Association between deep neural network-derived electrocardiographic-age and incident stroke.

Background: Stroke continues to be a leading cause of death and disability worldwide despite improvements in prevention and treatment. Traditional stroke risk calculators are biased and imprecise. Novel stroke predictors need to be identified. Recently, deep neural networks (DNNs) have been used to determine age from ECGs, otherwise known as the electrocardiographic-age (ECG-age), which predicts clinical outcomes. However, the relationship between ECG-age and stroke has not been well studied. We hypothesized that ECG-age is associated with incident stroke. Methods: In this study, UK Biobank participants with available ECGs (from 2014 or later). ECG-age was estimated using a deep neural network (DNN) applied to raw ECG waveforms. We calculated the Δage (ECG-age minus chronological age) and classified individuals as having normal, accelerated, or decelerated aging if Δage was within, higher, or lower than the mean absolute error of the model, respectively. Multivariable Cox proportional hazards regression models adjusted for age, sex, and clinical factors were used to assess the association between Δage and incident stroke. Results: The study population included 67,757 UK Biobank participants (mean age 65 ± 8 years; 48.3% male). Every 10-year increase in Δage was associated with a 22% increase in incident stroke [HR, 1.22 (95% CI, 1.00-1.49)] in the multivariable-adjusted model. Accelerated aging was associated with a 42% increase in incident stroke [HR, 1.42 (95% CI, 1.12-1.80)] compared to normal aging. In addition, Δage was associated with prevalent stroke [OR, 1.28 (95% CI, 1.11-1.49)]. Conclusions: DNN-estimated ECG-age was associated with incident and prevalent stroke in the UK Biobank. Further investigation is required to determine if ECG-age can be used as a reliable biomarker of stroke risk.

Comparing the Efficacy of Targeted and Blast Portal Messaging in Message Opening Rate and Anticoagulation Initiation in Patients With Atrial Fibrillation in the Preventing Preventable Strokes Study II: Prospective Cohort Study.

BACKGROUND: The gap in anticoagulation use among patients with atrial fibrillation (AF) is a major public health threat. Inadequate patient education contributes to this gap. Patient portal-based messaging linked to educational materials may help bridge this gap, but the most effective messaging approach is unknown. OBJECTIVE: This study aims to compare the responsiveness of patients with AF to an AF or anticoagulation educational message between 2 portal messaging approaches: sending messages targeted at patients with upcoming outpatient appointments 1 week before their scheduled appointment (targeted) versus sending messages to all eligible patients in 1 blast, regardless of appointment scheduling status (blast), at 2 different health systems: the University of Massachusetts Chan Medical School (UMass) and the University of Florida College of Medicine-Jacksonville (UFL). METHODS: Using the 2 approaches, we sent patient portal messages to patients with AF and grouped patients by high-risk patients on anticoagulation (group 1), high-risk patients off anticoagulation (group 2), and low-risk patients who may become eligible for anticoagulation in the future (group 3). Risk was classified based on the congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, stroke, vascular disease, age between 65 and 74 years, and sex category (CHA2DS2-VASc) score. The messages contained a link to the Upbeat website of the Heart Rhythm Society, which displays print and video materials about AF and anticoagulation. We then tracked message opening, review of the website, anticoagulation use, and administered patient surveys across messaging approaches and sites using Epic Systems (Epic Systems Corporation) electronic health record data and Google website traffic analytics. We then conducted chi-square tests to compare potential differences in the proportion of patients opening messages and other evaluation metrics, adjusting for potential confounders. All statistical analyses were performed in SAS (version 9.4; SAS Institute). RESULTS: We sent 1686 targeted messages and 1450 blast messages. Message opening was significantly higher with the targeted approach for patients on anticoagulation (723/1156, 62.5% vs 382/668, 57.2%; P=.005) and trended the same in patients off anticoagulation; subsequent website reviews did not differ by messaging approach. More patients off anticoagulation at baseline started anticoagulation with the targeted approach than the blast approach (adjusted percentage 9.3% vs 2.1%; P<.001). CONCLUSIONS: Patients were more responsive in terms of message opening and subsequent anticoagulation initiation with the targeted approach.

Magnetic resonance microscopy may enable distinction between normal histomorphological features and prostate cancer in the resected prostate gland.

