Comparison of three different tools for prediction of seminal vesicle invasion at radical prostatectomy.

BACKGROUND: Statistical prediction tools are increasingly common, but there is considerable disagreement about how they should be evaluated. Three tools--Partin tables, the European Society for Urological Oncology (ESUO) criteria, and the Gallina nomogram--have been proposed for the prediction of seminal vesicle invasion (SVI) in patients with clinically localized prostate cancer who are candidates for a radical prostatectomy. OBJECTIVES: Using different statistical methods, we aimed to determine which of these tools should be used to predict SVI. DESIGN, SETTINGS, AND PARTICIPANTS: The independent validation cohort consisted of 2584 patients treated surgically for clinically localized prostate cancer at four North American tertiary care centers between 2002 and 2007. INTERVENTIONS: Robot-assisted laparoscopic radical prostatectomy. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary outcome was the presence of SVI. Traditional (area under the receiver operating characteristic [ROC] curve, calibration plots, the Brier score, sensitivity and specificity, positive and negative predictive value) and novel (decision curve analysis and predictiveness curves) statistical methods quantified the predictive abilities of the three models. RESULTS AND LIMITATIONS: Traditional statistical methods (ie, ROC plots and Brier scores) could not clearly determine which one of the three SVI prediction tools should be preferred. For example, ROC plots and Brier scores seemed biased against the binary decision tool (ESUO criteria) and gave discordant results for the continuous predictions of the Partin tables and the Gallina nomogram. The results of the calibration plots were discordant with those of the ROC plots. Conversely, the decision curve indicated that the Partin tables represent the best strategy for stratifying the risk of SVI, resulting in the highest net benefit within the whole range of threshold probabilities. CONCLUSIONS: When predicting SVI, surgeons should prefer the Partin tables over the ESUO criteria and the Gallina nomogram because this tool provided the highest net benefit. In contrast to traditional statistical methods, decision curve analysis gave an unambiguous result applicable to both continuous and binary models, providing an insight into clinical utility.

Laparoscopic partial nephrectomy versus laparoscopic ablative therapy: a comparison of surgical and functional outcomes in a matched control study.

BACKGROUND AND PURPOSE: Patients who are undergoing laparoscopic ablative therapy (LAT) are often older with more comorbidities in comparison with patients who are undergoing laparoscopic partial nephrectomy (LPN). A matched control study was performed to compare the surgical and functional outcomes of LPN and LAT. PATIENTS AND METHODS: A prospectively maintained database of 250 patients who underwent nephron-sparing surgery was explored. Fifty-one LAT patients (21 and 30 laparoscopic radiofrequency and cryoablation, respectively) were matched with 51 LPN patients. A comparison of preoperative, operative, and postoperative outcomes was performed. RESULTS: The groups were similar in age, sex, body mass index, preoperative estimated glomerular filtration rate (eGFR), number of comorbidities and tumor size. Patients who were undergoing LAT had a lower incidence of endophytic tumor and higher incidence of upper pole and midpolar tumors. Hilar vessels clamping was performed in LPN (47/51 patients). Mean estimated blood loss and operative time were higher in those undergoing LPN (P<0.01). There was no significant difference in transfusion rate and hospital stay, however. Mean follow-up was 27 and 18 months in LAT and LPN, respectively (P<0.01). The mean percent decline of eGFR at the last follow-up was 10 (95% confidence interval [CI]: 4-15) and 7.5 (95% CI: 4-11), respectively (P<0.43). In comparison with baseline, eGFR declined significantly (P<0. 01), but there was no difference between the groups. CONCLUSION: Despite renal ischemia, longer operative time, and higher blood loss associated with LPN, the hospital stay and long-term functional outcomes are similar to those of LAT in a matched control study.

Clinical and histologic predictors of renal function decline after laparoscopic partial nephrectomy.

