Does changeover by an experienced open prostatic surgeon from open retropubic to robot-assisted laparoscopic prostatectomy mean a step forward or backward?

We assessed whether changeover from open retropubic [RRP] to robotic-assisted laparoscopic prostatectomy [RALP] means a step forward or backward for the initial RALP patients. Therefore the first 105 RALPs of an experienced open prostatic surgeon and robotic novice-with tutoring in the initial 25 cases-were compared to the most recent 105 RRPs of the same surgeon. The groups were comparable with respect to patient characteristics and postoperative tumor characteristics (all P > 0.09). The only disadvantage of RALP was a longer operating time; the advantages were lower estimated blood loss, fewer anastomotic leakages, earlier catheter removal, shorter hospital stay (all P < 0.04), and less major complications within 90 days postoperatively (P < 0.01). Positive surgical margin rates were comparable both overall and stratified for pT stage in both groups (all P < 0.08). In addition, an equivalent number of lymph nodes were removed (P > 0.07). Twelve months after surgery, patient reported continence and erectile function were comparably good (all P > 0.11). Our study indicates that an experienced open prostatic surgeon and robotic novice who switches to RALP can achieve favorable surgical results despite the initial RALP learning curve. At the same time neither oncological nor functional outcomes are compromised.

Tumour characteristics, oncological and functional outcomes in patients aged ≥ 70 years undergoing radical prostatectomy.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The marked increase in life expectancy in recent years calls for reconsideration of the decision-making process for the treatment of prostate cancer, a condition particularly affecting the elderly. To date the general approach in elderly patients has tended to be more conservative, not least as it is generally thought that prostate cancer in these patients is less biologically aggressive. The present data showed that patients aged ≥70 years had biologically more aggressive tumours significantly more often than those aged <70 years. Nevertheless, advanced age itself was not an independent predictor of survival after retropubic radical prostatectomy, whereas adverse prostate cancer features and severe comorbidities were. OBJECTIVE: To investigate the effect of advanced age (≥70 years) on prostate cancer characteristics, oncological and functional outcomes in patients undergoing retropubic radical prostatectomy (RP). PATIENTS AND METHODS: Between June 1997 and September 2009, 1636 patients underwent RP at one institution. Of these patients, 1225 were aged < 70 years and 411 ≥70 years. Both groups were compared for prostate cancer characteristics, oncological and functional outcomes. Multivariate analyses were used to estimate the effect of advanced age on overall survival (OS), cancer-specific survival (CSS), biochemical recurrence-free survival (BFS) and postoperative continence. RESULTS: The median (range) age of the patients aged ≥ 70 years was 72 (70-85) years and for those aged < 70 years was 64 (40-69) years (P < 0.001), respectively. The patients aged ≥ 70 years were assigned higher American Society of Anesthesiologists (ASA) classes (P < 0.001) reflecting a higher rate of severe comorbidities in this group. In the patients aged ≥ 70 years there were significantly more clinically palpable and pathologically non-organ-confined tumours (P= 0.030 and P= 0.026, respectively), and higher biopsy and RP Gleason scores (P= 0.002 and P= 0.004, respectively). Accordingly, patients aged ≥ 70 years presented with a higher proportion of high-risk prostate cancer, although the difference was not significant (P= 0.060). There were no differences between the groups for preoperative prostate-specific antigen level (P= 0.898), rate of pelvic lymph node dissection (P= 0.231), pN+ (P= 0.526) and R+ status (P= 0.590). Kaplan-Meier curves showed a significantly lower 10-year OS (67 vs 82%; P= 0.017) and a trend towards a lower 10-year CSS (70 vs 83%; P= 0.057) in patients aged ≥ 70 years. However, on multivariate analysis advanced age was not an independent predictor of OS (P= 0.102) or CSS (P= 0.195), whereas pN+ status (both P < 0.001), RP Gleason scores 8-10 (both P < 0.001) and ASA classes 3-4 (P= 0.037 and P= 0.028, respectively) were. The 2-year postoperative continence rates was comparable between the groups (International Continence Society [ICS] male incontinence symptom score 2.10 vs 2.01; P= 0.984). In multivariate analysis it depended only on the preoperative ICSmale incontinence symptom score (P < 0.001) but not on advanced age (P= 0.341). CONCLUSIONS: Patients aged ≥ 70 years had biologically more aggressive and locally advanced tumours significantly more often than those aged < 70 years. However, advanced age itself was not an independent predictor of survival after RP. Rather, survival was associated with adverse prostate cancer features and severe comorbidities. Consequently, it seems unjustifiable to generally exclude elderly patients from RP, not least because surgery achieved excellent postoperative continence in this age group, too.

