Transperineal biopsy as a new technique versus well-established transrectal biopsy for diagnosis of prostate cancer - A comparative study.

Introduction: Transrectal (TR) prostate biopsy has been the gold standard for prostate cancer diagnosis for years. With the emergence of transperineal (TP) prostatic biopsy, there is a shift in practice across medical services to adopt TP biopsy as the primary method of prostatic biopsy. Objective: The objective of the study is to compare cancer detection rates and complications between TP and TR biopsies in our region providing single-center experience with introduction of TP biopsy. Patients and Methods: This is a retrospective study utilizing a prospectively designed database comparing consecutive 80 cases of TP biopsy to 80 cases of TR biopsy in a single center. Results: Prebiopsy PSA was 14.2 ± 24.9 ng/dl in the TP group versus 23.7 ± 71.3 ng/dl in the TR group with P = 0.108. Prostate Imaging-Reporting and Data System (PIRAD) 4 and 5 lesions were found in 47 (58.9%) cases of TP biopsy versus 44 (60.3%) of TR group cases and P = 0.131. Cancer was detected in 49 (61.25%) patients in the TP group versus 45 (56.25%) in the TR group with no statistically significant difference and P = 0.665. No cases of hematochezia was reported in TP group, vs 14 (17.5%) reported in TR group with P value <.001. There were no statistically significant differences regarding the incidence of febrile urinary tract infection (UTI), hematuria, and hematospermia in the TP group 0 (0%), 7 (8.75%), and 3 (3.75%) versus 2 (2.50%), 14 (17.50%), and 5 (6.25%) in the TR group with P = 0.497, 0.159, and 0.719 consecutively. Conclusion: TP and TR biopsy have comparable cancer detection rates. TP biopsy has a significantly lower rectal bleeding rate than TR biopsy. There is a trend toward lower febrile UTI in the TP group; however, it did not reach statistical significance.

A mathematical method to estimate angle and distance for percutaneous renal puncture based on computed tomography data: Description and validation.

Introduction: Gaining access to the kidney is crucial step in percutaneous nephrolithotomy (PCNL); it has a steep learning curve. Objective: Describe the mathematical method to predict renal puncture angle and distance based on preoperative computed tomography (CT) measurements. Then evaluating how it correlates with measured values. Patients and Methods: The study was prospectively designed. After ethical committee approval, the study uses data from preoperative CT to construct a triangle so we can estimate puncture depth and angle. A triangle of three points, the first is point of entry to the pelvicalyceal system (PCS), the second is point on the skin perpendicular to it, and the third where the needle punctures the skin. The needle travel is estimated using the Pythagorean theorem and puncture angle using the inverse sine function. We evaluated 40 punctures in 36 PCNL procedures. After PCS puncture using fluoroscopy-guided triangulation, we measured the needle travel distance and angle to the horizontal plane. Then compared the results with mathematically estimated values. Results: We targeted posterior lower calyx in 21 (70%) case. The correlation between measured and estimated needle travel distance with Rho coefficient of 0.76 with P < 0.001. The mean difference between the estimated and the measured needle travel was - 0.37 ± 1.2 cm (-2.6-1.6). Measured and estimated angle correlate with Rho coefficient of 0.77 and P < 0.001. The mean difference between the estimated and the measured angle was 2° ± 8° (-21°-16°). Conclusion: Mathematical estimation of needle depth and angle for gaining access to the kidney correlates well with measured values.

Early predictors of Brucella epididymo-orchitis.

Introduction: Epididymo-orchitis (EO) is a common urological condition. In endemic areas, EO may be the presenting picture of brucellosis. Early suspicion and proper diagnosis is necessary for patient recovery. Objective: The aim of our study is to identify early predictors of Brucella EO. Patients and Methods: We retrospectively collected the data of all patients who were treated at the Urology Unit, Farwaniya Hospital, with acute EO above the age of 12 years between April 2017 and February 2019. Data from electronic and hardcopy files were gathered and analyzed. The diagnosis of acute EO was based on clinical, laboratory, and radiological findings. A total of 120 patients under the diagnosis of EO, epididymitis, and orchitis were reviewed. Thirty-one patients were tested for Brucella based on the history of animal contact, ingestion of unpasteurized dairy products, or persistent fever for more than 48 h. of those patients, 11 tested positive for Brucella orchitis. Results: A comparison between Brucella-positive and Brucella-negative patients regarding age, presence of fever, complete blood count (CBC) parameters, pyuria, and abscess formation was made. In the Brucella group, 72% of the patients had a history of animal contact compared to 33% in non-Brucella group (P = 0.006). When comparing CBC parameters in the two groups, Brucella group had statistically significant lower total leukocytic count and neutrophil count (mean ± standard deviation [SD]) 13.07 ± 4.22, 6.4 ± 9.98 versus Brucella negative group 17.35 ± 5.28, 7.8 ± 10.53, and P values were 0.037 and 0.004, respectively. Brucella group showed lymphocytosis (mean ± SD) 25.95 ± 9.78 versus non-Brucella group 13.22 ± 8.05 and P < 0.01. Conclusion: Brucella orchitis constituted 9% of the orchitis patients treated in our hospital. Patients with a history of animal contact, EO with lymphocytosis, and relative neutropenia should raise the suspicion for Brucella orchitis in endemic areas.

