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Background and Objective: Persistent prostatic specific antigen (PSA) represents a poor prognostic factor for recurrence after radical prostatectomy (RP). However, the impact of persistent PSA on oncologic outcomes in patients undergoing salvage RP is unknown. To investigate the impact of persistent PSA after salvage RP on long-term oncologic outcomes., Material and Methods: Patients who underwent salvage RP for recurrent prostate cancer between 2000 and 2021 were identified from twelve high-volume centers. Only patients with available PSA after salvage RP were included. Kaplan-Meier analyses and multivariable Cox regression models were used to test the effect of persistent PSA on biochemical recurrence (BCR), metastasis and any death after salvage RP. Persistent PSA was defined as a PSA-value ≥ 0.1 ng/ml, at first PSA-measurement after salvage RP., Results: Overall, 580 patients were identified. Of those, 42% (n = 242) harbored persistent PSA. Median follow-up after salvage RP was 38 months, median time to salvage RP was 64 months and median time to first PSA after salvage RP was 2.2 months. At 84 months after salvage RP, BCR-free, metastasis-free, and overall survival was 6.6 vs. 59%, 71 vs. 88% and 77 vs. 94% for patients with persistent vs. undetectable PSA after salvage RP (all p < 0.01). In multivariable Cox models persistent PSA was an independent predictor for BCR (HR: 5.47, p < 0.001) and death (HR: 3.07, p < 0.01)., Conclusion: Persistent PSA is common after salvage RP and represents an independent predictor for worse oncologic outcomes. Patients undergoing salvage RP should be closely monitored after surgery to identify those with persistent PSA., (© 2023. The Author(s).)

Background: Salvage radical prostatectomy (sRP) yields poor functional outcomes and relatively high complication rates. Gleason score (GS) 6 prostate cancer (PCa) has genetic and clinical features showing little, if not absent, metastatic potential. However, the behavior of GS 6 PCa recurring after previous PCa treatment including radiotherapy and/or ablation has not been investigated., Objective: To evaluate the oncological outcomes of sRP for radio- and/or ablation-recurrent GS 6 PCa., Design, Setting, and Participants: Retrospective data of sRP for recurrent PCa after local nonsurgical treatment were collected from 14 tertiary referral centers from 2000 to 2021., Intervention: Prostate biopsy before sRP and sRP., Outcome Measurements and Statistical Analysis: A survival analysis was performed for pre-sRP biopsy and sRP-proven GS 6. Concordance between PCa at pre-sRP biopsy and sRP histology was assessed., Results and Limitations: We included GS 6 recurrent PCa at pre-sRP biopsy (n = 142) and at sRP (n = 50), as two cohorts. The majority had primary radiotherapy and/or brachytherapy (83.8% of GS 6 patients at pre-sRP biopsy; 78% of GS 6 patients at sRP) and whole-gland treatments (91% biopsy; 85.1% sRP). Biopsy GS 6 10-yr metastasis, cancer-specific survival (CSS), and overall survival (OS) were 79% (95% confidence interval [CI] 61-89%), 98% (95-99%), and 89% (78-95%), respectively. Upgrading at sRP was 69%, 35.5% had a pT3 stage, and 13.4% had positive nodes. The sRP GS 6 10-yr metastasis-free survival, CSS, and OS were 100%, 100%, and 90% (95% CI 58-98%) respectively; pT3 and pN1 disease were found in 12% and 0%, respectively. Overall complications, high-grade complications, and severe incontinence were experienced by >50%, >10%, and >15% of men, respectively (in both the biopsy and the sRP cohorts). Limitations include the retrospective nature of the study and absence of a centralized pathological review., Conclusions: GS 6 sRP-proven PCa recurring after nonsurgical primary treatment has almost no metastatic potential, while patients experience relevant morbidity of the procedure. However, a significant proportion of GS 6 cases at pre-sRP biopsy are upgraded at sRP. In the idea not to overtreat, efforts should be made to improve the diagnostic accuracy of pre-sRP biopsy., Patient Summary: We investigated the oncological results of salvage radical prostatectomy for recurrent prostate cancer of Gleason score (GS) 6 category. We found a very low malignant potential of GS 6 confirmed at salvage radical prostatectomy despite surgical complications being relatively high. Nonetheless, biopsy GS 6 was frequently upgraded and had less optimal oncological control. Overtreatment for recurrent GS 6 after nonsurgical first-line treatment should be avoided, and efforts should be made to increase the diagnostic accuracy of biopsies for recurrent disease., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Purpose: Our goal was to evaluate the comparative effectiveness of robot-assisted laparoscopic prostatectomy (RALP) and open radical prostatectomy (ORP) in a multicenter study., Materials and Methods: We evaluated men with localized prostate cancer at 11 high-volume academic medical centers in the United States from the PROST-QA (2003-2006) and the PROST-QA/RP2 cohorts (2010-2013) with a pre-specified goal of comparing RALP (549) and ORP (545). We measured longitudinal patient-reported health-related quality of life (HRQOL) at pre-treatment and at 2, 6, 12, and 24 months, and pathological and perioperative outcomes/complications., Results: Demographics, cancer characteristics, and margin status were similar between surgical approaches. ORP subjects were more likely to undergo lymphadenectomy (89% vs 47%; p <0.01) and nerve sparing (94% vs 89%; p <0.01). RALP vs ORP subjects experienced less mean intraoperative blood loss (192 vs 805 mL; p <0.01), shorter mean hospital stay (1.6 vs 2.1 days; p <0.01), and fewer blood transfusions (1% vs 4%; p <0.01), wound infections (2% vs 4%; p=0.02), other infections (1% vs 4%; p <0.01), deep venous thromboses (0.5% vs 2%; p=0.04), and bladder neck contractures requiring dilation (1.6% vs 8.3%; p <0.01). RALP subjects reported less pain (p=0.04), less activity interference (p <0.01) and higher incision satisfaction (p <0.01). Surgical approach (RALP vs ORP) was not a significant predictor of longitudinal HRQOL change in any HRQOL domain., Conclusions: In high-volume academic centers, RALP and ORP patients may expect similar long-term HRQOL outcomes. Overall, RALP patients have less pain, shorter hospital stays, and fewer post-surgical complications such as blood transfusions, infections, deep venous thromboses, and bladder neck contractures.

Extraction site incisional hernia (IH) has been recognized as an important complication in minimally invasive procedures but has not been as well characterized following robotic-assisted laparoscopic prostatectomy (RALP). Approximately 29% of IH required surgical repair. A number of techniques have been utilized to reduce the rates of IH following minimally invasive procedures. First, off-midline extraction was investigated, this did not demonstrate a reduction in incisional hernia rates. Recently, supra-umbilical transverse incisions have been utilized to extract prostate specimen and this method decreased the extraction site IH rate compared to the vertical midline incision. In addition, the choice of fascial closure technique and choice of the suture may influence the incidence of extraction site IH. For example, studies showed that abdominal fascial closure using a nonabsorbable suture and a continuous running suture technique decreased IH rate from 32 to 17%. Finally, "the small bites technique" has been recommended to reduce hernia incidence after midline fascial closure following a randomized controlled trial (RCT) which demonstrated the superiority of the small-bite technique. In summary, a supra-umbilical transverse incision to extract the specimen was shown to decrease the rate of extraction site IH. In vertical midline incisional closure, the small bites technique with slowly- or non-absorbable suture, such as #0 or 2-0 PDS II with SH or CT-2 needle (26 mm arch length), reduces the IH rate. Urologists should consider this data to reduce the risk of IH following RALP.

