Spinal anesthesia does not impact prostate cancer recurrence in a cohort of men undergoing radical prostatectomy: an observational study.

BACKGROUND AND OBJECTIVES: Prior studies suggest a possible association between the use of neuraxial-general anesthesia and a decrease in prostate cancer recurrence after radical prostatectomy. We examine the correlation of a spinal anesthesia-only technique on prostate cancer recurrence. METHODS: Charts from consecutive radical prostatectomy patients of 3 experienced urologists from January 1999 to December 2005 were reviewed. In addition to the usual clinical and pathologic predictors of disease recurrence, patient records were queried for the type of anesthesia (general vs spinal) performed. A Cox proportional hazards model was used to determine the statistical significance of predictors of biochemical recurrence. RESULTS: A total of 1964 patients-1166 and 798 receiving spinal with sedation or general anesthesia, respectively-had complete preoperative and follow-up data. In univariate proportional hazards analysis, the use of general anesthesia was associated with a trend toward an increased risk of biochemical recurrence when compared with the use of spinal anesthesia (hazard ratio, 1.29; 95% confidence interval, 0.99-1.66; P = 0.053). In multivariable analysis, the effect size (hazard ratio, 1.10; 95% confidence interval, 0.85-1.42; P = 0.458) was diminished by clinical and pathologic variables. CONCLUSIONS: This was a retrospective study of patients with prostate cancer who have undergone radical prostatectomy during a time period when the practice of anesthesia for prostatectomy at our institution was transitioned from spinal to general anesthesia. In our study, when controlling for other predictors of advanced prostate cancer, the type of anesthetic given during prostatectomy had no effect on the risk of biochemical recurrence.

Repeat prostate biopsies predict location of index cancer in an active surveillance cohort.

OBJECTIVE: • To evaluate the ability of repeat prostate biopsies to determine the location of the index cancer for men on prostate cancer surveillance. PATIENTS AND METHODS: • Forty-five men on active surveillance had a record of the locations of their positive diagnostic biopsy, repeat surveillance biopsy and index cancer (i.e. largest cancer) from prostatectomy specimens. • Logistic regression analysis was used to evaluate the association between two consecutive needle biopsies showing cancer in an identical location and the outcome of finding the index cancer at the same location as the initial diagnostic biopsy. RESULTS: • Eighteen of 45 (40%) men ultimately had an index cancer at the same location as their diagnostic biopsy. • Thirteen men had two consecutive biopsies that showed cancer at the same location each time; nine of these men ultimately had an index cancer at that same location. • In multivariable logistic regression analysis of men with at least two biopsies, having two initial consecutive biopsies with the same location increased the odds (odds ratio 5.9; 95% CI 1.1-31, P= 0.037) of having an index cancer at the same location as the initial biopsy in a cohort of men on active surveillance. CONCLUSIONS: • A substantial proportion of men in an active surveillance cohort who undergo prostatectomy ultimately have evidence of an index cancer at the same location as their initial biopsy. • This is more likely to be the case when a repeat biopsy shows evidence of cancer at the same location.

Risk stratification of men choosing surveillance for low risk prostate cancer.

PURPOSE: We sought to predict biopsy progression in men on prostate cancer surveillance. MATERIALS AND METHODS: A total of 376 men with a median age of 65.5 years (range 45.8 to 79.5) with low risk prostate cancer on surveillance underwent at least 1 followup biopsy after diagnosis. Progression was defined at surveillance biopsy as Gleason pattern 4 or 5, greater than 2 biopsy cores with cancer or greater than 50% involvement of any core with cancer. Proportional hazards analysis was used to evaluate the association between covariates and progression at surveillance biopsy. The Kaplan-Meier method was used to estimate the probability of disease progression. RESULTS: Of the 376 men 123 (32.7%) had progression a median of 5.6 years (range 0.3 to 8.5) after diagnosis. Percent free PSA and maximum percent core involvement at diagnosis were associated with progression, allowing stratification of the progression risk at initial surveillance biopsy. Cancer presence and PSA density at initial surveillance biopsy were associated with subsequent progression, allowing stratification of the cumulative incidence of progression 3 years after initial surveillance biopsy (cumulative incidence 11.1%, 95% CI 4.7 to 25.2 for negative biopsy and PSAD less than 0.08 ng/ml/cm(3) vs 53.6%, 95% CI 38.6 to 70.0 for positive biopsy and PSAD 0.08 ng/ml/cm(3) or greater, log rank test p <0.0001). CONCLUSIONS: Clinical variables at diagnosis and at first surveillance biopsy during followup in an active surveillance program can be used to inform men about the likelihood of an unfavorable prostate biopsy. This information could improve patient and physician acceptance of active surveillance in carefully selected men.

A case of a lower pole renal calculus managed with percutaneous nephrolithotomy.

BACKGROUND: A 50-year-old man presented to an outpatient urology clinic with left-sided flank pain. He had received treatment for a left renal pelvis calculus 5 years earlier; shock wave lithotripsy had been unsuccessful and ureteroscopic laser lithotripsy had left the patient with a 2 mm residual stone fragment. The fragment was deemed clinically insignificant, and the patient remained asymptomatic without any further follow-up. INVESTIGATIONS: Physical examination, CT of the abdomen and pelvis, and complete metabolic evaluation. DIAGNOSIS: Left lower pole renal calculus and idiopathic hypercalciuria. MANAGEMENT: The patient was counseled about his treatment options, and he elected to undergo percutaneous nephrolithotomy. After a single-stage procedure, CT confirmed a stone-free state. The patient was administered thiazide therapy and dietary counseling to treat his hypercalciuria. This condition resolved, and the patient remained stone-free 1 year after treatment.