U.S. Army Medical Corps Recruitment, Job Satisfaction, and Retention: Historical Perspectives and Current Issues.

INTRODUCTION: This study was conducted to identify and understand the current factors affecting recruitment, job satisfaction, and retention of U.S. Army Medical Corps officers and provide historical background to understand if the current factors are dissimilar. MATERIALS AND METHODS: An anonymous, voluntary questionnaire was sent to U.S. Army Medical Corps officers, and responses were tabulated and analyzed. Historical research was conducted and historical analysis applied. RESULTS: Recruiting, job satisfaction, and retention among Army Medical Corps Officers have been problematic throughout the 50-year history of the all-volunteer force. Recruiting has largely been of medical students, with very limited numbers of direct accessions. At times, satisfactory overall numbers have camouflaged shortages in key go-to-war specialties. Also, satisfactory numbers in a specialty have sometimes camouflaged problems in depth of experience. Satisfaction has been seen as a problem but apparently only studied informally and/or episodically. Retention has largely been addressed through service obligations, followed by monetary bonuses, although these have to be across the Department of Defense, limiting service flexibility. There has never been consistent, longitudinal sampling of opinion among Medical Corps Officers to allow senior leaders to influence the Department of Defense policy. A recent (2016) study provides substantial data but should be repeated rather than being isolated. CONCLUSION: As the situation in the Department of Defense and Army Medical Department changes, with more focus on go-to-war specialties, the Army needs to better measure opinion among Medical Corps Officers to inform policy. These studies should be conducted regularly to generate reliable information on trends and allow prioritization of effort to areas that hamper recruiting, undermine satisfaction, and prevent retention.

Army Physician Career Satisfaction Based on a Medical Corps Survey.

INTRODUCTION: It is critical the U.S. Army retains skilled physicians in the Medical Corps (MC) to ensure direct support to military operations and medical readiness. The purpose of this study was to examine U.S. Army physicians' opinions concerning: readiness to perform required duties, work environment, support and recognition they receive, military career intentions, and how these factors may relate to Army physician job satisfaction. MATERIALS AND METHODS: A cross-sectional study of Army physicians was conducted using a 45-item web-based survey tool, "Army Medicine Medical Corps (MC) Engagement/Satisfaction Survey 2018." The survey used a combination of multiple choice (Likert-scaled and categorical) and open text statements and questions. Satisfaction with their Army physician career was measured using a 5-point unipolar Likert scale response on level of satisfaction. Chi-square tests of independence were conducted on all demographic characteristics to examine if levels of satisfaction with Army physician career were associated with a particular demographic profile. Agreement opinions expressed on 20 statements about professional readiness, work environment, and job recognition were summarized and rank-ordered by percentage of "strongly agree" responses. Categorical responses to several questions related to career intentions were summarized overall and by career satisfaction level. Multivariate logistic regression was performed to identify demographic factors, which may influence career satisfaction as an Army physician. RESULTS: Approximately 47% (2,050/4,334) of U.S. Army physicians participated in the MC 2018 survey. Career satisfaction percentages overall were: "extremely satisfied" (10.0%), "quite satisfied" (24.8%), "moderately satisfied" (33.9%), "slightly satisfied" (22.6%), and "not at all satisfied" (8.3%). Respondents were in least agreement to statements about sufficient administrative support and recognition of doing good work. Logistic regression results showed military rank as a significant predictor of negative career satisfaction as an Army physician. For Captains, the odds for being "not at all satisfied" with their military career were almost nine times that of Colonels. Also, compared to their baseline group, physicians who completed their graduate medical education training, mission critical surgeons, and physicians who worked in military treatment facilities that were either a hospital (not a medical center) or a clinic-ambulatory surgery center had a greater risk of being "not at all satisfied" with their career as an Army physician. CONCLUSIONS: There is significant room for improvement in MC officer career satisfaction. The drivers of satisfaction are multiple and apply differently among MC officers of varied ranks and experience. Senior officers are the ones who are the most satisfied with their military career. Results of this novel MC officer study may serve as an impetus to identify existing shortcomings and make necessary changes to retain skilled Army physicians. Army leaders should invest resources to develop and sustain initiatives that improve military career satisfaction and retention of MC officers.