Oral dissolution therapy for renal radiolucent stones, outcome, and factors affecting response: A prospective study.

BACKGROUND: Urolithiasis is a widespread problem, that affects up to 10% of population. Uric acid stones come second to calcium stones in prevalence (around 10% of urolithiasis). Potassium citrate is currently the treatment of choice for urine alkalization with minimal side effects and high tolerability. AIMS AND OBJECTIVES: This study is trying to present the outcome of oral dissolution therapy (ODT) for treating radiolucent renal stones and evaluating factors affecting its success in a prospective manner. MATERIALS AND METHODS: Between 2015 and 2018, 147 patients with solitary radiolucent renal stones were offered ODT using potassium sodium hydrogen citrate (K citrate). The study included patients diagnosed by noncontrast computed tomography (NCCT) with stone size of 5-30 mm in the longest dimension and attenuation less than 600 Hounsfield units (HU). Patient compliance, blood pressure, creatinine level, K level, and tolerance to side effects were followed up at days 3, 7, and 15 and then monthly for 3 months. Follow-up renal ultrasound at 6-week intervals and a final NCCT at the end of treatment. Successful dissolution was defined as complete stone dissolution or residual that measures up to 2 mm in maximum length. Data were collected, tabulated, and analyzed using Stata 12.0 software (Stata Corporation, College Station, TX, USA). RESULTS: One hundred and thirty-nine patients were included in the analyses. The age was 45.1 ± 10.5 years. DJ stent was used in 47 (33.8%) patients. Overall response rate was 64.8%. The stone location within the kidney (pelvic or calyceal) showed no difference between responders and non-responders. Stone longest diameter was smaller in responders (17 ± 5.7 mm) versus 19.2 ± 6.1 mm in nonresponders (P value = 0.039). The mean stone attenuation value (HU) was also lower in responders (347.4 ± 68.5 HU) versus (428.9 ± 84.0 HU) in nonresponders with P < 0.001. DJ insertions seemed to have marginal effect on stone dissolution on univariate analysis but found insignificant in multivariate analysis. CONCLUSION: ODT is safe and effective in the treatment of radiolucent renal stones. The efficacy was affected by stone density and stone size with more tendencies to failure with bigger stones and denser stones. Double J stent insertion may facilitate dissolution rate. There was no effect of the baseline urinarypH, hyperuricemia, or stone location on the dissolution rate of the stones.

Outcome of staged buccal mucosal graft for repair of long segment anterior urethral stricture.

BACKGROUND: Long anterior urethral stricture due to variable etiological factors constitutes a challenge for reconstruction. We evaluated our centers experience with cases of long anterior urethral stricture due to different etiologies that were managed by 2-stage substitution urethroplasty using buccal mucosal graft procedure. METHODS: During the period between November 2009 and November 2016. All cases with long anterior urethral stricture that were planned for substitution urethroplasty in our department were enrolled in this study. The first stage was excision of most fibrotic areas of the urethral plate, the remaining of the urethra is laid open and augmented with buccal mucosal graft for second stage closure after 6-9 months. RESULTS: The study included 123 patients who underwent first stage, 105 patients of them underwent second stage urethroplasty. Eighteen cases were missed after first stage. The mean (range) age was 38.4 (17-60 years). The mean (range) stricture length was 8.3 (4-13 cm). The cause of stricture was idiopathic in 47, inflammatory in 15, lichen sclerosus in 26 and post failed hypospadias repair in 35 patients. First stage was complicated by graft contracture in 11 (8.9%) patients that needed re-grafting, 5(4.1%) patient had bleeding from the buccal mucosa site that needed haemostatic sutures, oral numbness was reported in 7 (5.7%) patients. Second stage was complicated by wound dehiscence in 2(1.9%) patients, restricture in 11 (10.5%), fistula in 6 (5.7%) patients, meatal stenosis in 3 (2.9%). The overall success rate was 79.1% (83 cases out of 105) with a mean (range) follow-up of 34.7 (10-58 months). CONCLUSIONS: Staged urethroplasty using buccal mucosal graft procedure is an effective surgical option for patients with long anterior urethral strictures especially for patients with lichen sclerosus and those with failed previous surgical repair.

