Transient stent placement versus tubeless procedure after ureteroscopy retrograde surgery stone extraction (Fast Track Stent study 2): A randomized prospective evaluation.

OBJECTIVES: To determine whether in pre-stented patients undergoing ureteroscopic stone removal (ureteroscopy retrograde surgery) a tubeless procedure provides a better outcome compared with short-term (6 h) ureteral stenting using an external ureteral catheter. METHODS: In this single academic center study (Fast Track Stent study 2), carried out between May 2016 and April 2018, 121 patients with renal or ureteral calculi were initially treated with double-J insertion. Before secondary ureteroscopy retrograde surgery, patients were prospectively randomized into two groups: tubeless versus ureteral catheter insertion for 6 h after ureteroscopy retrograde surgery. Exclusion criteria were acute urinary tract infection, solitary kidney or stone diameter >25 mm. Study end-points were stent-related symptoms assessed by a validated questionnaire (ureteral stent symptom questionnaire), administered both before and 4 weeks after surgery. Numerical ureteral stent symptom questionnaire scores were compared using the Mann-Whitney-U-test. The level of significance was defined as P < 0.05. RESULTS: Ureteroscopy retrograde surgery procedures carried out by 13 surgeons resulted in >90% stone removal in all patients (n = 121), with a mean operation time of 19.9 versus 18.0 min for ureteral catheter versus tubeless, respectively (P = 0.37). Patient groups did not differ significantly in their ureteral stent symptom questionnaire scores (urinary index P = 0.24; pain index P = 0.35). Patients showed a significant preference for tubeless procedure over ureteral catheter reinsertion (Question GQ P < 0.0001). The reintervention rate was 13.3% for the tubeless procedure (n = 8) and 1.6% for the ureteral catheter group (n = 1), respectively (P = 0.034). CONCLUSIONS: Short-term ureteral catheter and no stent insertion after ureteroscopy retrograde surgery stone extraction in pre-stented patients result in comparable quality of life. However, the reintervention rate is higher for tubeless procedures.

Association between the Surgical Apgar Score and Perioperative Complications after Radical Prostatectomy.

OBJECTIVE: To evaluate whether the Surgical Apgar Score (SAS) can identify patients who are at risk for perioperative adverse events (PAE) following radical prostatectomy for prostate cancer. PATIENTS AND METHODS: At a single academic institution, 994 patients undergoing radical prostatectomy between 2010 and 2013 were analyzed retrospectively. The SAS was calculated from anesthesia records, evaluated to predict PAE within a 30-day time period postoperatively; these events were classified according to standardized classification systems. RESULTS: We observed adverse events in 45.4% (451/994) of patients with a total of 694 events. Overall, 41% (408/994) had low- and 9.9% (98/994) had high-grade events. A lower SAS was identified as an independent predictor of any (p < 0.001) and low-grade adverse events (p = 0.001) for those patients who had undergone open retropubic radical prostatectomy (ORRP). Each 1-point increment resulted in a 24% decrease in the odds of any (95% CI 0.66-0.88) and a 21% decrease in the odds of a low-grade (95% CI 0.69-0.91) event. Adverse events of robot-assisted prostatectomy were not associated with the SAS. CONCLUSIONS: Lower SAS values indicate patients at risk for adverse events after ORRP. The SAS might serve as one variable for outcome assessment, reflecting the challenge of mutual surgical and anesthesiology procedure management.

Detecting Prostate Cancer.