Epidemiology of Genitourinary Injuries among Male U.S. Service Members Deployed to Iraq and Afghanistan: Early Findings from the Trauma Outcomes and Urogenital Health (TOUGH) Project.

PURPOSE: In this study we report the number, nature and severity of genitourinary injuries among male U.S. service members deployed to Operations Iraqi Freedom and Enduring Freedom. MATERIALS AND METHODS: This retrospective cross-sectional study of the Department of Defense Trauma Registry used ICD-9-CM codes to identify service members with genitourinary injuries, and used Abbreviated Injury Scale codes to determine injury severity, genitourinary organs injured and comorbid injuries. RESULTS: From October 2001 to August 2013, 1,367 male U.S. service members sustained 1 or more genitourinary injuries. The majority of injuries involved the external genitalia (1,000, 73.2%), including the scrotum (760, 55.6%), testes (451, 33.0%), penis (423, 31%) and/or urethra (125, 9.1%). Overall more than a third of service members with genitourinary injury sustained at least 1 severe genitourinary injury (502, 36.7%). Loss of 1 or both testes was documented in 146 men, including 129 (9.4%) unilateral orchiectomies and 17 (1.2%) bilateral orchiectomies. Common comorbid injuries included traumatic brain injury (549, 40.2%), pelvic fracture (341, 25.0%), colorectal injury (297, 21.7%) and lower extremity amputations (387, 28.7%). CONCLUSIONS: An unprecedented number of U.S. service members sustained genitourinary injury while deployed to Operation Iraqi Freedom/Operation Enduring Freedom. Further study is needed to describe the long-term impact of genitourinary injury and determine the potential need for novel treatments to improve sexual, urinary and/or reproductive function among service members with severe genital injury.

Genitourinary injuries and extremity amputation in Operations Enduring Freedom and Iraqi Freedom: Early findings from the Trauma Outcomes and Urogenital Health (TOUGH) project.

BACKGROUND: In Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF), genitourinary (GU) wounds have occurred in unprecedented numbers. Severe concomitant injuries, including extremity amputations, are common. The epidemiology of GU injury and extremity amputation in OEF/OIF has not been described. MATERIALS AND METHODS: The Department of Defense Trauma Registry was queried from October 2001 through August 2013 to identify all surviving US male service members with GU injuries sustained in OEF/OIF. Genitourinary injury was defined as sustaining one or more injuries to any organ or structure within the genitourinary and/or reproductive system(s) based on International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Injury severity was quantified based on Abbreviated Injury Scale scores and overall Injury Severity Scores. The incidence, nature, and severity of GU injuries and extremity amputations are described. RESULTS: Of the 1,367 service members with GU injury included in this analysis, 433 (31.7%) had one or more extremity amputations. Most GU injuries were to the external genitalia [scrotum (55.6%), testes (33.0%), penis (31.0%), and urethra (9.1%)] vs. the kidneys (21.1%). Those with amputation(s) had greater GU injury severity (Abbreviated Injury Scale score ≥ 3) than those without amputations (50.1% vs. 30.5%, respectively; p < 0.0001). Approximately 3.4% of male service members with GU injury had an upper extremity amputation only, 8.9% had both lower and upper extremity amputation(s), and 19.4% had lower extremity amputation(s) only. Of the 387 patients with GU injury and lower extremity amputations, 87 (22.5%) had amputations below the knee and 300 (77.5%) had amputation(s) at/above the knee. CONCLUSION: In OEF/OIF, concomitant GU injury and extremity amputation are common and have serious implications for health and quality of life. This wounding pattern presents new challenges to the military medical and research and development communities to prevent, mitigate, and treat these battlefield injuries. LEVEL OF EVIDENCE: Epidemiologic/prognostic study, level III.