OBJECTIVES: To determine imaging protocol parameters for characterization of prostate tissue at histological length scales. MATERIAL AND METHODS: Rapid acquisition with relaxation enhancement, spin echo and gradient echo fast low angle shot data were acquired using ex vivo 3-Tesla or 7-Tesla magnetic field strengths from fresh prostatectomy specimens (n = 15) obtained from either organ donor or patients with prostate cancer (PCa). To achieve the closest correspondence between histopathological components and magnetic resonance imaging (MRI) results, in terms of resolution and sectioning planes, multiple high-resolution imaging protocols (ranging from a few minutes to overnight) were tested. Ductograms were generated as part of image post-processing. Specimens were subsequently submitted for histopathological evaluation. RESULTS: A total of seven imaging protocols were tested. Ex vivo 7-Tesla MRI identified normal components of prostate glands, including ducts, blood vessels, concretions and stroma at a spatial resolution of 60 × 60 × 60 µm3 to 107 × 107 × 500 µm3 . Malignant glands and nests of tumour cells identified at 60 × 60 × 90 µm3 were highly similar to low-magnification (×2) histopathology. Ductograms enhanced the differentiation between benign and malignant glands. The results of the present study were encouraging, and further work is warranted with a larger sample size. CONCLUSION: We showed that critical histopathological features of the prostate gland can be identified with high-resolution ex vivo MRI examination and this offers promise that MRI microscopy of PCa will ultimately be possible in vivo.

A Multidimensional Analysis of Prostate Surgery Costs in the United States: Robotic-Assisted versus Retropubic Radical Prostatectomy.

BACKGROUND: The economic value of robotic-assisted laparoscopic prostatectomy (RALP) in the United States is still not well understood because of limited view analyses. OBJECTIVES: The objective of this study was to examine the costs and benefits of RALP versus retropubic radical prostatectomy from an expanded view, including hospital, payer, and societal perspectives. METHODS: We performed a model-based cost comparison using clinical outcomes obtained from a systematic review of the published literature. Equipment costs were obtained from the manufacturer of the robotic system; other economic model parameters were obtained from government agencies, online resources, commercially available databases, an advisory expert panel, and the literature. Clinical point estimates and care pathways based on National Comprehensive Cancer Network guidelines were used to model costs out to 3 years. Hospital costs and costs incurred for the patients' postdischarge complications, adjuvant and salvage radiation treatment, incontinence and potency treatment, and lost wages during recovery were considered. Robotic system costs were modeled in two ways: as hospital overhead (hospital overhead calculation: RALP-H) and as a function of robotic case volume (robotic amortization calculation: RALP-R). All costs were adjusted to year 2014 US dollars. RESULTS: Because of more favorable clinical outcomes over 3 years, RALP provided hospital ($1094 savings with RALP-H, $341 deficit with RALP-R), payer ($1451), and societal ($1202) economic benefits relative to retropubic radical prostatectomy. CONCLUSIONS: Monte-Carlo probabilistic sensitivity analysis demonstrated a 38% to 99% probability that RALP provides cost savings (depending on the perspective). Higher surgical consumable costs are offset by a decreased hospital stay, lower complication rate, and faster return to work.

Newer concepts in neural anatomy and neurovascular preservation in robotic radical prostatectomy.

With more than 60% of radical prostatectomies being performed robotically, robotic-assisted laparoscopic prostatectomy (RALP) has largely replaced the open and laparoscopic approaches and has become the standard of care surgical treatment option for localized prostate cancer in the United States. Accomplishing negative surgical margins while preserving functional outcomes of sexual function and continence play a significant role in determining the success of surgical intervention, particularly since the advent of nerve-sparing (NS) robotic prostatectomy. Recent evidence suggests that NS surgery improves continence in addition to sexual function. In this review, we describe the neuroanatomical concepts and recent developments in the NS technique of RALP with a view to improving the "trifecta" outcomes.

Functional outcomes following robotic prostatectomy using athermal, traction free risk-stratified grades of nerve sparing.