BACKGROUND: When prostate cancer is suspected, the prostate gland is biopsied with the aid of transrectal ultrasound (TRUS). The sensitivity of prostatic biopsy is about 50%. The fusion of magnetic resonance imaging (MRI) data with TRUS enables the targeted biopsy of suspicious areas. We studied whether this improves the detection of prostate cancer. METHODS: 168 men with suspected prostate cancer underwent prostate MRI after a previous negative biopsy. Suspicious lesions were assessed with the classification of the Prostate Imaging Reporting and Data System and biopsied in targeted fashion with the aid of fused MRI and TRUS. At the same sitting, a systematic biopsy with at least 12 biopsy cores was performed. RESULTS: Prostate cancer was detected in 71 patients (42.3%; 95% CI, 35.05-49.82). The detection rate of fusion-assisted targeted biopsy was 19% (95% CI, 13.83-25.65), compared to 37.5% (95% CI, 30.54-45.02) with systematic biopsy. Clinically significant cancer was more commonly revealed by targeted biopsy (84.4%; 95% CI, 68.25-93.14) than by systematic biopsy (65.1%; 95% CI, 52.75-75.67). In 7 patients with normal MRI findings, cancer was detected by systematic biopsy alone. Compared to systematic biopsy, targeted biopsy had a higher overall detection rate (16.5% vs. 6.3%), a higher rate of infiltration per core (30% vs. 10%), and a higher rate of detection of poorly differentiated carcinoma (18.5% vs. 3%). Patients with negative biopsies did not undergo any further observation. CONCLUSION: MRI/TRUS fusion-assisted targeted biopsy improves the detection rate of prostate cancer after a previous negative biopsy. Targeted biopsy is more likely to reveal clinically significant cancer than systematic biopsy; nevertheless, systematic biopsy should still be performed, even if the MRI findings are negative.

Predictors of short-term recovery of urinary continence after radical prostatectomy.

PURPOSE: To evaluate treatment variables for early urinary continence status 6 weeks following radical prostatectomy. METHODS: In this retrospective analysis, 4,028 consecutive patients underwent open radical retropubic (RRP) or robot-assisted transperitoneal prostatectomy (RARP) at a single academic institution (07/2003-07/2013). After discharge, patients were offered 3-week treatment in a rehabilitation facility. Patients who opted for rehabilitation (n = 2,998, 74.4%) represent our study cohort. Exclusion criteria were acute urinary retention after catheter removal (n = 55, 1.4%), incomplete datasets (n = 50, 1.2%) or refusal of rehabilitation (n = 925, 23.0%). Results of urinary continence were evaluated from final rehabilitation reports. Twenty-two clinical and oncological variables were statistically analysed in uni- and multivariable analyses to determine whether they were associated with early urinary continence status six weeks after radical prostatectomy. Odds ratios and 95% CI as well as p values were calculated. A p level of 0.05 was considered as significant. RESULTS: Six weeks after surgery, 1,962 (65.4%) patients were continent (≤1 pad/day) and 1,036 (34.6%) patients were considered incontinent. Age, clinical stage, PSA, ASA score, prior TURP, seminal vesicle invasion, Gleason score, nerve-sparing status, intraoperative blood loss, catheterisation time, OR time, surgical caseload >1,000 and the surgeon were associated with continence status on univariable analysis (p < 0.05). On multivariable analysis, nerve-sparing procedure (NS), clinical stage, individual surgeon, patient age, surgical procedure (RARP vs. RRP) and duration of catheterisation were independent predictors (p < 0.05) of incontinence status. CONCLUSIONS: Strategies that can ensure NS procedures and early catheter removal should be applied to enable early recovery of urinary continence.

Standardized assessment of complications in a contemporary series of European patients undergoing radical cystectomy.

OBJECTIVES: To examine postoperative complications in a contemporary series of patients after radical cystectomy using a standardized reporting system, and to identify readily available preoperative risk factors. METHODS: Using the modified Clavien-Dindo classification, we assessed the 90-day postoperative clinical course of 535 bladder cancer patients who underwent radical cystectomy and urinary diversion (ileal conduit n = 349, ileal neobladder n = 186) between June 2003 and February 2012 at a single institution. All Martin criteria for standardized reporting of complications were met. Uni- and multivariable analyses for prediction of complications were carried out; covariates included body mass index, Charlson Comorbidity Index, age, sex, American Society of Anesthesiologists Score, neoadjuvant chemotherapy, prior abdominal or pelvic surgery, localized tumor and urinary diversion type. RESULTS: The 90-day rates for overall (Clavien-Dindo classification I-V) and high-grade complications (Clavien-Dindo classification III-V), as well as mortality (Clavien-Dindo classification V), were 56.4, 18.7 and 3.9%, respectively. Infections (16.4%), bleeding (14.2%) and gastrointestinal complications (10.7%) were the most common adverse outcomes. Independent risk factors for overall complications were body mass index (odds ratio 1.08) and Charlson Comorbidity Index ≥3 (odds ratio 1.93). Risk factors for high-grade complications were Charlson Comorbidity Index ≥3 (odds ratio 1.86), American Society of Anesthesiologists Score ≥3 (odds ratio 1.92) and body mass index (odds ratio 1.07, all P < 0.03). CONCLUSIONS: Radical cystectomy is associated with significant morbidity; nevertheless, the majority of complications are minor. Charlson Comorbidity Index, American Society of Anesthesiologists Score and body mass index might help to identify patients at risk for high-grade complications after radical cystectomy.

