The association between nerve sparing and a positive surgical margin during radical prostatectomy.

PURPOSE: A positive surgical margin (SM) during radical prostatectomy (RP) increases risk of biochemical recurrence. We evaluated the effect of nerve-sparing procedures on risk of positive SM for pT2- and pT3-category tumors. We hypothesized that nerve sparing would increase rates of pT2 positive margins. METHODS: We evaluated a historical cohort of 9,915 consecutive RP patients treated at The Ottawa Hospital or Memorial Sloan-Kettering Cancer Center from 2000 to 2010. Patients underwent open, laparoscopic, or robotic RP. The primary outcome was presence of a positive SM stratified by pathologic pT2 and pT3 categories. The association between nerve sparing and positive margin was adjusted for prostate-specific antigen, RP Gleason sum, surgical modality, surgical date, and location in the multivariable model. RESULTS: Of 6,120 eligible patients, 3,958 (64.7%) had open RP, 1,566 (25.6%) had laparoscopic RP, and 596 (9.7%) had robotic RP. Approximately 8.6% (363/4,199) of patients with pT2-category disease and 25.2% (485/1,921) of patients with pT3-category disease had a positive margin. Patients with pT2-category disease who underwent a bilateral nerve-sparing procedure were more likely to have a positive margin when compared with those who underwent nerve resection on multivariable analysis (relative risk [RR] = 1.52, 95% CI: 0.97-2.39) after adjusting for confounders. Patients with pT3-category disease who underwent a bilateral nerve-sparing procedure had no associated increase in risk of positive margin after adjustment for other variables (RR = 0.96, 95% CI: 0.80-1.16). Prostate incision into tumor (pT2R1) was significantly more likely in patients treated with robotic surgery (RR = 1.76, 95% CI: 1.25-2.48) than in those with open surgery. There was no difference between laparoscopic and open RP (RR = 0.86, 95% CI: 0.65-1.12). CONCLUSIONS: Bilateral nerve sparing is associated with increased risk of positive SMs in patients with pathologic T2-category disease during RP.

Coexisting mantle cell lymphoma and prostate adenocarcinoma.

Prostatic mantle cell lymphoma (MCL) is a very rare entity with only 5 reported cases in the literature. We report a case of coexisting MCL and prostate adenocarcinoma (PCa) in an elderly male and review the morphologic features of classic and rare prostatic MCL subtypes. Careful morphologic evaluation and immunohistochemical findings of positive CD5, CD20, and cyclin D1 and negative CD23 and CD3 can guide us to the diagnosis of MCL. Given the fact that transurethral resection of prostate is done quite routinely, this paper draws attention to the manner in which long standing bladder outlet obstruction and postbiopsy prostate specimens with dense lymphoid infiltration can masquerade as lymphoma. It highlights the importance of exercising care while reviewing prostate specimens with evidence of chronic prostatitis so as not to miss this rare neoplasm.

Predicting the Gleason sum of a patient with a prostate biopsy core Gleason ≤7 and a prostate biopsy core Gleason ≥8.

INTRODUCTION: We review a subset of men who had discordant prostate biopsy sums and were treated with radical prostatectomy. METHODS: Consecutive patients treated with radical prostatectomy at The Ottawa Hospital between 2000 and 2012 were reviewed. Those with at least 1 prostate biopsy core of Gleason sum ≥8 and at least 1 prostate biopsy core of Gleason sum ≤7 cancer were included. RESULTS: Of the 764 radical prostatectomies, 661 (87%) were eligible for the study and 35 (5%) met inclusion criteria. Of these, only 16 (46%) had prostatectomy Gleason sum of ≥8. When the highest biopsy core was Gleason sum 8 (n = 24), only 7 (29%) had a prostatectomy Gleason sum ≥8. When the highest biopsy core was Gleason 9 (n = 11), 9 (82%) had a prostatectomy Gleason sum ≥8 (relative risk [RR] 2.8; p = 0.004). Patients with clinical T3 tumours were at higher risk of Gleason sum ≥8 compared to cT1 patients (RR 3.7; p = 0.008). Patient age (p = 0.89), preoperative prostate-specific antigen (p = 0.34), prostate volume (p = 0.86), number of biopsy cores (p = 0.18), and proportion of biopsy cores with cancer (p = 0.96) were not strongly associated with risk of prostatectomy Gleason sum ≥8. CONCLUSION: These data should be considered when assigning patients into prognostic risk categories based on prostate biopsy information. Further study to verify our findings using larger samples is warranted.

The association between tumour density and prostate cancer recurrence following radical prostatectomy.

PURPOSE: Tumour density (TD) may be an independent prognostic factor in men with prostate cancer. The purpose of this study was to evaluate the association between prostate cancer TD and recurrence following radical prostatectomy. MATERIALS AND METHODS: Between 1995 and 2007, 645 patients from The Ottawa Hospital or Memorial Sloan-Kettering Cancer Center who had cancer and prostate volumes measured from radical prostatectomy specimens. Tumour density was defined as the relative tumour to prostate volume (tumour volume/prostate volume) and recurrence was defined as a prostate-specific antigen (PSA) >0.2 ng/mL and rising, or postoperative use of radiation or hormonal therapy. Associations between TD and recurrence are adjusted for preoperative PSA, prostatectomy Gleason sum, tumour stage and margin status. RESULTS: Median follow-up was 40.8 months. Tumour density was associated with preoperative PSA, Gleason sum, tumour stage and surgical margin status (all p < 0.0001). As a continuous variable, TD predicted recurrence-free survival (adjusted HR 1.34 per 10% increase in TD; p = 0.04). As a categorical variable, the group of patients with a TD of >10% had a 2.7 times greater hazard of recurrence compared to patients with a TD <5% (95%CI 1.41, 5.19; p = 0.003). Despite the independent association between TD and recurrence, the clinical value of TD remains in question as the discriminative performance (area under the curve) of predictive models only improved from 0.865 to 0.876. CONCLUSIONS: Prostate cancer TD is associated with known prognostic factors and is also independently predictive of recurrence following radical prostatectomy.

