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Background and Objective: The transrectal biopsy approach is traditionally used to detect prostate cancer. An alternative transperineal approach is historically performed under general anesthesia, but recent advances enable transperineal biopsy to be performed under local anesthesia. We sought to compare infectious complications of transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis., Methods: We assigned biopsy-naïve participants to undergo transperineal biopsy without antibiotic prophylaxis versus transrectal biopsy with targeted prophylaxis (rectal culture screening for fluoroquinolone-resistant bacteria and antibiotic targeting to culture and sensitivity results) through a multicenter, randomized trial. The primary outcome was post-biopsy infection captured by a prospective medical review and patient report on a 7-d survey. The secondary outcomes included cancer detection, noninfectious complications, and a numerical rating scale (0-10) for biopsy-related pain and discomfort during and 7-d after biopsy., Key Findings and Limitations: A total of 658 participants were randomized, with zero transperineal versus four (1.4%) transrectal biopsy infections (difference -1.4%; 95% confidence interval [CI] -3.2%, 0.3%; p = 0.059). The rates of other complications were very low and similar. Importantly, detection of clinically significant cancer was similar (53% transperineal vs 50% transrectal, adjusted difference 2.0%; 95% CI -6.0, 10). Participants in the transperineal arm experienced worse periprocedural pain (0.6 adjusted difference [0-10 scale], 95% CI 0.2, 0.9), but the effect was small and resolved by 7-d., Conclusions and Clinical Implications: Office-based transperineal biopsy is tolerable, does not compromise cancer detection, and did not result in infectious complications. Transrectal biopsy with targeted prophylaxis achieved similar infection rates, but requires rectal cultures and careful attention to antibiotic selection and administration. Consideration of these factors and antibiotic stewardship should guide clinical decision-making., Patient Summary: In this multicenter randomized trial, we compare prostate biopsy infectious complications for the transperineal versus transrectal approach. The absence of infectious complications with transperineal biopsy without the use of preventative antibiotics is noteworthy, but not significantly different from transrectal biopsy with targeted antibiotic prophylaxis., (Copyright © 2024 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Radical cystectomy (RC) is the gold standard treatment for patients with organ-confined bladder cancer. However, despite the success of this treatment, many men who undergo orthotopic neobladder substitution develop significant erectile dysfunction and urinary symptoms, including daytime and nighttime urinary incontinence. Prostate-capsule-sparing radical cystectomy (PCS-RC) with orthotopic neobladder (ONB) has been described in the literature as a surgical technique to improve functional outcomes in appropriately selected patients. We performed a systematic review and meta-analysis of manuscripts on PCS-RC with ONB published after 2000. We included retrospective and prospective studies with more than 25 patients and compared PCS-RC with nerve-sparing or conventional RC. Studies in which the entire prostate was spared (including the transitional zone) were excluded. Comparative studies were analyzed to assess rates of daytime continence, nighttime continence, and satisfactory erectile function in patients undergoing PCS-RC compared with those undergoing conventional RC. Fourteen reports were included in the final review. Our data identify high rates of daytime (83%-97%) and nighttime continence (60%-80%) in patients undergoing PCS-RC with ONB. In comparative studies, meta-analysis results demonstrate no difference in daytime continence (RR:1.12; 95% CI: 0.72-1.73) in those undergoing PCS-RC compared to those undergoing conventional RC. Similarly, nighttime continence was similar between the 2 groups (RR:1.85; 95% CI: 0.57-6.00. Erectile function was improved in those undergoing PCS-RC (RR 5.35; 95% CI: 1.82-15.74) in the PCS-RC series. Bladder cancer margin positivity and recurrence rates were similar to those reported in the literature with conventional RC with an average weighted follow-up of 52.2 months. While several studies utilized