Is there a need for the Fournier's gangrene severity index? Comparison of scoring systems for outcome prediction in patients with Fournier's gangrene.

UNLABELLED: Study Type - Prognosis (prospective cohort) Level of Evidence 2a. What's known on the subject? and What does the study add? Fournier's gangrene (FG) is a rare but life-threatening disease challenging the treating medical staff. Despite the fact that antibiotic therapy combined with surgery and intensive care surveillance are performed as standard treatment, mortality rates remain high. There have been efforts to develop a reliable tool to predict severity of the disease, not only to identify patients at highest risk of major complications or death but also to provide a target for medical teams and researchers aiming to improve outcome and to gather information for counselling patients. Laor et al. published the FG severity index (FGSI) in 1995 presenting a complex prediction score solely for patients with FG. Fifteen years later, Yilmazlar et al. suggested a new and supposedly more powerful scoring system, the Uludag FGSI (UFGSI), adding an age score and an extent of disease score to the FGSI. In the present study population we applied two scoring systems for outcome prediction that are solitarily applicable in patients with FG (FGSI, UFGSI), as well as two general scoring systems such as the established age-adjusted Charlson Comorbidity Index (ACCI) and the recently introduced surgical Apgar Score (sAPGAR) to compare them and to test whether one system might be superior to the other. In addition, we identified potential prognostic factors in the study population. By contrast to many earlier studies, we performed a combined prospective and retrospective analysis and provided a 30-day follow up. In the cohort of the present study, older patients with comorbidities as well as a need for mechanical ventilation and blood transfusion are at higher risk of lethal outcome. All scores are useful to predict mortality. Despite including more variables, the UFGSI does not seem to be more powerful than the FGSI. In daily routine we suggest applying ACCI and sAPGAR, as they are more easily calculated, generally applicable and well validated. OBJECTIVE: • To compare four published scoring systems for outcome prediction (Fournier's gangrene severity index [FGSI], Uludag FGSI [UFGSI], age-adjusted Charlson Comorbidity Index [ACCI] and surgical Apgar Score [sAPGAR]) and evaluate risk factors in patients with Fournier's gangrene (FG). PATIENTS AND METHODS: • In all, 44 patients were analysed. The scores were applied. • A Mann-Whitney U-test, Fisher's exact test, receiver operator characteristic (ROC) analysis and Pearson correlation analysis were performed. RESULTS: • The results of the present study show a significant association among FGSI (P= 0.002), UFGSI (P= 0.002), ACCI (P= 0.004), sAPGAR (P= 0.018) and death. • The differences between the area under the receiver operating characteristic curve of the scores were not significant. • Non-survivors were older (P= 0.046), had a greater incidence of acute renal failure (P < 0.001) and coagulopathy (P= 0.041), were treated more often with mechanical ventilation (P= 0.001) and received more packed red blood cells (RBCs; P= 0.001). CONCLUSION: • Older patients with comorbidities and need for mechanical ventilation and RBCs are at higher risk for death. • In the present cohort, scores calculated easily at the bedside, such as ACCI and sAPGAR, seemed to be as good at predicting outcome in patients with FG as FGSI and UFGSI.

Comprehensive report on prostate cancer misclassification by 16 currently used low-risk and active surveillance criteria.

