Long-term Natural History of Lower Urinary Tract Symptoms Following Radical Retropubic Prostatectomy: A Prospective 15-Year Longitudinal Study.

OBJECTIVE: To provide insights into the long-term impact of radical retro-pubic prostatectomy (ORRP) on lower urinary tract symptoms (LUTS) which are age and prostate dependent and adversely impact quality of life. METHODS: 1995 men undergoing ORRP enrolled in a prospective longitudinal outcomes study. The American Urological Association Symptom Index was self-administered before ORRP and at predetermined time-points after surgery. A multivariate generalized linear model was used to evaluate the association of time since ORRP with American Urological Association symptom score (AUASS). McNemar's test and paired sample t-tests were used to assess whether the proportion of men with clinically significant LUTS (CSLUTS) defined by an AUASS >7 or mean AUASS differed significantly between the time-dependent assessments, respectively. RESULTS: The 15-year mean adjusted AUASS was similar to baseline (7.00 vs 6.85, P = .66). Throughout the 15 years of follow-up, the proportion of men with CSLUTS was lower than baseline with the exception of the 3 month and 15 year assessments. Among men with baseline clinically insignificant LUTS (CILUTS), the mean adjusted AUASS at 15 years was significantly greater than baseline (6.09 vs 3.19, P < .001). Among men with baseline CSLUTS, ORRP led to a significant decrease in mean adjusted AUASS between baseline and 15 years (13.26 vs 8.67, P < .001). CONCLUSION: ORRP favorably affects the long-term natural history of LUTS. The long-term economic and quality of life benefits of ORRP on LUTS should inform the risks and benefits of RP for treatment of localized prostate cancer.

Long-Term Continence Outcomes in Men Undergoing Radical Prostatectomy: A Prospective 15-Year Longitudinal Study.

PURPOSE: We examined the time dependent rates of urinary continence following open retropubic radical prostatectomy. MATERIALS AND METHODS: A total of 1,995 men treated with radical prostatectomy were enrolled in a prospective longitudinal outcomes study. The UCLA-PCI-UFS (UCLA-Prostate Cancer Index-Urinary Function Index) was administered at baseline, and 3, 6, 12, 24, 96, 120 and 180 months after open retropubic radical prostatectomy. Urinary continence was defined by 1 pad or less in 24 hours. Two multiple regression models were constructed to evaluate the association of time since open retropubic radical prostatectomy with the UCLA-PCI-UFI score and urinary continence. RESULTS: The decrease in urinary continence rates between baseline and 15 years (99.6% vs 87.2%, p <0.001), and 2 and 15 years (95.3% vs 87.2%, p = 0.021) were statistically significant. Urinary continence rates were consistently higher in the younger group at all time points. CONCLUSIONS: A significant decrease in urinary continence rates was observed between baseline and 2 years, and between 2 and 15 years in the entire cohort. Urinary continence rates in age matched men in the general population who were followed longitudinally for 15 years were comparable to those in our study population. This suggests that while open retropubic radical prostatectomy causes primarily sphincteric urinary incontinence, it may be protective for subsequent benign prostatic hyperplasia mediated urinary incontinence.

The Use of Magnetic Resonance Imaging to Predict Oncological Control Among Candidates for Focal Ablation of Prostate Cancer.

OBJECTIVE: To provide insights into the role of multiparametric magnetic resonance imaging (mpMRI) in predicting oncological control following 2 focal ablation (FA) templates for selective cases of prostate cancer. MATERIALS AND METHODS: A total of 59 radical prostatectomies were performed between 2012 and 2016 on cases that fulfilled criteria for FA. The Gleason score (GS), extent of Gleason pattern (GP) 4, maximum linear cross-sectional length (MLCSL), and location of tumor foci were recorded and related to scale on corresponding 3-mm transverse slice prostate maps. Gleason pattern 4 extra-focal disease (GP4EFD) was defined as prostate cancer with any GP 4 not detected by mpMRI and transrectal ultrasound systematic biopsy observed outside a specified ablation zone. The location of these GP4EFD relative to the MRI lesion (MRI-L) (contralateral or ipsilateral) was recorded and used to predict oncological control following a hypothetical margin and ipsilateral hemi-ablation templates. RESULTS: Overall, 15 of 59 (25.4%) of the prostate specimens had at least 1 GP4EFD. Of the total 20 GP4EFD, 7 of 20 (35%) were ipsilateral and 13 of 20 (65%) were contralateral to the MRI-L. Of the GP4EFD, 16 of 20 (80%), 2 of 20 (10%), and 2 of 20 (10%) were GS 3 + 4, GS 4 + 3, and GS 4 + 4, respectively. Of these GP4EFD, 10 of 20 (50%) exhibited an MLCSL <5 mm. Ablating only the MRI-L+10 mm or performing an ipsilateral hemi-ablation would leave residual GP4 in 14 of 59 (23.7%) and 11 of 59 (18.6%) of cases, respectively. CONCLUSION: Because a significant proportion of candidates for FA based on mpMRI and systematic biopsy will have pre-existing GP4EFD outside ablation templates, active surveillance of the untreated prostate is mandatory.

