Perceptions of the care experience in critical care units enhanced by a tele-ICU.

The purpose of this study was to determine patients' and families' perceptions of care in 10 critical care units enhanced by a tele-intensive care unit (ICU) in a 5-hospital health care system. Patients and family members who had a critical care experience were approached for participation. An adapted version of the Schmidt Perception of Nursing Care Survey was administered. The Schmidt Perception of Nursing Care Survey factors--seeing the individual patient, explaining, responding, and watching over-were analyzed for 637 participants (263 before and 374 after the tele-ICU implementation). Analysis of data from patients and family members indicated significantly higher means for the following factors: seeing the individual patient (P =.004), responding (P =.002), and watching over (P =.006) only when there was an awareness by the patient and family members that the care team was at the bedside and at the tele-ICU command center. The perceptions of care in these cases may suggest an improved patient experience when a tele-ICU is part of the care team.

Clinical outcomes after telemedicine intensive care unit implementation.

OBJECTIVE: To examine clinical outcomes before and after implementation of a telemedicine program in the intensive care units of a five-hospital healthcare system. DESIGN: Observational study with the baseline period of 1 yr before the start of a telemedicine intensive care unit program implementation at each of 5 hospitals. The post periods are 1, 2, and 3 yrs after telemedicine intensive care unit program implementation at each hospital. SETTING: Ten adult intensive care units (114 beds) in five community hospitals in south Florida. A telemedicine intensive care unit program with remote 24/7 intensivist and critical care nurse electronic monitoring was implemented by a phased approach between December 2005 and July 2007. MEASUREMENTS AND MAIN RESULTS: Records from 24,656 adult intensive care unit patients were analyzed. Hospital length of stay, intensive care unit length of stay, hospital mortality, and Case Mix Index were measured. Severity of illness using All Patient Refined-Diagnosis Related Groups scores was used as a covariate. From the baseline year to year 3 postimplementation, the severity-adjusted hospital length of stay was lowered from 11.86 days (95% confidence interval [CI] 11.55-12.21) to 10.16 days (95% CI 9.80-10.53; p < .001), severity-adjusted intensive care unit length of stay was lowered from 4.35 days (95% CI 4.22-4.49) to 3.80 days (95% CI 3.65-3.94; p < .001), and the relative risk of hospital mortality decreased to 0.77 (95% CI 0.69-0.87; p < .001). CONCLUSIONS: After 3 yrs of deployment of a telemedicine intensive care unit program, this retrospective observational study of mortality and length of stay outcomes included all cases admitted to an adult intensive care unit and found statistically significant decreases in severity-adjusted hospital length of stay of 14.2%, intensive care unit length of stay of 12.6%, and relative risk of hospital mortality of 23%, respectively, in a multihospital healthcare system.

Radical cystectomy after bacillus Calmette-Guérin for high-risk Ta, T1, and carcinoma in situ: defining the risk of initial bladder preservation.

OBJECTIVES: To critically evaluate the survival of patients with high-grade Ta or T1 urothelial cancer (UC) or carcinoma in situ of the bladder who have received bacillus Calmette-Guérin (BCG) and who have undergone radical cystectomy. METHODS: We retrospectively reviewed our single-surgeon database of those patients who underwent cystectomy and previously received BCG. We evaluated the baseline characteristics, pathologic outcomes, and survival data. RESULTS: Of 313 patients who underwent cystectomy between January 1992 and March 2004, 90 (29%) received BCG before bladder removal. The mean time from the first BCG course to the date of cystectomy was 27.9 months. The mean duration of follow-up from cystectomy was 32.1 months. The risk of progression to muscle invasion for those who underwent cystectomy less than or more than 1 year from the time of their first BCG dose was 59% and 36%, respectively (P = 0.05). The disease-specific survival rate was 81% versus 80% for those who underwent early versus delayed cystectomy (P = 0.9). CONCLUSIONS: Patients with high-grade UC are at risk of dying from this cancer, even if they ultimately undergo cystectomy. Patients who receive BCG should be appropriately counseled that they remain at risk for disease progression and death from UC. It is difficult to ascertain the proper time to proceed with cystectomy if an initial bladder conservation approach is used.