UNLABELLED: What's known on the subject? and What does the study add? Prostate cancer characterisation, based on laboratory findings, clinical examination and histopathological cancer features that are used to define selection criteria for AS, is not ideal. Consequently, a panel of strict or more lenient criteria to select patients for AS have been published. Studies investigating the relationship between pretreatment variables and final pathology have been done in the past showing the risk of cancer misclassification for some criteria. No study has presented an overview of cancer selection using a panel of 16 currently used AS criteria that is presented in the present study. In an exactly defined cohort after radical prostatectomy, each set of criteria was used as a diagnostic test to separate between patients with more favourable (pT2, no Gleason upgrade between biopsy grading and final pathology) and unfavourable cancer features (pT3, pN+, Gleason upgrade). To the best of our knowledge a comparison of test quality criteria for AS criteria given by sensitivity, specificity, positive and negative predictive value and likelihood ratio has not yet been reported. Moreover, we showed that tumour characterisation, by a formally sufficient 12-core biopsy, in the present dataset harboured a risk of ≈20% that unfavourable cancer features were missed regardless of whether strict or more lenient selection criteria for AS were chosen. OBJECTIVE: To evaluate final histopathological features among men diagnosed with prostate cancer eligible for low-risk (LR) or active surveillance (AS) criteria. PATIENTS AND METHODS: Retrospective application of 16 definitions for AS or LR prostate cancer to a contemporary (January 2008 to March 2011) open retropubic radical prostatectomy (RRP) series of 1745 patients. EXCLUSION CRITERIA: neoadjuvant hormones, radiotherapy, inadequate histopathological reports, <10 biopsy cores. Report on the number of men with insignificant tumours (defined as: ≤pT2, Gleason score ≤6, tumour volume <0.5 mL) and men who had unfavourable tumour characteristics on final pathology (defined as: extracapsular extension or seminal vesicle invasion or lymph node metastasis or Gleason upgrading). Sensitivity, specificity, positive predictive value (PPV) and negative predictive values (NPV) were calculated. RESULTS: Eligibility of patients in the final study cohort (n = 1070) varied from 5.1% to 92.7% depending on the AS or LR criteria used. Final pathology revealed 77 insignificant cancers and 578 patients who had unfavourable histopathological criteria. The detection rate for insignificant cancers on final pathology was variable ranging from 7.8% to 28.3% depending on the AS- or LR-prediction tool used; unfavourable tumour characteristics were found in up to 33.5% on final pathology. The sensitivity, specificity, PPV and NPV were 8.5-97.9%, 24.7-97.8%, 67.7-89.1% and 45.3-78.2%, respectively. The likelihood ratio to correctly identify a patient with LR disease on final pathology ranged from 1.3 to 8. CONCLUSIONS: AS or LR criteria have a significant risk of cancer misclassification. Better prediction tools are needed to improve these criteria. Re-biopsy might improve safety and should be considered more frequently in patients who opt for AS.

Assessment of the perfusion and morbidity of the buccal mucosal donor site for grafting of urethral strictures.

UNLABELLED: Buccal mucosal grafting has become the gold standard for reconstruction of urethral strictures. The aim of this study was to investigate donor site morbidity with a unique emphasis on objective measurements of perfusion and oxygenation. METHODS: In a prospective study 15 male patients with recurrent urethral strictures, underwent urethroplasty using an intraoral mucosal graft. Donor site was closed primarily (group 1) or left to granulation (group 2). Clinical examinations of recipient and donor sites, urograms and the modified SF-8™ health questionnaire were carried out 1, 3 and 24 weeks postoperatively. Oxygenation and perfusion parameters of the donor site were measured by the O2C (oxygen-to-see) monitoring device - a combined technique of laser Doppler flowmetry and tissue spectroscopy. RESULTS: No recurrence of strictures at recipient site or infections at either sites occurred. 24 weeks after operation, haemoglobin oxygenation (72.1±5.9%) and deep flow (177.2 Arbitrary Units (AU)) of the donor site were slightly, but not significantly, lower compared to the contralateral unoperated buccal mucosa (haemoglobin oxygenation: 75.4±5.2%, deep flow: 187.3 AU). Significant differences between the two groups of different wound healing could not be revealed. CONCLUSIONS: Using free mucosal grafts for urethroplasty is a simple and safe method in the interdisciplinary treatment of urethral strictures. Donor site morbidity within the first 3 weeks after operation is noticeable, but tolerable measured by a validated Quality of Life-tool. Six months after the operation, perfusion and oxygenation of the former graft harvest site are equal to the contralateral unoperated mucosa.