Utility of Single-Cell Genomics in Diagnostic Evaluation of Prostate Cancer.

A distinction between indolent and aggressive disease is a major challenge in diagnostics of prostate cancer. As genetic heterogeneity and complexity may influence clinical outcome, we have initiated studies on single tumor cell genomics. In this study, we demonstrate that sparse DNA sequencing of single-cell nuclei from prostate core biopsies is a rich source of quantitative parameters for evaluating neoplastic growth and aggressiveness. These include the presence of clonal populations, the phylogenetic structure of those populations, the degree of the complexity of copy-number changes in those populations, and measures of the proportion of cells with clonal copy-number signatures. The parameters all showed good correlation to the measure of prostatic malignancy, the Gleason score, derived from individual prostate biopsy tissue cores. Remarkably, a more accurate histopathologic measure of malignancy, the surgical Gleason score, agrees better with these genomic parameters of diagnostic biopsy than it does with the diagnostic Gleason score and related measures of diagnostic histopathology. This is highly relevant because primary treatment decisions are dependent upon the biopsy and not the surgical specimen. Thus, single-cell analysis has the potential to augment traditional core histopathology, improving both the objectivity and accuracy of risk assessment and inform treatment decisions.Significance: Genomic analysis of multiple individual cells harvested from prostate biopsies provides an indepth view of cell populations comprising a prostate neoplasm, yielding novel genomic measures with the potential to improve the accuracy of diagnosis and prognosis in prostate cancer. Cancer Res; 78(2); 348-58. ©2017 AACR.

Multiparametric magnetic resonance imaging identifies significant apical prostate cancers.

OBJECTIVE: To determine if multiparametric (mp) magnetic resonance imaging (MRI) can identify significant apical disease, thereby informing decisions regarding preservation of the membranous urethra. MATERIALS AND METHODS: Men undergoing radical prostatectomy (RP) between January 2012 and June 2016, who underwent a 12-core transrectal ultrasonography-guided systematic biopsy (SB), preoperative 3-Tesla MRI, and sectioning of the prostate specimen with tumour foci mapping, were extracted from a single surgeon's prospective longitudinal outcomes database. Apical SB and mpMRI lesion results were compared with regard to their ability to predict aggressive tumours in the prostatic apex (PA), defined as prostate cancer grade group >1. RESULTS: Of the 100 men who met the eligibility criteria, 43 (43%) exhibited aggressive prostate cancer in the distal 5 mm of the apex. A Likert score >2 in the apical one-third of the prostate was found to be more reliable than any cancer found on apical SB at detecting aggressive cancer in the apex. On multivariate regression analysis, which included Likert score in the apex, age, prostate-specific antigen (PSA) level, prostate size and presence of any cancer on apical biopsy, only Likert score (P = 0.005) and PSA level (P = 0.025) were significant and independent predictors of aggressive cancer in the distal apex. CONCLUSION: The results of the study showed that MRI was superior to SB at identifying aggressive prostate cancer within the distal PA and may be useful for planning the extent of apical preservation during RP.

Two-year Outcomes Following Focal Laser Ablation of Localized Prostate Cancer.

