy (RP) for localized prostate cancer (PC) are to: a) achieve disease recurrence free, b) urinary continence (UC), and c) maintain sexual potency (SP). These 3 combined desirable outcomes we called it the "Trifecta". Our aim is to assess the likelihood of achieving the Trifecta, and to analyze the influencing the Trifecta . MATERIALS AND METHODS: A total of 1738 men with localized PC underwent RP from 1992-2007 by a single surgeon. The exclusion criteria for this analysis were: preoperative hormonal or radiation therapy, preoperative urinary incontinence or erectile dysfunction, follow-up less than 24 months or insufficient data. Post-operative Trifecta factors were analyzed, including biochemical recurrence (BR).. We defined: BR as PSA > 0.2 ng/mL, urinary continence as wearing no pads, and sexual potency as having erections sufficient for intercourse with or without a phosphodiesterase-5 inhibitor. RESULTS: A total of 831 patients met the inclusion criteria. The mean age of the entire cohort was 59 years old. The median follow-up was 52 months (mean 60, range 24-202). The BR, UC and SP rates were 18.7 percent, 94.5 percent, and 71 percent respectively. Trifecta was achieved in 64 percent at 2 year follow-up, and 61 percent at 5 year follow-up. Multivariate analysis revealed age at time of surgery, pathologic Gleason score (PGS), pathologic stage, specimen weight, and nerve sparing (NS) were independent factors. CONCLUSIONS: Age at time of surgery, pathologic GS, pathologic stage, specimen weight and NS were independent predictors to achieve the Trifecta following radical prostatectomy. This information may help patients counseling undergoing radical prostatectomy for localized prostate cancer.

The role of liver transplantation techniques in the surgical management of advanced renal urothelial carcinoma with or without inferior vena cava thrombus

Purpose: Standard radical nephrectomy for large masses is significantly facilitated by liver transplantation techniques, which have been successfully employed over the last ten years at our institution. Large and locally-advanced urothelial carcinoma of the kidney with or without extension into the inferior vena cava is rare. The purpose of this study was to present the surgical management of large and locally-advanced urothelial tumors arising from the renal pelvis using liver transplantation techniques and to evaluate patient outcome. Materials and Methods: Diagnostic work-up and surgical management of 4 patients with large and locally-advanced renal urothelial carcinoma were retrospectively reviewed. Two out of four patients with urothelial carcinoma presented with inferior vena cava thrombus. Mean tumor size was 11.6 cm. All patients underwent surgery, 2 patients with the presumed diagnosis of renal cell cancer. Liver transplantation techniques were an integral part in all radical nephrectomies. Results: No intraoperative complications and postoperative mortality occurred. Mean operative time was 7.5 hours, estimated blood loss was 1.5 L, and an average of 4.8 units of blood was transfused intraoperatively. Three patients succumbed to cancer recurrence at a mean postoperative time of 6.3 months; 1 patient is still alive 24 months after surgery. Conclusions: Large and locally-advanced renal masses of urothelial origin can be successfully removed by a combination of radical nephrectomy with liver transplantation techniques. Since long-term outcome of such patients has been poor, accurate preoperative diagnosis is essential to consider neoadjuvant treatment and to plan nephroureterectomy.

Epigenetic targets in the diagnosis and treatment of prostate cancer

Prostate cancer (PC) is one of leading cause of cancer related deaths in men. Various aspects of cancer epigenetics are rapidly evolving and the role of 2 major epigenetic changes including DNA methylation and histone modifications in prostate cancer is being studied widely. The epigenetic changes are early event in the cancer development and are reversible. Novel epigenetic markers are being studied, which have the potential as sensitive diagnostic and prognostic marker. Variety of drugs targeting epigenetic changes are being studied, which can be effective individually or in combination with other conventional drugs in PC treatment. In this review, we discuss epigenetic changes associated with PC and their potential diagnostic and therapeutic applications including future areas of research.

Orthotopic ileal neobladder reconstruction for bladder cancer: is adjuvant chemotherapy safe?

OBJECTIVE: We examined our database of patients undergoing radical cystectomy (RC) with orthotopic neobladder (NB) to determine whether adjuvant chemotherapy in this group is safe. MATERIALS AND METHODS: We performed a retrospective analysis of patients who underwent radical cystectomy and urinary diversion between 1992 and 2004. Relevant clinical and therapeutic data were entered into a database. High-risk bladder cancer patients who underwent NB were identified. They were stratified into 2 groups, those who received adjuvant chemotherapy and those who did not. The incidence of complications between the 2 groups was analyzed and compared. RESULTS: Over the 12-year period, 136 patients underwent RC and NB construction for bladder cancer. Of these, 83 patients were at high risk for recurrence. Nineteen patients received adjuvant chemotherapy and 64 did not. The complication rate in the adjuvant chemotherapy group was 53 percent and it was 23 percent in those who did not receive chemotherapy. There were no perioperative or treatment related death. There were 2 patients with grade 4 toxicity in the adjuvant chemotherapy group. There was a statistical difference between these two groups with regard to the incidence of complications. However, none of these complications was life-threatening, required only conservative treatment and caused no long-term disability. CONCLUSIONS: Adjuvant chemotherapy is a safe treatment for patients undergoing RC and NB substitution. Hence, the option of orthotopic NB should not be denied in selected bladder cancer patients with high risk for recurrent disease.

Intraoperative cell salvage during radical prostatectomy: a safe technique for Jehovahs witnesses

Radical retropubic prostatectomy (RRP) is an operation historically associated with the potential for significant blood loss. Patients who refuse a blood transfusion, such as Jehovahs witnesses, may be only offered radiation therapy as potentially curative treatment for prostate cancer because of the potential for a transfusion. Intraoperative cell salvage (IOCS) is an effective blood managient strategy for patients who are not willing to accept predonated autologous or allergenic blood. We present our managient for Jehovah's Witness patients with clinically localized prostate cancer, iphasizing our blood managient approach. This is the first such report.