different prostate cancer (CaP) screening techniques, the rates of CaP were low (incidence 0.02; 95% CI:0.01-0.04), and oncologic outcomes were similar to standard RC. PCS-RC is associated with improved nighttime continence and erectile function compared to conventional RC techniques. Further work is needed to standardize CaP screening before surgery, but the data suggest low rates of CaP with similar oncologic outcomes when compared to RC., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Prostatic fascia-sparing robotic-assisted radical prostatectomy (PFS-RARP) has improved short-term postoperative continence compared to standard prostatectomy (S-RARP) but long-term differences remain unclear., Materials and Methods: One hundred two S-RARP followed by 239 PFS-RARPs were performed by a single surgeon. Univariate analyses were performed with t-test, χ 2 , Wilcoxon rank sum, Fisher exact, and analysis of variance (ANOVA). Regression models analyzed associates of EPIC-CP scores and oncologic outcomes. Cox proportional hazards modeling assessed postoperative continence. Primary outcomes included patient-reported urinary incontinence (UI) via EPIC-CP and continence rates. Secondary outcomes included EPIC-CP scores, positive surgical margins (PSM), and biochemical recurrence (BCR). Perioperative outcomes and time to continence were measured., Results: Median follow-up for PFS-RARP vs. S-RARP was 26 vs. 65 months. PFS-RARP demonstrated improved EPIC-CP UI and total scores at 24 months. On multivariate analysis, PFS-RARP was associated with improved EPIC-CP UI and total scores through 18 months, but not with PSM or BCR. PFS-RARP had a 39% and 66% reduced risk of incontinence using 0 and 0 to 1 pad-use definitions (HR 0.61, 95% CI 0.39 - 0.95; HR:0.34, 95% CI 0.16 - 0.76). Continence returned faster with PFS-RARP (0 PPD: 91.0 days vs. 261 days, P < 0.001; 0-1 PPD: 32.7 days vs. 171 days, P < 0.001). There were no differences in PSM (35% vs. 25%, P = 0.064). There were more anterior PSM in PFS-RARP vs. S-RARP (47% vs. 26% P = 0.035), but no differences in BCR (16% vs. 22% P = 0.241)., Conclusions: PFS-RARP improves continence and patient-reported QOL up to 24 months postoperatively without compromising oncologic outcomes., Competing Interests: Declaration of Competing Interest We submit that this paper has not been published previously and is not under consideration for publication elsewhere. Furthermore, the paper has been approved by all authors, who contributed substantially to the work in its final form., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Urethral catheter (UC) discomfort remains a burden following robotic-assisted radical prostatectomy (RARP). Suprapubic catheters (SPCs) may reduce patient discomfort and increase satisfaction. Pelvic fascia‒sparing (PFS) RARP reduces the technical challenges of intraoperative SPC placement. We examined postoperative outcomes of SPC vs UC placement following PFS-RARP., Methods: We conducted a retrospective review of a prospective institutional review board‒approved database of PFS-RARP patients from June 2020 to December 2022 receiving SPC (n = 108) or UC (n = 104) postoperatively. Demographics and clinical and perioperative outcomes were captured. Postoperative patient-reported quality of life was measured using EPIC-CP (Expanded Prostate Cancer Index Composite for Clinical Practice). Patients with intraoperative complications or intraoperative leaks or undergoing salvage prostatectomy were excluded. Univariate and multivariate regression analyses were performed to compare outcomes., Results: No significant differences in demographics or oncologic outcomes existed. There were no differences in complications, including urethral stricture or anastomotic leak. Men receiving SPC vs UC had earlier return to continence (7 vs 16 days, P < .001) and higher continence rates at catheter removal (67.6% vs 43.3%, P = .0003). On adjusted analyses, SPC was an independent predictor of continence at catheter removal (OR 2.21, P = .023). There were no differences between groups in preoperative or postoperative EPIC-CP scores, including no differences in postoperative quality of life ( P = .46)., Conclusions: SPC after PFS-RARP is a safe and feasible alternative to UC. SPC is associated with an earlier return to continence and higher continence rates at catheter removal. Use of SPC may increase overall patient satisfaction following PFS-RARP.