BACKGROUND: There is no consensus regarding how to assess oncological control following focal ablation of prostate cancer. OBJECTIVE: To assess quality of life and in-field recurrence following focal laser ablation (FLA). DESIGN, SETTING, AND PARTICIPANTS: Of 34 men participating in a prospective outcomes study following FLA, 32 underwent prostate-specific antigen (PSA) testing and magnetic resonance imaging (MRI) at 6 mo and 2 yr. All underwent assessment of urinary and sexual function at 1 yr. INTERVENTION: FLA and MRI-targeted biopsy of the ablation zone. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The American Urological Association Symptom Score and the Sexual Health Inventory for Men at baseline and 12 mo were compared using a two-sided Wilcoxon signed-rank test with a significance level of p=0.05. The percentage of positive and negative in-field biopsies was calculated for suspicious and nonsuspicious post-ablation MRI scans. RESULTS AND LIMITATIONS: FLA was associated with no adverse impact on urinary or sexual function. For men with suspicious MRI (MRI+) findings, in-field disease recurrence of intermediate and low risk disease was detected in 75% and 25% of cases, respectively. For men with nonsuspicious MRI (MRI-) findings, in-field disease recurrence of intermediate- and low-risk disease was detected in 22.4% and 50% of cases, respectively. The change in PSA from baseline did not discriminate cases with MRI- findings with and without cancer at 2 yr. CONCLUSIONS: MRI reliably identifies in-field recurrence of only intermediate-risk prostate cancer at 2 yr after FLA. A biopsy of the ablation zone must be performed for MRI+ findings. The decision to perform an ablation-zone biopsy for men with MRI- scans should be influenced by whether detection of low-risk disease would influence management. PATIENT SUMMARY: Our study provides compelling evidence that men should undergo interval magnetic resonance imaging to assess the probability of intermediate-risk disease in the ablation zone following focal laser ablation of localized prostate cancer.

Low levels of serum testosterone in middle-aged men impact pathological features of prostate cancer.

BACKGROUND: Serum testosterone deficiency increases with aging. Age is also a major risk factor for prostate cancer (PrCa) and PCa tumors are more frequently diagnosed among men >65 years old. We evaluated the relationship between preoperative serum testosterone and clinical/ pathological features of PrCa in middle-aged and elderly patients. METHODS: A total of 605 PrCa patients who underwent robotic-assisted radical prostatectomy between September 2010 and January 2013 at the University of Pennsylvania, and who had serum testosterone levels measured using Elecsys Testosterone II Immunoassay were included in this IRB-approved protocol. Androgen deficiency was determined as serum free testosterone (FT) <47 pg/ml and total testosterone (TT) <193 ng/dl. Demographic, clinical and tumor characteristics of men with low vs. normal TT or FT were compared using t-test or chi-square tests. Logistic regression was used to determine associations of clinical and pathological variables with FT or TT levels. RESULTS: Among middle-aged men (45-64 years; n = 367), those with low FT and low TT had, on average, a higher BMI (29.7 vs. 27.4, P < 0.01; and 32.2 vs. 27.6; P < 0.01, respectively) and higher proportion of Gleason 8-10 PrCa (13.3% vs. 4.8%, P = 0.011; and 19.2% vs. 5.1%, P = 0.012) compared to men with normal FT and normal TT values. Patients with low FT had also higher number of positive cores on biopsy (3.9 vs. 3.1 P = 0.019) and greater tumor volume (7.9 ml vs. 6.1 ml, P = 0.045) compared to those with normal FT. Among men ≥65 years (n = 135) there was no difference in prostatectomy specimens of PrCa between patients with low or normal FT or TT. CONCLUSION: Among men aged 45-64 years low serum pretreatment FT and TT predicted more aggressive features of PrCa in prostatectomy specimens. In middle-aged patients low testosterone levels measured pre-operatively may indicate more aggressive disease parameters.

Aetiology and management of earlier vs later biochemical recurrence after retropubic radical prostatectomy.

OBJECTIVES: To examine the characteristics and management of earlier (within 5 years) vs later (after 5 years) biochemical recurrence (BCR) after radical prostatectomy (RP). MATERIALS AND METHODS: Between October 2000 and October 2009, 1597 men underwent open retropubic RP. BCRs were managed using salvage radiation therapy (SRT), androgen deprivation therapy (ADT) or active surveillance (AS). BCR-free survival was assessed using Kaplan-Meier analysis. Factors predicting earlier or later BCR and BCR after SRT were assessed using logistic regression and Cox proportional hazard models, respectively. RESULTS: The probabilities of developing BCR within 5 years and 10 years were 12.3% (95% confidence interval [CI] 10.7-13.9) and 18.4% (95% CI 16.2-20.6), respectively. On multivariate analysis, prostate-specific antigen doubling time, positive surgical margins and pathological Gleason score significantly differentiated earlier from later BCR. Overall, 74.5, 12.7 and 12.7% of men developing BCR underwent SRT, ADT or AS, respectively. A significantly greater proportion of men in the earlier BCR group underwent SRT (80.8 vs 59%) and ADT (14.6 vs 8.2%), and a significantly greater proportion of men in the later BCR group underwent AS (32.8 vs 4.6%; P<0.001). The response to SRT was independent of time to BCR. On multivariate analysis, clinical stage and pathological stage significantly predicted failure of SRT. CONCLUSIONS: Approximately one third of BCRs occurred between 5 and 10 years after RP. The aetiology and management of BCR was dependent on time to BCR, whereas response to SRT was independent of time to recurrence. Long-term follow-up is mandatory beyond 5 years for all men after RP.