Vitamin D deficiency and lower urinary tract symptoms in males above 50 years of age.

CONTEXT: Lower urinary tract symptoms (LUTSs) in elderly males are usually related to benign prostatic hyperplasia (BPH) in the majority of cases. It is estimated that BPH affects half of men above the age of 50 years. Recently, a relationship between Vitamin D deficiency and LUTS in elderly males has been reported. AIMS: The aim of this study was to analyze Vitamin D levels in males aged above 50 years presenting with LUTS. SETTINGS AND DESIGN: This is a prospective case-control study. PATIENTS AND METHODS: This was a case-control study in which males above 50 years of age who presented with LUTS (Group A) were compared with a control group (Group B) without LUTS. Both groups were investigated regarding Vitamin D level, prostate-specific antigen (PSA), International Prostatic Symptoms Score (IPSS), prostate size, flow rate, serum calcium levels, and abdominal ultrasonography. STATISTICAL ANALYSIS USED: Statistical software package (SPSS Inc., Chicago, IL, USA) was used for the statistical analyses, performing t-test for quantitative data to compare between the two groups. Pearson's correlation coefficient "r" test was calculated between two quantitative, continuous variables in Group A. P <0.05 was considered statistically significant. RESULTS: A total of 150 patients were studied. There were 70 and 80 patients in Groups A and B, respectively. The mean age of Group A patients was 60.32 ± 11.93 years versus 58.12 ± 10.55 years for Group B patients (P > 0.05). The mean value of Vitamin D level was 40.82 ± 29.46 nmol/L in Group A and 70.25 ± 22.42 nmol/L in Group B (P < 0.001). The mean value of prostate size was 50.12 ± 23.24 g in Group A and 30.68 ± 4.90 g in Group B (P < 0.001). The mean serum calcium level was 2.4 ± 0.14 mmol/L and 2.50 ± 0.15 mmol/L in Groups A and B, respectively (P < 0.001). The mean value of PSA in Group A was 2.24 ± 1.95 ng/ml versus 2.11 ± 0.45 ng/ml in Group B (P < 0.001). The mean value of IPSS in Group A was 13.38 ± 5.32 ml/s versus 3.41 ± 2.42 ml/s in Group B. The mean value of Q max in uroflowmetry in Group A was 11.5 ± 2 ml/s versus 15.4 ± 1 ml/s in Group B. CONCLUSIONS: Men older than 50 years of age with LUTS have lower levels of Vitamin D compared to men without LUTS.

Management of equivocal (early) Fournier's gangrene.

BACKGROUND: Fournier's gangrene (FG) is an acute progressive necrotizing fasciitis of the genital area and perineum with possible extension to the abdominal wall. Surgical debridement is the gold standard management modality of established patients. Equivocal (early) FG represents a challenge in diagnosis. The objective of this study was to compare conservative management and early exploration in cases of equivocal (early) FG. METHODS: This was an observational study where data of all patients diagnosed as early FG in our departments over 4 years (2011-2015) were enrolled. Patients were divided into two groups: group 1 with conservative treatment, and group 2 managed with urgent exploration with longitudinal hemiscrotal incision starting from external inguinal ring. All patients' demographics, vital signs, laboratory finding and clinical findings were reported. RESULTS: A total of 28 patients were enrolled in the study. Group 1 was managed with conservative treatment (17 patients) and group 2 underwent urgent exploration (11 patients). Overall, four patients (23.5%) out of 17 patients of group 1 showed a good response to conservative management without any surgical debridement. A total of 13 patients (76.5%) developed gangrenous discoloration and needed surgical debridement later. In group 2, four patients (36.4%) underwent scrotal exploration and release incision only without debridement and showed an excellent clinical outcome. A total of four patients (36.4%) underwent debridement with excision of doubtful deep subcutaneous and fascial tissues. The remaining three patients (27.2%) underwent debridement of necrotic fascia. The hospital stay was significantly shorter in group 2 patients than group 1 (7.5 ± 3.75 versus 13.4 ± 5.19 days p < 0.05). The mean number of debridement sessions was 3.74 ± 0.69 in group 1 versus 1.82 ± 0.34 in group 2. CONCLUSIONS: Early exploration and debridement in equivocal (early) FG has a better clinical outcome with reduced hospital stay and number of debridement sessions than conservative treatment with delayed debridement.