The prognostic significance of capsular incision into tumor during radical prostatectomy.

BACKGROUND: The prognostic significance of capsular incision (CapI) into tumor during radical prostatectomy (RP) with otherwise organ-confined disease remains uncertain. OBJECTIVE: To evaluate the impact of CapI into tumor on oncologic outcome. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of 8110 consecutive patients with prostate cancer treated at Ottawa Hospital and at Memorial Sloan-Kettering Cancer Center, both tertiary academic centers, between 1985 and 2008. INTERVENTION: All patients underwent an open, laparoscopic or robotic RP. MEASUREMENTS: Patients were divided into four pathologic categories: group 1 (CapI group), positive surgical margins (PSMs) without extraprostatic extension (EPE); group 2, negative surgical margins (NSMs) without EPE; group 3, NSM with EPE; group 4, PSMs with EPE. Estimates of recurrence-free survival were generated with the Kaplan-Meier method. Recurrence was defined as a prostate-specific antigen (PSA) >0.2 ng/ml and rising. Cox proportional hazards regression was used to estimate the hazard ratio (HR) for recurrence controlling for pretreatment PSA, RP date, RP Gleason sum, seminal vesicle invasion, and lymph node involvement. Pathologic categories were defined in the model by including the variables EPE and surgical margins (SMs) as well as their interaction. RESULTS AND LIMITATIONS: Median follow-up was 37.3 mo. The 5-yr recurrence-free probability after RP for the CapI group was 77% (95% confidence interval [CI], 72-83). This was not only inferior to patients with NSMs and no EPE (log rank p<0.0001) but also to those with NSMs and EPE (log rank p=0.0002). In multivariate analysis the interaction between EPE and SM was not significant (p=0.26). In the adjusted model excluding the interaction term, patients with EPE had an increased risk for recurrence (HR: 1.80; 95% CI, 1.49-2.17; p<0.0001) as did those with positive margins (HR: 1.81; 95% CI, 1.51-2.15; p<0.0001). This was a retrospective study. CONCLUSIONS: CapI into tumor has a significant impact on patient outcome following RP. Patients, who otherwise would have organ-confined disease, will now have a higher probability of recurrence than those with completely resected extraprostatic disease.

Mantle cell lymphoma of the prostate.

Lymphoma of the prostate, either primary or secondary, is very rare. We report the case of an 82-year-old man with symptoms of bladder outlet obstruction presumably due to benign prostate hyperplasia (BPH). He underwent an uneventful transurethral resection of the prostate. Pathological review of the resected tissue demonstrated substantial infiltration by an atypical lymphoid infiltrate positive for CD20, BCL2, CD5, kappa light chain and cycline D1. Histology and immunoprofile were consistent with mantle cell lymphoma.

Gone in 24 hours: the feasibility of performing pubovaginal sling surgery with an overnight hospital stay.

INTRODUCTION: Numerous management strategies are available for stress urinary incontinence, a significant problem for many women. The pubovaginal sling (PVS) with rectus fascia has proven efficacy with minimal morbidity. Historically, patients were admitted for an average of 4 days at the Ottawa Hospital. Since November 2001, patients have spent one night in hospital thereby cutting their total length of stay to less than 24 hours. This study assesses the feasibility of this approach. MATERIALS AND METHODS: Ethics approval was obtained. All patient charts were reviewed retrospectively. Exclusion criteria included women booked for combined procedures or patient refusal. Each case was reviewed to determine if admission to hospital following surgery was required or if subsequent visits to emergency occurred. The Financial Department of the Ottawa Hospital provided financial information to estimate cost savings. Each patient was contacted and administered a standard satisfaction questionnaire. RESULTS: The length of stay was less than 24 hours in all but one case. One patient required a 48-hour stay secondary to post operative nausea. No patient returned to the ER for assessment following discharge. The estimated cost savings were $2709 per case. Patients tolerated having this procedure performed on a daycare basis. CONCLUSIONS: PVS may be performed safely as short stay surgery with a high degree of patient satisfaction. This results in increased efficiency and improved utilization of increasingly limited healthcare resources.

Urethral erosion following autologous rectus fascial pubovaginal sling.

Urethral erosion following pubovaginal sling is a rare occurrence. When synthetic sling materials are used urethral erosion often necessitates removal of the sling and urethral reconstruction. The literature is sparse with respect to the best approach to fascial sling erosion. We report a case of a 73 year-old woman who underwent a pubovaginal sling using autologous rectus fascia for treatment of stress urinary incontinence (SUI). She developed urethral erosion following 2 weeks of clean intermittent catheterization (CIC). Visual internal urethrotomy (VIU) was performed to incise the sling and the prolene sutures were removed to eliminate any tension. The patient subsequently voided spontaneously and had resolution of her SUI. This case demonstrates that urethral erosion may occur even when fascial slings are used. Unlike synthetic slings, when autologous fascia is used, the tissue may be left in-situ. A minimally invasive approach may achieve an excellent result without the need for complex surgical repair.

An unusual cause for granulomatous inflammation of the penis.

We report a highly unusual type of inflammatory reaction secondary to the insertion of needle in the penis with formation of a nodule of 2.1 cm in diameter, histologically mimicking lymphogranuloma venereum.