The Role of Ipsilateral and Contralateral Transrectal Ultrasound-guided Systematic Prostate Biopsy in Men With Unilateral Magnetic Resonance Imaging Lesion Undergoing Magnetic Resonance Imaging-ultrasound Fusion-targeted Prostate Biopsy.

OBJECTIVE: To determine how ipsilateral (ipsi) and contralateral (contra) systematic biopsies (SB) impact detection of clinically significant vs insignificant prostate cancer (PCa) in men with unilateral magnetic resonance imaging (MRI) lesion undergoing MRI-ultrasound fusion-targeted biopsy (MRF-TB). MATERIALS AND METHODS: A total of 211 cases with 1 unilateral MRI lesion were subjected to SB and MRF-TB. Biopsy tissue cores from the MRF-TB, ipsi-SB, and contra-SB were analyzed separately. RESULTS: A direct relationship was observed between MRI suspicion score and (1) detection of any cancer, (2) Gleason 6 PCa, and (3) Gleason >6 PCa. MRF-TB alone, MRF-TB + ipsi-SB, and MRF-TB + contra-SB detected 64.1%, 89.1%, and 76.1% of all PCa, respectively; 53.5%, 81.4%, and 69.8% of Gleason 6 PCa, respectively; and 73.5%, 96.0%, and 81.6% of Gleason >6 PCa, respectively. MRF-TB + ipsi-SB detected 96% of clinically significant PCa and avoided detection of 18.6% of clinically insignificant PCa. MRF-TB + contra-SB detected 81.6% of clinically significant PCa and avoided detection of 30.2% of clinically insignificant PCa. CONCLUSION: Our study suggests that ipsi-SB should be added to MRF-TB, as detection of clinically significant PCa increases with only a modest increase in clinically insignificant PCa detection. Contra-SB in this setting may be deferred because it primarily detects clinically insignificant PCa.

Does previous transurethral prostate surgery affect oncologic and continence outcomes after RARP?

We examined the effect of previous transurethral resection of the prostate (TURP) on multiple oncologic and continence outcomes after robotic-assisted radical prostatectomy (RARP). We performed a retrospective cohort study of a total of 2693 patients from 2007 to 2014 who underwent RARP. Patients were stratified into 49 patients who had previous TURP prior to RARP (group 1) and 2644 patients who had no TURP prior to RARP (group 2). We collected operative variables including estimated blood loss, operative time, and positive surgical margin (PSM) rates. Urinary continence, defined as 0 pads per day (PPD), and social continence, defined as 1-PPD, were also assessed. American Urological Association Symptoms Score (AUASS), overall ability to function sexually, and Expanded Prostate Cancer Index Composite (EPIC) questionnaire were evaluated at 3 and 12 months after RARP. Weakness of urinary stream (EPIC #4d) at 12 months imposed a greater problem for group 1 patients with prior TURP compared to group 2 patients without prior TURP (p = 0.012). PSM was not statistically significant between the two groups (p = 0.110). Group 1 patients had a greater PSM rate (30.61 %) as compared to group 2 (20.95 %). PSM locations in group 1 patients showed the most common locations at the posterior and apex. The difference between the two groups for AUASS, overall sexual function, estimated blood loss, operative time, urinary continence, and social continence was not statistically significant. We examined the effect of previous TURP on postoperative RARP continence and oncologic outcomes. This data can be used to counsel those with prior TURP before RARP.

Oncologic outcomes in men with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institution international study.