Introduction: Approximately one million prostate biopsies are performed annually in the USA, and most are performed using a transrectal approach under local anaesthesia. The risk of postbiopsy infection is increasing due to increasing antibiotic resistance of rectal flora. Single-centre studies suggest that a clean, percutaneous transperineal approach to prostate biopsy may have a lower risk of infection. To date, there is no high-level evidence comparing transperineal versus transrectal prostate biopsy. We hypothesise that transperineal versus transrectal prostate biopsy under local anaesthesia has a significantly lower risk of infection, similar pain/discomfort levels and comparable detection of non-low-grade prostate cancer., Methods and Analysis: We will perform a multicentre, prospective randomised clinical trial to compare transperineal versus transrectal prostate biopsy for elevated prostate-specific antigen in the first biopsy, prior negative biopsy and active surveillance biopsy setting. Prostate MRI will be performed prior to biopsy, and targeted biopsy will be conducted for suspicious MRI lesions in addition to systematic biopsy (12 cores). Approximately 1700 men will be recruited and randomised in a 1:1 ratio to transperineal versus transrectal biopsy. A streamlined design to collect data and to determine trial eligibility along with the two-stage consent process will be used to facilitate subject recruitment and retention. The primary outcome is postbiopsy infection, and secondary outcomes include other adverse events (bleeding, urinary retention), pain/discomfort/anxiety and critically, detection of non-low-grade (grade group ≥2) prostate cancer., Ethics and Dissemination: The Institutional Review Board of the Biomedical Research Alliance of New York approved the research protocol (protocol number #18-02-365, approved 20 April 2020). The results of the trial will be presented at scientific conferences and published in peer-reviewed medical journals., Trial Registration Number: NCT04815876., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Stereotactic Body Radiation Therapy (SBRT) has emerged as a definitive therapy for localized prostate cancer (PCa). However, more data is needed to predict patient prognosis to help guide which patients will benefit most from treatment. The FACIT-Fatigue (FACIT-F) is a well validated, widely used survey for assessing fatigue. However, the role of fatigue in predicting PCa survival has yet to be studied. Herein, we investigate the role of FACIT-F as a baseline predictor for overall survival (OS) in patients undergoing SBRT for localized PCa., Methods: A retrospective review was conducted of 1358 patients who received SBRT monotherapy between January 2008 to April 2021 at an academic, tertiary referral center. FACIT-F scores (range 0 to 52) were summed for patients who answered all 13-items on the survey. FACIT-F total scores of ≥35 represented severe fatigue. Patients receiving androgen deprivation therapy were excluded. Differences in fatigue groups were evaluated using chi-squared tests. OS rates were determined using the Kaplan-Meier method and predictors of OS were evaluated using Cox proportional hazard method., Results: Baseline full FACIT-F scores and survival data was available for 891 patients. 5-year OS was 87.6% and 95.2%, respectively, for the severely fatigued and non-fatigued groups. Chi-squared analysis of fatigue groups showed no significant difference in the following categories: D'Amico risk group, age, ethnicity, grade group, T-stage, or PSA density. Severe fatigue was associated with a significant decrease in OS (hazard ratio 2.76; 95%CI 1.55 - 4.89). The Cox proportional hazard model revealed that age and FACIT-F were both statistically significant (p <0.05)., Conclusion: Baseline FACIT-F scores are significantly associated with OS. Higher FACIT-F scores, representing less fatigued patients, are associated with an overall survival benefit. These results indicate that the FACIT-F survey could serve as an additional metric for clinicians in determining prognostic factors for patients undergoing SBRT., Competing Interests: SC is a consultant for Accuray, Inc. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Simhal, Sholklapper, Simhal, Zwart, Danner, Kumar, Aghdam, Suy, Hankins, Kowalczyk and Collins.)