OBJECTIVE: To report our unique approach for individualizing robotic prostate cancer surgery by risk stratification and sub classification of the periprostatic space into 4 distinct compartments, and thus performing 4 precise different grades of nerve sparing based on neurosurgical principles and to present updated potency and continence outcomes data of patients undergoing robotic-assisted laparoscopic prostatectomy (RALP) using our risk-stratified approach based on layers of periprostatic fascial dissection. PATIENTS AND METHODS: (1) Between January 2005 and December 2010, 2,536 men underwent RALP by a single surgeon at our institution. (2) Included patients were those with ≥ 1-year follow-up and were preoperatively continent and potent, defined as having a SHIM questionnaire score of >21; thus, the final number of patient in the study cohort was 1,335. (3) Postoperative potency was defined as the ability to have successful intercourse (score of ≥ 4 on question 2 of the SHIM); continence was defined as the use of no pads per 24 h. RESULTS: (1) The potency and continence for NS grades 1, 2, 3, and 4 were found to be 90.6, 76.2, 60.5, and 57.1 % (P < 0.001) and 98, 93.2, 90.1, and 88.9 % (P < 0.001), respectively. (2) The overall PSM rates for patients with NS grades 1, 2, 3, and 4 were 10.5, 7, 5.8, and 4.8 %, respectively (P = 0.064). CONCLUSIONS: The study found a correlation between risk-stratified grades of NS technique and continence and potency. Patients with lesser grades of NS had higher rates of potency and continence.

Effect of a risk-stratified grade of nerve-sparing technique on early return of continence after robot-assisted laparoscopic radical prostatectomy.

BACKGROUND: The impact of nerve sparing (NS) on urinary continence recovery after robot-assisted laparoscopic radical prostatectomy (RALP) has yet to be defined. OBJECTIVE: To evaluate the effect of a risk-stratified grade of NS technique on early return of urinary continence. DESIGN, SETTING, AND PARTICIPANTS: Data were collected from 1546 patients who underwent RALP by a single surgeon at a tertiary care center from December 2008 to October 2011. Patients were categorized preoperatively by a risk-stratified approach into risk grades 1-4, with risk grade 1 patients more likely to receive NS grade 1 or complete hammock preservation. This categorization was also conducted for risk grades 2-4, with grade 4 patients receiving a non-NS procedure. INTERVENTION: Risk-stratified grading of NS RALP. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Univariate and multivariate analysis identified predictors of early return of urinary continence, defined as no pad use at ≤ 12 wk postoperatively. RESULTS AND LIMITATIONS: Early return of continence was achieved by 791 of 1417 men (55.8%); of those, 199 of 277 (71.8%) were in NS grade 1, 440 of 805 (54.7%) were in NS grade 2, 132 of 289 (45.7%) were in NS grade 3, and 20 of 46 (43.5%) were in NS grade 4 (p<0.001). On multivariate analysis, better NS grade was a significant independent predictor of early return of urinary continence when NS grade 1 was the reference variable compared with NS grade 2 (p<0.001; odds ratio [OR]: 0.46), NS grade 3 (p<0.001; OR: 0.35), and NS grade 4 (p=0.001; OR: 0.29). Lower preoperative International Prostate Symptom Score (p=0.001; OR: 0.97) and higher preoperative Sexual Health Inventory for Men score (p=0.002; OR: 1.03) were indicative of early return of urinary continence. Positive surgical margin rates were 7.2% (20 of 277) of grade 1 cases, 7.6% (61 of 805) of grade 2 cases, 7.6% (22 of 289) of grade 3 cases, and 17.4% (8 of 46) of grade 4 cases (p=0.111). Extraprostatic extension occurred in 6.1% (17 of 277) of NS grade 1 cases, 17.5% (141 of 805) of NS grade 2 cases, 42.5% (123 of 289) of NS grade 3 cases, and 63% (29 of 46) of NS grade 4 cases (p<0.001). Some limitations of the study are that the study was not randomized, grading of NS was subjective, and possible selection bias existed. CONCLUSIONS: Our study reports a correlation between risk-stratified grade of NS technique and early return of urinary continence as patients with a lower grade (higher degree) of NS achieved an early return of urinary continence without compromising oncologic safety.

Improving time to continence after robot-assisted laparoscopic prostatectomy: augmentation of the total anatomic reconstruction technique by adding dynamic detrusor cuff trigonoplasty and suprapubic tube placement.