Management of upper ureteral stones exceeding 15 mm in diameter: Shock wave lithotripsy versus semirigid ureteroscopy with holmium:yttrium-aluminum-garnet laser lithotripsy.

OBJECTIVES: We conducted a retrospective study to evaluate the efficacy and outcome of shock wave lithotripsy versus semirigid ureteroscopy in the management of the proximal ureteral stones of diameter exceeding 15 mm. METHODS: During the 2009-2014 study period, 147 patients presenting with the proximal ureteral stones exceeding 15 mm in diameter were treated. Both shock wave lithotripsy and ureteroscopy with laser lithotripsy were offered for our patients. A 6/8.9 Fr semirigid ureteroscope was used in conjunction with a holmium:yttrium-aluminum-garnet laser. The stone-free rate was assessed at 2 weeks and 3 months post-treatment. All patients were evaluated for stone-free status, operation time, hospital stay, perioperative complications, and auxiliary procedures. RESULTS: Of the 147 patients who took part in this study, 66 (45%) had undergone shock wave lithotripsy and 81 (55%) underwent ureteroscopy. At the 3-month follow-up, the overall stone-free rate in the shock wave lithotripsy group was 39/66 (59%) compared to 70/81 (86.4%) in the ureteroscopic laser lithotripsy group. Ureteroscopic laser lithotripsy achieved a highly significant stone-free rate (p = 0.0002), and the mean operative time, auxiliary procedures, and postoperative complication rates were comparable between the two groups. CONCLUSION: In terms of the management of proximal ureteral stones exceeding 15 mm in diameter, ureteroscopy achieved a greater stone-free rate and is considered the first-line of management. Shock wave lithotripsy achieved lower stone-free rate, and it could be used in selected cases.

Balloon dilator versus telescopic metal dilators for tract dilatation during percutaneous nephrolithotomy for staghorn stones and calyceal stones.

OBJECTIVE: To compare the results of balloon dilatation (BD) vs. telescopic metal dilators (TMDs) in establishing the tract for percutaneous nephrolithotomy (PCNL) in patients with calyceal stones or staghorn stones, but with no hydronephrosis. PATIENTS AND METHODS: Data from selected patients over 4 years were recorded retrospectively. Patients with complex staghorn stones, an undilated targeted calyx, or the stone filling the targeted calyx, were included in the study. In all, 97 patients were included, of 235 undergoing PCNL between March 2010 and March 2014, and were divided into two groups according to the technique of primary tract dilatation. Group A included patients who had BD and group B those treated using TMDs. RESULTS: In group A (BD, 55 patients) dilatation was successful in 34 (62%). The dilatation failed or there was a need for re-dilatation using TMD in 21 patients (38%). In one of these 21 patients the dilatation failed due to extravasation. In group B (TMD, 42 patients) dilatation was successful in 38 (90%) patients, with incomplete dilatation and a need for re-dilatation in four (10%) patients, and no failed procedures. Group A had a significantly higher failure rate than group B (P < 0.001). Differences in operative duration, blood loss, stone-removal success rate and complication rate were statistically insignificant. CONCLUSION: BD has a higher failure rate than TMD when establishing access for calyceal stones or staghorn stones that have little space around them.

The relationship between perioperative blood transfusion and overall mortality in patients undergoing radical cystectomy for bladder cancer.