BACKGROUND AND PURPOSE: Clinical and surgical factors predict renal function decline after laparoscopic partial nephrectomy (LPN). Additional histopathologic predictors may be found in the specimen's nonneoplastic tissue but were not studied. This study investigated the significance of histologic findings in addition to other known predictors of renal function after LPN. PATIENTS AND METHODS: Data of 150 patients who underwent LPN was analyzed. Renal function changes (median follow-up 15 months) were correlated with perioperative and histopathologic parameters. Three histopathologic features were evaluated and graded in the nonneoplastic parenchyma: Glomerulosclerosis, arteriosclerosis (AS), and interstitial fibrosis/tubular atrophy. Estimated GFR (eGFR) and percent decline on postoperative day 1 (POD1) and at the last follow-up were measured. RESULTS: Median eGFR percent decline at POD1 and last follow-up was -17 and -10, respectively (P<0.001). New-onset ≥stage III chronic kidney disease developed in only 7% of the patients. Three factors independently predicted POD1 eGFR decline: Artery and vein clamping vs artery only clamping (P=0.002), male sex (P=0.015), and larger tumor (P=0.02). Long-term loss of renal function was associated with POD1 eGFR decline (P=0.002) and the percentage of AS (P=0.01). The study limitations include a retrospective analysis leading to variability in the follow-up length and a small size cohort. CONCLUSIONS: LPN is associated with a favorable renal function outcome in most patients. Pathologic findings in the nonneoplastic tissue, in addition to clinical parameters, can be used to predict which patients are more likely to experience renal function impairment.

Laparoscopic radical versus laparoscopic partial nephrectomy for clinical T1bN0M0 renal tumors: comparison of perioperative, pathological, and functional outcomes.

AIM: To compare outcomes in patients treated with laparoscopic partial nephrectomy (LPN) and laparoscopic radical nephrectomy (LRN) for clinical T1bN0M0 renal masses. MATERIALS AND METHODS: Between 2002 and 2008, 33 and 52 consecutive patients who underwent LPN and LRN, respectively, for clinical stage T1bN0M0 tumors were retrospectively identified from a prospectively maintained database of 450 patients undergoing laparoscopic renal surgery. Perioperative, pathological, and postoperative outcomes were compared. RESULTS: The two groups of patients were similar in age, sex, and body-mass index. Mean radiographic tumor size was smaller (4.8 vs. 5.2 cm, p = 0.04) in the LPN group. Mean operative time (228 vs. 175 minutes, p < 0.0001) and mean estimated blood loss (233 vs. 112 mL, p = 0.003) were higher in the LPN group. Intraoperative complication rates of 15.2% versus 5.7% (p = 0.28) and postoperative complication rates of 24.2% versus 13.5% (p = 0.20) were observed in the LPN and LRN groups, respectively. Overall median follow-up was 15 and 21 months for the LPN and LRN cohorts, respectively. A 12.5% and 29.3% decline in estimated glomerular filtration rate was observed (p = 0.002), and 30.3% compared with 55.7% of patients developed an estimated creatinine clearance (eCrCl) < 60 mL/minutes after treatment (p = 0.04) for LPN and LRN, respectively. There were no differences in pathological stage distribution between the two groups. In the LPN group there were no local or systemic recurrences, and one positive surgical margin was observed. One patient developed metastatic disease in the LRN group. CONCLUSIONS: LPN for T1b renal tumors provides superior intermediate-term preservation of renal function compared with LRN. Continued follow-up of these patients is required to evaluate oncological outcomes.

Localized T1a renal lesions in the elderly: outcomes of laparoscopic renal surgery.

