Is the apical soft tissue margin a better predictor of biochemical recurrence than the surgical specimen?

PURPOSE: To identify predictors of apical surgical margin (ASM) and apical soft tissue margin (ASTM), determine if the ASTM is a better predictor of biochemical recurrence (BR) than the ASM, and ascertain the impact of apical biopsies on BR rates. MATERIALS AND METHODS: One thousand three hundred eight consecutive men underwent open radical retropubic prostatectomy (RP) between October 2000 and December 2006. Circumferential biopsies of the ASTM were obtained intraoperatively and submitted for frozen section analysis. Logistic regression models were utilized to identify the factors associated with the presence of positive ASMs and ASTMs. The estimated 5-year risk of BR was calculated by the Kaplan-Meier method. RESULTS: Overall, 43 (3.3%) and 86 (6.6%) of cases exhibited positive ASM and ASTM, respectively. ASM was significantly associated with higher mean serum prostate-specific antigen levels, presence of perineural invasion, and greater volume of tumor in the biopsy specimen. None of these factors were observed to be associated with the presence of cancer in the ASTMs. In the multivariate analysis, only the presence of perineural invasion was a significant independent predictor of ASMs. The estimated 5-year BR rates in the positive ASMs only, ASTMs only, and both positive ASMs and ASTMs groups were 48.6%, 4.7%, and 38.8%, respectively. CONCLUSIONS: A positive ASM was associated with a significantly greater risk of BR compared with a positive ASTM. The very low estimated risk of BR at 5 years in cases with ASTM suggests that performing the ASTM biopsies may increase the cure rates achieved with RP.

Site of positive surgical margins influences biochemical recurrence after radical prostatectomy.

OBJECTIVE: To determine whether the number and location of positive surgical margins (PSMs) in radical prostatectomy (RP) surgical specimens affect biochemical recurrence (BCR) rates. PATIENTS AND METHODS: The locations of PSMs were recorded for 1308 consecutive men who underwent RP between October 2000 and December 2006. BCR was defined as three consecutive prostate-specific antigen (PSA) level rises with the peak level >or=0.15 ng/mL. Multivariate regression analyses were used to identify preoperative predictors of PSMs and BCR. The estimated 5-year risk of BCR was calculated using the Kaplan-Meier method. RESULTS: In all, 128 (9.8%) men had one or more PSMs. The mean body mass index, mean preoperative serum PSA level, the distributions of clinical stage and biopsy Gleason scores, and the presence or absence of biopsy perineural invasion were significantly different between men with or with no PSMs. In multivariate analysis, baseline serum PSA level, Gleason score and perineural invasion were independent preoperative predictors of PSMs. The 5-year actuarial BCR rates were dependent on the site of the PSM (P = 0.035) and not the number of PSMs (P = 0.18). The rank order of estimated 5-year BCR rates according to the site of PSMs were base > anterior > posterolateral > apex approximately posterior. CONCLUSIONS: About half of the men with PSMs in the RP surgical specimen in our prospective series did not develop BCR. The risk of BCR was dependent on the site and not the number of PSMs. Adjuvant therapy should be considered in cases with anterior and basilar PSMs due to the very high risk of BCR.

Does benign prostatic tissue contribute to measurable PSA levels after radical prostatectomy?

OBJECTIVES: To provide insights into the likelihood that benign prostatic tissue represents a source of measurable prostate-specific antigen (PSA) after radical prostatectomy. METHODS: From October 2000 to December 2006, 1308 consecutive men underwent open radical retropubic prostatectomy by a single surgeon. Of these 1308 men, 331 (25.3%) met our criteria for having "extremely" low-risk disease as determined by the preoperative and pathologic factors, including a preoperative PSA level <10 ng/mL, clinical Stage T1c or T2a, a Gleason score of < or =6, an estimated cancer volume in the specimen of <5%, and no evidence of positive surgical margins. This cohort was selected because any measurable PSA level would be highly suspicious for a benign origin. Undetectable PSA was defined as a PSA level of < or =0.04 ng/mL. A measurable PSA level included values between 0.05 and 0.14 ng/mL on > or =2 consecutive measurements 6 months apart. Biochemical recurrence was defined as 3 consecutively increasing PSA levels with a peak level of > or =0.15 ng/mL. RESULTS: At 3 months to 6 years of follow-up (mean 36.2 months), 0.6% and 0.3% of patients had developed a measurable PSA level or biochemical recurrence, respectively. The single patient with biochemical recurrence responded to salvage radiotherapy, strongly suggesting a malignant etiology for the recurrence. CONCLUSIONS: A measurable PSA level or biochemical recurrence was an extraordinarily rare event in our select group of patients with extremely low-risk disease. These results provide compelling evidence that retained benign prostatic elements are an unlikely source of elevated PSA levels in men who have undergone radical prostatectomy.

Effect of warm ischemia time during laparoscopic partial nephrectomy on early postoperative glomerular filtration rate.