Purpose: We sought to determine whether bladder neck size is associated with incontinence scores after robot-assisted laparoscopic radical prostatectomy., Materials and Methods: Consecutive eligible patients undergoing robot-assisted laparoscopic radical prostatectomy between July 19 and December 28, 2016 were enrolled in a prospective, longitudinal, observational cohort study. The primary outcome was patient reported urinary incontinence on the EPIC (Expanded Prostate Cancer Index Composite) scale 6 and 12 weeks postoperatively. The relationship between the EPIC score of urinary incontinence and bladder neck size was evaluated by multiple regression. Predicted EPIC scores for incontinence were displayed graphically after using restricted cubic splines to model bladder neck size., Results: A total of 107 patients were enrolled. The response rate was 98% and 87% at 6 and 12 weeks, respectively. Bladder neck size was not significantly associated with incontinence scores at 6 and 12 weeks. Comparing the 90th percentile for bladder neck size (18 mm) with the 10th percentile (7 mm) revealed no significant difference in adjusted EPIC scores for incontinence at 6 weeks (β coefficient 0.88, 95% CI -10.92-12.68, p = 0.88) or at 12 weeks (β coefficient 5.80, 95% CI -7.36-18.97, p = 0.39)., Conclusions: These findings question the merit of creating an extremely small bladder neck during robot-assisted laparoscopic radical prostatectomy. We contend that doing so increases the risk of positive margins at the bladder neck without facilitating early recovery of continence., (Copyright © 2017 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To compare biochemical recurrence (BCR)-free survival and predictors of BCR in intermediate-risk (IR) and high-risk (HR) patients undergoing robotic-assisted laparoscopic prostatectomy (RALP) vs open radical prostatectomy (ORP)., Materials and Methods: We conducted a retrospective study on 1336 men with D'Amico IR or HR prostate cancer who underwent RALP or ORP between 2003 and 2009. Exclusion criteria were use of neoadjuvant therapy, <6 months of follow-up, and insufficient clinicopathologic data. We compared demographic, clinical, and pathologic variables between groups. Kaplan-Meier analysis was performed to compare the 5-year BCR-free survival between groups. Multivariate models were developed to determine whether surgical approach influences BCR., Results: A total of 979 IR and HR patients (237 ORP and 742 RALP patients) met inclusion criteria. Median follow-up was shorter for RALP (43 vs 63 months; P<.001). ORP patients had a higher median prostate-specific antigen level (7.9 vs 6.7 ng/mL; P<.002), significantly more Gleason sum 8-10 tumors, and more adverse pathologic features overall. There was no difference in positive surgical margins between groups. Pathologic features including extraprostatic extension, seminal vesicle involvement, lymph node involvement, pathologic Gleason sum, and positive surgical margin were significant independent predictors of BCR in multivariate analysis. Surgical approach (RALP vs ORP) did not predict BCR when controlling for other known predictors of BCR., Conclusion: Among IR and HR prostate cancer patients, the oncologic outcomes are similar between RALP and ORP. Not surprisingly, adverse pathologic features are harbingers of BCR., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Unlabelled: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Multiple treatment alternatives exist for localised prostate cancer, with few high-quality studies directly comparing their comparative effectiveness and costs. The present study is the most comprehensive cost-effectiveness analysis to date for localised prostate cancer, conducted with a lifetime horizon and accounting for survival, health-related quality-of-life, and cost impact of secondary treatments and other downstream events, as well as primary treatment choices. The analysis found minor differences, generally slightly favouring surgical methods, in quality-adjusted life years across treatment options. However, radiation therapy (RT) was consistently more expensive than surgery, and some alternatives, e.g. intensity-modulated RT for low-risk disease, were dominated - that is, both more expensive and less effective than competing alternatives., Objective: To characterise the costs and outcomes associated with radical prostatectomy (open, laparoscopic, or robot-assisted) and radiation therapy (RT: dose-escalated three-dimensional conformal RT, intensity-modulated RT, brachytherapy, or combination), using a comprehensive, lifetime decision analytical model., Patients and Methods: A Markov model was constructed to follow hypothetical men with low-, intermediate-, and high-risk prostate cancer over their lifetimes after primary treatment; probabilities of outcomes were based on an exhaustive literature search yielding 232 unique publications. In each Markov cycle, patients could have remission, recurrence, salvage treatment, metastasis, death from prostate cancer, and death from other causes. Utilities for each health state were determined, and disutilities were applied for complications and toxicities of treatment. Costs were determined from the USA payer perspective, with incorporation of patient costs in a sensitivity analysis., Results: Differences across treatments in quality-adjusted life years across methods were modest, ranging from 10.3 to 11.3 for low-risk patients, 9.6-10.5 for intermediate-risk patients and 7.8-9.3 for high-risk patients. There were no statistically significant differences among surgical methods, which tended to be more effective than RT methods, with the exception of combined external beam + brachytherapy for high-risk disease. RT methods were consistently more expensive than surgical methods; costs ranged from $19 901 (robot-assisted prostatectomy for low-risk disease) to $50 276 (combined RT for high-risk disease). These findings were robust to an extensive set of sensitivity analyses., Conclusions: Our analysis found small differences in outcomes and substantial differences in payer and patient costs across treatment alternatives. These findings may inform future policy discussions about strategies to improve efficiency of treatment selection for localised prostate cancer., (© 2012 BJU International.)

Purpose: Salvage robotic assisted laparoscopic prostatectomy is a treatment option for certain patients with recurrent prostate cancer after primary therapy. Data regarding patient selection, complication rates and cancer outcomes are scarce. We report the largest, single institution series to date, to our knowledge, of salvage robotic assisted laparoscopic prostatectomy., Materials and Methods: We reviewed our database of 4,234 patients treated with robotic assisted laparoscopic prostatectomy at Vanderbilt University and identified 34 men who had surgery after the failure of prior definitive ablative therapy. Each patient had biopsy proven recurrent prostate cancer and no evidence of metastases. The primary outcome measure was biochemical failure., Results: Median time from primary therapy to salvage robotic assisted laparoscopic prostatectomy was 48.5 months with a median preoperative prostate specific antigen of 3.86 ng/ml. Most patients had Gleason scores of 7 or greater on preoperative biopsy, although 12 (35%) had Gleason 8 or greater disease. After a median followup of 16 months 18% of patients had biochemical failure. The positive margin rate was 26%, of which 33% had biochemical failure after surgery. On univariable analysis there was a significant association between prostate specific antigen doubling time and biochemical failure (HR 0.77, 95% CI 0.60-0.99, p = 0.049) as well as between Gleason score at original diagnosis and biochemical failure (HR 3.49, 95% CI 1.18-10.3, p = 0.023). There were 2 Clavien II-III complications, namely a pulmonary embolism and a rectal laceration. Postoperatively 39% of patients had excellent continence., Conclusions: Salvage robotic assisted laparoscopic prostatectomy is safe, with many favorable outcomes compared to open salvage radical prostatectomy series. Advantages include superior visualization of the posterior prostatic plane, modest blood loss, low complication rates and short length of stay., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Post-prostatectomy urinary incontinence can impact health related quality of life in men treated with radical prostatectomy for prostate cancer. Currently no consensus exists on which patients are at risk for impaired health related quality of life secondary to post-prostatectomy urinary incontinence. Using trajectory clustering analysis we identified predictors of post-prostatectomy urinary incontinence recovery in unique patient groups., Materials and Methods: In a 5-year period health related quality of life was evaluated in patients treated with radical prostatectomy using UCLA-PCI preoperatively, and 3, 6 and 12 months postoperatively. We used a novel cluster modeling technique to identify unique group trajectories of urinary function recovery with time., Results: Group based modeling of UCLA-PCI urinary function scores identified 3 distinct post-prostatectomy urinary incontinence recovery patterns. The 73 group 1 patients had a significant postoperative decrease with only 33.4% of optimum function at 12 months. The 258 group 2 patients had moderately decreased urinary function at 3 months with improvement to 76.8% of optimum function at 12 months. The 89 group 3 patients had high scores throughout. Group 1 patients tended to be older (p=0.001), have major depression (p=0.008) and lower extremity circulatory disease (p=0.004), be a past or a current smoker (p=0.004) and have more comorbidities (p<0.001) than those in groups 2 and 3. On multivariate analysis age and the number of comorbidities significantly predicted inclusion in the poor function group., Conclusions: A novel modeling approach identified 3 distinct post-prostatectomy urinary incontinence recovery patterns. Patient age and the number of comorbidities predicted worse outcome. These findings have implications for preoperative patient counseling and early intervention for post-prostatectomy urinary incontinence., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether robotic-assisted laparoscopic radical prostatectomy (RALP) is associated with a lower transfusion rate than radical retropubic prostatectomy (RRP)., Patients and Methods: In this cohort study, we evaluated 1244 consecutive patients who underwent RALP (830) or RRP (414) between June 2003 and July 2006. Demographics, clinical characteristics, pathology, blood loss and transfusion data were collected prospectively. Groups were compared for baseline characteristics, blood loss, change in haematocrit and transfusion using univariate statistics, and an exploratory multivariate model was developed., Results: RALP was associated with lower blood loss (median 100 vs 450 mL, P < 0.001) and a smaller change in haematocrit (median 7% vs 10%, P < 0.001) than RRP. Although both groups had low transfusion rates, the RALP group required fewer transfusions than the RRP group (0.8% vs 3.4%, P= 0.002). On univariate analysis, surgical approach (RRP vs RALP), estimated blood loss ≥500 mL and change in haematocrit ≥10% were the only the significant predictors of transfusion. In the exploratory multivariate model RALP was the only significant predictor of reduced need for transfusion, with an odds ratio of 0.23 (95% confidence interval 0.09-0.58; P= 0.002)., Conclusions: This study shows that RALP is associated not only with less blood loss and a smaller decrease in haematocrit, but also a decreased need for transfusion., (© 2010 THE AUTHORS. JOURNAL COMPILATION © 2010 BJU INTERNATIONAL.)

