The Effect of Radical Prostatectomy, External Beam Radiation Therapy and Active Surveillance on Life Insurance Premiums in Patients with Prostate Cancer.

INTRODUCTION: Patients with early stage, low risk prostate cancer are typically treated with radical prostatectomy, external beam radiation therapy or active surveillance. We examine how these different management options affect life insurance underwriting practices. METHODS: A total of 20 life insurance companies were sent questionnaires with 9 sample patient cases. Patients were diagnosed with low risk prostate cancer at age 55, 65 or 75 years, and treated with radical prostatectomy, external beam radiation therapy or active surveillance. The life insurance companies were then asked what their underwriting decision would be (standard, substandard or decline) for each sample patient if he submitted a $500,000 term life insurance application at 1, 3 and 5 years after treatment initiation with no evidence of disease on followup. RESULTS: Of the 20 life insurance companies 12 (60%) responded to the questionnaire. In all age groups standard life insurance premiums were most likely to be granted after radical prostatectomy (52.7%), followed by external beam radiation therapy (36.0%) and lastly by active surveillance (5.6%). Regardless of management option, standard premiums were also more likely to be granted if prostate cancer was diagnosed at an older patient age and if there had been a longer duration of disease-free followup (54.6% after 5 years vs 31.0% after 1 year). CONCLUSIONS: For patients diagnosed with low risk prostate cancer life insurance companies are more likely to grant standard life insurance premiums after radical prostatectomy or external beam radiation therapy rather than active surveillance. Other predictors of favorable underwriting decisions are older age at diagnosis as well as longer duration of disease-free followup.

Testosterone Pellet Implantation Practices: A Sexual Medicine Society of North America (SMSNA) Member Questionnaire.

INTRODUCTION: There has been renewed interest in the use of subcutaneous testosterone pellets for the treatment of hypogonadism since the introduction of Testopel in 2008 by Slate Pharmaceuticals (Durham, NC, USA). Manufacturer guidelines recommend using two to six pellets; however, in the clinical setting, this is deemed insufficient. This has produced a wide variety of testosterone pellet usage that is not fully understood. AIM: To better understand subcutaneous testosterone pellet implantation practices among members of the Sexual Medicine Society of North America (SMSNA). METHODS: A 19-item questionnaire was emailed to the 687 members of the SMSNA. Of the 19 questions, 17 were multiple choice and two required write-in responses. Usage patterns, satisfaction rates, and complication rates were investigated. MAIN OUTCOME MEASURES: Data regarding indications for initiating treatment with Testopel, initial dosage, follow-up of testosterone levels and dose titration, patient tolerance and satisfaction, technique of implantation, and procedural complications were collected. RESULTS: Eighty-seven survey responses were received (12.9%). At initiation of Testopel therapy, 80.5% of respondents would implant at least 10 pellets, whereas only 4.6% would place six to seven pellets and 3.4% would implant fewer than six pellets. Many respondents would determine the starting dose based on some combination of baseline testosterone level and weight, although 24.1% described using a standard starting dose for all patients. All respondents would check testosterone levels within 3 months of initiating therapy, with the vast majority (72.4%) doing so at 1 month. Subsequent dosing of Testopel was not changed in most patients, with 41.4% and 26.4% of respondents reporting that 60% to 80% and 80% to 100% of patients, respectively, remained on their initial dose. Most respondents would re-implant pellets at a 3-month (21.8%) or 4-month (43.7%) interval. High patient satisfaction was described by respondents, with 56.3% finding patients to be satisfied "most times" and 34.5% "almost always." CONCLUSION: This study provides insight into the usage of Testopel among members of the SMSNA. We found that the vast majority of specialists use at least 10 pellets at initial implantation, with limited need for subsequent dose adjustments, good durability of response, and high patient satisfaction and tolerability.

Lessons Learned from Routine Intraoperative Ureteral Margin Frozen Sections during Radical Cystectomy.

INTRODUCTION: We examined the practice patterns of intraoperative ureteral frozen section during radical cystectomy and the impact of ureteral margin positivity on operative characteristics and oncologic outcomes. METHODS: The records of patients who underwent radical cystectomy at our institution from 2004 to 2011 were identified. Intraoperative ureteral frozen section characteristics were examined, including number, laterality, positivity, conversion to negative and final permanent section status. Logistic regression analysis was performed for predictors of operative time, change in urinary diversion, and biopsy confirmed upper tract recurrence and metastasis. RESULTS: A total of 590 intraoperative ureteral frozen sections were sent for analysis from 241 patients (mean age 69 years). The sections were positive in 12.9% of cases and conversion to negative was accomplished in 82%. Multiple sections were associated with longer operating time (561 vs 511 minutes, p=0.011). Sensitivity for the sections was 100% and specificity was 93.6%. Taking multiple ureteral resections did not alter the planned urinary diversion in any patient or increase perioperative complication rates. At a mean followup of 22±19.8 months, 7 patients (3%) experienced upper tract recurrence. Intraoperative ureteral frozen section conversion to negative was associated with improved overall survival but not with upper tract recurrence. CONCLUSIONS: Our practice of taking intraoperative ureteral frozen sections provided excellent sensitivity and specificity, and the prolonged operative time did not translate into increased perioperative complications. Conversion of positive to negative was associated with improved overall survival, independent of patient comorbidities and post-operative complications. No association was seen with upper tract recurrence but this was likely due to our high conversion rate to negative margins (82%), negative permanent section ureteral margin status in 97% of cases and the long followup time needed to demonstrate an association.

Time course of recovery of erectile function after radical retropubic prostatectomy: does anyone recover after 2 years?

INTRODUCTION: Given the paucity of literature on the time course of recovery of erectile function (EF) after radical prostatectomy (RP), many publications have led patients and clinicians to believe that erections are unlikely to recover beyond 2 years after RP. AIMS: We sought to determine the time course of recovery of EF beyond 2 years after bilateral nerve sparing (BNS) RP and to determine factors predictive of continued improved recovery beyond 2 years. METHODS: EF was assessed prospectively on a 5-point scale: (i) full erections; (ii) diminished erections routinely sufficient for intercourse; (iii) partial erections occasionally satisfactory for intercourse; (iv) partial erections unsatisfactory for intercourse; and (v) no erections. From 01/1999 to 01/2007, 136 preoperatively potent (levels 1-2) men who underwent BNS RP without prior treatment and who had not recovered consistently functional erections (levels 1-2) at 24 months had further follow-up regarding EF. Median follow-up after the 2-year visit was 36.0 months. MAIN OUTCOME MEASURES: Recovery of improved erections at a later date: recovery of EF level 1-2 in those with level 3 EF at 2 years and recovery of EF level 1-3 in those with level 4-5 EF at 2 years. RESULTS: The actuarial rates of further improved recovery of EF to level 1-2 in those with level 3 EF at 2 years and to level 1-3 in those with level 4-5 EF at 2 years were 8%, 20%, and 23% at 3, 4, and 5 years postoperatively, and 5%, 17%, and 21% at 3, 4, and 5 years postoperatively, respectively. Younger age was predictive of greater likelihood of recovery beyond 2 years. CONCLUSION: There is continued improvement in EF beyond 2 years after BNS RP. Discussion of this prolonged time course of recovery may allow patients to have a more realistic expectation.