BACKGROUND: The presence of lymph nodes (LN) within the prostatic anterior fat pad (PAFP) has been reported in several recent reports. These PAFP LNs rarely harbor metastatic disease, and the characteristics of patients with PAFP LN metastasis are not well-described in the literature. Our previous study suggested that metastatic disease to the PAFP LN was associated with less severe oncologic outcomes than those that involve the pelvic lymph node (PLN). Therefore, the objective of this study is to assess the oncologic outcome of prostate cancer (PCa) patients with PAFP LN metastasis in a larger patient population. METHODS: Data were analyzed on 8800 patients from eleven international centers in three countries. Eighty-eight patients were found to have metastatic disease to the PAFP LNs (PAFP+) and 206 men had isolated metastasis to the pelvic LNs (PLN+). Clinicopathologic features were compared using ANOVA and Chi square tests. The Kaplan-Meier method was used to calculate the time to biochemical recurrence (BCR). RESULTS: Of the eighty-eight patients with PAFP LN metastasis, sixty-three (71.6%) were up-staged based on the pathologic analysis of PAFP and eight (9.1%) had a low-risk disease. Patients with LNs present in the PAFP had a higher incidence of biopsy Gleason score (GS) 8-10, pathologic N1 disease, and positive surgical margin in prostatectomy specimens than those with no LNs detected in the PAFP. Men who were PAFP+ with or without PLN involvement had more aggressive pathologic features than those with PLN disease only. However, there was no significant difference in BCR-free survival regardless of adjuvant therapy. In 300 patients who underwent PAFP LN mapping, 65 LNs were detected. It was also found that 44 out of 65 (67.7%) nodes were located in the middle portion of the PAFP. CONCLUSIONS: There was no significant difference in the rate of BCR between the PAFP LN+ and PLN+ groups. The PAFP likely represents a landing zone that is different from the PLNs for PCa metastasis. Therefore, the removal and pathologic analysis of PAFP should be adopted as a standard procedure in all patients undergoing radical prostatectomy.

10-Year Mortality After Radical Prostatectomy for Localized Prostate Cancer in the Prostate-specific Antigen Screening Era.

OBJECTIVE: To provide insight into the impact of radical prostatectomy (RP) on prostate cancer-specific mortality (PCSM) in a primarily prostate-specific antigen screen-detected cohort of men with localized prostate cancer (PCa). METHODS: Between 2000 and 2013, 1864 men consented to participate in a prospective longitudinal outcomes study after RP for localized PCa by a single surgeon. Men lost to follow-up were queried to the National Death Index to acquire mortality data. RESULTS: From our cohort of 1864 men (median age 59 years, median preoperative prostate-specific antigen 5.0, median follow-up 9.1 years), Kaplan-Meier analysis demonstrated 10-year all-cause mortality and PCSM of 4.6% and 1.4%, respectively. Ten-year PCSM for low, intermediate, and high D'Amico risk were 0.9%, 1.0%, and 7.4%, respectively (P <.001). For men with postoperative Gleason score 4-6, 7, and 8-10, 10-year PCSM was 0.8%, 1.0%, and 11.5%, respectively (P <.001). Men with pT2, pT3a, and pT3b disease had 10-year PCSM of 0.7%, 2.6%, and 9.5%, respectively (P <.001). Pathologic stage and grade were the only significant independent predictor of PCSM at 10 years (P = .002 and P = .025, respectively). CONCLUSION: In our series with up to 13 years of follow-up from the National Death Index, 10-year PCSM after RP for clinically localized PCa was very low and strongly predicted by pathologic stage and grade. Death unrelated to PCa was a rare event, suggesting that we are identifying candidates for RP who are likely to live long enough to benefit from surgical intervention.

Complications, Recovery, and Early Functional Outcomes and Oncologic Control Following In-bore Focal Laser Ablation of Prostate Cancer.

UNLABELLED: From April 2013 to July 2014, 25 consecutive men participated in a longitudinal outcomes study following in-bore magnetic resonance imaging (MRI)-guided focal laser ablation (FLA) of prostate cancer (PCa). Eligibility criteria were clinical stage T1c and T2a disease; prostate-specific antigen (PSA) <10 ng/ml; Gleason score <8; and cancer-suspicious regions (CSRs) on multiparametric MRI harboring PCa. CSRs harboring PCa were ablated using a Visualase cooled laser applicator system. Tissue temperature was monitored throughout the ablation cycle by proton resonance frequency shift magnetic resonance thermometry from phase-sensitive images. There were no significant differences between baseline and 3-mo mean American Urological Association Symptom Score or Sexual Health Inventory in Men scores. No man required pads at any time. Overall, the mean PSA decrease between baseline and 3 mo was 2.3 ng/ml (44.2%). Of 28 sites subjected to target biopsy after FLA, 26 (96%) showed no evidence of PCa. Our study provides encouraging evidence that excellent early oncologic control of significant PCa can be achieved following FLA, with virtually no complications or adverse impact on quality of life. Longer follow-up is required to show that oncologic control is durable. PATIENT SUMMARY: Early results for focal laser ablation of prostate cancer are very encouraging. Until long-term oncologic control is demonstrated, focal laser ablation must be considered an investigational treatment option.