After robot-assisted laparoscopic prostatectomy, total anatomic reconstruction (TR) with the additions of a circumapical urethral dissection, a dynamic detrusor cuff trigonoplasty, and placement of a suprapubic catheter was performed in 49 patients from June to July 2012. Continence at 6 weeks after catheter removal was assessed for an initial group of 23 patients, and also at 2 weeks in an additional 26 patients who most recently had undergone surgery. Follow-up appointments and telephone interviews were used to assess pad use and continence. Of the initial 23 patients receiving the modified TR, 60.9% had 0 pad use at 6 weeks. By 2 weeks, 65.4% of the most recent 26 patients operated on achieved continence with 0-1 pad use. Preservation and reconstruction of the pelvic floor and supporting bladder structures leads to an earlier return of continence. These key steps need to be validated and confirmed in larger and randomized trials.

Genetic and functional analyses implicate the NUDT11, HNF1B, and SLC22A3 genes in prostate cancer pathogenesis.

One of the central goals of human genetics is to discover the genes and pathways driving human traits. To date, most of the common risk alleles discovered through genome-wide association studies (GWAS) map to nonprotein-coding regions. Because of our relatively poorer understanding of this part of the genome, the functional consequences of trait-associated variants pose a considerable challenge. To identify the genes through which risk loci act, we hypothesized that the risk variants are regulatory elements. For each of 12 known risk polymorphisms, we evaluated the correlation between risk allele status and transcript abundance for all annotated protein-coding transcripts within a 1-Mb interval. A total of 103 transcripts were evaluated in 662 prostate tissue samples [normal (n = 407) and tumor (n = 255)] from 483 individuals [European Americans (n = 233), Japanese (n = 127), and African Americans (n = 123)]. In a pooled analysis, 4 of the 12 risk variants were strongly associated with five transcripts (NUDT11, MSMB, NCOA4, SLC22A3, and HNF1B) in histologically normal tissue (P ≤ 0.001). Although associations were also observed in tumor tissue, they tended to be more attenuated. Previously, we showed that MSMB and NCOA4 participate in prostate cancer pathogenesis. Suppressing the expression of NUDT11, SLC22A3, and HNF1B influences cellular phenotypes associated with tumor-related properties in prostate cancer cells. Taken together, the data suggest that these transcripts contribute to prostate cancer pathogenesis.

Next-generation prostate cancer biobanking: toward a processing protocol amenable for the International Cancer Genome Consortium.

Next-generation DNA and RNA sequencing requires intact nucleic acids from high-quality human tissue samples to better elucidate the molecular basis of cancer. We have developed a prostate biobanking protocol to acquire suitable samples for sequencing without compromising the accuracy of clinical diagnosis. To assess the clinical implications of implementing this protocol, we evaluated 105 consecutive radical prostatectomy specimens from November 2008 to February 2009. Alternating levels of prostate samples were submitted to Surgical Pathology as formalin-fixed, paraffin-embedded blocks and to the institutional biobank as frozen blocks. Differences in reported pathologic characteristics between clinical and procured specimens were compared. Clinical staging and grading were not affected by the biobank protocol. Tumor foci on frozen hematoxylin and eosin slides were identified and high-density tumor foci were scored and processed for DNA and RNA extractions for sequencing. Both DNA and RNA were extracted from 22 cases of 44 with high-density tumor foci. Eighty-two percent (18/22) of the samples passed rigorous quality control steps for DNA and RNA sequencing. To date, DNA extracted from 7 cases has undergone whole-genome sequencing, and RNA from 18 cases has been RNA sequenced. This protocol provides prostate tissue for high-throughput biomedical research and confirms the feasibility of actively integrating prostate cancer into The Cancer Genome Atlas Program, a member of the International Cancer Genome Consortium.

Nerve sparing can preserve orgasmic function in most men after robotic-assisted laparoscopic radical prostatectomy.

OBJECTIVE: • To investigate orgasmic outcomes in patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) and the effects of age and nerve sparing on these outcomes. PATIENTS AND METHODS: • Between January 2005 and June 2007, 708 patients underwent RALP at our institution. • We analysed postoperative potency and orgasmic outcomes in the 408 men, of the 708, who were potent, able to achieve orgasm preoperatively and available for follow-up. RESULTS: • Of men aged ≤60 years, 88.4% (198/224) were able to achieve orgasm postoperatively in comparison to 82.6% (152/184) of older men (P < 0.001). • Of patients who received bilateral nerve sparing (BNS) during surgery, 273/301 (90.7%) were able to achieve orgasm postoperatively compared with 46/56 (82.1%) patients who received unilateral nerve sparing and 31/51 (60.8%) men who received non-nerve-sparing surgery (P < 0.001). • In men ≤60 years who also underwent BNS, decreased sensation of orgasm was present in 3.2% of men, and postoperative orgasmic rates were significantly better than men ≤60 years who underwent unilateral or no nerve sparing (92.9% vs 83.3% vs 65.4%, respectively; P < 0.001). • Potency rates were also significantly higher in men ≤60 years and in those who underwent BNS. CONCLUSIONS: • Age and nerve sparing influence recovery of orgasm and erectile function after RALP. • Men ≤60 years old and those who undergo BNS are most likely to maintain normal sexual function.