PURPOSE: We evaluated the effect of warm ischemia time on early postoperative renal function following laparoscopic partial nephrectomy. MATERIALS AND METHODS: Of 453 patients who were surgically treated for renal tumors between May 2001 and September 2007, and who were identified in our database 128 underwent laparoscopic partial nephrectomy. Of these 128 patients 101 who were evaluable had complete demographic, operative, preoperative and early postoperative data available. Renal function was estimated using the glomerular filtration rate. Warm ischemia time was stratified into 4 interval groups and also analyzed based on different time cutoffs. Ultimately we also tested the relationship between postoperative renal failure, and preoperative factors and warm ischemia time. RESULTS: Warm ischemia time interval analysis was not significant. However, when analyzing the effect of warm ischemia time cutoffs, patients with warm ischemia time greater than 40 minutes had a significantly greater decrease in the glomerular filtration rate (p = 0.03) and a lower glomerular filtration rate postoperatively. The incidence of renal function impairment was more than 2-fold higher in those with a warm ischemia time of greater than 40 minutes than in the other groups (p = 0.077). Warm ischemia time was significant on univariate analysis when only patients with a preoperative glomerular filtration rate of 60 ml per minute per 1.73 m(2) or greater were analyzed. However, this did not hold as an independent predictor of postoperative renal function impairment on multivariate analysis. The preoperative glomerular filtration rate was the only independent predictor of postoperative renal function impairment. CONCLUSIONS: A warm ischemia time of 40 minutes appears to be an appropriate cutoff, after which a significantly greater decrease in renal function occurs after laparoscopic partial nephrectomy. The preoperative glomerular filtration rate was the only independent predictor of an increased risk of renal insufficiency following laparoscopic partial nephrectomy.

Robot-assisted laparoscopic partial cystectomy and diverticulectomy: initial experience of four cases.

PURPOSE: We report our initial experience with four cases of robot-assisted laparoscopic partial cystectomy and diverticulectomy performed between June 2005 and August 2007. PATIENTS AND METHODS: The series consisted of three male patients and one female with a mean age of 64 years (range 36-77 years). In each case, a transperitoneal laparoscopic approach was used to mobilize the bladder. Next the bladder lesion was scored circumferentially cystoscopically with a Collings knife. The remainder of the excision and bladder reconstruction was performed with the da Vinci robot. RESULTS: Mean operative time was 194 minutes with a mean blood loss of 35 mL. The urethral catheter was removed between 5 and 14 days following a normal cystogram. There were no significant complications. Postoperative hospital stay was 2 to 3 days. CONCLUSION: Robot-assisted laparoscopic partial cystectomy and diverticulectomy are technically feasible and represent an alternative to open and conventional laparoscopic approaches.

Necrotic mass after transurethral resection of a bladder tumor: novel management with robotic partial cystectomy.

A 76-year-old female with a history of high-grade transitional cell carcinoma (TCC) of the bladder presented with persistent nocturia and urge incontinence and was diagnosed with a necrotic bladder lesion. Cystoscopy revealed a 4 cm area of necrosis, ulceration, calcification, and fat. Transurethral biopsy confirmed the lesion to be benign, and two attempts to re-epithelialize the area of necrosis with cold scraping of exudate failed. Decision was then made to proceed with removal of necrotic lesion with bladder preservation. With the aid of concomitant cystoscopic visualization of the necrotic lesion, a robotic partial cystectomy with bladder reconstruction was performed. The patient tolerated the procedure, had an uneventful post-operative course, and remains asymptomatic and disease-free at last follow-up of 6 months. To our knowledge, this case represents the first report of a necrotic lesion as a complication of transurethral resection of a bladder tumor (TURBT) and the first description of a robotic partial cystectomy for the management of either benign or malignant bladder disease.

Role of positional instillation of contrast cystography in the algorithm for evaluating children with confirmed pyelonephritis.

OBJECTIVES: To assess the utility of positional instillation of contrast (PIC) cystography in detecting vesicoureteral reflux (VUR) in patients with renal scarring from recurrent febrile urinary tract infections that standard voiding cystourethrography and nuclear cystogram imaging failed to reveal. METHODS: Between June 2004 and November 2004, a total of 5 pediatric patients with recurrent febrile urinary tract infections and radiologic evidence of upper tract involvement were examined with PIC cystography. All patients had at least one previous negative standard reflux study (voiding cystourethrography or nuclear cystography). RESULTS: All 5 patients showed VUR on PIC cystography. Unilateral reflux was detected in 3 patients, and 2 patients had bilateral VUR. CONCLUSIONS: The PIC cystogram should be integrated into the algorithm for diagnosing patients with recurrent febrile urinary tract infection, who do not exhibit VUR on standard imaging modalities. The morbidity associated with undiagnosed VUR, as demonstrated by this group of patients, suggests that permanent renal damage may be prevented by early diagnosis and treatment.

Novel method used to test pullout parameters of different nephrostomy catheters.

PURPOSE: To present a novel in-vitro pig model for testing the design and function of different internal catheter constructs, along with the resulting exit wound resulting from removal. MATERIALS AND METHODS: We compared the pullout parameters of two nephrostomy catheters that differ only in their internal loop design. RESULTS: Greater force, work, and displacement are necessary to extricate catheters with a double loop without increasing exit-wound size. CONCLUSION: Although the differences were not statistically significant, results from this model have potential clinical implications that may prompt further design modifications and prototype development to improve the retention of catheters in the kidney, thus reducing patient discomfort and costs associated with repeated catheter placement.