OBJECTIVES: The relationship between perioperative blood transfusion (PBT) and oncologic outcomes is controversial. In patients undergoing surgery for colon cancer and several other solid malignancies, PBT has been associated with an increased risk of mortality. Yet, the urologic literature has a paucity of data addressing this topic. We sought to evaluate whether PBT affects overall survival following radical cystectomy (RC) for patients with bladder cancer. METHODS: The medical records of 777 consecutive patients undergoing RC for urothelial carcinoma of the bladder were reviewed. PBT was defined as transfusion of red blood cells during RC or within the postoperative hospitalization. The primary outcome was overall survival. Clinical and pathologic variables were compared using χ(2) tests, and Cox multivariate survival analyses were performed. RESULTS: A total of 323 patients (41.6%) underwent PBT. In the univariate analysis, PBT was associated with increased overall mortality (HR 1.40, 95% CI 1.11-1.78). Additionally, an independent association was demonstrated in a non-transformed Cox regression model (HR, 95% CI 1.01-1.36) but not in a model utilizing restricted cubic splines (HR 1.03, 95% CI 0.77-1.38). The c-index was 0.78 for the first model and 0.79 for the second. CONCLUSIONS: In a traditional multivariate model, mirroring those that have been applied to this question in the general surgery literature, we demonstrated an association between PBT and overall mortality after RC. However, this relationship is not observed in a second statistical model. Given the complex nature of adequately controlling for confounding factors in studies of PBT, a prospective study will be necessary to fully elucidate the independent risks associated with PBT.

The use of a biological model for comparing two techniques of fluoroscopy-guided percutaneous puncture: A randomised cross-over study.

OBJECTIVES: To develop a new and inexpensive model for training in fluoroscopic puncture into the pelvicalyceal system, and to use this model to compare the learning curve of two fluoroscopic techniques, the 'eye of the needle' (EN) and triangulation techniques. MATERIALS AND METHODS: For the trial we used a commercial plastic model (a shop-window mannequin) in which a bovine kidney, embedded in sponge with a spatial orientation similar to the human, was inserted into the model. The ureter of the animal kidney was connected to contrast fluid. Ten residents and interns were randomised into two groups; group A started the puncture using the EN technique, each member making five attempts, and then five attempts using the triangulation technique, and group B started with triangulation and then used the EN technique. RESULTS: There was no statistically significant difference between the techniques for the mean (SD) number of trials to make a correct puncture, at 2.68 (1.00) in the EN technique and 2.86 (1.05) in the triangulation technique, or for the duration of each trial, at 523 (189) s for the EN technique and 578 (175) s for the triangulation technique. The fluoroscopy time was less in the EN technique, at 113.9 (48.9) s than for the triangulation method, at 135.8 (42.4) (P < 0.005). CONCLUSIONS: The model was easy to construct and feasible for training. Both techniques had a similar learning curve, with higher fluoroscopy exposure for the triangulation technique.

Prostate size as a predictor of Gleason score upgrading in patients with low risk prostate cancer.

PURPOSE: Gleason score upgrading between biopsy and surgical pathological specimens occurs in 30% to 50% of cases. Predicting upgrading in men with low risk prostate cancer may be particularly important since high grade disease influences management decisions and impacts prognosis. We determined whether prostate size predicts Gleason score upgrading in patients with low risk prostate cancer. MATERIALS AND METHODS: A total of 1,251 consecutive patients with D'Amico low risk disease and complete data available underwent radical prostatectomy at our institution between January 2000 and June 2008. Patients were divided into 3 groups by pathological Gleason score, including no, minor (3 + 4 = 7) and major (4 + 3 = 7 or greater) Gleason score upgrading. We developed bivariate and multivariate models to determine whether prostate size was an important predictor of upgrading while controlling for clinical and biopsy characteristics. RESULTS: Of 1,251 cases 387 (31.0%) were upgraded, including 324 (26%) and 63 (5%) with minor and major upgrading, respectively. As expected, Gleason score upgrading was associated with worse pathological and cancer control outcomes. On multivariate analysis smaller prostate size was an independent predictor of any and major upgrading (OR 0.58, 95% CI 0.48-0.69, p <0.01 and OR 0.67, 95% CI 0.49-0.96, p = 0.03, respectively). Men with prostate volume at the 25th percentile (36 cm(3)) were 50% more likely to experience upgrading than men with prostate volume at the 75th percentile (58 cm(3)). CONCLUSIONS: Of low risk cases 31% were upgraded at final pathology. Smaller prostate size predicts Gleason score upgrading in men with clinically low risk prostate cancer. This is important information when counseling patients on management and prognosis.

Successful control of schistosomiasis and the changing epidemiology of bladder cancer in Egypt.

Schistosomiasis is a parasitic disease caused by flatworms that live in snail-infested fresh water. It is endemic to 74 countries and affects some 200 million people worldwide, causing an estimated 200,000 deaths annually [1]. Schistosomiasis can affect the gastrointestinal tract and liver (S. mansoni and S. japonicum species), resulting in diarrhoeal disease and hepatic fibrosis, or the urinary tract (S. haematobium) where it causes haematuria, strictures, obstruction, super-infection and, ultimately, cancer. In children and vulnerable adults, systemic effects such as anaemia, malnutrition, stunted growth and impaired cognition can be profound. The association between this parasitic infestation and the development of bladder cancer literally took millennia to uncover. It is unusual for a parasitic disease to result in a fatal neoplastic process, and rarer still to have public health efforts, aimed at eradication of the parasitic menace, to result in a dramatic shift in the epidemiology of the most common cancer in a nation.