Purpose: Whole mount processing is more resource intensive than routine systematic sampling of radical retropubic prostatectomy specimens. We compared whole mount and systematic sampling for detecting pathological outcomes, and compared the prognostic value of pathological findings across pathological methods., Materials and Methods: We included men (608 whole mount and 525 systematic sampling samples) with no prior treatment who underwent radical retropubic prostatectomy at Vanderbilt University Medical Center between January 2000 and June 2008. We used univariate and multivariate analysis to compare the pathological outcome detection rate between pathological methods. Kaplan-Meier curves and the log rank test were used to compare the prognostic value of pathological findings across pathological methods., Results: There were no significant differences between the whole mount and the systematic sampling groups in detecting extraprostatic extension (25% vs 30%), positive surgical margins (31% vs 31%), pathological Gleason score less than 7 (49% vs 43%), 7 (39% vs 43%) or greater than 7 (12% vs 13%), seminal vesicle invasion (8% vs 10%) or lymph node involvement (3% vs 5%). Tumor volume was higher in the systematic sampling group and whole mount detected more multiple surgical margins (each p <0.01). There were no significant differences in the likelihood of biochemical recurrence between the pathological methods when patients were stratified by pathological outcome., Conclusions: Except for estimated tumor volume and multiple margins whole mount and systematic sampling yield similar pathological information. Each method stratifies patients into comparable risk groups for biochemical recurrence. Thus, while whole mount is more resource intensive, it does not appear to result in improved detection of clinically important pathological outcomes or prognostication., (Copyright © 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We compared biochemical recurrence-free survival of patients who underwent radical retropubic prostatectomy vs robot assisted laparoscopic prostatectomy in concurrent series at a single institution., Materials and Methods: A total of 2,132 patients were treated between June 2003 and January 2008. We excluded from study patients with prior treatment (115), missing data (83) and lymph node involvement (30). The remaining cohort (1,904) was compared based on clinical, surgical and pathological factors. Kaplan-Meier analysis was performed comparing biochemical recurrence after robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy. A Cox proportional hazards model was generated to determine whether surgical approach is an independent predictor of biochemical recurrence., Results: There were 491 radical retropubic prostatectomies (25.9%) and 1,413 robot assisted laparoscopic prostatectomies (74.1%) performed, and median followup was 10 months (IQR 2 to 23). On univariate analysis the robot assisted laparoscopic prostatectomy group was slightly lower risk with lower median prostate specific antigen (5.4 vs 5.8, p <0.01), a lower proportion of pathological grade 7-10 (48.5% vs 54.7%, p <0.01) and lower pathological stage (80.5% pT2 vs 69.6% pT2, p <0.01). The 3-year biochemical recurrence-free survival rate was similar between the robot assisted laparoscopic prostatectomy and radical retropubic prostatectomy groups on the whole as well as when stratified by pathological stage, grade and margin status. On multivariate analysis extracapsular extension (p <0.01), pathological grade 7 or greater (p <0.01) and positive surgical margin (p <0.01) were independent predictors of biochemical recurrence while surgical approach was not., Conclusions: The likelihood of biochemical recurrence was similar between groups when stratified by known risk factors of recurrence. Surgical approach was not a significant predictor of biochemical recurrence in the multivariate model. Our analysis is suggestive of comparable effectiveness for robot assisted laparoscopic prostatectomy, although longer term studies are needed., (2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We evaluated whether a positive surgical margin at the apex confers a different likelihood of biochemical recurrence than at other sites., Material and Methods: A total of 3,087 men underwent radical prostatectomy between January 2000 and June 2008. Patients with prior treatment, positive seminal vesicles, lymph node involvement or less than 6 months of followup were excluded from analysis. The remaining 1,667 men were grouped by margin status, including negative surgical margins, a solitary positive apical margin, a solitary nonapical positive margin and multiple positive margins. Kaplan-Meier analysis was used to compare biochemical recurrence across groups. Cox proportional hazards models were constructed to determine whether a solitary positive apical margin is an independent risk factor for biochemical recurrence., Results: Median followup was 21.1 months. Of the cases 1,295 (77.7%) had negative surgical margins, 96 (5.8%) had a solitary positive apical margin, 82 (4.9%) had a solitary positive nonapical margin and 194 (11.6%) had multiple positive margins. The likelihood of biochemical recurrence in solitary positive apical margin cases was between that of negative surgical margins and a solitary positive nonapical margin with multiple positive margins showing the highest likelihood of biochemical recurrence (p <0.001). Three-year likelihood of freedom from biochemical recurrence was 94.7% (95% CI 92.7-96.2), 87.0% (95% CI 74.1-93.7), 81.4% (95% CI 67.2-89.9) and 73.0% (95% CI 63.9-80.2) for negative surgical margins, a solitary positive apical margin, a solitary positive nonapical margin and multiple positive margins, respectively. In the multivariate model a solitary positive nonapical margin (2.17, 95% CI 1.17-4.03, p = 0.01) and multiple positive margins (3.03, 95% CI 1.99-4.61, p <0.001) were independent predictors of biochemical recurrence but a solitary positive apical margin was not (1.34, 95% CI 0.65-2.75, p = 0.43)., Conclusions: A solitary positive apical margin was associated with worse biochemical recurrence but on multivariate analysis it was not an independent predictor of recurrence. Models to predict biochemical recurrence after radical prostatectomy should account for differences in the prognostic significance of different positive margin sites.