Is adjuvant chemotherapy for bladder cancer safer in patients with an ileal conduit than a neobladder?

OBJECTIVE: To assess the safety of adjuvant chemotherapy in patients with neobladder reconstruction in comparison to ileal conduit, as radical cystectomy and urinary diversion is an effective curative surgical treatment for muscle-invasive and high-risk superficial bladder cancer, and adjuvant chemotherapy is usually considered for patients with clinical stage > T2 and nodal metastasis. PATIENTS AND METHODS: We analysed retrospectively patients who had had a radical cystectomy and urinary diversion between 1992 and 2004. Patients with high-risk disease who had adjuvant chemotherapy were identified and stratified based on the type of urinary diversion (ileal conduit or neobladder). The chemotherapy regimen, complications from the adjuvant chemotherapy and other relevant data were analysed. RESULTS: Overall, 343 patients had radical cystectomy, 40 had adjuvant chemotherapy; 25 had an ileal conduit and 15 had a neobladder. Patient characteristics including age, stage and follow-up were similar. In all, 55% of patients had grade 1 toxicity, 23% grade 2, 18% grade 3, and 13% grade 4. No patients had serious organ toxicity and none died. There were no significant differences in the toxicity among the two groups. CONCLUSIONS: Adjuvant chemotherapy appears to be safe in patients with a neobladder and equally safe in patients with an ileal conduit. Hence neobladder reconstruction should not be denied to patients with bladder cancer who are at high risk of recurrence and who might require adjuvant chemotherapy.

Transurethral bladder tumor resection: intraoperative and postoperative complications in a residency setting.

PURPOSE: We established a database on the incidence of intraoperative and postoperative complications associated with transurethral bladder tumor resection (TURBT) in an academic teaching setting, and we prospectively recorded all TURBTs performed by residents and fellows in our urology department. MATERIALS AND METHODS: : We prospectively evaluated all TURBTs performed between November 2003 and October 2004. All cases were performed at least in part by residents and fellows under direct attending supervision at a single academic medical center with 3 different teaching hospitals. Intraoperative complications were recorded by the resident and attending surgeon at the completion of the operative procedure. At patient discharge from the hospital the data sheet was reviewed, and length of stay, postoperative transfusions and any other complications were recorded. RESULTS: A total of 173 consecutive TURBTs were performed by residents and fellows at 3 different teaching hospitals. There were 10 (5.8%) complications, including 4 (2.3%) cases of hematuria that required blood transfusion and 6 (3.5%) cases of bladder perforation. Of these 6 perforations 4 were small extraperitoneal perforations requiring only prolonged catheter drainage. These perforations were caused by residents in their first or third year of urology training. Two perforations were intraperitoneal, caused by a senior resident or a fellow, 1 of which required abdominal exploration to control bleeding. CONCLUSIONS: TURBT is a reasonably safe procedure when performed by urologists in training under direct attending supervision. The complication rate was 5.8%, however only 1 case required surgical intervention. Contrary to expected findings, more senior residents were involved in the complications, likely secondary to their disproportionate roles in more difficult resections.

Venous thromboembolism in radical prostatectomy: is heparinoid prophylaxis warranted?

OBJECTIVE: To review the incidence of venous thromboembolism (VTE) after radical retropubic prostatectomy (RRP) and evaluate the need for heparinoid prophylaxis as opposed to mechanical compression devices after RRP. PATIENTS AND METHODS: RRP is classified as a category 1 (high risk) procedure for VTE by the American College of Chest Physicians and several international guidelines recommend subcutaneous heparinoids as the preferred prophylaxis. However, this regimen may be associated with a greater risk of bleeding. We have not used heparinoid prophylaxis but place a mechanical compression device for prophylaxis of VTE, and report our clinical experience over a 12-year period. Between 1992 and 2004, all RRPs carried out by one surgeon (M.S.S.) at our centre were retrospectively reviewed after obtaining institutional review board approval. The protocol for prophylaxis of VTE consisted of compression stockings and a sequential compression device from the time of entry into the operating room until complete ambulation (we encourage early ambulation). Patients were evaluated for VTE if they developed any clinical signs or symptoms. Patients were followed at 7 days, 6 weeks and 3 months after RRP in the first year and 6-monthly thereafter. All relevant clinical data and complications were entered in a database. RESULTS: In all there were 1364 RRPs; the mean (sd) age of the patients was 61 (7) years and the mean follow-up 44 (38) months. All patients had a mechanical compression device and ambulated on the first day after surgery. None received heparinoid prophylaxis. Three VTE events were identified (0.21%); two patients had a lower limb VTE and one an upper limb VTE. All were successfully treated with anticoagulation. No patient had a documented pulmonary embolus and none died from VTE. There was one death after RRP, from myocardial infarction. CONCLUSION: The incidence of VTE after RRP is low, possibly related to the use of a mechanical compression device and early aggressive mobilization. Despite the recommendations by some, we feel that routine heparinoid prophylaxis is questionable.