Tumor volume as a predictor of adverse pathologic features and biochemical recurrence (BCR) in radical prostatectomy specimens: a tale of two methods.

PURPOSE: The prognostic value of tumor volume in predicting biochemical recurrence after prostatectomy has been debated. Our aim in this study was to (a) evaluate tumor volume as an independent predictor of adverse pathologic outcomes and BCR and (b) determine the effect of two different methods of tumor volume estimation. METHODS: We reviewed the charts of 3,087 patients who underwent radical prostatectomy at Vanderbilt University Medical Center between 2000 and 2008; of which 1,747 patients had data sufficient for analysis. Prostate specimens were processed as whole mount between 2000 and 2003 and then via systematic sampling from 2003 to 2008, with tumor volume measured by planimetry in the whole-mount group and tumor volume estimated by percent tumor involvement in the systematic sampling group. RESULTS: Tumor volume estimates were higher with SS than with WM. There were significant associations between larger tumor volume and adverse pathological outcomes, regardless of pathologic method (all with P<0.001). Controlling for other pathologic parameters, tumor volume was an independent predictor of PGS, EPE, and SM in logistic regression models (P<0.001 for TV in all models). Tumor volume was demonstrated to be an independent predictor of BCR in the WM group (1.06, 95% CI 1.01-1.11, P=0.013), though tumor volume was not a significant predictor of BCR in the SS group. CONCLUSIONS: Though the prognostic value of tumor volume is debated, our data demonstrate that tumor volume, when calculated via planimetry on whole-mount pathologic sectioning, is a significant predictor of biochemical recurrence after prostatectomy.

Determining factors for hospital discharge status after radical cystectomy in a large contemporary cohort.

PURPOSE: We describe hospital discharge status in patients after radical cystectomy for bladder cancer. We determined factors affecting discharge status. MATERIALS AND METHODS: The 445 patients underwent radical cystectomy for urothelial carcinoma from January 2004 to December 2007. Patients were grouped by hospital discharge status into 1 of 4 groups, including home under self-care without services, home with home health services, subacute, rehabilitation or skilled nursing facility, or hospice/in-hospital mortality. We compared clinical, perioperative and pathological variables in these groups. We also examined the association of discharge status with the hospital readmission rate and 90-day mortality. RESULTS: Of the 440 patients 250 (56.8%), 145 (32.9%), 39 (8.9%) and 6 (1.4%) were in the home without services, home with services, facility and mortality groups, respectively. On multivariate analysis older age, lower preoperative albumin, unmarried status and higher Charlson comorbidity index were predictors of discharge home with services while older age, poor preoperative exercise tolerance and longer hospital stay predicted discharge to a facility. Patients in the facility group were more likely to die within 90 days of surgery than those who returned home independently or with services. There was no difference in the likelihood of rehospitalization. CONCLUSIONS: Sociodemographic factors, preoperative performance status, and comorbidities and perioperative factors contribute to the discharge decision after radical cystectomy. Some subgroups can be predicted to have increased postoperative care needs and may be appropriate targets for disposition planning preoperatively.

Effect of preoperative nutritional deficiency on mortality after radical cystectomy for bladder cancer.