Natural History of Pathologically Benign Cancer Suspicious Regions on Multiparametric Magnetic Resonance Imaging Following Targeted Biopsy.

PURPOSE: We determined the natural history of pathologically benign cancer suspicious regions on multiparametric magnetic resonance imaging following targeted biopsy. MATERIALS AND METHODS: Between January 2012 and September 2014, 330 men underwent prostate multiparametric magnetic resonance imaging. A total of 533 cancer suspicious regions were identified and scored on a Likert scale of 1 to 5 based on suspicion for malignancy with 5 indicating the highest suspicion level. Following multiparametric magnetic resonance imaging all men underwent magnetic resonance imaging-ultrasound fusion targeted prostate biopsy using ProFuse software and the ei-Nav|Artemis system (innoMedicus, Cham, Switzerland), and a computer generated 12-core random biopsy. We analyzed a cohort of 34 men with a total of 51 cancer suspicious regions who had benign prostate biopsies and underwent repeat multiparametric magnetic resonance imaging and prostate specific antigen testing at 1 year. Changes in the greatest linear measurement, the suspicion score and serum prostate specific antigen were ascertained. RESULTS: During 1 year the suspicion score distribution and the mean greatest linear measurement of the cancer suspicious regions decreased significantly (p <0.0001) while mean prostate specific antigen did not significantly change (p = 0.632). Two (3.9%), 15 (29.4%) and 34 cancer suspicious regions (66.7%) showed an increase, no change and decrease in suspicion score, respectively. No (0%), 21 (42.0%) and 29 cancer suspicious regions (58.0%) showed an increase of 20% or greater, no change and a decrease of 20% or greater in greatest linear measurement, respectively. Of the 2 cancer suspicious regions exhibiting an increased suspicion score neither showed a prostate specific antigen increase of 0.5 ng/ml or greater. CONCLUSIONS: Our study provides compelling evidence that few benign cancer suspicious regions increase in suspicion score and/or the greatest linear measurement within 1 year independent of the baseline suspicion score. Therefore, routinely repeating multiparametric magnetic resonance imaging at 1 year in men with pathologically benign cancer suspicious regions should be discouraged since it is unlikely to influence management decisions.

Positive Surgical Margin Trends in Patients with Pathologic T3 Prostate Cancer Treated with Robot-Assisted Radical Prostatectomy.

INTRODUCTION: We analyzed the trends of positive surgical margin (PSM) location in patients who had pT3 disease at robot-assisted radical prostatectomy (RARP). We aimed to describe our changing incidence of PSMs in the largest series to date of patients with pT3 disease who were treated by RARP. METHODS: A single-institution, single-surgeon review was performed of all patients who underwent RARP from 2005 to 2011. Perioperative data were collected for all patients with pT3 prostate cancer from a prospectively maintained RARP database. The PSM incidence and rates were stratified by location. The PSM rates per location were trended over time. RESULTS: In total, 2478 consecutive patients underwent RARP between July 2005 and December 2011. Of these patients, 555 were found to have pT3 disease. The PSM rate for patients with pT3 disease was 47%. The PSM rate for patients with pT3a and pT3B disease was 42.8% and 60.6%, respectively. Over the duration of this study, the PSM rate in patients with pT3 disease decreased significantly from 70.6% in 2005 to 32.3% in 2011 (p=0.002). The apical PSM rate showed the greatest decrease during this period going from 52.9% in 2005 to 5.2% in 2011 (p=0.018). CONCLUSION: We present the largest series to date involving the treatment of locally advanced prostate cancer initially managed with RARP. Our findings suggest that patients with locally advanced prostate cancer can be treated with RARP with acceptable positive margin rates. Overall PSM rates improved nearly 40% over the 6.5-year period of this study.

Robotic management of genitourinary injuries from obstetric and gynaecological operations: a multi-institutional report of outcomes.