Purpose: We evaluated whether the 2002 TNM substages of pathological T2 prostate cancer predict intermediate term biochemical recurrence-free survival., Materials and Methods: The cohort consisted of men who underwent radical prostatectomy between January 2000 and June 2008, and had pT2 disease at final pathological evaluation. We excluded patients with prior treatment, less than 6 months of followup or missing data, leaving 1,370 available for analysis, including 340 with pT2a, 35 with pT2b and 995 with pT2c disease. Clinical and pathological characteristics were compared between groups using univariate analysis. Biochemical recurrence-free survival was compared between substages using Kaplan-Meier analysis. A Cox proportional hazards model was used to evaluate tumor substage as a biochemical recurrence-free survival predictor., Results: Median followup was 21 months. No differences were seen in the likelihood of biochemical recurrence-free survival between T2 subclasses (p = 0.174). No patient with T2b disease had recurrence. The 3 and 5-year likelihood of freedom from biochemical recurrence was 95.5% (95% CI 90.9-97.8) and 93.8% (95% CI 87.3-97.0) for pT2a, and 94.3% (95% CI 91.8-96.0) and 87.5% (95% CI 82.7-91.1) for pT2c, respectively. Multivariate analysis showed that significant predictors of biochemical recurrence-free survival were margin status (HR 2.7, 95% CI 1.3-5.5, p = 0.006), preoperative prostate specific antigen (HR 1.0, 95% CI 1.0-1.1, p = 0.029), pathological Gleason score 7 (HR 2.5, 95% CI 1.1-5.7, p = 0.024) and pathological Gleason score 8-10 (HR 6.2, 95% CI 2.2-17.4, p <0.001). Compared to pathological stage T2a neither pT2b nor pT2c predicted biochemical recurrence-free survival (p = 0.99 and 0.42, respectively)., Conclusions: Current pT2 prostate cancer substages may not have prognostic significance for intermediate term outcomes. If borne out during longer followup, future staging systems may collapse the substages into a single category.

Objective: To determine the impact of hospital variables on immediate surgical outcomes for patients treated with radical prostatectomy (RP) in academic centres., Patients and Methods: The University HealthSystem Consortium (UHC) Clinical Data Base was queried for data corresponding to patients who had RP at one of 130 academic medical centres nationwide between 2003 and the second quarter of 2007 (48,086). RP case volume (1-99, 100-499 and >500), total discharges (1-49,999, 50,000-99,999 >100,000), and geographical region (five categories) were determined and categorized for each academic centre. Analysis of variance and the Tukey statistic were used to assess the results. Length of stay (LOS), intensive care unit (ICU) rate, complication rate (CR) and in-hospital mortality (IHM) were analysed., Results: Case volume was a significant predictor of LOS, ICU and CR. The mean LOS was 3.77, 2.65 and 2.09 days, respectively, for centres from three tiers of lowest to highest case volumes (P < 0.001). ICU rates for the three tiers were 18.57, 3.61, and 1.30 (P < 0.001); CRs were 15.93, 8.79 and 5.76 (P < 0.001). Tukey analysis showed a 'ceiling' effect for ICU and CRs; there were no differences between the two higher case-volume groups. IHM was not significantly different between groups stratified by case volume. Stratification by total discharges showed differences in ICU rates only (P = 0.003). Stratification by geographical region showed no differences in outcome., Conclusions: RP case volume was an important variable in predicting three of the four outcome variables. CRs and ICU rates showed a 'ceiling effect' suggesting that an unknown 'critical volume' of cases portends improved surgical outcomes.

Objective: To examine the risk factors for urothelial carcinoma (UC) involvement of the prostate in patients undergoing radical cystoprostatectomy (RCP) for bladder cancer, as such involvement has both prognostic and therapeutic implications., Patients and Methods: We examined 308 consecutive men from 1998 to 2005 who had RCP for UC of the bladder, with whole-mount processing of their prostate. Prostatic involvement was categorized by site of origin (the bladder or the prostatic urethra) and, in the case of prostatic urethral origin, by depth of invasion, i.e. dysplasia/carcinoma in situ (CIS), involving the prostatic urethra, prostatic ductal invasion or prostatic stromal invasion. The impact of pathological characteristics was evaluated., Results: In all, 121 (39.3%) patients had some form of urothelial involvement of the prostate, of whom 59 (48.8%) had dysplasia/CIS of the prostatic urethra, 20 (16.5%) had ductal involvement and 32 (26.4%) had stromal involvement. Multivariate analysis showed that bladder CIS (odds ratio 2.0, 95% confidence interval, 1.2-3.6, P = 0.012) and trigonal involvement of bladder tumours (2.0, 1.1-3.7, P = 0.028) were independent risk factors for urothelial involvement of the prostate., Conclusion: There was prostatic involvement with UC in nearly 40% of patients undergoing RCP. In this study CIS and trigonal involvement were independent predictors of risk, but were not adequate enough to accurately identify most patients who have UC within their prostate; further prospective studies are needed to more accurately predict risk factors and depth of invasion.

Objective: To evaluate the impact of prostatic urothelial carcinoma (PUC) on survival of patients with bladder cancer undergoing radical cystoprostatectomy (RCP)., Patients and Methods: From 1998 to 2005, 463 consecutive RCPs were performed for UC of the bladder. Patients with PUC at final pathology were grouped by route of prostatic invasion (bladder origin or prostatic urethral origin) and by depth of invasion (carcinoma in situ, ductal invasion, and stromal invasion). Univariate and multivariate survival analyses were performed., Results: In all, 35% (162/463) of patients had PUC. The 3-year overall survival (OS) was 58.2% for patients who did not have PUC, 59.2%, 51.7%, and 16.8% in order of increasing depth of prostatic invasion for patients with PUC of urethral origin, and 6.7% for patients with bladder-origin PUC. Survival differed significantly between stromal and non-stromal PUC (P < 0.001). Patients with PUC of bladder origin had a higher rate of positive lymph nodes (LNs) than patients with stromal PUC of prostate origin (74.3% vs 27.8%, P < 0.001), but survival was similar (P = 0.619). On multivariate analysis, age (P = 0.035), increasing bladder stage (P = 0.003), stromal invasion (P = 0.002) and positive LNs (P < 0.001) were predictors of poor OS., Conclusion: Depth of prostatic invasion correlates with outcome. While prostatic involvement originating in the bladder is associated with higher rates of positive LNs, survival is similar to patients with stromal involvement of urethral origin. Age, bladder tumour stage, prostatic stromal involvement and positive LNs predict adverse outcome. Our data support separate staging of the prostate in RCP specimens.

Objectives: To review the role of radical prostatectomy in the management of patients with low risk carcinoma of the prostate., Methods: A summary of personal experience and pertinent literature is provided. In particular, information which permits conclusions on the efficacy and side effects of radical prostatectomy in this situation is considered., Results: For patients with low risk carcinoma of the prostate who choose to undergo treatment with curative intent, radical prostatectomy is an excellent option. Removal of the prostate with negative surgical margins can be achieved with a high frequency. Patients are afforded these curity of an undetectable PSA postoperatively which helps eliminate some of the inherent concerns which go along with an untreated or inadequately treated tumor. Recent modifications in surgical approach, including laparoscopic and robotic-assisted surgery, have lessened even further the impact of surgery on quality of life., Conclusion: Some patients with low risk disease who undergo radical prostatectomy are over treated and cured of a cancer which may not have been a significant threat to life or health. However, the uncertainty of active surveillance leads many patients to pursue curative therapy and radical prostatectomy offers an extremely low risk of death from prostate cancer, even with long term follow-up. Erectile dysfunction remains a potential quality of life compromise for some patients but, otherwise, the overwhelming majority return to their preoperative status within a short time with minimal risk for quality of life compromise.

Objective: To evaluate the outcomes based on gland size between robotically assisted radical prostatectomy (RALP) and open RP (RRP), as larger prostates might increase the difficulty of RP., Patients and Methods: We reviewed 660 patients who had RALP and 340 who had RRP from May 2003 to August 2006; the patients were divided into two groups, with a prostate of >75 and or=75 g had fewer positive margins than smaller glands, regardless of surgical technique. There was also a significant decrease in positive margin rate in among prostates of >75 g in favour of RALP. Thus, RALP appears to be comparable with RRP for patients with large glands, and might reduce the positive margin rate.