(Background) Radiation failure for localized prostate cancer is seen in 20-60% of patients who do not undergo extirpative surgery. Though potentially curative, salvage prostatectomy (SS) has not been frequently performed historically due to high rates of complications and postoperative incontinence. With the advent of robotic-assisted radical prostatectomy, these rates appear to be improved. Retzius-sparing approaches have additionally been shown to improve continence outcomes in the index setting, and may further improve continence outcomes in salvage cases while maintaining oncologic integrity. (Methods) We performed a literature review and qualitative analysis of published papers on salvage Retzius-sparing robotic-assisted radical prostatectomy (SRS). Three studies met criteria and were included in analysis. (Results) There were more patients with Gleason Grade Group 1 disease after initial treatment in the SRS group vs. SS (22% vs. 8%). Patients most frequently underwent external beam radiation therapy in both groups (52% vs. 49%). 30-day complication rates were 10% and 26% for SRS and SS, respectively. Continence outcomes were significantly improved in SRS with 59% of continence (based on study criteria) compared to 38% in SS. Time to continence was similarly improved for SRS. Positive surgical margins and biochemical recurrence were not significantly different between SRS and SS in any study. (Conclusions) SRS is a safe and feasible option for salvage treatment of localized prostate cancer and may improve postoperative continence outcomes. Positive surgical margin and biochemical recurrence rates are similar to those reported in SS.

Purpose: Salvage radical prostatectomy is rare due to the risk of postoperative complications. We compare salvage Retzius-sparing robotic assisted radical prostatectomy (SRS-RARP) with salvage standard robotic assisted radical prostatectomy (SS-RARP)., Materials and Methods: A total of 72 patients across 9 centers were identified (40 SRS-RARP vs 32 SS-RARP). Demographics, perioperative data, and pathological and functional outcomes were compared using Student's t-test and ANOVA. Cox proportional hazard models and Kaplan-Meier curves were constructed to assess risk of incontinence and time to continence. Linear regression models were constructed to investigate postoperative pad use and console time., Results: Median followup was 23 vs 36 months for SRS-RARP vs SS-RARP. Console time and estimated blood loss favored SRS-RARP. There were no differences in complication rates or oncologic outcomes. SRS-RARP had improved continence (78.4% vs 43.8%, p <0.001 for 0-1 pad, 54.1% vs 6.3%, p <0.001 for 0 pad), lower pads per day (0.57 vs 2.03, p <0.001), and earlier return to continence (median 47 vs 180 days, p=0.008). SRS-RARP was associated with decreased incontinence defined as >0-1 pad (HR 0.28, 95% CI 0.10-0.79, p=0.016), although not when defined as >0 pad (HR 0.56, 95% CI 0.31-1.01, p=0.053). On adjusted analysis SRS-RARP was associated with decreased pads per day. Lymph node dissection and primary treatment with stereotactic body radiation therapy were associated with longer console time., Conclusions: SRS-RARP is a feasible salvage option with significantly improved urinary function outcomes. This may warrant increased utilization of SRS-RARP to manage men who fail nonsurgical primary treatment for prostate cancer.