OBJECTIVE: The objective of this study was to compare the outcomes of patients >or=70 years of age undergoing laparoscopic partial nephrectomy (LPN), laparoscopic radical nephrectomy (LRN), and laparoscopic ablative techniques (LAT) for small renal masses. METHODS: From a prospectively maintained database we identified 19 (LRN), 28 (LPN), and 19 (LAT) patients aged >or=70 who underwent surgery for cT1aN0M0 lesions. Perioperative, surgical, and functional outcomes were compared. RESULTS: The three groups were similar in age, race, body mass index, and estimated creatinine clearance. In the LRN group, mean tumor diameter was larger (3.3 vs. 2.4 cm [LPN] and 2.7 cm [LAT]; p = 0.0005) and there was a higher percentage of central tumors (73.7% vs. 25.0% and 5.3%; p < 0.0005) when compared with the LPN and LAT groups, respectively. Although intraoperative and postoperative complication rates were similar, mean estimated blood loss and operative time were highest in the LPN group (p < 0.05). Moreover, 42.1%, 39.3%, and 42.1% of patients had preoperative stage 3 chronic kidney disease in the LRN, LPN, and LAT groups, respectively. Patients who underwent LRN had a lower follow-up estimated creatinine clearance (43.4 vs. 61.4 mL/min [LPN] and 59.2 [LAT]; p < 0.01) and a higher likelihood of developing stage 3 chronic kidney disease after treatment (100% vs. 25.0% [LPN] vs. 18.2 [LAT]; p < 0.0005). CONCLUSIONS: Impaired renal function is common in elderly patients presenting with renal masses. LPN and LAT provide superior preservation of renal function when compared with LRN in this population. In appropriately selected patients >or=70 years of age presenting with T1a renal lesions, laparoscopic nephron-sparing approaches should be considered.

Laparoscopic partial nephrectomy: a single-center evolving experience.

OBJECTIVES: To review our laparoscopic partial nephrectomy (LPN) experience, examine the evolution of technique, and compare the outcomes between the early and recent experience. The indications and surgical technique of LPN continuously evolve. METHODS: Data for 184 patients who underwent LPN for a tumor between October 2002 and August 2008 was retrieved from a prospective database. Surgical and functional outcomes for the entire cohort were analyzed and the first 50 (group 1) and most recent 50 (group 2) cases were compared. RESULTS: The groups were similar in terms of baseline renal function, body mass index, and comorbidities. The mean tumor size and the proportion of central tumors in groups 1 and 2 were 2.4 vs 3 cm and 12% vs 52%, respectively (P <.003). In group 2 we stopped the use of ureteral catheters and bolster renorrhaphy, and routinely clamped the renal hilum. Mean warm ischemia time in groups 1 and 2 (30 and 27 minute, respectively, P = .3) and the complication rate were similar. Overall, patients with tumors >4 cm had more complications (P = .042). In group 2 the estimated blood loss and hospital stay decreased (243 vs 140 mL, P = .01, 1.4 vs 2.5 days, P <.001). Overall 78% of the tumors were malignant and the positive margin rate was 3%. With a median follow-up of 18 months, no local or distant tumor recurrences were observed. CONCLUSIONS: With growing experience and technical modifications, LPN is now performed for patients with larger and more central tumors. Longer follow-up is necessary to evaluate oncologic outcomes.

Laparoscopic partial nephrectomy for tumors larger than 4 cm: a comparative study.

PURPOSE: To compare the perioperative and functional outcomes of patients with clinical T(1a) and T(1b) renal tumors after laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Data of 184 patients who underwent LPN were retrieved from a prospective, Institutional Review Board-approved database. The patients were stratified for analysis into groups: 149 (81%) patients with clinical stage T(1a) (group 1) and 35 (19%) patients with clinical stage T(1b) (group 2). Perioperative and postoperative outcomes were compared. RESULTS: No significant differences between groups 1 and 2 in warm ischemia time, estimated blood loss, operative time, conversion rate, intraoperative complication rate, and hospital stay were observed. The incidence of postoperative complications in group 2, however, was twice that of group 1 (25.7% vs 12%) (P = 0.04). Clinical staging correlated with the pathologic staging in 96% of the patients in group 1 and in only 71% in group 2 (P < 0.001). Upstaging to pT(2) or pT(3) occurred in 29% of the patients in group 2. High-grade tumors were more prevalent in group 2 (36% vs 12%) (P = 0.001). The number of patients with positive margin was higher in group 2, but the difference was not statistically significant. The mean decline in estimated creatinine clearance (median follow-up 18 months) was significantly higher in group 2. CONCLUSIONS: LPN in patients with tumors >4 cm, while safe and feasible in experienced hands, is associated with a higher postoperative complication rate, as well as a higher rate of pathologic upstaging. Such data should be discussed when counseling patients with larger tumors for LPN.

Analysis of continence rates following robot-assisted radical prostatectomy: strict leak-free and pad-free continence.