Comparison of real-time elastography with grey-scale ultrasonography for detection of organ-confined prostate cancer and extra capsular extension: a prospective analysis using whole mount sections after radical prostatectomy.

OBJECTIVE: •To evaluate whether transrectal real-time elastography (RTE) improves the detection of intraprostatic prostate cancer (PCa) lesions and extracapsular extension (ECE) compared with conventional grey-scale ultrasonography (GSU). PATIENTS AND METHODS: •In total, 229 patients with biopsy-proven PCa were prospectively screened for cancer-suspicious areas and ECE using GSU and RTE. •The largest tumour focus detected by RTE was defined as the index lesion. •The prostate gland was stratified into six sectors on GSU and RTE, which were compared with histopathological whole mount sections after radical prostatectomy. RESULTS: •Histopathologically, PCa was confirmed in 894 out of 1374 (61.8%) evaluated sectors and ECE was identified in 47 (21%) patients. •Of these 894 sectors, RTE correctly detected 594 (66.4%) and GSU 215 (24.0%) cancer suspicious lesions. •Sensitivity was 51% and specificity 72% using RTE compared to 18% and 90% for GSU. •RTE identified the largest side specific tumour focus in 68% of patients. •ECE was identified with a sensitivity of 38% and specificity of 96% using RTE compared to 15% and 97% using GSU. CONCLUSIONS: •Compared with GSU, RTE provides a statistically significant improvement in detection of PCa lesions and ECE. •RTE enhances GSU, although improvement is still needed to achieve a clinically meaningful sensitivity.

Open radical retropubic prostatectomy gives favourable surgical and functional outcomes after transurethral resection of the prostate.

OBJECTIVES: To assess the peri- and postoperative outcome of patients treated with open radical retropubic prostatectomy (RRP) for prostate cancer and who had previously undergone transurethral resection of the prostate (TURP). PATIENTS AND METHODS: Prospectively collected data from a consecutive series of 1760 patients who had RRP between July 2003 and June 2007 at our institution were used to retrospectively match 62 cases (with previous TURP) with the same number of controls (without previous TURP). Matching variables were patient age, body mass index, prostate volume, preoperative total prostate-specific antigen (PSA) level, Gleason score, pathological stage, and intraoperative nerve-sparing procedure. Complete 1-year follow-up data were available for all patients. All collected data on surgery and perioperative complications were analysed. Functional outcome data at the 1-year follow-up were evaluated by applying an institutional questionnaire. Sexual function was assessed using the abbreviated International Index of Erectile Function-5 questionnaire, and urinary control was evaluated by defining complete urinary control as no pad usage. RESULTS: The rate of complete urinary control rate in cases and controls was similar (81% vs 82%). When nerves were spared, 60% (15/25) of patients in either group were capable of sexual intercourse. The overall positive surgical margin rate was insignificantly higher in cases (19% vs 13, P>0.05). After 1 year of follow-up the biochemical recurrence rate (PSA>0.04 ng/mL) did not differ significantly in patients who had RRP after TURP vs RRP alone (six of 62, 10%, vs five of 62, 8%; P=0.77). CONCLUSIONS: RRP for prostate cancer in patients who have had previous TURP does not result in a higher perioperative complication rate, or a worse functional outcome.

Assessing the vesico-urethral anastomosis after radical retropubic prostatectomy: transrectal ultrasonography can replace cystography.

OBJECTIVE: To determine if transrectal ultrasonography (TRUS) is as reliable as cystography in detecting vesico-urethral extravasation (VE) after radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: Between October 2005 and February 2006 we prospectively investigated 100 consecutive patients undergoing RRP. The vesico-urethral anastomosis was assessed 6 days after RRP by a combined investigation with TRUS and cystography. RESULTS: In most patients (79%), at 6 days after RRP the vesico-urethral anastomosis was watertight or showed minimal leakage (8%), so that the urinary catheter was removed. Different degrees of VE were detected in 21 patients. Because of small, moderate or marked VE, the indwelling catheter remained until 9, 14 and 21 days after RRP in five, three and five patients, respectively. Every VE documented by cystography was detected by TRUS beforehand; therefore TRUS showed no false-negative results in detecting a leaking anastomosis. In two patients paraurethral fluid was detected by TRUS mimicking VE, with no confirmation by cystography. CONCLUSIONS: TRUS can safely replace cystography for detecting anastomotic leakage after RRP. The decision to remove the catheter after RRP can be made without radiation exposure and use of expensive contrast medium.