OBJECTIVE: To evaluate the utility of robotic repair of injuries to the ureter or bladder from obstetrical and gynaecological (OBGYN) surgery PATIENTS AND METHODS: A retrospective review of all patients from four different high-volume institutions between 2002 and 2013 that had a robot-assisted (RA) repair by a urologist after an OBGYN genitourinary injury. RESULTS: Of the 43 OBGYN operations, 34 were hysterectomies: 10 open, 10 RA, nine vaginally, and five pure laparoscopic. Nine patients had alternative OBGYN operations: three caesarean sections, three oophorectomies (one open, two laparoscopic), one RA colpopexy, one open pelvic cervical cerclage with mesh and one RA removal of an invasive endometrioma. In all, 49 genitourinary (GU) injuries were sustained: ureteric ligation (26), ureterovaginal fistula (10), ureterocutaneous fistula (one), vesicovaginal fistula (VVF; 10) and cystotomy alone (two). In all, 10 patients (23.3%) underwent immediate urological repair at the time of their OBGYN RA surgery. The mean (range) time between OBGYN injury and definitive delayed repair was 23.5 (1-297) months. Four patients had undergone prior failed repair: two open VVF repairs and two balloon ureteric dilatations with stent placement. In all, 22 ureteric re-implants (11 with ipsilateral psoas hitch) and 15 uretero-ureterostomies were performed. Stents were placed in all ureteric cases for a mean (range) of 32 (1-63) days. In all, 10 VVF repairs and two primary cystotomy closures were performed. Drains were placed in 28 cases (57.1%) for a mean (range) of 4.1 (1-26) days. No case required open conversion. Two patients (4.1%) developed ureteric obstruction after RA repair requiring dilatation and stenting. The mean (range) follow-up of the entire cohort was 16.6 (1-63) months. CONCLUSIONS: RA repair of GU injuries during OBGYN surgery is associated with good outcomes, appears safe and feasible, and can be used successfully immediately after injury recognition or as a salvage procedure after prior attempted repair. RA techniques may improve convalescence in a patient population where quick recovery is paramount.

Functional and oncologic outcomes of graded bladder neck preservation during robot-assisted radical prostatectomy.

PURPOSE: To describe our bladder neck dissection during robot-assisted radical prostatectomy (RARP), to describe the degrees of robot-assisted bladder neck preservation (R-BNP) we have encountered, and to determine the effect of increasing R-BNP on postoperative continence and positive surgical margin (PSM) rates. PATIENTS AND METHODS: We performed a retrospective analysis of 599 patients who underwent robot-assisted radical prostatectomy (RARP) by a single surgeon (DIL). All bladder neck dissections were graded between 1 and 4; higher grades corresponded to an increasing degree of robot-assisted bladder neck preservation (R-BNP). After grouping patients by R-BNP grade, postoperative continence and positive surgical margin (PSM) rates were compared. The association between R-BNP and continence was also assessed using multivariate binary logistic regression models. RESULTS: Similar outcomes were seen for two definitions of continence (0 pads per day [ppd]; 0 ppd or security pad, respectively). A higher proportion of patients were continent at 3 months postoperatively who received grade 4 compared with grade 1 (P=0.043; P=0.001) and grade 2 (P=0.006; P=0.009); and grade 3 compared with grade 1 (P=0.048; P=0.002) and grade 2 (P=0.009; P=0.030) R-BNP. There was no difference between grade 1 and 2 (P=0.541; P=0.064), and grade 3 and 4 (P=0.898; P=0.584) R-BNP. At 1 year postoperatively, there was no difference among the four groups in continence rate (P=0.771; P=0.411). R-BNP was an independent predictor of continence at 3 months (odds ratio [OR] [95% confidence interval (CI)]=1.33 [1.06-1.67]; OR [95% CI]=1.45 [1.1-1.82]), but not at 1 year (OR [95% CI]=1.07 [0.82-1.39]; OR (95% CI)=1.30 [0.92-1.85]). There was no difference among the four groups in PSM rates (P=0.946). CONCLUSIONS: R-BNP is a graded, rather than all-or-none outcome. An increasing degree of R-BNP is associated with an earlier return to continence, without compromising oncologic outcomes.

Single-surgeon experience with robot-assisted ureteroneocystostomy for distal ureteral pathologies in adults.