Pathological outcomes and strategies to achieve optimal cancer control during robotic radical prostatectomy in Asian-Indian men.

INTRODUCTION AND OBJECTIVES: There is a paucity of information in the literature about the characteristics of prostate cancer in the Asian-Indian population. We wanted to evaluate the oncological outcomes of Asian-Indians and Caucasians. We also derived a nomogram for prediction of extraprostatic extension (EPE) and presented biochemical recurrence (BCR) rates in the Asian-Indian population. MATERIALS AND METHODS: A total of 2367 D'Amico low-risk patients underwent robotic-assisted radical prostatectomy (RARP) for clinically localized prostate cancer between January 2005 and July 2010 by a single surgeon. Of these 56 (2.4%) patients were Asian-Indians and 2025 were Caucasians (85.6%). Univariate and multivariate models were created for predicting EPE. A multivariate logistic regression model was used to develop a predictive nomogram. BCR was defined as a prostate-specific antigen ≥0.2 at any postoperative time point. Kaplan-Meier survival analysis was used to investigate BCR rates. RESULTS: A significantly greater percentage of Asian-Indians compared to Caucasians had EPE (32.3 vs. 16.5; P = 0.01). In multivariate analysis adjusted for significant variables from univariate analyses, Asian-Indian race (P = 0.028), age (P = 0.050), maximum percentage cancer on biopsy (P < 0.001), and pathology prostate weight (P = 0.047) were independent predictors of EPE. Kaplan-Meier analysis demonstrated BCR free rates of 94.6% and 95.4%, for Asian-Indians and Caucasians, respectively, at a median follow-up of 16 months (range 2-70 months). There was no statistically significant difference in BCR rates across the two cohorts (log-rank P-value = 0.405). CONCLUSIONS: This study highlights that while Asian-Indians have more advanced cancer variables, their risk of BCR after surgery is similar to Caucasian patients. Further work is required to better understand the social, genetic and environmental factors that affect the biology of prostate cancer in men of Asian-Indian descent.

Anatomical grades of nerve sparing: a risk-stratified approach to neural-hammock sparing during robot-assisted radical prostatectomy (RARP).

OBJECTIVES: • To report the potency and oncological outcomes of patients undergoing robot-assisted radical prostatectomy (RARP) using a risk-stratified approach based on layers of periprostatic fascial dissection. • We also describe the surgical technique of complete hammock preservation or nerve sparing grade 1. PATIENTS AND METHODS: • This is a retrospective study of 2317 patients who had robotic prostatectomy by a single surgeon at a single institution between January 2005 and June 2010. • Included patients were those with ≥ 1 year of follow-up and who were potent preoperatively, defined as having a sexual health inventory for men (SHIM) questionnaire score of >21; thus, the final number of patients in the study cohort was 1263. • Patients were categorized pre-operatively by a risk-stratified approach into risk grades 1-4, where risk grade 1 patients received nerve-sparing grade 1 or complete hammock preservation and so on for risk grades 2-4, as long as intraoperative findings permitted the planned nerve sparing. • We considered return to sexual function post-operatively by two criteria: i) ability to have successful intercourse (score of ≥ 4 on question 2 of the SHIM) and ii) SHIM >21 or return to baseline sexual function. RESULTS: • There was a significant difference across different NS grades in terms of the percentages of patients who had intercourse and returned to baseline sexual function (P < 0.001), with those that underwent NS grade 1 having the highest rates (90.9% and 81.7%) as compared to NS grades 2 (81.4% and 74.3%), 3 (73.5% and 66.1%), and 4 (62% and 54.5%). • The overall positive surgical margin (PSM) rates for patients with NS grades 1, 2, 3, and 4 were 9.9%, 8.1%, 7.2%, and 8.7%, respectively (P = 0.636). • The extraprostatic extension rates were 11.6%, 14.3%, 29.3%, and 36.2%, respectively (P < 0.001). • Similarly, in patients younger than 60, intercourse and return to baseline sexual function rates were 94.9% and 84.3% for NS grade 1 as compared to 85.5% and 77.2% for NS grades 2, 76.9% and 69% for NS grades 3, and 64.8% and 57.7% for NS Grade 4 (P < 0.001). CONCLUSIONS: • The risk-stratified approach and anatomical technique of neural-hammock sparing described in the present manuscript was effective in improving potency outcomes of patients without compromising cancer control. • Patients with greater degrees of NS had higher rates of intercourse and return to baseline sexual function without an increase in PSM rates.