Treatment of long ureteric strictures with buccal mucosal grafts.

OBJECTIVE: To describe the reconstruction of long ureteric strictures using buccal mucosal patch grafts and to report the intermediate-term functional outcome. PATIENTS AND METHODS: Between November 2000 and October 2006 reconstruction of seven long ureteric strictures using buccal mucosal patch grafts and omental wrapping was performed in five women (one with bilateral strictures) and one man. The surgical steps of stricture reconstruction and wrapping with omentum are described in detail. Stricture recurrence was defined as persistent impaired ureteric drainage as displayed by imaging techniques or the necessity to prolong JJ stenting. Patency rates and stricture recurrence-free survival rates are provided. RESULTS: With a median follow up of 18 months five of the seven strictures were recurrence-free. Graft take was good in all patients. In one asymptomatic patient, there was impaired ureteric drainage on the reconstructed side, and in one patient with reconstruction of both ureters prolonged JJ stenting of one side was necessary. In both patients, the impaired drainage was caused by persistent stricture below the reconstructed ureteric segments. CONCLUSIONS: At intermediate-term follow-up in a small group of patients with long ureteric strictures, treatment with buccal mucosal patch grafts and omental wrapping showed good functional outcome.

The incidence of lymph node metastases in prostate carcinoma depends not only on tumor characteristics but also on surgical performance and extent of pelvic lymphadenectomy.

OBJECTIVES: The purpose of the present study was to determine whether predictions of the incidence of pelvic lymph node metastases in patients with similar prostate cancer characteristics are influenced by the extent of pelvic lymphadenectomy or surgical performance. MATERIAL AND METHODS: Data from a prostate cancer database were analyzed to investigate associations between incidence of lymph node metastasis and preoperative prostate-specific antigen level, clinical stage, biopsy Gleason score, extent of pelvic lymphadenectomy, and surgical performance. Subgroups of patients with the same characteristics were formed, and a multivariate analysis was performed. RESULTS: Data of 668 patients with cT1-T2c prostate cancer who underwent radical retropubic prostatectomy with pelvic lymphadenectomy were analyzed. Lymph node metastases were found in 8.7% of these patients. In the subgroup of patients undergoing limited pelvic lymphadenectomy, 6.3% were affected compared with 14.7% of patients undergoing extended pelvic lymphadenectomy (P<0.0005). In the subgroups of patients with the same tumor characteristics (with only two exceptions), the impact of the extent of lymphadenectomy on the incidence of lymph node metastases was evident. The results of the multivariate analysis corroborated the influence of the extent of pelvic lymphadenectomy (P<0.03) and surgical performance (P<0.04) on the incidence of lymph node metastases. CONCLUSIONS: The incidence of lymph node metastases was dependent not only on preoperative prostate-specific antigen level, clinical stage, and biopsy Gleason score but also to a large degree on surgical performance and the extent of pelvic lymphadenectomy. Our data suggest that a limited and/or not thoroughly performed pelvic lymphadenectomy results in failure to detect a relevant proportion of lymph node metastases.

Complications of pelvic lymphadenectomy in 1,380 patients undergoing radical retropubic prostatectomy between 1993 and 2006.

PURPOSE: We evaluated the perioperative complications associated with pelvic lymphadenectomy in patients undergoing radical retropubic prostatectomy. In particular the influence of the extent of pelvic lymphadenectomy and of other possible risk factors on the complication rate was examined. MATERIALS AND METHODS: All intraoperative and early postoperative complications in 1,380 patients who underwent radical retropubic prostatectomy were documented. Complications related to pelvic lymphadenectomy were described and evaluated statistically to explore the role of possible risk factors. RESULTS: Limited pelvic lymphadenectomy was performed in 867 patients and an extended procedure was done in 434. In 60 cases pelvic lymphadenectomy was not specified and in 19 pelvic lymphadenectomy was omitted. Intraoperative complications associated with pelvic lymphadenectomy were rare events (8 cases). Early postoperative complications included hemorrhage of the obturator artery in 1 patient, symptomatic lymphocele in 72, thromboembolic sequelae in 6 and lymphocele infection in 2. Lymphocele formation depended on the extent of pelvic lymphadenectomy (p <0.0001), the number of lymph nodes removed (p = 0.0038) and the operating surgeon (p = 0.0073). Thromboembolic events (p = 0.001) and re-interventions (p <0.0001) were more frequent in patients with a lymphocele. Multivariate analysis confirmed extended pelvic lymphadenectomy as an independent risk factor for lymphocele and re-intervention. CONCLUSIONS: Pelvic lymphadenectomy is the cause of a relevant number of perioperative complications in patients undergoing radical retropubic prostatectomy. Lymphocele formation, and the associated re-interventions and thromboembolic sequelae account for by far the highest percent of these complications. In the current study lymphocele formation depended on the extent of pelvic lymphadenectomy, the number of lymph nodes removed and the operating surgeon.