Intraoperative cell salvage during radical prostatectomy is not associated with greater biochemical recurrence rate.

OBJECTIVES: To evaluate the risk of long-term biochemical recurrence for patients who receive cell-salvaged blood. Radical retropubic prostatectomy (RRP) is historically associated with the potential for significant blood loss. Different blood management strategies include blood donation, hemodilution, preoperative erythropoietin, and intraoperative cell salvage (IOCS). Oncologic surgeons have been reluctant to use IOCS because of the potential risk of tumor dissemination. METHODS: We retrospectively analyzed an RRP database and compared those who did and did not receive cell-salvaged blood by baseline parameters, pathologic outcomes, and biochemical recurrence. We also stratified our patients according to the risk of recurrence. RESULTS: A total of 1038 patients underwent RRP between 1992 and 2003. Of these, 265 (25.5%) received cell-salvaged blood and 773 (74.5%) did not. The two groups had similar baseline characteristics. No differences were found between the two groups when compared by risk of seminal vesicle invasion or positive surgical margins. Those who received cell-salvaged blood had a lower risk of extraprostatic extension. The median follow-up for all patients was 40.2 months. The overall risk of biochemical recurrence at 5 years for those who did and did not receive cell-salvaged blood was 15% and 18%, respectively (P = 0.76). No significant differences were found in the risk of biochemical recurrence when patients were stratified according to low, intermediate, and high risk. CONCLUSIONS: IOCS is a safe and effective blood management strategy for patients undergoing RRP. The risk of biochemical recurrence was not increased for those who received cell-salvaged blood. Concerns about spreading tumor cells by way of IOCS would seem unwarranted.

Sexual, psychological and dyadic qualities of the prostate cancer 'couple'.

OBJECTIVES: To examine the levels of sexual, psychological and dyadic functioning of the prostate cancer 'couple' (as studies have shown that spouses/partners play an integral role in the patient's adjustment to prostate cancer treatment), to encourage the creation of innovative psychosexual interventions to be used in the outpatient setting, and to offer insights into a novel area of prostate cancer research. PATIENTS AND METHODS: In all, 103 men newly diagnosed with prostate cancer, and their partners, were assessed in an academic outpatient setting using instruments measuring sexual function, depressed mood, psychological distress and dyadic adjustment. RESULTS: The partners' mean scores on sexual function questions were 55.75, significantly higher than those of the patients (51.7, P = 0.018), showing that partners perceived their sexual performance at a better level. Partners' mean scores on the depression and distress measures were also significantly higher. On those items that monitored the accuracy of the patients' perceptions of their sexual function, partners rated the patients significantly lower in ability to gain erections (patient/partner means 2.67/4.52; P < 0.001) and to perform sexually (patient/partner means 1.38/4.68; P < 0.001) than they rated themselves. CONCLUSIONS: Information from this study could be useful in constructing interventions that allow the physician and the prostate cancer 'couple' to reflect on issues of sexual function and psychological distress that might once have been considered taboo. The results characterize the disparities between patients with prostate cancer and their partners on self-reported questionnaires, and underscore how important it is to hear the voice of the 'couple'.

Evaluation of analgesic requirements and postoperative recovery after radical retropubic prostatectomy using long-acting spinal anesthesia.