Models to predict positive prostate biopsies using the Tyrol screening study.

OBJECTIVE: To describe two predictive models that predict for prostate cancer on biopsy derived from a large screening population. There are no published predictive models that predict prostate cancer in a screened population. METHODS: The patients from the Tyrol screening study of known age, total prostate-specific antigen (PSA) level, digital rectal examination (DRE) findings, prostate volume, and percentage of free PSA, and who underwent an initial prostate biopsy from January 1992 to June 2004 were included (n = 2271). Multivariate logistic regression models were used to develop the biopsy positivity predictive models: nomogram 1, age, DRE, and total PSA; and nomogram 2, age, DRE, total PSA, and percentage of free PSA. The predictive accuracy of the models was assessed in terms of discrimination and calibration. External validation of the nomograms was performed using a urologically referred population of patients who underwent prostate biopsy (n = 599). RESULTS: Both nomograms were well-calibrated internally and externally and discriminated well between patients with positive and negative biopsy findings for both the European and U.S. cohorts (model 2 better than model 1). CONCLUSION: Our nomogram with age, total PSA, and DRE had good predictive ability to differentiate between screened patients with cancer on the initial prostate biopsy and those without. Adding the percentage of free PSA improves this predictive power further. These models might aid in clinical decision making regarding the need for biopsy in both European and U.S. populations.

Biobanking after robotic-assisted radical prostatectomy: a quality assessment of providing prostate tissue for RNA studies.

BACKGROUND: RNA quality is believed to decrease with ischaemia time, and therefore open radical prostatectomy has been advantageous in allowing the retrieval of the prostate immediately after its devascularization. In contrast, robotic-assisted laparoscopic radical prostatectomies (RALP) require the completion of several operative steps before the devascularized prostate can be extirpated, casting doubt on the validity of this technique as a source for obtaining prostatic tissue. We seek to establish the integrity of our biobanking process by measuring the RNA quality of specimens derived from robotic-assisted laparoscopic radical prostatectomy. METHODS: We describe our biobanking process and report the RNA quality of prostate specimens using advanced electrophoretic techniques (RNA Integrity Numbers, RIN). Using multivariate regression analysis we consider the impact of various clinicopathological correlates on RNA integrity. RESULTS: Our biobanking process has been used to acquire 1709 prostates, and allows us to retain approximately 40% of the prostate specimen, without compromising the histopathological evaluation of patients. We collected 186 samples from 142 biobanked prostates, and demonstrated a mean RIN of 7.25 (standard deviation 1.64) in 139 non-stromal samples, 73% of which had a RIN ≥ 7. Multivariate regression analysis revealed cell type--stromal/epithelial and benign/malignant--and prostate volume to be significant predictors of RIN, with unstandardized coefficients of 0.867(p = 0.001), 1.738(p < 0.001) and -0.690(p = 0.009) respectively. A mean warm ischaemia time of 120 min (standard deviation 30 min) was recorded, but multivariate regression analysis did not demonstrate a relationship with RIN within the timeframe of the RALP procedure. CONCLUSIONS: We demonstrate the robustness of our protocol--representing the concerted efforts of dedicated urology and pathology departments--in generating RNA of sufficient concentration and quality, without compromising the histopathological evaluation and diagnosis of patients. The ischaemia time associated with our prostatectomy technique using a robotic platform does not negatively impact on biobanking for RNA studies.

Duration of microdissection testicular sperm extraction procedures: relationship to sperm retrieval success.