PURPOSE: Poor preoperative nutritional status is a risk factor for adverse outcomes after major surgery. We evaluated the effect of preoperative nutritional deficiency on perioperative mortality and overall survival in patients undergoing radical cystectomy for bladder cancer. MATERIALS AND METHODS: A total of 538 patients underwent radical cystectomy for urothelial carcinoma between January 2000 and June 2008, and had nutritional parameters documented. Patients with preoperative albumin less than 3.5 gm/dl, body mass index less than 18.5 kg/m(2) or preoperative weight loss greater than 5% of body weight were considered to have nutritional deficiency. Primary outcomes were 90-day mortality and overall survival. Survival was estimated using Kaplan-Meier analysis and compared using the log rank test. Cox proportional hazards models were used for multivariate survival analysis. RESULTS: Of 538 patients 103 (19%) met the criteria for nutritional deficiency. The 90-day mortality rate was 7.3% overall (39 deaths), with 16.5% in patients with nutritional deficiency and 5.1% in the others (p < 0.01). Nutritional deficiency was a strong predictor of death within 90 days on multivariate analysis (HR 2.91; 95% CI 1.36, 6.23; p < 0.01). Overall survival at 3 years was 44.5% (33.5, 54.9) for nutritionally deficient patients and 67.6% (62.4, 72.2) for those who were nutritionally normal (p < 0.01). On multivariate analysis nutritional deficiency cases had a significantly higher risk of all cause mortality (HR 1.82; 95% CI 1.25, 2.65; p < 0.01). CONCLUSIONS: Nutritional deficiency, as measured by preoperative weight loss, body mass index and serum albumin, is a strong predictor of 90-day mortality and poor overall survival. Prospective studies are needed to demonstrate the best indices of preoperative nutritional status and whether nutritional intervention can alter the poor prognosis for patients treated with radical cystectomy who have nutritional deficiencies.

Comparative analysis of whole mount processing and systematic sampling of radical prostatectomy specimens: pathological outcomes and risk of biochemical recurrence.

PURPOSE: Whole mount processing is more resource intensive than routine systematic sampling of radical retropubic prostatectomy specimens. We compared whole mount and systematic sampling for detecting pathological outcomes, and compared the prognostic value of pathological findings across pathological methods. MATERIALS AND METHODS: We included men (608 whole mount and 525 systematic sampling samples) with no prior treatment who underwent radical retropubic prostatectomy at Vanderbilt University Medical Center between January 2000 and June 2008. We used univariate and multivariate analysis to compare the pathological outcome detection rate between pathological methods. Kaplan-Meier curves and the log rank test were used to compare the prognostic value of pathological findings across pathological methods. RESULTS: There were no significant differences between the whole mount and the systematic sampling groups in detecting extraprostatic extension (25% vs 30%), positive surgical margins (31% vs 31%), pathological Gleason score less than 7 (49% vs 43%), 7 (39% vs 43%) or greater than 7 (12% vs 13%), seminal vesicle invasion (8% vs 10%) or lymph node involvement (3% vs 5%). Tumor volume was higher in the systematic sampling group and whole mount detected more multiple surgical margins (each p <0.01). There were no significant differences in the likelihood of biochemical recurrence between the pathological methods when patients were stratified by pathological outcome. CONCLUSIONS: Except for estimated tumor volume and multiple margins whole mount and systematic sampling yield similar pathological information. Each method stratifies patients into comparable risk groups for biochemical recurrence. Thus, while whole mount is more resource intensive, it does not appear to result in improved detection of clinically important pathological outcomes or prognostication.

Robotic assisted laparoscopic prostatectomy versus radical retropubic prostatectomy for clinically localized prostate cancer: comparison of short-term biochemical recurrence-free survival.

PURPOSE: We compared biochemical recurrence-free survival of patients who underwent radical retropubic prostatectomy vs robot assisted laparoscopic prostatectomy in concurrent series at a single institution. MATERIALS AND METHODS: A total of 2,132 patients were treated between June 2003 and January 2008. We excluded from study patients with prior treatment (115), missing data (83) and lymph node involvement (30). The remaining cohort (1,904) was compared based on clinical, surgical and pathological factors. Kaplan-Meier analysis was performed comparing biochemical recurrence after robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy. A Cox proportional hazards model was generated to determine whether surgical approach is an independent predictor of biochemical recurrence. RESULTS: There were 491 radical retropubic prostatectomies (25.9%) and 1,413 robot assisted laparoscopic prostatectomies (74.1%) performed, and median followup was 10 months (IQR 2 to 23). On univariate analysis the robot assisted laparoscopic prostatectomy group was slightly lower risk with lower median prostate specific antigen (5.4 vs 5.8, p <0.01), a lower proportion of pathological grade 7-10 (48.5% vs 54.7%, p <0.01) and lower pathological stage (80.5% pT2 vs 69.6% pT2, p <0.01). The 3-year biochemical recurrence-free survival rate was similar between the robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy groups on the whole as well as when stratified by pathological stage, grade and margin status. On multivariate analysis extracapsular extension (p <0.01), pathological grade 7 or greater (p <0.01) and positive surgical margin (p <0.01) were independent predictors of biochemical recurrence while surgical approach was not. CONCLUSIONS: The likelihood of biochemical recurrence was similar between groups when stratified by known risk factors of recurrence. Surgical approach was not a significant predictor of biochemical recurrence in the multivariate model. Our analysis is suggestive of comparable effectiveness for robot assisted laparoscopic prostatectomy, although longer term studies are needed.