Objectives: The true incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing laparoscopic radical prostatectomy is unknown. Our aim was to determine the incidence of symptomatic DVT and PE and the risk factors for these complications., Methods: Fourteen surgeons from 13 referral institutions from both Europe and the United States provided retrospective data for all 5951 patients treated with laparoscopic radical prostatectomy (LRP), with or without robotic assistance, since the start of their institution's experience. Symptomatic DVT and PE within 90 d of surgery were regarded as venous thromboembolism (VTE). DVT was diagnosed mostly by Doppler ultrasound or contrast venography and PE by lung ventilation/perfusion scan or chest computed tomography or both. Statistical analysis included evaluation of incidence of symptomatic DVT and PE and risk factors as determined by exact methods and logistic regression., Results: Of 5951 patients in the study, 31 developed symptomatic VTE (0.5%; 95% confidence interval [CI], 0.4%, 0.7%). Among patients with an event, 22 (71%) had DVT only, 4 had PE without identified DVT, and 5 had both. Two patients died of PE. Prior DVT (odds ratio [OR]=13.5; 95%CI, 1.4, 61.3), current tobacco smoking (OR=2.8; 95%CI, 1.0, 7.3), larger prostate volume (OR=1.18; 95%CI, 1.09, 1.28), patient re-exploration (OR=20.6; 95%CI, 6.6, 54.0), longer operative time (OR=1.05; 95%CI, 1.02, 1.09), and longer hospital stay (OR=1.05; 95%CI, 1.01, 1.09) were associated with VTE in univariate analysis. Neoadjuvant therapy, body mass index, surgical experience, surgical approach, pathologic stage, perioperative transfusion, and heparin administration were not significant predictors., Conclusions: The incidence of symptomatic VTE after LRP is low. These data do not support the administration of prophylactic heparin to all patients undergoing LRP, especially those without risk factors for VTE.

Purpose: Surgical technique, patient characteristics and method of pathological review may influence surgical margin status. We evaluated the incidence and location of positive surgical margins in 200 sequential robotic assisted laparoscopic radical prostatectomy and 200 sequential open radical retropubic prostatectomy cases., Materials and Methods: From July 2002 until December 2006 a total of 1,747 patients underwent radical prostatectomy at our institution (robotic assisted laparoscopic radical prostatectomy in 1,238, radical retropubic prostatectomy in 509). From these we selected the last 200 consecutive radical retropubic prostatectomies and 200 robotic assisted laparoscopic radical prostatectomies performed before August 2006. Preoperative clinical characteristics including age, clinical stage, prostate specific antigen and Gleason score were evaluated. Postoperatively pathological specimens were assessed for specimen weight, Gleason score, tumor volume, pathological stage and margin status. The incidence and location of positive surgical margins were compared between robotic assisted laparoscopic radical prostatectomy and radical retropubic prostatectomy., Results: Patients undergoing robotic assisted laparoscopic radical prostatectomy compared to radical retropubic prostatectomy had more favorable tumor characteristics including lower prostate specific antigen, clinical stage and Gleason score. No statistically significant differences were found between groups for prostate volume or tumor volume. However, tumor volume as a percentage of prostate volume was higher among radical retropubic prostatectomy compared to robotic assisted laparoscopic radical prostatectomy cases (17.7% vs 13%, p = 0.001). The overall incidence of positive surgical margins was significantly lower among the robotic assisted laparoscopic radical prostatectomy compared to radical retropubic prostatectomy cases (15% vs 35%, p <0.001). The incidence of positive surgical margins according to pathological stage for robotic assisted laparoscopic radical prostatectomy vs radical retropubic prostatectomy cases was 16 of 171 (9.4%) vs 33 of 137 (24.1%) for pT2 (p <0.001) and 14 of 28 (50%) vs 36 of 60 (60%) for pT3. In both groups the apex was the most common site of positive surgical margins with 52% in the robotic assisted laparoscopic radical prostatectomy group vs 37% in the radical retropubic prostatectomy group (p >0.05)., Conclusions: In the hands of surgeons experienced in robotic assisted laparoscopic radical prostatectomy and radical retropubic prostatectomy, there was a statistically significant lower positive margin rate for patients undergoing robotic assisted laparoscopic radical prostatectomy. The most common location of a positive surgical margin in robotic assisted laparoscopic radical prostatectomy and radical retropubic prostatectomy cases was at the apex. Patients treated with radical retropubic prostatectomy had higher risk features which may have independently influenced these results. The method of pathological specimen analysis and reporting may account for the higher positive margin rates in both groups compared to some reports.

Objective: To assess reports supporting the novel and comprehensive evidence-based pathway for radical prostatectomy (RP), as collaborative-care pathways have helped to optimize management of patients treated with RP and such clinical pathways provide an ideal framework for constructing an original evidence-based pathway for the complete peri-operative care of these patients., Patients and Methods: We searched for articles on Medline via PubMed to identify reports describing consensus opinions on appropriate aspects of the peri-operative management of patients treated with RP, specifically seeking to discern information on preoperative antibiotic regimen, peri-operative laboratory testing, use of beta-blockers for those at cardiac risk, pulmonary treatment, deep venous thrombosis prophylaxis, diet advancement, pain management, anti-emetic use, bowel regimen, and catheter removal after RP., Results: Available reports were used to substantiate each variable of our collaborative-care pathway for RP. When available, meta-analyses were used to provide a broad review of the recognized clinical research. Otherwise, many controlled studies and retrospective reviews were relied upon to provide evidence to construct a framework for clinical decision-making., Conclusions: This is the first pathway for the peri-operative management of major urological procedure that is well integrated into current literature. The critical aspects of clinical decision-making in the patient treated with RP were validated by the available research.

Objective: To assess gastrointestinal (GI) and genitourinary (GU) toxicity in patients treated with salvage radiotherapy (SRT) at doses of 70.2 Gy after radical retropubic prostatectomy (RRP)., Patients and Methods: Medical records were reviewed retrospectively to identify patients treated with SRT after RRP between January 1999 and December 2005. Of the 62 patients identified, 30 were included for analysis. GI and GU toxicity was assessed using the National Cancer Institute Common Terminology Criteria for Adverse Events and the American Urological Association Symptom Index (AUASI), respectively., Results: The median AUASI score of the 17 patients with scores before SRT was 4, of the 24 with scores after SRT was 6, and of the 15 with scores before and after SRT the median increase was 3. Of the 29 patients with GI toxicity data, nine (31%) had diarrhoea after SRT (three after <70.2 Gy and six after 70.2 Gy). In all cases, the diarrhoea was mild (grade 1). Of all patients, 12 (41%) had proctitis after SRT (four after <70.2 Gy and eight after 70.2 Gy); the proctitis was grade 1 in four and grade 2 in eight, with no cases of grade 3 proctitis. There was no statistically significant difference in the median change in AUASI scores and GI toxicity incidence between patients receiving <70.2 or 70.2 Gy of SRT., Conclusion: High-dose SRT (70.2 Gy) is generally well tolerated with acceptable low-grade GI toxicity and minimal changes in AUASI scores.