Implementation of TeamSTEPPS at a Level-1 Military Trauma Center: The San Antonio Military Medical Center Experience.

CONTEXT: When a health care system deals with complex trauma patients while simultaneously serving as an educational platform, teamwork and clear communication are imperative. While there are numerous tools and resources available to address the concerns surrounding patient safety, Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) emphasizes a team approach to improve communication among all caregivers and is specifically designed to improve patient safety through improved communication. This article reports the interim results of implementation of TeamSTEPPS in the operating room environment at the most complex and busiest tertiary military trauma center in the Department of Defense in the midst of the longest period of continuous combat operations in US history. METHODS: Data were collected from December 2013 through March 2014 on the number of total cases performed by month, number of debrief surveys submitted for those months, and associated percentage of surveys completed based on case category. RESULTS: The overall compliance rate for the TeamSTEPPS process (from the pre-op brief to the debrief survey completion) was 75.1%. Responses showed a decrease in concerns in all areas during the period of observation. Equipment-related complaints decreased by 48%; instrument-related issues decreased by 29.9%; supply issues decreased by 53.3%; personnel issues decreased by 90.5%; case scheduling issues decreased by 35.7%; and preference card issues decreased by 72.1%. CONCLUSIONS: Our results demonstrate that TeamSTEPPS can be successfully implemented in an integrated level-1 trauma center in the midst of combat casualty care with a greater than 75% overall compliance with TeamSTEPPS briefs. Further study on the sustainability of these results and the effect on operating room safety, productivity, and efficiency is necessary.

Complications of male circumcision treated at a military hospital in Afghanistan.

Circumcision of male infants and children is a common ritual in Afghanistan. As in many other developing countries, there are few safeguards relating to the procedure, particularly in rural areas. Performance of ritual circumcision may result in complications requiring treatment beyond the capabilities of the practitioner performing the initial procedure. It is not uncommon for local nationals to seek care at deployed military medical facilities for a wide variety of problems, and complications related to attempted circumcision are no exception. We describe 2 such cases recently presented to a US Army combat support hospital in rural Afghanistan for surgical treatment of the unintended consequences of male circumcision. We offer a review of the most common complications associated with circumcision and treatment options for each. It is valuable for the surgeon operating at the military medical hospital in remote areas of the world to be familiar with the management of the most common complications of circumcision.

External validation of a virtual reality transurethral resection of the prostate simulator.

PURPOSE: Virtual reality surgical simulation is an emerging technology that may eventually fill the gaps in surgical education created by changes in our medical system. We assessed the construct validity of a commercially available, virtual reality transurethral prostate resection simulator. MATERIALS AND METHODS: Participants performed 2, 5-minute transurethral prostate resection exercises on a standardized virtual reality prostate. Data from the first exercise were discarded. Simulator based metrics from the second exercise were tabulated, including tissue resected in gm, number of cuts, coagulation time, number of coagulation attempts, tissue per cut in gm and blood loss. Complications were recorded. Performance metrics were compared between groups based on urological training level and prior real-world experience with transurethral prostate resection. RESULTS: A total of 35 participants with varied levels of transurethral prostate resection experience completed the exercise. Several performance metrics had statistically significant correlations with urology training level and prior experience with transurethral prostate resection. There was a positive correlation of all measures of experience with mass resected, mass resected per cut and blood loss. Number of cuts correlated significantly with transurethral prostate resection experience in the previous year. Complications were present in most groups with medical students more likely to encounter external urethral sphincter and rectal injuries. CONCLUSIONS: We report the construct validity of a commercially available, virtual reality transurethral prostate resection simulator. The more experienced participants resected more tissue in a more efficient manner but with increased blood loss. Further investigations are needed before the widespread application of transurethral prostate resection simulators for training, certification and accreditation.

Combat urologic trauma in US military overseas contingency operations.