PURPOSE: We evaluated the operative time of microdissection testicular sperm extraction in successful and failed procedures to identify the chance of sperm retrieval during longer microsurgical procedures. MATERIALS AND METHODS: A total of 793 men with nonobstructive azoospermia underwent a first attempt at microdissection testicular sperm extraction from January 2000 to September 2009. Clinical factors were analyzed, including age, testicular volume, endocrinological data and histology. Operative time was calculated from incision until the procedure was terminated. RESULTS: Testicular sperm were successfully retrieved in 57% of the men. Sperm were found within 2, 2 to 4 and 4 to 7 hours in 89%, 30% and 37% of the men, respectively. There were no differences in preoperative clinical characteristics, age, follicle-stimulating hormone, testicular volume, incidence of a Klinefelter's syndrome diagnosis and distribution of most advanced histopathology in patients in the 3 operative time groups. In men in whom sperm were retrieved the clinical pregnancy and live birth rates were 48%, 45% and 29%, and 37%, 30% and 29% for operative times up to 2, 2 to 4 and 4 to 7 hours, respectively (p >0.05). ROC curve analysis of the different operative times for detecting sperm showed that 125 minutes was the most accurate time (AUC 0.81) with 84% sensitivity and 95% specificity. CONCLUSIONS: The chance of sperm retrieval during microdissection testicular sperm extraction was best during the first 2 hours of the operation. However, sperm were still found in up to 37% of men who required greater than 4 hours of microdissection. Retrospective analysis of our data indicated no cutoff point after which sperm retrieval was uniformly unsuccessful.

Successful repeat microdissection testicular sperm extraction in men with nonobstructive azoospermia.

PURPOSE: We studied factors that can predict successful repeat microdissection testicular sperm extraction in men with nonobstructive azoospermia. MATERIALS AND METHODS: We retrospectively analyzed the records of 126 men with nonobstructive azoospermia who underwent 1 successful microdissection testicular sperm extraction attempt. Clinical factors identifiable at the second procedure, including age, testicular volume, endocrinological data and histology, were analyzed. RESULTS: Overall testicular spermatozoa were successfully retrieved at 103 of 126 repeat attempts (82%). Men with a successful repeat attempt had lower follicle-stimulating hormone (mean±SD 23.1±12.4 vs 29.2±12.8, p=0.04) and larger testicular volume (mean 10±5 vs 7±4, p=0.0001) at the repeat procedure compared to men with a failed repeat attempt. Adjusted associations from a multiple logistic regression model showed that no factors predicted sperm retrieval during repeat microdissection testicular sperm extraction. An ROC curve showed a fair prediction model (AUC=0.71). CONCLUSIONS: The follicle-stimulating hormone level and testicular volume at the repeat attempt appear to have predictive value to determine the success of a second attempt. These observations are interesting since testicular volume and follicle-stimulating hormone in men with nonobstructive azoospermia do not predict sperm retrieval at a primary microdissection testicular sperm extraction attempt.

Prostate volume and its correlation with histopathological outcomes in prostate cancer.

INTRODUCTION: There is a paucity of data investigating the relationship between histopathological variables of oncologic importance and prostate volume, and we aimed to investigate this. PATIENTS AND METHODS: 2,207 consecutive patients who underwent robotic-assisted radical prostatectomy were studied. Preoperative demographic and both pre- and postoperative histopathological parameters were compared among the small (<40 cm(3)), intermediate (40-70 cm(3)), and large (>70 cm(3)) prostate groups. RESULTS: Patients with smaller prostates were younger, had slightly lower BMIs, and lower prostate-specific antigen (PSA) levels than those with larger prostates (p < 0.001). They also had worse histopathological criteria (Gleason, core positivity, and maximum percent cancer) on preoperative biopsy and had worse radical specimen Gleason sums (p < 0.001), percent cancer (p < 0.001), and pathological stage (p = 0.016). 11.5% of the men in the small prostate group suffered a positive surgical margin (PSM) compared to 8.3 and 5.6% in the intermediate and large prostate groups, respectively (p = 0.008). Basilar, posterolateral, and multifocal PSMs were commoner in the small prostate group. CONCLUSIONS: Younger men have smaller prostates and worse preoperative histopathological parameters despite lower PSA values. Men with small prostates undergoing robotic-assisted radical prostatectomy have worse final Gleason sums, tumour volume, extraprostatic extension, and PSM rates than those with larger prostates.