Search

INTRODUCTION AND OBJECTIVE:Cytoreductive radical prostatectomy (cRP) might be an option in oligometastatic prostate cancer (PCa). However, no preoperative risk tool is available to select candidate...

INTRODUCTION AND OBJECTIVES:Most of the preoperative risk tools predicting prostate cancer (PCa) recurrence after radical prostatectomy (RP) considered biochemical recurrence (BCR) as the main endp...

implant placements and the remaining 3,721 procedures (32.4%) were revision procedures. Of the primary placements, there were 6,705 (86.3%) inflatable penile prostheses and 1,060 (13.7%) malleable penile prostheses placed. There were no differences in type of implant placed based on age or race. There were no differences between type of surgery or numbers of surgeries per patient between races. As age increased there were fewer implant placements and more revision surgeries, as well as more implant removals without replacement (see chart below). CONCLUSIONS: In contrast to previously studied populations, age and race do not appear to play a role in the selection of malleable penile prostheses compared to inflatable penile prostheses in the veteran population. As veterans age, they are more likely to undergo revision surgery and more likely to have implants removed without replacement. Further studies are warranted to determine preoperative risk factors for eventual revision surgery.

The National Surgical Quality Improvement Program was established in 1994 to measure and enhance of the quality of surgical care. Since its inception, 30-day postoperative morbidity after major surgery in the Veterans Administration has decreased by 45%. We performed a pilot study to assess risk factors associated with 30-day morbidity using National Surgical Quality Improvement Program indicators in a private setting.A total of 643 subjects were accrued by a trained surgical reviewer from our institution between December 2003 and December 2004. Patient preoperative, intraoperative and nonNational Surgical Quality Improvement Program data elements were abstracted from clinical records. Bivariate relationships between preoperative risk factors, intraoperative process measures and 30-day postoperative morbidity were determined. Multiple variable logistic regression analysis was used to identify patient preoperative and intraoperative risk factors associated with 30-day morbidity.On multivariate analysis the preoperative risk factors history of congestive heart failure (OR 14.42, 95% CI 2.66 to 78.30), diabetes with end organ damage (OR 12.56, 95% CI 2.09 to 75.53), angioplasty (OR 2.75, 95% CI 1.27 to 5.93), quadriplegia (OR 4.39, 95% CI 1.36 to 14.14), low albumin (OR 2.49, 95% CI 1.18 to 5.24) and hydronephrosis (OR 2.51, 95% CI 1.11 to 5.69) were statistically significant predictors of 30-day postoperative morbidity. Intraoperative process measures, that is operative time in hours (OR 1.24, 95% CI 1.12 to 1.37) and transfusion (OR 3.11, 95% CI 1.49 to 6.50), were also significant contributors to postoperative morbidity.We found that patient preoperative risk factors and intraoperative process measures were important determinants of postoperative morbidity. Implementation of the National Surgical Quality Improvement Program in urology may be used to measure processes of care that are associated with surgical outcomes and, thereby, improve the quality of urological care.

INTRODUCTION AND OBJECTIVES: Preoperative variables used to plan radical prostatectomy are associated with a significant risk of misclassification. To evaluate whether intraoperative frozen section analysis of the relevant prostate surface might provide significant information ensuring nerve-sparing and minimizing positive margin rates. METHODS: Between June 2011 and September 2012, 236 patients treated with radical prostatectomy (RP) (n 176 open retropubic RP; n 60 robot assisted laparoscopic RP) received intraoperative whole surface frozen section analysis of the removed prostate. Median patient age was 64 years (IQR: 60 70) and median pre-operative PSA 6.75 ng/ml (IQR: 5.1 10.0). The apex and base were circumferencially dissected as well as the whole posterolateral tissue corresponding to the neurovascular bundles (NVB). The dissected specimens were perpendicularly cut for frozen section analysis resulting in 22-24 surface sections to navigate the procedure. Pre-, intraand postoperative parameters were prospectively collected. RESULTS: Intraoperative frozen section analysis identified positive surgical margins in 22% (NVB: 56.9%, apex 34.5%, base: 8.6%). Nerve-sparing in pT2, pT3a and pT3b patients was performed in 96.5%, 84.1% and 81.8%, respectively. Of men with a positive surgical margin detected at frozen section analysis, 92.3% could be converted to a negative status, while 7.7% remained positive. Final positive margin status of the total cohort was 3% including a false negative frozen section rate of 1.6%. In 14.8% the initial nerve sparing plan was intraoperatively changed due to positive frozen section results. In secondary resected specimen cancer was histopathologically detected in 25%. Final pathology showed Gleason upgrading ( 6 to 7 or 7 to 8) or upstaging (cT1c cT2 to T3) in 40.7% compared to preoperative variables. Comparing the group of patients with positive versus negative margins on frozen section, preoperative variables were not significantly different while postoperatively pathologic stage, tumor volume, length of surgery and final margin status were. 13% of patients who had exclusively unilateral positive biopsies showed an intraoperative positive surgical margin on the opposite, biopsy negative, site. CONCLUSIONS: Frozen section analysis might help to keep the positive surgical margin rate as low as possible but allow safer preservation of functional anatomic structures in misclassified patients or even patients at higher preoperative risk.