BACKGROUND: This article reports on the occurrences and patterns of genitourinary (GU) trauma in the contemporary high-intensity conflict of the overseas contingency operations (OCOs). METHODS: The Joint Theater Trauma Registry was queried for all US military members who received treatment for GU wounds and concomitant injuries sustained in OCOs for >75 months between October 2001 and January 2008. RESULTS: Of the 16,323 trauma admissions annotated in the Joint Theater Trauma Registry, 819 (5%) had one or more GU injuries. Of the GU casualties, 90% were sustained in Iraq and 65% were because of explosions. The average casualty age was 26 years (range, 18-58 years) and 98.5% were men. There were 887 unique GU injuries distributed as follows: scrotum, 257 (29.0%); kidney, 203 (22.9%); bladder, 189 (21.3%); penis, 126 (14.2%); testicle, 81 (9.1%); ureter, 24 (2.7%); and urethra, 7 (0.8%). Of the 203 patients with kidney injuries, 22% went to the operating room with 31 patients having nephrectomies. There were 189 bladder injuries with 26 patients (14%) having concomitant pelvic fractures. CONCLUSIONS: This is the largest report of GU injuries during any military conflict. The distribution and percentage of casualties with GU injuries in the OCO are similar to those of previous conflicts. Consideration should be given to personnel protective equipment for the areas associated with GU injuries and predeployment training directed at the care of these injuries.

Patient risk stratification using Gleason score concordance and upgrading among men with prostate biopsy Gleason score 6 or 7.

PURPOSE: To define the impact of discordant Gleason sum (GS) between prostate biopsy (Pbx) tissue and radical prostatectomy (RP) specimen among men initially diagnosed with Gleason 6 or 7 prostate adenocarcinoma. MATERIALS AND METHODS: We evaluated patients diagnosed with GS 6 or 7 and treated primarily with RP. We defined the frequency of GS discordance between Pbx and RP pathology reports. We analyzed pretreatment parameters associated with GS discordance and compared immediate postprostatectomy outcome variables across patient groups defined by their GS and concordance. We then conducted survival analysis for biochemical recurrence across patient groups defined by their GS and concordance status. RESULTS: Among patients with GS 6 on Pbx, 681/1,847 (36.86%) patients were upgraded to GS 7 or higher after RP. Surgical margin, capsular involvement, seminal vesicle, and nodal involvement status were more favorable in patients with concordant Pbx and RP specimen with GS 6 (P < 0.0001). Patients with smaller transrectal ultrasound (TRUS) prostate volume were found to have higher PSA densities and were more likely to be upgraded at RP. Multivariate survival analysis also predicted fewer biochemical recurrence events over time in men with concordant Pbx tissue and RP specimen of GS 6 vs. 6/7 or 7/7 (P = 0.0025) controlling for other relevant covariates. CONCLUSIONS: GS discordance between Pbx tissue and RP specimens among prostate cancer patients initially diagnosed with either GS 6 or 7 adenocarcinoma of the prostate is substantial. This discordance has potential clinical significance in predicting oncologic outcomes.

Gunshot wound injuries of the prostate and posterior urethra: reconstructive armamentarium.

PURPOSE: Descriptions of posterior urethral penetrating injuries are rare in the literature and their management is poorly described. We reviewed the medical records of 19 men who sustained posterior urethral gunshot wounds and report our experience with various treatment options. MATERIALS AND METHODS: We retrospectively reviewed the records of 19 men (mean age 27 years) who sustained posterior urethral gunshot wound injuries confirmed by retrograde urethrography and/or exploratory laparotomy. Treatment options included immediate primary repair in 2 patients, delayed reconstruction in 15 and complete prostatectomy in 2. Outcomes were described by flow rates and lower urinary tract symptoms. RESULTS: Of 15 patients who underwent delayed repair 13 (86.6%) demonstrated normal flow rates and lack of lower urinary tract symptoms. The 2 remaining patients experienced obliterative stricture recurrences and were treated with open surgery. Both patients who underwent immediate primary repair had normal flow rates. Of the 2 men who underwent immediate prostatectomy 1 had moderate incontinence requiring absorbent pad use and the other was lost to followup after he was discharged home with a suprapubic catheter in place. CONCLUSIONS: An initial management strategy based on the principles of maximizing urinary catheter drainage, with direct retropubic repair/urethral realignment when possible and definitive perineal reconstruction when necessary, appears to provide acceptable outcomes while minimizing the number of subsequent interventions required.