OBJECTIVES: To propose a strict and specific definition of continence (leak-free and pad-free [LFPF]) and apply it to robot-assisted radical prostatectomy (RARP) outcomes on the basis of University of California-Los Angeles-Prostate Cancer Index (UCLA-PCI), as postprostatectomy incontinence is not well defined. METHODS: A single-institution RARP database was reviewed concerning continence variables prospectively recorded by the UCLA-PCI. Specific responses to urinary function and continence items were reviewed at baseline and 1, 3, 6, 12, and 24 months after surgery. RESULTS: From February 2003 to September 2007, a total of 1005 of 1500 RARP patients had data available for review. At baseline, only 73% of these patients were LFPF. This decreased to 4%, 9%, 17%, 24%, and 28% at 1, 3, 6, 12, and 24 months after surgery, respectively. Applying less strict definitions, at 24 months, 68% of patients reported no pad use and 90% of patients reported no pad use or the use of a security pad. When stratified by baseline LFPF status, patients not LFPF at baseline had higher baseline international prostate symptom score scores, lower urinary function scores, lower urinary bother scores, and larger prostate weights. Patients LFPF at baseline disproportionately regained LFPF continence starting 6 months after surgery compared with those not LFPF at baseline: 20% vs 9% (P = .005), 27% vs 15% (P = .0009), and 33% vs 15% (P = .0146) at 6, 12, and 24 months, respectively. CONCLUSIONS: A strict definition of urinary continence results in more conservative postoperative outcomes. Preoperative LFPF status can be predictive of postoperative LFPF continence. However, only one-third of patients LFPF at baseline returned to LFPF at 24 months.

Continued improvement of perioperative, pathological and continence outcomes during 700 robot-assisted radical prostatectomies.

BACKGROUND: Several robot-assisted radical prostatectomy (RARP) series have reviewed the impact of the initial learning curve on perioperative outcomes. However, little is known about the impact of experience on urinary and sexual outcomes. Herein, we review the perioperative, pathological and functional outcomes of our initial 700 consecutive procedures with at least 1 year follow up. METHODS: From 2003-2006, 700 consecutive men underwent RARP at a single, academic institution. Perioperative data and pathologic outcomes were prospectively collected. Validated, UCLA-PCI-SF36v2 quality-of-life questionnaires were also obtained at 1, 3, 6 and 12 months following surgery. Outcomes between groups (cases 1-300, 301-500, and 501-700) were compared. RESULTS: Mean operative time (OT) and blood loss significantly decreased during the experience (286, 198, 190 min; p or=7 in 24%, 40%, 44%; p

Trifecta outcomes after robotic-assisted laparoscopic prostatectomy.

OBJECTIVE: To evaluate the trifecta outcomes following robotic-assisted laparoscopic prostatectomy (RALP) and compare the results applying definitions of continence and potency as reported in the literature vs validated questionnaire. The trifecta rate of achieving continence, potency, and undetectable prostate-specific antigen (PSA) following radical prostatectomy has been estimated to be approximately 60% at 1-2 years in open radical prostatectomy series. The definitions of continence and potency were not standardized, which poses difficulty in comparing published results. METHODS: A prospective, institutional RALP database was analyzed for preoperatively continent and potent men with >/= 1 year follow-up after bilateral nerve-sparing surgery. Continence and potency were evaluated preoperatively and at 3, 6, 12, and 24 months after surgery by surgeon interview (subjective) and using University of California Los-Angeles Prostate Cancer Index self-administered questionnaire (objective). Biochemical recurrence was defined as a detectable (> 0.05 ng/mL), increasing PSA on 2 consecutive tests. RESULTS: Among 1362 consecutive RALPs, 380 patients were preoperatively potent and continent underwent surgery with bilateral nerve-sparing technique and had sufficient follow-up. Trifecta rates applying subjective continence and potency definitions were 34%, 52%, 71%, and 76% at 3, 6, 12, and 24 months, respectively. The corresponding trifecta rates using objective continence and potency definitions stood at 16%, 31%, 44%, and 44%. The difference was statistically significant at each time point (P < .0001). CONCLUSIONS: RALP provides trifecta outcome rates comparable to open surgery. The outcome rates vary significantly depending on the tools used for continence and potency evaluation.