OBJECTIVES: To analyze the postoperative pain, analgesic requirements, and convalescence of patients undergoing radical retropubic prostatectomy (RRP) under spinal anesthesia using long-acting morphine sulfate as preemptive analgesia. METHODS: A total of 103 consecutive men underwent RRP by a single surgeon. The time to tolerate oral fluids, time to unassisted ambulation, postoperative pain levels (visual analog pain score of 0 to 10), and analgesic requirements expressed in morphine equivalents were evaluated. Baseline patient characteristics and intraoperative factors (operating room time, blood loss) were also evaluated. RESULTS: The mean time to tolerate oral fluids and unassisted ambulation was 11.3 +/- 7.6 hours and 20 +/- 6 hours, respectively. The mean narcotic requirements were 7.4 +/- 6.1 morphine equivalents before discharge and 28.5 +/- 25.9 morphine equivalents in the first week after discharge. The mean visual analog pain score was 4.5 +/- 2.1 at discharge and fell significantly to 1.5 +/- 1.0 by the time of Foley catheter removal on postoperative day 7 or 8. The analgesic requirements after discharge correlated with the pain score at discharge (P = 0.016). The mean time to resumption of normal preoperative activities was 19.4 +/- 9.4 days. Two patients developed postspinal anesthesia headache. No other complications attributable to the anesthetic occurred. CONCLUSIONS: RRP may be performed through a small modified Pfannenstiel incision under spinal anesthesia containing long-acting morphine with little postoperative pain, low narcotic requirements, and a short convalescence. A prospective, randomized study is needed to compare the early postoperative outcomes of RRP performed using general versus spinal anesthesia.

Neither alpha-blocker therapy nor cystography is required before early catheter removal after radical prostatectomy.

OBJECTIVE: To evaluate the success of early catheter removal from men after radical retropubic prostatectomy (RRP) without using either cystography or giving an alpha-blocker. PATIENTS AND METHODS: We retrospectively analysed 156 consecutive patients who had RRPs between June 2003 and May 2004 to determine the incidence of urinary retention after early catheter removal, with no cystogram or using an alpha-blocker. RESULTS: The mean age of the men was 60 years and 99% were clinical stage T1 or T2; 74% had their catheters removed 8 days after RRP. The incidence of urinary retention was 1.3%, and of haematuria requiring catheter replacement 2.6%. Two patients (1.3%) developed a bladder neck contracture. CONCLUSIONS: In the present study removing an indwelling catheter 1 week after RRP was safe, with a minimal risk of urinary retention or bladder neck contracture. The addition of an alpha-blocker is unlikely to reduce the already low incidence of urinary retention.

Intraoperative cell salvage during radical prostatectomy: a safe technique for Jehovah's 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 Jehovah's 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 management strategy for patients who are not willing to accept predonated autologous or allergenic blood. We present our management for Jehovah's Witness patients with clinically localized prostate cancer, emphasizing our blood management approach. This is the first such report.

Urethral recurrence after cystoprostatectomy: implications for urinary diversion and monitoring.

OBJECTIVES: To review our cystoprostatectomy (CP) database to determine the urethral recurrence rate. Urethral recurrence after CP has been reported to occur in up to 10% of patients. Recent data have suggested a much lower incidence. This has important implications when considering the type of urinary diversion and postoperative monitoring. METHODS: We retrospectively analyzed our single-surgeon, consecutive CP series and determined the urethral recurrence rate and prognostic factors for recurrence. Urethrectomy was performed at CP if the prostatic apical margin was positive for carcinoma. All patients were followed up quarterly for 2 years and then semiannually. Urethral wash cytology was obtained if the patient had an ileal conduit. Cytology and cystoscopy were performed if they had an orthotopic neobladder. RESULTS: A total of 226 men had undergone radical CP. The mean age for all patients was 69 years. Eight (3.5%) had undergone urethrectomy at CP. The mean follow-up was 42 months for the remaining 218 patients, of whom 108 had an orthotopic neobladder and 110 had supravesical diversion. Of the 218 patients, 8 (3.7%) developed urethral recurrence, 7 (6.4%) in the 110 who had undergone supravesical diversion and 1 in the 108 (0.9%) who had an orthotopic neobladder. Seven patients underwent urethrectomy for the recurrence and had no evidence of disease at last follow-up. One patient died of metastatic transitional cell carcinoma at 61 months. CONCLUSIONS: In our series, the risk of urethral recurrence after radical CP was low. The risk was substantially lower for patients who had an orthotopic neobladder. Our results show that urethrectomy at CP is rarely necessary because the proximal urethral margin is usually free of cancer. An orthotopic neobladder can therefore be safely considered in most patients. Delayed urethrectomy can be safely performed in those few patients with isolated urethral recurrence without compromising their survival.