Surgical management of prostate cancer: advances based on a rational approach to the data.

The management of localised prostate cancer has undergone important changes in the past two decades, with major improvements in surgical technique, a greater emphasis on structured assessment of quality of life, and a greater attempt to tailor treatment to biological risk. Disease diagnosis is predicated on identification of demographic risk factors, serum levels of prostate-specific antigen and its derivatives, and extended biopsy techniques. Surgical removal of the prostate may be accomplished by open or minimally invasive techniques and in experienced hands results in good functional outcomes a high rate of cure for those with organ confined disease. Radical prostatectomy is also appropriate in selected patients with locally advanced disease and after failed radiation therapy.

Gain of androgen receptor gene copies in primary prostate cancer due to X chromosome polysomy.

BACKGROUND: Prostate cancer is an androgen dependent tumor. In advanced prostate cancers androgen deprivation has proved to be an effective therapy, but 25% show no response. In this study prostatectomy specimens from patients without preoperative therapy were analyzed to determine the possible mechanism of primary antiandrogen resistance. METHODS: The number of androgen receptor (AR) gene copies and X-centromeres were investigated from 80 prostate cancer specimens by FISH analysis. RESULTS: In 9 out of 80 prostate cancers additional X-chromosomes with the corresponding AR gene could be detected. Polysomy of the X-chromosome correlates with pathological classification and tumor volume. CONCLUSIONS: Additional AR genes due to polysomy of the X-chromosome are present in a subgroup of primary prostate cancers prior to antiandrogen therapy. Because the growth of prostate cancers is androgen dependent, these specimens may have an advantage in low concentrations of androgens. This may be a factor for initial antiandrogen resistance.

Comparison of accuracy between the Partin tables of 1997 and 2001 to predict final pathological stage in clinically localized prostate cancer.

PURPOSE: We validated externally the predictive accuracy of the 2001 Partin tables and compared the 1997 and 2001 versions. MATERIALS AND METHODS: We used ROC derived AUC to test the predictive accuracy of organ confinement (OC), extraprostatic extension (ECE), seminal vesicle invasion (SVI) and lymph node involvement (LNI) of 1997 and 2001 Partin tables derived probabilities. These probabilities were defined by the pretreatment clinical stage, serum prostate specific antigen and biopsy Gleason grade of 2,139 patients treated with radical prostatectomy for clinically localized prostate cancer. RESULTS: OC, ECE, SVI and LNI were noted in 63.5%, 23.1%, 10.5% and 2.9% of cases, respectively. AUC of the 2001 tables was 0.787, 0.766, 0.775 and 0.790, for OC, ECE, SVI and LNI, respectively. These values were virtually the same as the respective 1997 Partin table AUC values, namely 0.784, 0.728, 0.791 and 0.799. CONCLUSIONS: This external validation of the 2001 Partin tables confirms good predictive accuracy of the updated tables. However, predictive accuracy in this external validation data set of 2,139 European men is virtually the same as that of the original 1997 tables. Therefore, a transition from the 1997 tables to the updated 2001 version does not appear warranted unless superior accuracy is demonstrated in other external cohorts.

Characterisation of biomolecular profiles in primary high-grade prostate cancer treated by radical prostatectomy.