Intraoperative and early postoperative complications of radical retropubic prostatectomy.

INTRODUCTION: To determine the perioperative complications and morbidity of radical retropubic prostatectomy (RRP) and to analyze risk factors for observed complications. MATERIALS AND METHODS: Data of 1,000 patients undergoing RRP and pelvic lymphadenectomy (pLA) performed by different surgeons of the same hospital were collected. Uni- and multivariate analysis was performed to detect associations between intra- and postoperative complications and specific variables. RESULTS: Relevant intraoperative complications were observed in 28 cases and relevant postoperative complications in 187 cases requiring reoperations in 46 patients. Diverse minor postoperative complications occurred in 75 cases. The surgeon's experience and the operating time significantly influenced the incidence of intraoperative complications. Extended pLA was associated with significantly higher rates of lymphoceles and reoperations. The patients with lymphocele showed significantly higher rates of deep venous thrombosis (DVT), pulmonary embolism (PE) and reoperation and patients with DVT a higher incidence of PE and a higher rate of reoperations. The incidence of anastomotic strictures correlated significantly with postoperative urine retention. CONCLUSIONS: RRP is a safe surgical procedure. In the hands of experienced urologic surgeons it is associated with lower incidences of severe intraoperative complications. A substantial proportion of postoperative complications are associated with pLA and its extension.

[Hemospermia]. / Hemospermija.

Hemospermia refers to the presence of blood in the seminal fluid and is not very common urologic symptom. Its prevalence remains unknown. Historically, hemospermia was linked to excessive sexual overindulgence, prolonged sexual abstinence, interrupted coitus. Newer imaging modalities have altered the diagnosis and etiological factors of hemospermia are now more frequently identified. Hemospermia can result from many causes. Infections or inflammatory disorders account from 39% to 55% of cases, malignancies and trauma account just 4-13%. The remaining 11% of cases were caused by a variety of other pathologic conditions. Predisposing diseases are prostatitis, epididymitis, urinary stones, tuberculosis, cirrhosis of the liver, arterial hypertension, hematologic diseases. In 30-70% of the cases there is no association with any significant pathology. Cases of primary and solitary hemospermia can be adequately assessed by urinanalysis, blood pressure measurement, genital and rectal examination, PSA-test, and reassurance of the patient. Persistent and recurrent cases of hemospermia are best clarified by transrectal ultrasound examination, cystoscopy, computer tomography and magnetic resonance imaging. Treatment depends on the diagnostic findings but often simply involves reassurance.

A multicenter clinical trial on the use of complexed prostate specific antigen in low prostate specific antigen concentrations.

PURPOSE: The determination of complexed prostate specific antigen (cPSA) has been suggested to be promising for prostate cancer (PCa) diagnosis. In a multicenter trial we evaluate the diagnostic use of PSA forms in the low total PSA (tPSA) range. MATERIALS AND METHODS: A total of 283 white men with and 417 without PCa and tPSA concentrations between 0 and 6 ng/ml were retrospectively analyzed. All 700 untreated subjects underwent a multisector needle biopsy of the prostate. The Elecsys analyser 1010 (Roche Diagnostics, Mannheim, Germany) was used for determination of tPSA and free PSA. Determination of cPSA and tPSA was performed using immunoassays of the Bayer Immuno 1 system (Bayer Diagnostics, Tarrytown, New York). RESULTS: Receiver operating characteristics analyses for discrimination between cases with and without PCa were performed. The areas under the curves (AUC) for cPSA, tPSA and free-to-total PSA (f/tPSA) showed no significant differences in the tPSA ranges of 0 to 6 (700 cases), 0 to 4 (510) and 0.5 to 2.5 ng/ml (253). Within the tPSA range of 2.5 to 4 ng/ml (230 cases) the AUC for cPSA (0.61) was significantly larger than that for tPSA (Roche 0.51, Bayer 0.54) but did not differ from the AUC of f/tPSA (Roche). On the basis of the cutoffs for 95% specificity or sensitivity, no significant increase in corresponding sensitivity or specificity was found between tPSA with cPSA. CONCLUSIONS: In the tPSA range of less than 4 ng/ml no improvement in diagnostic accuracy was shown between cPSA with tPSA or the ratio of f/tPSA. The search for a useful marker in the low PSA range must continue.