Pelvic lymphadenectomy during robot-assisted radical prostatectomy: Assessing nodal yield, perioperative outcomes, and complications.

OBJECTIVES: To describe our pelvic lymphadenectomy (PLND) technique during robot-assisted radical prostatectomy and to evaluate the nodal yield and perioperative outcomes. PLND is commonly performed with radical prostatectomy for localized prostate cancer. Because of the limitations of the robotic arm pitch in accessing the pelvic sidewall and undersurface of the iliac bifurcation, uro-oncologists have questioned the adequacy of robotic PLND. METHODS: PLND was routinely performed on men with higher risk preoperative prostate cancer parameters (ie, prostrate-specific antigen >10 ng/mL, primary Gleason score > or =4, or clinical Stage T2b or greater). The outcomes of robot-assisted radical prostatectomy with bilateral, standard template PLND (group 1; n = 296 [26%]) were compared with those of a cohort of 859 robot-assisted radical prostatectomy patients (74%) without PLND (group 2). We also compared these data with those from a single-surgeon experience of open, standard-template PLND for retropubic radical prostatectomy. RESULTS: The mean number of lymph nodes removed was 12.5 (interquartile range 7-16). The mean operative time (224 vs 216 minutes; P = .09), estimated blood loss (206 vs 229 mL; P = .14), and hospital stay (1.32 vs 1.24 days; P = .46) were comparable between the 2 groups. The rate of intraoperative complications (1% vs 1.5%; P = .2), overall postoperative complications (9% vs 7%; P = .8), and lymphocele formation (2% vs 0%; P = .9) were not significantly different. The review of our open series and the historically published open standard-template PLND series revealed a mean yield of 15 and a range of 6.7-15 lymph nodes removed, respectively. CONCLUSIONS: Our data support the feasibility and low complication rate of robotic standard-template PLND with lymph node yields comparable to those with open PLND. Considering the low morbidity of PLND in experienced hands, coupled with the potential of preoperative undergrading and understaging and the therapeutic benefit to patients with micrometastatic disease, an increase in overall standard-template PLND use should be considered.

Is seminal vesiculectomy necessary in all patients with biopsy Gleason score 6?

BACKGROUND AND PURPOSE: Radiotherapists are excluding the seminal vesicles (SVs) from their target volume in cases of low-risk prostate cancer. However, these glands are routinely removed in every radical prostatectomy. Dissection of the SVs can damage the pelvic plexus, compromise trigonal, bladder neck, and cavernosal innervation, and contribute to delayed gain of continence and erectile function. In this study we evaluated the oncological benefit of routine removal of the SVs in currently operated patients. MATERIALS AND METHODS: A total of 1003 patients (mean age, 59.7 years) with prostate cancer underwent robot-assisted radical prostatectomy between February 2003 and July 2007. RESULTS: Seminal vesicle invasion (SVI) was found in 46 of the operated patients (4.6%). Biopsy Gleason score (BGS), preoperative serum PSA, clinical tumor stage, percent of positive cores, and maximal percentage of cancer in a core had all a significant impact on the risk of SVI. Only 4/634 patients (0.6%) with BGS < or =6 suffered from SVI, as opposed to 42/369 (11.4%) with higher Gleason scores. CONCLUSIONS: Seminal vesiculectomy does not benefit more than 99% of the patients with BGS < or =6. Considering the potential neural and vascular damage associated with seminal vesiculectomy, we suggest that routine removal of these glands during radical prostatectomy in these cases is not necessary.

Estimation and prediction of renal function in patients with renal tumor.