PURPOSE: The aim of this study was to compare the biomolecular profile of high-grade (HG) with low-grade (LG) prostate cancers matched by preoperative serum prostate-specific antigen (PSA) levels. METHODS: From 2,560 patients undergoing radical prostatectomy for localised disease, 24 men with HG cancer (Gleason score > or =9) were eligible. Their clinical data were compared with those of 24 LG tumours (Gleason score < or =6), matched by PSA values. The expression of Ki-67, p53, Bcl-2, chromogranin A, alpha-catenin, and PSA were analysed and compared between both groups. RESULTS: The expression of Ki-67 (P=0.031), p53 (P=0.008), Bcl-2 (P=0.002), and chromogranin A (P=0.042) were expressed significantly higher, and alpha-catenin (P=0.020) and PSA (P<0.001) significantly lower in HG tumours. Cancer volumes of HG and LG differed significantly (10.6 cm3 vs 5.3 cm3; P=0.006). Overall, cancer volume correlated with increased expression of p53 (r=0.52; P<0.001) and chromogranin A (r=0.46; P<0.001), and with decreased expression of PSA (r=0.41; P<0.004). CONCLUSIONS: According to our data, tumour grade is clearly associated with a change in the biomolecular profile, even between patients with similar serum PSA levels. As the prognosis of HG prostate cancer is poor, these tumours should be analysed by immunohistochemical staining to identify specific tumour features for an appropriate selection of adjuvant therapy.

Zonal location of prostate cancer: significance for disease-free survival after radical prostatectomy?

OBJECTIVES: To analyze the zonal location of prostate cancer as a possible predictive feature of progression-free survival after radical prostatectomy. METHODS: Prostate cancers were divided into three groups according to the percentage of cancer volume (70% or more, 31% to 69%, and 30% or less) located in the transition zone (TZ). In a total of 307 patients, 5-year progression-free probabilities were estimated for different clinical and pathologic tumor characteristics using the Kaplan-Meier method. With emphasis on the percentage of cancer volume located in the TZ, univariate and multivariate analyses were performed to calculate their prognostic significance in predicting progression-free probability. RESULTS: Prostate cancer with 70% or more, 31% to 69%, and 30% or less of the cancer volume in the TZ was found in 17.3%, 6.8%, and 75.9% of the patients, respectively. Patients with tumors with 70% or more of the cancer volume in the TZ had a significantly (log-rank P = 0.0402) greater rate of biochemical cure than those with 30% or less (82.1% versus 66.2%). The increasing percentage of cancer volume located in the TZ was significantly (P = 0.0258) associated with a greater progression-free probability in univariate analysis, but did not retain independent significance (P = 0.5748) in multivariate analysis. Instead, pathologic stage (P <0.0001), lymph node involvement (P = 0.0189), and Gleason score on prostatectomy specimen (P = 0.0023) were independent prognosticators. CONCLUSIONS: The location of prostate cancer in the TZ was associated with a greater overall biochemical cure rate after radical prostatectomy. However, it was not an independent prognosticator on multivariate analysis. Therefore, the knowledge about zonal location of prostate cancer offers no advantage over the well-established prognostic factors in predicting disease recurrence.

Prognostic significance of visible lesions on transrectal ultrasound in impalpable prostate cancers: implications for staging.

PURPOSE: The current tumor-node metastasis (TNM) staging system classifies impalpable prostate cancers identified by needle biopsy and invisible by imaging as T1c and those visible as T2. Palpable cancers are classified as at least T2. However, most urologists consider impalpable prostate cancers T1c tumors, irrespective of findings on transrectal ultrasound (TRUS). The aim of this article is to provide a differentiated view of the significance of TRUS findings for staging purposes in impalpable prostate cancers. PATIENTS AND METHODS: A consecutive series of 1670 patients with impalpable tumors and palpable T2 cancers after radical prostatectomy were evaluated. Tumor characteristics and 5-year biochemical cure rates of cancers invisible and visible on TRUS were compared, as well as the rates of impalpable but visible and palpable T2 cancers. RESULTS: Impalpable cancers invisible on TRUS presented significantly more favorable pathologic stages and lower cancer volumes than those visible on TRUS (P =.002, P =.010). In the latter, these clinical features were more favorable compared with T2 cancers (P <.001, P <.001). Progression-free probability of impalpable cancers invisible on TRUS was 86.8%; progression-free probability for impalpable cancers visible on TRUS was 85.4% (log-rank test P =.2060). The corresponding rate for T2 tumors was 73.9%, significantly lower when compared to those of visible and impalpable cancers (log-rank test P =.0001). CONCLUSION: Impalpable prostate cancers invisible on TRUS present more favorable cancer features than those that are visible on TRUS. However, these differences are not as pronounced as those between impalpable but visible cancers and palpable T2 tumors. Thus, based on our data, it seems inappropriate to classify impalpable prostate cancers visible on TRUS as T2 cancers.