Purpose: Minimally invasive surgery has been shown to decrease postoperative morbidity and length of stay for a number of surgical procedures. Furthermore, length of stay after open radical prostatectomy has decreased dramatically during the last decade. We examined differences in length of stay between a prospectively evaluated cohort of patients who underwent radical retropubic prostatectomy and robot assisted laparoscopic prostatectomy., Materials and Methods: Between January 2003 and March 2006, 1,003 radical prostatectomies were performed at our hospital. Data were collected in prospective fashion and a comparison was made between 374 patients who underwent radical retropubic prostatectomy and 629 who underwent robot assisted laparoscopic prostatectomy. Length of stay, factors influencing length of stay, readmission rates and unscheduled clinic or emergency room visits were evaluated. Patients in the 2 groups were treated using the same clinical care pathway., Results: Overall 94.3% of patients in the radical retropubic prostatectomy group and 97.5% in the robot assisted laparoscopic prostatectomy group were discharged home on or before postoperative day 1. Mean length of stay in the radical retropubic and robot assisted laparoscopic prostatectomy groups was 1.25 (median 1.09) and 1.17 days (median 1.03), which was similar and not statistically different (p=0.27). Readmission rates were similar in robot assisted laparoscopic and radical retropubic prostatectomy patients (7% and 5%, respectively, p=0.12). Unscheduled clinic or emergency room visits were the same in the robot assisted laparoscopic and radical retropubic prostatectomy groups (10%, p=0.95)., Conclusions: Patients who underwent radical retropubic prostatectomy or robot assisted laparoscopic prostatectomy can be treated on the same clinical pathway. A targeted hospital discharge date of postoperative day 1 can be achieved in the majority of patients who underwent radical prostatectomy. Readmission rates or unscheduled hospital visits are necessary in a small percent of patients treated with an early discharge program, of which the majority are caused by ileus.

Objectives: To review our experience with genitofemoral nerve grafting after radical prostatectomy, to determine both morbidity and efficacy., Methods: We identified patients who underwent genitofemoral nerve grafting between 2001 and 2003 at our hospital. Morbidity was recorded prospectively in the charts, and a validated questionnaire (International Index of Erectile Function, IIEF-5) was used to determine erectile function., Results: Twenty-seven patients received 32 genitofemoral nerve grafts. Five patients (19%) received bilateral grafts. In 3, a single nerve was harvested for a bilateral graft. Mean graft length was 5 cm, and mean follow-up was 14 months. Two patients (7%) reported persistent, minor numbness or tingling of the ipsilateral thigh or hemiscrotum. No other morbidity was noted. Overall, 56% of the patients were able to sustain an erection with enough firmness for penetration at the time of follow-up. Of those patients who reported no preoperative erectile dysfunction, 69% were able to have sexual intercourse., Conclusions: Harvesting and interposition of genitofemoral nerve grafts in the neurovascular bundle adds very minimal morbidity to radical prostatectomy. The results reported in our patients are at least comparable to those achieved with sural nerve grafting. Whether these results are a consequence of an effective unilateral nerve-sparing dissection or the nerve grafting itself is uncertain.

Objective: To define changes in the clinical pathway for open radical retropubic prostatectomy (RRP) and to determine their impact on patient care under the indirect influence of minimally invasive prostatectomy after implementing robotically assisted laparoscopic prostatectomy (RALP) at our institution and modifying the collaborative-care pathway., Patients and Methods: We retrospectively reviewed the Vanderbilt Prostate Database since the initiation of RALP in May 2003, evaluating those patients who had open RRP. Data were analysed in three consecutive 5-month blocks to determine incremental changes in protocol and outcomes, including complications and re-admissions., Results: Between May 2003 and August 2004, 196 patients had RALP and 183 had RRP. After May 2003, there was a progressive reduction for open RRP in the length of stay from 1.6 to 1.3 days. Analysis also showed an elimination of patient-controlled analgesia, a rapid diet advancement, and drain removal at the surgeon's discretion. There were no major complications after surgery, and three minor complications (1.6%). The rate of re-admission after open RRP was low throughout the study period (seven patients, 3.8%), and did not increase progressively., Conclusions: The management after open RRP was modified substantially after implementing RALP, with the two clinical pathways now similar. Despite these modifications in the treatment of patients having open RRP there was no increase in morbidity or compromise in patient outcome. Indeed, this study shows the feasibility and safety of a 1-day length of stay for open RRP.

Objectives: To compare intraoperative blood loss, perioperative hematocrit, and transfusion requirements in patients undergoing radical retropubic prostatectomy (RRP) versus robotic-assisted laparoscopic prostatectomy (RALP) by a single surgeon., Methods: During a 14-month period, 279 patients with localized carcinoma of the prostate were prospectively enrolled in this comparative study. The decision of which surgical approach to use was by patient choice. Of the 279 patients, 176 underwent RALP and 103 underwent RRP. The serum hematocrit was obtained preoperatively and 24 hours postoperatively in all patients. The intraoperative blood loss was recorded, and transfusion requirements were noted., Results: Patients in the RALP group had significantly less intraoperative blood loss compared with the RRP group (mean 191 mL versus 664 mL, P < 0.001). Additionally, the difference in the discharge hematocrit (36.8% versus 32.8%, P < 0.001) and the mean perioperative change in hematocrit (8.0% decrease versus 10.7% decrease, P < 0.001) were significant between the RALP and RRP groups, respectively. Three patients in the RRP group (2.9%) and one in the RALP group (0.5%) required transfusion of blood products (P = 0.14)., Conclusions: The results of this study have shown that RALP is associated with less intraoperative bleeding than RRP, and patients undergoing RALP have a greater serum hematocrit at hospital discharge. The lack of a statistically significant difference in blood transfusion was partially attributable to the low transfusion rate in both groups in this series.

Radical prostatectomy has maintained a cardinal role in the treatment of localized prostate cancer. Robotic-assisted laparoscopic prostatectomy (RALP) has been introduced as a less invasive surgical approach. Available data on RALP versus open approaches were reviewed for surgical and cancer related outcomes. RALP is consistently associated with decreased blood loss and limited postoperative pain and hospital stay. Surgical margins seem similar between most reported series of RALP or open radical prostatectomy. Most intrainstitutional comparisons demonstrate better postoperative continence and potency with RALP, but there is still debate about whether results are superior to radical retropubic prostatectomy in the hands of a highly experienced surgeon. RALP provides outcomes at least comparable, and, in some measures, superior to open surgery. Refinements of instrumentation may provide even better results in the future.

Although equipment for performance of robotic-assisted laparoscopic prostatectomy (RALP) is becoming more widely available, few surgeons have acquired the skill and experience necessary to master RALP. A significant issue has been the requisite training and experience (ie, the "learning curve") necessary for a qualified surgeon to become an expert at RALP. The senior author (J.A.S.) has experience with > 2500 radical retropubic prostatectomy (RRP) and > 350 RALP procedures. He assessed his learning curve in achieving expertise with RALP. Because there are no objective measures to define expertise with RALP, achievement of expert status depends on the surgeon's comfort, experience, and results with alternative approaches. Surgeons with extensive experience with open approaches may "set the bar" higher for the learning curve because of expectations. RALP results comparable to those obtained routinely with RRP were not achieved until after > or = 150 procedures. Surgeon comfort and confidence comparable to that with RRP did not occur until after 250 RALP procedures. Defining the learning curve for RALP as the point at which a surgeon could provide outcomes comparable to those obtainable with alternative surgical approaches means that the point varies, depending on the experience and expertise of the surgeon. Surgeons whose sole or dominant experience is with laparoscopic or robotic approaches may have a different perception of the learning curve compared with an experienced open surgeon.