PURPOSE: The goals of surgery for renal tumors include the preservation of renal function. When considering surgical options, it is important to accurately assess renal function and the risk of postoperative chronic kidney disease. MATERIALS AND METHODS: An institutional database was used to identify 359 patients who underwent nephrectomy or partial nephrectomy. Creatinine clearance was estimated using 14 previously published models and compared with creatinine clearance measured using a 24-hour urine collection. Models were generated for predicting renal function following nephrectomy or partial nephrectomy. All models were validated with an external data set of 245 patients. RESULTS: Models that accurately estimated creatinine clearance preoperatively and postoperatively were the Cockcroft-Gault model based on actual weight, and the Mawer, Björnsson, Hull and Martin models. In patients with an estimated creatinine clearance between 60 and 89 ml per minute preoperatively the risk of chronic kidney disease (creatinine clearance less than 60 ml per minute) after nephrectomy and partial nephrectomy was 58% and 15%, respectively (p <0.001). In patients undergoing nephrectomy age and weight were independent predictors of decreased creatinine clearance. A predictive model based on age and weight was highly accurate when applied to an external population (R = 0.757). A model for predicting renal function after partial nephrectomy based on age and tumor size was highly accurate in the external population (R = 0.848). A Web based tool was developed to estimate current and predict postoperative creatinine clearance (http://www.roswellpark.org/Patient_Care/Specialized_Services/Renal_Function_Estimator). CONCLUSIONS: The Cockcroft-Gault model based on actual weight is 1 of 5 models that accurately estimates renal function in patients with a kidney tumor. Models were developed and externally validated to predict renal function following nephrectomy.

Multi-institutional external validation of seminal vesicle invasion nomograms: head-to-head comparison of Gallina nomogram versus 2007 Partin tables.

PURPOSE: The Partin tables represent one of the most widely used prostate cancer staging tools for seminal vesicle invasion (SVI) prediction. Recently, Gallina et al. reported a novel staging tool for the prediction of SVI that further incorporated the use of the percentage of positive biopsy cores. We performed an external validation of the Gallina et al. nomogram and the 2007 Partin tables in a large, multi-institutional North American cohort of men treated with robotic-assisted radical prostatectomy. METHODS AND MATERIALS: Clinical and pathologic data were prospectively gathered from 2,606 patients treated with robotic-assisted radical prostatectomy at one of four North American robotic referral centers between 2002 and 2007. Discrimination was quantified with the area under the receiver operating characteristics curve. The calibration compared the predicted and observed SVI rates throughout the entire range of predictions. RESULTS: At robotic-assisted radical prostatectomy, SVI was recorded in 4.2% of patients. The discriminant properties of the Gallina et al. nomogram resulted in 81% accuracy compared with 78% for the 2007 Partin tables. The Gallina et al. nomogram overestimated the true rate of SVI. Conversely, the Partin tables underestimated the true rate of SVI. CONCLUSION: The Gallina et al. nomogram offers greater accuracy (81%) than the 2007 Partin tables (78%). However, both tools are associated with calibration limitations that need to be acknowledged and considered before their implementation into clinical practice.

Robotic laparoscopic radical prostatectomy for biopsy Gleason 8 to 10: prediction of favorable pathologic outcome with preoperative parameters.

PURPOSE: We sought to evaluate the pathologic results and postoperative outcomes for men undergoing robot-assisted laparoscopic radical prostatectomy (RLRP) for biopsy Gleason score (GS) 8 to 10 disease. Stratification of these patients according to preoperative variables was also performed in an attempt to predict organ-confined cancer. PATIENTS AND METHODS: A prospective RLRP database identified all patients with preoperative biopsy GS 8 to 10. Variables, including prostate-specific antigen (PSA), percent positive biopsy cores (%PBC), maximal percentage of cancer in biopsy core (%MCB), clinical stage, pathologic stage, pathologic GS, surgical margins status, lymph node status, time to biochemical recurrence, and recurrence rate, were evaluated. Preoperative variables were treated as continuous and categorical using PSA, %PBC and %MCB cutoffs of 10 ng/mL, 50%, and 30%, respectively. RESULTS: Between February 2003 and September 2007, a total of 1225 RLRPs were performed at the University of Chicago Medical Center. Seventy-two (5.9%) patients had preoperative biopsy GS 8 to 10. Two patients received neoadjuvant hormonal therapy and were excluded. Among 70 patients evaluated, 33 (47%) had organconfined (pT(2)N0) disease. Forty (60.6%) patients had pathologic downgrading to GS

Urinary and sexual quality of life 1 year following robotic assisted laparoscopic radical prostatectomy.