Optimal cost-effective staging evaluations in prostate cancer.

A new diagnosis of prostate cancer presents to both the patient and physician questions regarding the best approach for further assessing the extent of disease prior to selecting a treatment strategy. In addition to the initial clinical data such as serum prostate-specific antigen level, findings on digital rectal examination, and core biopsy Gleason score, several procedures and imaging modalities are available to further stage newly diagnosed prostate cancer. A substantial percentage of the cost of managing prostate cancer is directly related to staging evaluations. Often, staging evaluations are performed that have limited test performance characteristics, subject the patient to unnecessary morbidity, or simply do not provide additional useful clinical information. It is important that the physician be familiar with the indications for the available staging modalities as well as the test performance characteristics in order to proceed appropriately and in an economically judicious fashion. This paper reviews the literature on this topic and summarizes previous experiences with procedures and imaging modalities for staging newly diagnosed prostate cancer.

Laparoscopic radical prostatectomy: evaluation of specimen pathologic features to critically assess and modify surgical technique.

OBJECTIVES: To evaluate laparoscopic radical prostatectomy (LRP) specimens for pathologic stage and the malignant and benign surgical margin status to determine areas for improvement in surgical technique. LRP is gaining significant attention as a viable alternative to retropubic radical prostatectomy. METHODS: A total of 110 consecutive LRP specimens were retrospectively reviewed. A single experienced genitourinary pathologist examined all slides. In addition, exposure of benign glands at the inked margin was reported. Oncologic data were assessed by standard pathologic examination for stage, grade, and margin status. The pathologic data from year 1 (group 1, 52 patients) were compared with the data from subsequent years (group 2, 58 patients). RESULTS: The overall positive surgical margin rate was 18.2% (13.5% for pT2 disease). Benign parenchymal exposure was identified in 16 patients (14.5%). Six of these patients had concomitant negative surgical margins for cancer. The positive margin rate for patients with Stage pT2 disease was 22.2% in group 1 and 5.9% in group 2. The positive margin rate was 34.8%, 13.6%, and 13.8% for bilateral, unilateral, and non-nerve-sparing procedures, respectively. CONCLUSIONS: LRP offers comparable surgical margins to those of reported open prostatectomy series. Careful pathologic review provides feedback so that technique modifications can be implemented and the positive margin rates improved further. A low, but significant, positive margin or benign parenchymal exposure rate in pT2 disease indicates room for improvement in the surgical technique. The presence of benign glands at the inked margin is not routinely reported but does provide an additional parameter of surgical adequacy.

Endoscopic treatment of upper tract transitional cell carcinoma.

PURPOSE: To review the current literature and data describing primary endoscopic treatment of upper tract transitional cell carcinoma (TCC). MATERIALS AND METHODS: Published, peer-reviewed articles on ureteroscopic, percutaneous, and laparoscopic treatment of upper tract TCC were identified using the MEDLINE database. RESULTS: Nephroureterectomy has been considered the "gold standard" for upper tract TCC. Minimally invasive approaches, initially advocated for patients requiring a nephron sparing approach (i.e., solitary kidney or renal insufficiency) or those with significant comorbidities precluding definitive surgery, have been increasingly used with the further refinement of ureteroscopy, percutaneous renal surgery, and laparoscopy. Ureteroscopy has been used successfully, resulting in recurrence rates ranging from 31% to 65% and disease-free rates of 35% to 86%. Progression and metastatic rates are low and correlate with tumor grade. Likewise, percutaneous approaches show disease specific survival and recurrence rates correlating with tumor grade. Patients with low-grade tumors (Grades 1-2) do well with this approach with recurrence rates and disease specific survival rates of 26% to 28% and 96% to 100%, respectively. For those patients requiring complete extirpation of the kidney and ureter, laparoscopic nephroureterectomy results in decreased postoperative pain, shorter hospital stay, and more rapid convalescence without compromising cancer control. CONCLUSIONS: Nephron sparing approaches in well-selected patients with low stage and low-grade disease can be treated endoscopically with ureteroscopy and percutaneous renal surgery. Laparoscopic nephroureterectomy offers a safe, minimally invasive alternative to traditional open surgical techniques for patients with TCC of the upper urinary tract.