Upper tract tumour after radical cystectomy for transitional cell carcinoma of the bladder: incidence and risk factors.

OBJECTIVE: To review the incidence, pattern and outcome of upper tract transitional cell carcinoma (TCC) after radical cystectomy for carcinoma of the bladder, and identify risk factors for its development. PATIENTS AND METHODS: The records of 235 consecutive patients who had a radical cystectomy and urinary diversion for TCC at the authors' institution by one surgeon between January 1992 and August 2003 were retrospectively reviewed. RESULTS: Five (2%) of 235 patients developed an upper tract urothelial tumour. The mean follow-up for all patients was 42 months, and was 52.2 months for those with an upper tract tumour. Four of the five patients presented with haematuria and one was diagnosed on routine follow-up intravenous urography. The mean time to the diagnosis of an upper tract tumour was 39.6 months. Of the potential risk factors, only the presence of TCC of the prostatic urethra had a statistically significant association with eventual upper tract tumour (P < 0.01). At the last follow-up, four patients died from urothelial cancer and one was disease-free. CONCLUSIONS: The incidence of upper tract tumour after cystectomy for TCC is low; most patients present with symptoms (haematuria) and have advanced disease at diagnosis. Patients with prostatic urethral involvement at cystectomy are at greater risk of developing upper tract tumour.

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.

Radionuclide bone scintigraphy in patients with biochemical recurrence after radical prostatectomy: when is it indicated?

OBJECTIVE: To evaluate the use of radionuclide bone scintigraphy following biochemical recurrence after radical retropubic prostatectomy (RRP) for localized prostate cancer. PATIENTS AND METHODS: Of 1197 patients undergoing RRP we identified those with biochemical recurrence and who had also had a bone scan. Biochemical recurrence was defined as a prostate specific antigen (PSA) level of > or = 0.4 ng/mL. Patients with indeterminate bone scan findings and those in whom the interval between the PSA test and the bone scan was >3 months were excluded. Patient age, PSA level and other relevant pathological details were recorded. Clinical symptoms at the time of bone scan, androgen deprivation after RRP, bone scintigram details and time to recurrence were documented. RESULTS: Of the 1197 patients, 153 (12.8%) had a biochemical recurrence and 35 (23%) of these had a total of 44 bone scans taken over a mean (sd) follow-up of 70.4 (35.6) months; 34 (77%) bone scans were negative (group 1) and 10 (33%) positive (group 2). In group 1 the mean PSA at the bone scan was 5.2 ng/mL; 76% of the patients had a PSA of < 7 ng/mL. In group 2 the mean PSA at the bone scan was 30.7 ng/mL and all patients had a PSA of >7 ng/mL. The only significant difference between the groups was the PSA at the time of the bone scan (P < 0.001). CONCLUSION: Bone scintigraphy is a sensitive diagnostic tool for detecting prostate cancer metastases to bone. A bone scan in patients with a serum PSA of <7 ng/mL on biochemical recurrence after RRP is unlikely to be positive, whereas a PSA of > or = 20 ng/mL is. The presence of skeletal symptoms or a PSA level of >7 ng/mL should prompt the clinician to obtain a bone scintigram.

Grade 4 cystocele repair using four-defect repair and porcine xenograft acellular matrix (Pelvicol): outcome measures using SEAPI.