Impact of positive apical surgical margins on likelihood of biochemical recurrence after radical prostatectomy.

PURPOSE: We evaluated whether a positive surgical margin at the apex confers a different likelihood of biochemical recurrence than at other sites. MATERIAL AND METHODS: A total of 3,087 men underwent radical prostatectomy between January 2000 and June 2008. Patients with prior treatment, positive seminal vesicles, lymph node involvement or less than 6 months of followup were excluded from analysis. The remaining 1,667 men were grouped by margin status, including negative surgical margins, a solitary positive apical margin, a solitary nonapical positive margin and multiple positive margins. Kaplan-Meier analysis was used to compare biochemical recurrence across groups. Cox proportional hazards models were constructed to determine whether a solitary positive apical margin is an independent risk factor for biochemical recurrence. RESULTS: Median followup was 21.1 months. Of the cases 1,295 (77.7%) had negative surgical margins, 96 (5.8%) had a solitary positive apical margin, 82 (4.9%) had a solitary positive nonapical margin and 194 (11.6%) had multiple positive margins. The likelihood of biochemical recurrence in solitary positive apical margin cases was between that of negative surgical margins and a solitary positive nonapical margin with multiple positive margins showing the highest likelihood of biochemical recurrence (p <0.001). Three-year likelihood of freedom from biochemical recurrence was 94.7% (95% CI 92.7-96.2), 87.0% (95% CI 74.1-93.7), 81.4% (95% CI 67.2-89.9) and 73.0% (95% CI 63.9-80.2) for negative surgical margins, a solitary positive apical margin, a solitary positive nonapical margin and multiple positive margins, respectively. In the multivariate model a solitary positive nonapical margin (2.17, 95% CI 1.17-4.03, p = 0.01) and multiple positive margins (3.03, 95% CI 1.99-4.61, p <0.001) were independent predictors of biochemical recurrence but a solitary positive apical margin was not (1.34, 95% CI 0.65-2.75, p = 0.43). CONCLUSIONS: A solitary positive apical margin was associated with worse biochemical recurrence but on multivariate analysis it was not an independent predictor of recurrence. Models to predict biochemical recurrence after radical prostatectomy should account for differences in the prognostic significance of different positive margin sites.

Pathological stage T2 subgroups to predict biochemical recurrence after prostatectomy.

PURPOSE: We evaluated whether the 2002 TNM substages of pathological T2 prostate cancer predict intermediate term biochemical recurrence-free survival. MATERIALS AND METHODS: The cohort consisted of men who underwent radical prostatectomy between January 2000 and June 2008, and had pT2 disease at final pathological evaluation. We excluded patients with prior treatment, less than 6 months of followup or missing data, leaving 1,370 available for analysis, including 340 with pT2a, 35 with pT2b and 995 with pT2c disease. Clinical and pathological characteristics were compared between groups using univariate analysis. Biochemical recurrence-free survival was compared between substages using Kaplan-Meier analysis. A Cox proportional hazards model was used to evaluate tumor substage as a biochemical recurrence-free survival predictor. RESULTS: Median followup was 21 months. No differences were seen in the likelihood of biochemical recurrence-free survival between T2 subclasses (p = 0.174). No patient with T2b disease had recurrence. The 3 and 5-year likelihood of freedom from biochemical recurrence was 95.5% (95% CI 90.9-97.8) and 93.8% (95% CI 87.3-97.0) for pT2a, and 94.3% (95% CI 91.8-96.0) and 87.5% (95% CI 82.7-91.1) for pT2c, respectively. Multivariate analysis showed that significant predictors of biochemical recurrence-free survival were margin status (HR 2.7, 95% CI 1.3-5.5, p = 0.006), preoperative prostate specific antigen (HR 1.0, 95% CI 1.0-1.1, p = 0.029), pathological Gleason score 7 (HR 2.5, 95% CI 1.1-5.7, p = 0.024) and pathological Gleason score 8-10 (HR 6.2, 95% CI 2.2-17.4, p <0.001). Compared to pathological stage T2a neither pT2b nor pT2c predicted biochemical recurrence-free survival (p = 0.99 and 0.42, respectively). CONCLUSIONS: Current pT2 prostate cancer substages may not have prognostic significance for intermediate term outcomes. If borne out during longer followup, future staging systems may collapse the substages into a single category.