PURPOSE: To demonstrate our technical approach for robot-assisted ureteroneocystostomy (R-UNC) for benign and malignant distal ureteral pathologies. MATERIALS AND METHODS: Between January 2009 and January 2013, a total of 10 patients underwent R-UNC in the distal ureter by a single surgeon. Indications for R-UNC were as follows: idiopathic (3), fistula (2), iatrogenic (2), malignancy (2), and chronic vesicoureteral reflux (1). RESULTS: Tension-free anastomosis was attained in all 10 R-UNC procedures. A psoas hitch was performed in 6/10 cases (60%). Intravesical and extravesical reimplantations were completed in 5/10 (50%) and 5/10 cases (50%), respectively. A nonrefluxing ureter was constructed in 2/10 cases (20%). The patients' mean age was 52.9±16.6 years, their mean body mass index was 30.8±6.3 kg/m(2), the mean operative time was 211.7±69.3 minutes, mean estimated blood loss was 102.5±110.8 mL, and mean length of stay was 2.8±2.3 days. There were no intraoperative complications. There was one Clavien-Dindo grade I and one Clavien-Dindo grade II postoperative complication. The mean postoperative follow-up duration was 28.5±15.5 months. Two patients had recurrence of ureteral strictures at 3 months postoperatively and were managed successfully with balloon dilation. CONCLUSIONS: Our technique for R-UNC demonstrates good perioperative outcomes. However, underlying periureteral inflammation and pelvic adhesions may predispose patients for stricture recurrence after R-UNC.

Novel use of indocyanine green for intraoperative, real-time localization of ureteral stenosis during robot-assisted ureteroureterostomy.

OBJECTIVE: To present a novel method to intraoperatively localize ureteral strictures during robot-assisted ureteroureterostomy via indocyanine green (ICG) visualization under near-infrared (NIR) light. MATERIALS AND METHODS: Seven patients underwent robot-assisted ureteroureterostomy for ureteral stricture by a single surgeon (D.D.E.). Intraoperative localization of ureteral stricture involved instilling ICG (25 mg in 10 mL distilled water) above and below the level of stenosis through a ureteral catheter or a percutaneous nephrostomy tube, or both. The fluorescent tracer was detected as a green color using the NIR modality on the da Vinci Si (Intuitive Surgical, Sunnyvale, CA). All patients consented to off-label use of ICG after full disclosure. RESULTS: Intraoperative ICG injection and visualization under NIR light assisted in the performance of a tension-free anastomosis in all patients. At the time of surgery, mean age was 55.7 ± 12.4 years and mean body mass index was 30.3 ± 5.8 kg/m(2). Mean operative time was 171.3 ± 52.4 minutes, mean estimated blood loss was 175.0 ± 146.5 mL, and mean length of ureteral excision on pathologic analysis was 1.6 ± 0.7 cm. There were no immediate or delayed adverse effects attributable to intraureteral ICG administration. Mean hospital length of stay was 1.6 ± 1.5 days, with no postoperative complications. Mean follow-up was 5.9 ± 1.5 months, and all cases were clinically and radiographically successful at last follow-up. CONCLUSION: Intraureteral injection of ICG with visualization under NIR light allows for real-time delineation of the ureter. Additionally, ICG administration aids in discerning healthy ureter from diseased tissue, further assisting successful robotic ureteral repair.

Single surgeon experience with robot-assisted ureteroureterostomy for pathologies at the proximal, middle, and distal ureter in adults.

PURPOSE: To describe our initial experience with robot-assisted ureteroureterostomy (RUU) at the proximal, middle, and distal ureter. MATERIALS AND METHODS: Twelve consecutive patients underwent RUU by a single surgeon (D.D.E.) between July 2009 and November 2012. Indications included three iatrogenic injuries, two impacted stones, two ureterovaginal fistulas, two idiopathic ureteral strictures refractory to conservative treatment, one primary transitional cell carcinoma of the ureter, one colon cancer metastasis to the ureter, and one invasive endometriosis. There were two proximal, three middle, and seven distal ureteral pathologies. RESULTS: Tension-free anastomosis was achieved in all 12 patients. All patients with proximal and middle ureteral pathology received concomitant downward nephropexy (DN) as a standard part of RUU. Mean age of patients at the time of surgery was 52 years (range 30-69), mean body mass index was 30.0 kg/m(2) (range 21-38), mean operative room time was 190 minutes (range 104-354), mean estimated blood loss was 181 mL (range 50-400), and mean length of excised ureter on pathologic analysis was 2.0 cm (range 1.0-4.5). There was one intraoperative complication in which liver and gallbladder laceration occurred during trocar placement. Mean length of hospital stay was 1.4 days (range 1-5), and there were no postoperative complications. Mean follow up was 10 months (range 3-36). One patient had a ureteral stricture recurrence at 7 months postoperatively that led to renal unit loss and eventual nephrectomy. CONCLUSION: RUU is feasible, safe, and demonstrates good outcomes for pathologies at the proximal, middle, and distal ureter. Concomitant DN during RUU may assist in achieving a tension-free anastomosis for proximal and middle ureteral repairs.