Purpose: Laparoscopic prostatectomy, whether or not coupled with robotic assistance, is often considered less invasive than open radical retropubic prostatectomy (RRP). Minimal postoperative pain has been reported following robot assisted laparoscopic prostatectomy (RALP) but there have been few comparative studies with RRP. We compared perioperative narcotic use and patient reported pain in a prospective patient series., Materials and Methods: Between June 2003 and May 2004, 314 patients underwent radical prostatectomy at our institution, including RALP in 159, RRP in 154 and conversion in 1. All patients were treated on a postoperative clinical pathway that included 30 mg ketorolac intravenously immediately postoperatively, followed by 15 mg intravenously every 6 hours. No regional anesthesia (epidural/spinal) narcotics or patient controlled analgesic pumps were used. All narcotic use was converted to morphine sulfate equivalents for purpose of analysis. A Likert scale of 0 to 10 was used to assess pain on the day of surgery, and on postoperative days 1 and 14., Results: The total mean morphine sulfate equivalent +/- SD in patients in the RALP and RRP groups was low and, when corrected for length of stay, it was not statistically different (22.41 +/- 1.13 vs 23.01 +/- 1.16 mg, p = 0.72). Mean Likert pain perception scores were low at all time points in the RALP and RRP groups but statistically lower on the day of surgery in the RALP cohort (2.05 +/- 1.99 vs 2.60 +/- 2.25, p = 0.027). Patient reported mean pain scores were almost identical for RALP vs RRP on postoperative days 1 (1.76 +/- 1.87 vs 1.73 +/- 1.77, p = 0.880) and 14 (2.51 +/- 1.91 vs 2.42 +/- 1.84, p = 0.722)., Conclusions: Perioperative narcotic use and patient reported pain are low regardless of the surgical approach used for radical prostatectomy. RALP did not provide a clinically meaningful decrease in pain compared with RRP, primarily because of the low pain scores reported in each group. Outcomes other than pain will ultimately determine the role of laparoscopic radical prostatectomy and RALP.

Background: Collaborative care pathways have proven to be a safe and effective method of decreasing length of hospital stay (LOS) and costs after radical retropubic prostatectomy (RRP). In the current study, the authors evaluated the safety and efficacy of a pathway transitioning from a 3-day to a 2-day LOS., Methods: The authors performed a retrospective chart review of 994 patients who underwent RRP at the study institution between July 1994 and December 2001. A total of 561 patients were managed on a 3-day LOS pathway, 172 were managed during the transition period from 3 to 2 days, and 261 were managed on a 2-day LOS pathway. Statistical analysis was performed comparing preoperative variables and complications among the three groups., Results: No statistically significant differences were found in comparisons of preoperative and demographic variables including age, race, medical comorbidities, preoperative prostate-specific antigen level, clinical stage of disease at presentation, and biopsy Gleason score. Forty-nine of the 561 patients (8.7%) remained longer than their targeted 3-day LOS, whereas 14 of 261 patients (5.4%) were hospitalized for longer than their targeted 2-day LOS, a difference that approached statistical significance (P = 0.058). During the transition period, 99 of 172 patients (57.6%) were discharged on postoperative Day 2 and 73 patients (42.4%) were discharged on postoperative Day 3. Complication rates were found to be significantly lower (P = 0.013) in the 2-day LOS group (2.3%) compared with the 3-day LOS group (7.0%) and the transition group (8.1%). The rate of readmission remained constant at 3% during this time period., Conclusions: Overall, greater than 90% of patients were discharged within 2-3 days of surgery with acceptable complication rates, suggesting that in a consistent patient population, the transition from a 3-day LOS to a 2-day LOS can be done successfully without compromising patient safety. Evaluation currently is ongoing with regard to a 1-day LOS.

Radical prostatectomy has maintained a cardinal role in the treatment of localized carcinoma of the prostate. The combination of refinements in surgical technique and better definition of the anatomy have decreased the morbidity from surgery. Nonetheless, concerns about treatment-related side effects remain the primary limitation of surgical therapy for prostate cancer. Laparoscopic prostatectomy, with or without robotic assistance, is playing an increasing role in surgical treatment of prostate cancer. However, the minimally invasive aspect of laparoscopy may have less relevance for radical prostatectomy because the open surgical procedure requires a limited infraumbilical incision. In the present series comparing robotically assisted laparoscopic prostatectomy with open radical retropubic prostatectomy, no difference was seen in postoperative pain, length of stay, or requirement for blood replacement. However, the most important outcome measures are tumor control, continence, and sexual potency. The outstanding visibility and precision afforded by the robotic approach may offer advantages in each of these areas.

Purpose: Radical retropubic prostatectomy (RRP) has been associated with significant blood loss and/or transfusion requirement. While still a concern, routine autologous blood donation has not been standard at our institution for more than a decade. We assessed recent blood loss and transfusion requirements in contemporary patients undergoing RRP and examined the possible predictive impact of preoperative variables., Materials and Methods: A retrospective review of 436 consecutive patients who underwent RRP between July 1999 and December 2001 was performed with the primary purpose of analyzing estimated blood loss (EBL) and blood transfusion requirements as well as possible preoperative risk factors, including clinical demographic characteristics, body mass index (BMI), defined as weight in kg/height in m, comorbidities, American Society of Anesthesiologists classification and Charlson index score., Results: A total of 436 consecutive patients with a mean age of 60 years (range 39 to 78) underwent RRP under general anesthesia. Mean American Society of Anesthesiologists class was 2.3 (range 1 to 3) and the mean BMI was 27.7 (range 18.2 to 44.3). Mean preoperative and postoperative hematocrit was 43.9% and 32.5%, respectively. Overall mean EBL was 603 cc (range 100 to 3500) and the transfusion rate was 4.8%. On multivariate analysis the only significant correlative predictor of EBL was BMI. There was a significantly lower EBL in patients with an acceptable BMI (less than 25) vs overweight (25 to 30) and obese (greater than 30) patients (p = 0.021). Likewise the rate of transfusion was significantly higher in the overweight (6.9%) and obese (5.6%) groups compared to the normal BMI group (1.9%) (p = 0.009)., Conclusions: Our series demonstrates that blood loss during RRP continues to decrease. The respectable blood loss and low transfusion rates in this series were due to refinements in surgical technique rather than to perioperative modifications. To our knowledge the identification of BMI as a predictor of blood loss and transfusion is novel. These data serve as a benchmark for future comparisons and argue for continued refinements in techniques to decrease blood loss, particularly in overweight and obese patients.

Purpose: Prostatic carcinoma (Pca) at cystoprostatectomy is usually an incidental finding with the majority thought to be clinically insignificant. Most studies have not specifically addressed the location of Pca or the incidence and location of in situ or invasive urothelial carcinoma (Uca) in prostates of cystoprostatectomy specimens. The frequency of involvement of the apex with these processes has clinical implications. Specifically urinary continence following orthotopic diversion may be enhanced by prostate apical sparing. In this study the pathological features of Pca and Uca, and the frequency of apical involvement were investigated in prostates from cystoprostatectomy specimens., Materials and Methods: Whole mounted prostates from 121 consecutive cystoprostatectomy specimens were analyzed. Pca location, tumor volume, grade, stage, surgical margin and pelvic lymph node status of Pcas were assessed. Clinically insignificant Pcas had a volume of less than 0.5 cc without Gleason pattern 4, extracapsular extension, seminal vesicle invasion, lymph node involvement or positive surgical margins. Prostate involvement by Uca or urothelial carcinoma in situ (CIS)/severe dysplasia and its location were assessed., Results: Of 121 prostates 50 (41%) had unsuspected Pca, of which 24 (48%) were clinically significant. Of Pcas 30 of 50 (60%) involved the apex, including 19 of 24 (79%) that were significant and 11 of 26 (42%) that were insignificant. Of 121 prostates 58 (48%) had Uca involving the prostatic stroma, noninvasive Uca or urothelial CIS/severe dysplasia in the prostatic urethra or periurethral ducts, of which 19 (33%) had apical involvement. Overall only 32 of 121 patients (26%) had no Pca or prostate Uca/CIS and only 45 (37%) had no clinically significant Pca or Uca/CIS in the prostate. However, 74 of the 121 patients (61%) had no prostatic apical involvement by Pca or Uca/CIS and 85 (70%) had no apical involvement by clinically significant Pca or Uca/CIS. Patients with prostatic apical involvement by invasive or in situ Uca uniformly had involvement of more proximal (toward the base) portions of the prostate., Conclusions: The majority of prostates from cystoprostatectomies had no involvement of the prostatic apex by Uca or clinically significant Pca. Hence, most patients may be candidates for prostate apical sparing. However, involvement of the apex by Uca in any patient raises concern about procedures that leave portions of the prostate urethra after cystectomy in an effort to improve continence. In candidates for orthotopic neobladder reconstruction removing all of the prostatic urethra and sparing the remainder of the prostatic apex may allow improved preservation of urinary continence with an acceptable low risk of clinical Pca progression. Whether future strategies for preoperative exclusion of apical Pca and intraoperative assessment of more proximal prostate to help exclude apical urothelial disease may identify patients suitable for prostatic apical sparing remains to be determined. The impact on functional outcomes and cancer control also require additional study.