OBJECTIVES: To determine the efficacy of grade 4 cystocele repair using the four-defect repair (FDR) or modified FDR with porcine xenograft matrix (FDR+Pelvicol). METHODS: During a 4-year period, 45 women underwent grade 4 cystocele repair. Of the 45 patients, 43 (95.5%) were available for follow-up. The mean age was 65 years. Patients presented with the following problems: grade 4 cystocele in 43 (100.0%), stress urinary incontinence in 24 (55.8%), urge urinary incontinence in 26 (60.4%), and obstructive voiding symptoms in 26 (60.4%). Patients were evaluated using the stress, emptying, anatomic, protection, and instability (SEAPI) test. We performed FDR in the first consecutive 24 (55.8%) and FDR+Pelvicol in the remaining 19 (44.2%) patients. Cystocele repair was accompanied by other transvaginal repair in 38 (88.3%) of the 43 patients. RESULTS: The mean follow-up time was 15 months. A comparison of the preoperative and postoperative SEAPI scores of 0, representing the absence of complaints, revealed a statistically significant improvement in all the SEAPI domains using McNemar's test. Cystocele recurred in 3 patients (6.9%), all in the Pelvicol subgroup. Two patients (4.7%) had postoperative urinary retention. De novo urge incontinence occurred in 2 patients (11.7%). No infection, erosion, fistula, or vaginal stenosis have been reported. CONCLUSIONS: Grade 4 cystocele repair using FDR or FDR+Pelvicol are two effective methods of cystocele repair. Although cystocele failures occurred exclusively in the Pelvicol+FDR subgroup, their small number and asymptomatic presentation did not result in statistical or clinical significance at this point. Both techniques are simple, efficacious, and well tolerated by patients. Follow-up is ongoing to evaluate the durability of the techniques.

Limitations of biopsy Gleason grade: implications for counseling patients with biopsy Gleason score 6 prostate cancer.

PURPOSE: We examined the implications of underestimating Gleason score by prostate biopsy in patients with biopsy Gleason 6 prostate cancer with respect to adverse pathological findings and biochemical recurrence after radical prostatectomy. MATERIALS AND METHODS: We retrospectively reviewed clinical and pathological data on a cohort of 531 patients with Gleason score 6 on prostate biopsy who underwent radical retropubic prostatectomy between June 1992 and January 2002. Patients were excluded if they received neoadjuvant androgen deprivation. Concordance between biopsy and radical prostatectomy Gleason score was examined. A comparison was made with respect to final radical prostatectomy specimen pathology and the risk of biochemical recurrence between cases that remained Gleason 6 and those with a final grade of 7 or greater. RESULTS: A total of 451 patients were included in the analysis. Mean followup was 55.1 months (range 12 to 123.4). Of the patients 184 (41%) had a Gleason score of 7 or greater after a review of the entire prostate, while 37 (8%) had a score of less than 6 and 230 remained with Gleason 6. Patients who were under graded were more likely to have extraprostatic extension (22% vs 4%, p <0.01), seminal vesicle invasion (9% vs 2%, p <0.01) and biochemical recurrence (10% vs 3%, p <0.01) compared to those who remained with Gleason score 6. CONCLUSIONS: Gleason grade on needle biopsy is an inexact predictor of the final grade following radical prostatectomy. Patients with biopsy Gleason score 6 who are under graded are at significantly higher risk for adverse pathological features and biochemical recurrence than patients who remain with Gleason score 6 or less on final pathology findings.

Radical retropubic prostatectomy in Hispanic patients.

BACKGROUND: Hispanics are the largest minority group in the U.S. Most studies assessing race as a predictor of biochemical disease recurrence after radical retropubic prostatectomy (RRP) have focused on African-American patients. To the authors' knowledge, little has been published to date regarding radical prostatectomy in Hispanic patients. Hispanics represent 29% of the patients in the current study. The authors analyzed the presentation and outcome of Hispanic males managed with radical prostatectomy. METHODS: In the current study, 1163 RRPs were performed. Patients were categorized by ethnicity as Hispanics, white non-Hispanics, African-Americans, and other ethnicities. African-American and other minority group patients were excluded from the analysis because of the small number in the current series. A comparative analysis of Hispanics and white non-Hispanics was performed. RESULTS: RRP was performed in 1163 patients. Two hundred seven Hispanic and 518 white non-Hispanic patients met the study criteria. The mean follow-up was 46.9 months. Twenty-three percent of the Hispanic patients received neoadjuvant therapy. RRP Gleason scores of 2-6, 7, and 8-10 were found in 45% of patients, 38% of patients, and in 17% of patients, respectively. Lymph node metastases were present in 3%, seminal vesicle invasion in 13%, and extraprostatic extension in 23% of Hispanic patients. Adjuvant hormonal therapy was administered to 6% of the Hispanic patients. The biochemical disease recurrence rate was 12%. The mean time to biochemical disease recurrence was 29.7 months. A comparison between the Hispanic and the white non-Hispanic groups showed no significant differences in the analyzed variables. CONCLUSIONS: Hispanic patients managed with radical prostatectomy for prostate carcinoma were found to have similar presentation, pathologic findings, and outcome as the white non-Hispanic patients.