Prospective longitudinal comparative study of health-related quality of life in patients undergoing invasive treatments for localized prostate cancer.

BACKGROUND AND PURPOSE: Health-related quality of life (QoL) concerns are important for patients selecting treatment options for clinically localized prostate cancer and are critical in evaluating outcomes. We report pretreatment and post-treatment general and disease-specific QoL for the following invasive interventions: open radical prostatectomy (ORP), laparoscopic radical prostatectomy (LRP), and palladium-103 ((103)Pd) brachytherapy. PATIENTS AND METHODS: We performed a prospective longitudinal survey of 452 patients with newly diagnosed prostate cancer treated at a single medical center between 2001 and 2003. An Institutional Review Board-approved questionnaire comprised of validated QoL instruments was sent to patients scheduled to undergo ORP (N = 186), LRP (N = 116), or brachytherapy (N = 150). The same questionnaire was sent out 1, 3, 6, 9, and 12 months after therapy. Comparisons were made between the groups to determine if the choice of therapy resulted in differences in QoL. RESULTS: General QoL scores were minimally affected by the choices; however, the disease-specific domains of bowel, urinary, and sexual function were adversely affected by all modalities. The ORP and LRP groups were similar among disease-specific domains and received lower post-treatment urinary and sexual scores than the (103)Pd patients. At 12 months, 38% of ORP and 46% of LRP patients had returned to baseline urinary function compared with 75% of (103)Pd patients. At 12 months, 63% of (103)Pd patients had returned to baseline sexual function compared with 19% of both the LRP and ORP patients. CONCLUSIONS: Invasive treatments for localized prostate cancer have little impact on general QoL but significantly affect disease-specific domains. Both ORP and LRP have a greater initial negative impact on urinary and sexual function than (103)Pd. The differences among the treatments with regard to QoL provide information to patients faced with choosing a treatment.

Misattributed paternity in a living related donor: to disclose or not to disclose?

Many ethical considerations surround living kidney donation, some of which are not anticipated. We present a case in which misattributed paternity was inadvertently discovered during the workup of a father and son and present arguments for and against disclosure of this information. We recommend that transplant programs advise patients participating in living organ donor programs that misattributed paternity might be discovered during routine preoperative testing and that protocols for dealing with complex ethical issues be in place.

Ureteropelvic junction obstruction: does CT angiography allow better selection of therapeutic modalities and better patient outcome?

PURPOSE: To determine whether preoperative helical CT angiography (CTA) with three-dimensional (3D) reconstructed images improves outcome in patients with ureteropelvic junction obstruction (UPJO) by identifying crossing vessels that may lead to surgical failure. PATIENTS AND METHODS: Twenty-five patients with UPJO underwent imaging with CTA to identify crossing vessels. Patients with crossing vessels or severe hydronephrosis underwent laparoscopic dismembered pyeloplasty. In the absence of crossing vessels, and with >25% renal function on MAG-3 scan, the patient underwent an endopyelotomy. Procedures were assessed as successful by resolution of patient symptoms as well as relief of obstruction on renal scintography. RESULTS: Twenty-seven procedures (14 laparoscopic dismembered pyeloplasties [9 in the setting of a crossing vessel], 11 ureteroscopic endopyelotomies, and two antegrade endopyelotomy procedures) were performed. Follow-up ranged from 2.4 to 40 months (mean 21.6 months). Twenty-three of the primary procedures (92.0%) were successful. Primary laparoscopic pyeloplasty was successful in 100% of patients, while primary endopyelotomy had a success rate of 83.3%. Both secondary procedures were successful rendering the patients unobstructed and pain free. No complications occurred. The sensitivity and specificity of CTA in determining crossing vessels was 78% and 40%, respectively. CONCLUSIONS: Helical CT angiography with 3D reconstructed images provides valuable preoperative information in patients with UPJO scheduled for surgical intervention. This study may be used in selecting patients for proper operative intervention according to the anatomy of crossing vessels to attain high treatment success rates.