Insignificant prostate cancer in radical prostatectomy specimen: time trends and preoperative prediction.

OBJECTIVES: We analysed systematically a consecutive series of radical prostatectomy specimens performed between January 1992 and June 2002 with emphasis to time trends, tumour characteristics and preoperative prediction of insignificant prostate cancers (cancer volume < or =0.5 cm(3) and Gleason pattern < or =6). METHODS: In a total of 1254 patients, prostate cancers (PC) were divided by a cancer volume of 0.5 cm(3). The two groups were compared in their clinical and pathological tumour characteristics. Correlation was determined between yearly incidence rates of T1c and insignificant PC. Furthermore, a logistic regression analysis was performed to calculate the ability to predict insignificant PC and a statistical model was established. RESULTS: Overall, 73 (5.8%) of 1254 men presented with insignificant PC. The incidence of insignificant PC showed no significant linear correlation with that of T1c PC (p<0.61). PSA density and percentage of cancer per biopsy set were assessed as independent prognosticators predicting insignificant PC. Using a threshold of 1% of cancer per biopsy set and a PSA density < or =0.10, positive and negative predictive values were 45.0% and 93.3%, respectively. CONCLUSION: In our series, only few men undergoing radical prostatectomy were affected by insignificant PC. Their incidence showed no statistically significant correlation with that of T1c tumours. Furthermore, insignificant PC was predictable by PSA density and percentage of cancer per biopsy set. Mainly elderly patients facing different treatment options for localized PC may benefit from this information.

Biochemical recurrence following radical prostatectomy: a comparison between prostate cancers located in different anatomical zones.

BACKGROUND: To assess whether differences of biochemical recurrence after radical prostatectomy exist between prostate cancers located in the transition zone (TZ) and peripheral zone (PZ). METHODS: The 5-year biochemical recurrence rate of 307 patients was evaluated. A serum prostate specific antigen (PSA) level > or =0.1 ng/ml was defined as biochemical failure. Cancers were characterized by the location of the largest tumor area as TZ or PZ cancers. Pure PZ cancers were matched to TZ cancers by comparable pathological tumor stage, Gleason score, and surgical margin status. RESULTS: In 63 (20.5%) patients the largest tumor area was located in the TZ. A Kaplan-Meier analysis of the matched pairs calculated an 80% actuarial cure rate of TZ cancers compared to 89% of pure PZ cancers (log-rank test P = 0.742). CONCLUSIONS: TZ and pure PZ cancers matched by comparable pathological tumor stage, Gleason score, and surgical margin status showed no statistical difference in regard to biochemical cure following radical prostatectomy.

Intraoperative and perioperative morbidity of contemporary radical retropubic prostatectomy in a consecutive series of 1243 patients: results of a single center between 1999 and 2002.

OBJECTIVES: To up date counselling of patients in an experienced center, we assessed intraoperative and perioperative complications in a consecutive series of contemporary radical retropubic prostatectomy for localized prostate cancer. METHODS: In a prospective study, we analyzed all intraoperative and perioperative complications within 30 days in a consecutive series of 1243 patients undergoing radical prostatectomy between January 1999 and February 2002. All adverse events were graduated in major and minor complications by their severity and sequel. RESULTS: There were no deaths. Overall, 996 patients (80.2%) were not affected by any complication. Major complications were observed in 50 patients (4.0%), minor complications in 197 (15.8%). Pelvic lymphadenectomy was performed in 861 (69.3%) patients. This procedure was associated with a significantly higher rate of lymphoceles requiring a drainage, 4.2% versus 0.3% (p<0.006) and a higher rate of deep venous thrombosis, 1.4% versus 0.5% (p<0.2), respectively. CONCLUSION: Radical retropubic prostatectomy is a safe surgical procedure. Postoperatively the majority of our patients was not compromised by any complication within 30 days. Furthermore, due to a higher rate of lymphoceles and thromboembolic events the indication for pelvic lymphadenectomy should be considered carefully.