Visual estimate of percent of carcinoma predicts recurrence after radical prostatectomy.

PURPOSE: Tumor volume is an important prognosticator for predicting prostate cancer recurrence following radical prostatectomy (RP). We assessed the ability of the visual estimate of the percent of carcinoma (VEPC) to predict recurrence. METHODS AND MATERIALS: As performed by 1 surgeon (MSS), 1,114 men underwent radical prostatectomy between 1992 and February 2002. Patients who had less than 12 months of followup, who underwent salvage RP or in whom VEPC was not assessed in the pathology specimen were excluded. VEPC and other clinical variables were analyzed. We performed univariate analysis using the Kaplan-Meier log rank test. Multivariate analysis using Cox proportional hazards regression was performed. RESULTS: A total of 692 patients with a mean age of 61 +/- 7 years met the criteria for this analysis. Mean followup was 52 +/- 30 months. Of the patients 17% had biochemical recurrence. Mean VEPC was 25% and 13% in those with and without recurrence, respectively. On univariate analysis all variables were significant predictors of recurrence. However, multivariate analysis showed that the only significant predictors of recurrence were patient age, initial prostate specific antigen 10 ng/ml or greater, RP Gleason 8 to 10, extraprostatic extension, seminal vesicle involvement and VEPC. Based on disease-free survival curves patients were stratified into 3 broad groups, namely low, intermediate and high volume. The HR for biochemical recurrence was 2.1 for the intermediate VEPC group (9.1% to 20%) and 2.7 for the high VEPC group (greater than 20%). In the reference group it was less than 9% (low volume). CONCLUSIONS: VEPC is a simple and inexpensive method that is an independent predictor of recurrence after RP.

Estimation of acute blood loss in the anticoagulated rabbit model using 3 modalities of radio frequency energy ablation.

PURPOSE: An anticoagulated animal model was tested to evaluate estimated acute blood loss (EABL) following tissue ablation with 3 modalities of radio frequency (RF) thermal energy. MATERIALS AND METHODS: Four groups of randomly divided rabbits were established. Group 1 (3 control and 3 anticoagulated rabbits) underwent sham treatment (noRF), group 2 (2 control and 7 anticoagulated) received single probe dry RF (dRF) (475 KHz and 5 W for 2 minutes), group 3 (2 control and 7 anticoagulated) received single probe wet RF (wRF) (475 KHz with 14.6% hypertonic saline at 50 W for 40 seconds) and group 4 (3 control and 7 anticoagulated) was treated with vapor RF (vRF) (0.9% normal saline for 10 seconds). Oral warfarin sodium was the anticoagulant. Following a midline incision ablation was performed on the left kidney and liver. Pre-weighed gauze pads were used to collect EABL for a 5-minute observation period after needle probe removal. Temperature data were recorded from the right kidney using fiberoptic thermocouples. Lesions were grossly inspected and measured. RESULTS: Anticoagulation resulted in super anticoagulated animals with an average prothrombin time of almost 140 seconds. EABL was the least from the ablated left kidney for vRF (50 mg), followed by wRF (260 mg), dRF (390 mg) and noRF (1,800 mg). EABL was the least from the liver for vRF (10 mg), followed by wRF (470 mg), dRF (1,260 mg) and noRF (2,680 mg). A greater percent of total ablative time at 10 mm was spent at greater than 50C during wRF and vRF. Measured ablative lesions size was largest following vRF ablation. CONCLUSIONS: The thermal coagulative effects of RF ablation resulted in less bleeding compared with controls in this orally anticoagulated animal model. The novel RF modality vRF is introduced.