Pathologic variables and recurrence rates as related to obesity and race in men with prostate cancer undergoing radical prostatectomy.

PURPOSE: To determine if obesity is associated with higher prostate specific antigen recurrence rates after radical prostatectomy (RP), and to explore racial differences in body mass index (BMI) as a potential explanation for the disparity in outcome between black and white men. PATIENTS AND METHODS: A retrospective, multi-institutional pooled analysis of 3,162 men undergoing RP was conducted at nine US military medical centers between 1987 and 2002. Patients were initially categorized as obese (BMI > or = 30 kg/m(2)), overweight (BMI 25 to 30 kg/m(2)), or normal (BMI < or = 25 kg/m(2)). For analysis, normal and overweight groups were combined (BMI < 30 kg/m(2)) and compared with the obese group (BMI > or = 30 kg/m(2)) with regard to biochemical recurrence (prostate-specific antigen > or = 0.2 ng/mL) after RP. RESULTS: Of 3,162 patients, 600 (19.0%) were obese and 2,562 (81%) were not obese. BMI was an independent predictor of higher Gleason grade cancer (P <.001) and was associated with a higher risk of biochemical recurrence (P =.027). Blacks had higher BMI (P <.001) and higher recurrence rates (P =.003) than whites. Both BMI (P =.028) and black race (P =.002) predicted higher prostate specific antigen recurrence rates. In multivariate analysis of race, BMI, and pathologic factors, black race (P =.021) remained a significant independent predictor of recurrence. CONCLUSION: Obesity is associated with higher grade cancer and higher recurrence rates after RP. Black men have higher recurrence rates and greater BMI than white men. These findings support the hypothesis that obesity is associated with progression of latent to clinically significant prostate cancer (PC) and suggest that BMI may account, in part, for the racial variability in PC risk.

Laparoscopic radical prostatectomy: is intact organ removal attainable? Study of margin status.

PURPOSE: To determine the initial oncologic results (pathology) of specimens removed by laparoscopic radical prostatectomy (LRP) by examining the surgical margins. PATIENTS AND METHODS: The 70 consecutive LRP procedures performed for clinically localized prostate cancer at Eastern Virginia Medical School from April 2001 to November 2002 were reviewed for preoperative and important intraoperative variables. The initial histopathology report and a prospective review by a single genitourinary pathologist for margin status as well parenchymal exposure of benign glands were assessed. Postoperative prostate specific antigen (PSA) levels were noted. RESULTS: The clinical stage distribution was as follows: T1c = 59, T2a = 10, and T2b = 1. The preoperative median PSA value was 6.96 ng/mL. The mean operative time was 307 minutes. The mean estimated blood loss was 298 mL. The prospective pathologic review results were as follows: 1 pT0 (1.4%), 60 pT2 (85.7%), and 9 pT3 (12.8%). The overall positive surgical-margin rate was 15.7%. Of those patients with pT2 disease; 8 specimens (13.3%) had a positive margin, whereas 33% of patients with pT3 disease had a positive surgical margin. Parenchymal exposure of benign glands on the inked surface was recognized in 8 patients (13.3%). Data from PSA assays 1 month postoperatively were available in 69 patients. Serum PSA was undetectable (< or =0.1 ng/mL) in 67 men (97%). CONCLUSION: An LRP can offer surgical margins comparable to those of open procedures series reported in the literature. Long-term progression and survival outcome data are necessary before this procedure should be offered as a replacement for open prostatectomy.