Purpose: Studies of radical prostatectomy specimens have suggested that the majority of prostate specific antigen detected (clinical stage T1c) tumors are clinically significant. We compared tumor location and pathological parameters in the radical prostatectomy specimens of stages T1c versus T2 cases in a 3-year period. The percent of stage T1c disease represented a stable majority of patients undergoing treatment for clinically localized prostate cancer., Materials and Methods: From January 1, 1998 to December 31, 2000, 417 radical prostatectomies were performed at Vanderbilt University, including 246 for stage T1c and 108 for stage T2 disease. A total of 37 patients were excluded from study because of neoadjuvant antiandrogen treatment. Pathological parameters, including tumor location in the transition and/or peripheral zone, tumor Gleason grade, tumor stage, total tumor volume and surgical margins were compared in stages T1c and T2 cases, and in transition versus peripheral zone stage T1c tumors in completely embedded whole mount specimens., Results: In contrast to stage T2 lesions, stage T1c tumors were of significantly lower Gleason score with a higher percent of Gleason score 5 and lower percent of Gleason score 6, 7 and 8 or greater. They also had a significantly smaller volume and lower pathological stage. Of stage T1c tumors 77% were organ confined versus 62% of stage T2 tumors. There was no statistically significant increase in clinically insignificant neoplasms in stages T1c versus T2 cases (13% versus 7%) when using a volume criterion of less than 0.2 cc but a statistically significant increase in clinically insignificant disease was observed using a volume criterion of less than 0.5 cc (22% versus 9%). Whereas none of the T2 tumors were located in the transition zone and 17% were located in the transition and peripheral zones, 14% of stage T1c lesions were exclusively in the transition zone, with another 17% in the transition and peripheral zones. Compared with peripheral zone tumors transition zone stage T1c tumors had a lower Gleason score with an increase in Gleason score 5 and lower percent of Gleason score 6, 7 and 8 or greater. Although transition zone stage T1c lesions were significantly larger than peripheral zone stage T1c lesions, they had a lower pathological stage with 94% versus 72% organ confined., Conclusions: Prostate specific antigen detected stage T1c tumors had a lower grade, stage and volume than stage T2 tumors during the same period. Lower tumor grade in stage T1c cases is due at least in part to the increased detection of Gleason pattern 2 containing transition zone tumors. Despite the larger size, T1c transition zone tumors appear to be more favorable with higher rates of organ confined and lower grade tumors. If such transition zone tumors prove to be biologically distinct, improved strategies to identify these lesions preoperatively may result in more conservative treatment recommendations.

Purpose: The health related quality of life assessment is becoming increasingly important among patients with prostate cancer. Meanwhile, treatment of patients with increasing prostate specific antigen (PSA) after radical retropubic prostatectomy remains controversial. We attempt to define the impact of PSA recurrence on the health related quality of life of patients after radical retropubic prostatectomy., Materials and Methods: Of 604 consecutive patients who underwent radical retropubic prostatectomy between March 1991 and September 1998, 510 (84%) were available for followup. Each patient was mailed the RAND 36-Item Health Survey and University of California, Los Angeles, Prostate Cancer Index questionnaire. A total of 348 (70%) questionnaires were returned. Health related quality of life scores were then compared between patients with and without PSA recurrence. A multivariate analysis was also performed to elucidate further the cause of differences between the groups., Results: Overall, 88 (25%) patients had PSA recurrence. In regard to health related quality of life there were small (less than 10%) but statistically significant differences in 2 of 4 physical health domains (RAND 36-Item Health Survey). There was a significant decrease in only 1 category of the mental health domain for patients with PSA recurrence. Only sexual function was statistically lower on the University of California, Los Angeles, Prostate Cancer Index. This result reflects the lower incidence of nerve sparing in these patients, as confirmed by the multivariate analysis. Overall patient satisfaction was similar between those with and without PSA recurrence (76% and 79%, respectively)., Conclusions: Our study demonstrates small health related quality of life differences in patients with biochemical PSA recurrence versus those without. These findings provide a baseline assessment of general and disease specific health related quality of life domains among these patients. Future studies should focus on differences in the measure of cancer anxiety before and after administration of adjuvant therapy in these asymptomatic patients.

Objectives: Intraoperative nerve stimulation has been used to map the course of cavernosal nerve bundles to aid in nerve-sparing radical prostatectomy (RP). We sought to determine whether the intraoperative nerve stimulation response after removal of the prostate specimen predicts postoperative potency., Methods: We prospectively evaluated 63 consecutive patients undergoing RP. Among these 63 patients, 41 patients had a bilateral nerve-sparing procedure, and 22 underwent bilateral wide resection of the neurovascular bundles. Potency was determined at 1 year by direct patient interview., Results: Of the 22 patients with wide resection, 16 (73%) had no observed stimulated response, 4 (18%) had a measurable tumescence response, and 2 (9%) had detumescence. All 22 patients were impotent postoperatively. At a minimum follow-up of 1 year, of the 41 patients who underwent nerve-sparing RP, 27 (66%) had postoperative erections sufficient for penetration. Of the 30 men with an intraoperative stimulated tumescence response, 24 (80%) were potent; of the 6 with a detumescence response, 2 (33%) were potent; and of the 5 with no stimulated nerve response, 1 (20%) was potent. A tumescence response was significantly more predictive of postoperative potency than no intraoperative response (P = 0.017)., Conclusions: An intraoperative tumescence response with stimulation of the neurovascular bundles after prostate specimen removal is more likely to correspond to successful postoperative sexual function after nerve-sparing RP than is no response.

Purpose: We assess the reliability of intraoperative cavernous nerve stimulation for producing an erectile response during radical prostatectomy., Materials and Methods: In 61 patients cavernous nerve function was assessed during radical retropubic prostatectomy using a CaverMap nerve stimulator. Control stimulation was also performed before and after prostatic dissection by placing the nerve stimulator tip on the anterior bladder wall. An increase in penile circumference measured by the device was considered a tumescence response while any measurable detumescence was also categorized., Results: Patient age ranged 43 to 72 years (mean 59.8). Before apical dissection 41% and 46% had tumescence, 31% and 21% had detumescence, and 28% and 33% had no response with stimulation of the neurovascular bundle and anterior bladder wall, respectively. After dissection 42% and 25% had tumescence, 16% and 18% had detumescence, and 42% and 57% had no response with stimulation of the neurovascular bundle and anterior bladder wall, respectively., Conclusions: A response to neurovascular bundle stimulation using this device does not necessarily correlate with the precise anatomical location of the cavernous nerves. There is considerable background variability related to anesthesia, surgical manipulation and other undefined factors that may cause minor but measurable changes in penile circumference.

Purpose: We determined whether biofeedback enhanced pelvic floor exercises begun 6 weeks after radical prostatectomy improve the early recovery of continence., Materials and Methods: We randomized 30 patients who underwent radical retropubic prostatectomy into a group that received 5 biofeedback sessions and a control group., Results: Overall 87% of patients were pad-free at 6 months with similar results in the treatment and control groups (86% versus 88%). There was no statistically significant difference in pad test results or voiding diary records in the 2 groups., Conclusions: A treatment program of biofeedback enhanced pelvic floor exercises begun 6 weeks after radical retropubic prostatectomy did not significantly affect continence in this study.