PURPOSE: We evaluated urinary and sexual quality of life 1 year following robotic laparoscopic radical prostatectomy and identified preoperative variables predictive of a severe decrease from baseline. MATERIALS AND METHODS: Using a prospective robotic laparoscopic radical prostatectomy database we identified patients with greater than 1 year of postoperative followup. The UCLA-PCI SF-36v2 questionnaire was used to evaluate urinary and sexual quality of life before and 1 year after surgery. Severe worsening of the postoperative score was defined as a greater than 1 SD decrease. Demographic and preoperative clinical variables were evaluated along with baseline scores on univariate and multivariate analysis. RESULTS: Between February 2003 and September 2007 a total of 1,225 robotic laparoscopic radical prostatectomies were performed at our center and 361 patients (52%) met inclusion criteria. On multivariate analysis baseline urinary function was the only predictor of significant worsening of urinary function (OR 1.04, p = 0.003). Baseline urinary bother was the only predictor of significant worsening of urinary bother (OR 1.05, p <0.0001). A significant decrease in sexual function was predicted by baseline sexual function (OR 1.03, p = 0.0001), baseline sexual bother (OR 1.03, p = 0.005) and nerve sparing technique (OR 0.31, p = 0.05). Predictors of a significant decrease in sexual bother were also baseline sexual function (OR 1.02, p = 0.0001), baseline sexual bother (OR 1.04, p = 0.0007) and nerve sparing technique (OR 0.38, p = 0.02). ORs indicated that higher baseline scores corresponded to a higher risk of postoperative score worsening. CONCLUSIONS: We found that overall better baseline sexual and urinary scores are associated with better postoperative outcomes. However, the risk of a significant decrease in urinary function, urinary bother, sexual function and sexual bother is higher in patients with better baseline scores. Nerve sparing positively affects sexual function and sexual bother.

Long-term functional and oncological outcomes of patients undergoing sural nerve interposition grafting during robot-assisted laparoscopic radical prostatectomy.

PURPOSE: For men with high-volume or high-grade prostate cancer, wide excision of the ipsilateral neurovascular bundle is commonly performed. The concept of nerve reconstruction is intriguing as a feasible approach to preserve sexual function (SF). We sought to evaluate the functional, pathologic, and oncologic outcomes of men who underwent robot-assisted sural-nerve graft (SNG) interposition. PATIENTS AND METHODS: Between February 2003 and May 2007, 1175 consecutive men underwent robot-assisted laparoscopic radical prostatectomy (RLRP). Database analysis identified 27 men who had SNG: 4 bilateral (BL) and 23 unilateral (UL). SF was prospectively evaluated preoperatively and at 1, 3, 6, 12, and 24 months postoperatively using validated questionnaires. Positive surgical margins (PSMs), biochemical recurrence (BCR), and potency were evaluated. RESULTS: Compared with RLRP patients without SNG, patients with SNG were younger (57.2 v 61.8 years, P=0.02), had a higher Gleason score (P=0.02), and had a higher clinical and pathologic stage (P<0.001 for both). Mean surgical time was significantly longer (349 v 195 min, P<0.001) in patients with SNG. With a mean follow-up of 26.1 months, 11 (47.8%) patients with UL-SNG and zero men with BL-SNG regained potency. No significant difference in SF was observed between UL nerve sparing and no SNG (56%) compared with UL nerve sparing with UL-SNG (P=0.44). Rates of return-to-baseline SF (RTB-SF) at 6, 12, and 24 months were 11%, 36% and 45% for UL-SNG, respectively, which were also comparable to UL nerve sparing only (P>0.05). No patient (0%) in the BL-SNG group ever achieved RTB-SF status at any time point. PSMs were observed in 37% (10/27) of all patients. BCR occurred in nine patients (33.3%), seven of whom had PSM (78%); treatment failure occurred within 6 months of surgery, necessitating androgen deprivation therapy. CONCLUSION: Despite optimism regarding SNG, long-term functional outcomes have been disappointing, particularly for BL nerve interposition. UL-SNG functional outcomes do not appear to improve outcomes when compared with men with UL nerve preservation. With the greater risk of PSM and BCR in patients who are considered candidates for SNG, newer treatment modalities are needed to cure their disease while preserving SF.