Background: Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) has been shown to improve continence. However, questions remain regarding feasibility and generalizability of technique and outcomes., Objective: To compare the outcomes of 140 consecutive standard robot-assisted radical prostatectomy (S-RARP) versus RS-RARP., Design, Setting, and Participants: A total of 70 S-RARPs were performed followed by 70 RS-RARPs. Demographic, pathologic, and functional outcomes were compared preoperatively and through 12 mo. Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP) was used to compare functional outcomes. Logistic and linear regression analyses were utilized to analyze variables associated with EPIC-CP urinary incontinence and overall quality of life (QOL) scores, and oncologic outcomes. Cox regression analysis was used to analyze incontinence at 12 mo., Surgical Procedure: RS-RARP versus S-RARP., Measurements: Patient and tumor characteristics (age, body mass index, prostate-specific antigen, Charlson Comorbidity Index, Gleason group, clinical stage, and Prostate Imaging Reporting and Data System score), perioperative outcomes (console time, estimated blood loss, postoperative complications, and length of stay), oncologic outcomes (positive surgical margin [PSM], and biochemical recurrence), overall and 12-mo continence rates (zero pads and zero to one safety pad), time to continence, potency (erection sufficient for sexual activity), EPIC-CP urinary incontinence, sexual function, and overall QOL scores., Results and Limitations: Median follow-up for S-RARP versus RS-RARP was 46.3 versus 12.3 mo. RS-RARP versus S-RARP had improved overall continence rates at total follow-up (95.7% vs 85.7%, p = 0.042) and 12-mo follow-up (97.6% vs 81.4%, p = 0.002), and faster return to continence (zero to one safety pad, 44 vs 131 d, p < 0.001). RS-RARP EPIC-CP urinary incontinence and overall QOL scores remained significantly better at 12 mo. There were no differences in overall PSM rates, although RS-RARP had lower rates of nonfocal PSMs. There were no differences in sexual function. In multivariate analysis, RS-RARP was significantly associated with improved 12-mo EPIC-CP urinary incontinence and improved QOL scores, but was not associated with PSM or biochemical recurrence. Limitations include retrospective study design and unequal follow-up; however, significantly better RS-RARP continence at 12 mo is striking despite fewer patients attaining 12-mo follow-up., Conclusions: RS-RARP significantly improves early and long-term continence without compromising oncologic outcomes and leads to overall improved QOL., Patient Summary: Retzius-sparing robot-assisted radical prostatectomy is an emerging technique for robotic radical prostatectomy that improves urinary function and quality of life without compromising cancer control., (Copyright © 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Radical prostatectomy has undergone many adaptations since its inception, including the Retzius-sparing robotic-assisted radical prostatectomy approach. In this article, we review the origins of radical prostatectomy, the theoretic basis for Retzius-sparing robotic-assisted radical prostatectomy, and outline the key steps of the procedure. To date, there have been 9 studies comparing the outcomes of Retzius-sparing robotic-assisted radical prostatectomy with standard robotic-assisted radical prostatectomy, which have demonstrated improved continence outcomes for Retzius sparing robotic assisted radical prostatectomy within the first year and equivalent oncologic efficacy out to 18 months. Further research is needed to evaluate sexual function outcomes as well as long-term oncologic outcomes., Competing Interests: Disclosures None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) has improved urinary function compared with standard robotic-assisted radical prostatectomy (S-RARP). As RS-RARP spares the dorsal vascular complex, pelvic fascia, and anterior abdominal fascia, it may also lower the incidence of "neglected" postprostatectomy sequelae such as penile shortening, Peyronie's disease, and inguinal hernias., Objective: To determine whether there are patient-perceived differences in penile shortening, Peyronie's disease, and inguinal hernia rates among men undergoing RS-RARP versus S-RARP., Design Setting and Participants: Researchers uninvolved in clinical care and blinded to surgical approach surveyed 60 RS-RARP versus 57 S-RARP men with validated patient-reported items to assess penile shortening, Peyronie's disease, and inguinal hernia sequelae following surgery., Intervention: RS-RARP versus S-RARP., Outcome Measurements and Statistical Analysis: Univariate differences between the two cohorts were analyzed using Student t test. Logistic regression was used to analyze variables associated with postoperative penile shortening. Cox proportional hazards models were used to assess the risk of developing Peyronie's disease and inguinal hernia postoperatively., Results and Limitations: RS-RARP was associated with less patient-reported penile shortening (41.7% vs 64.9%, p  = 0.012), Peyronie's disease (0% vs 8.7%, p  = 0.020), and inguinal hernia (0.0% vs 13.0%, p  = 0.004). In adjusted analyses, RS-RARP (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.09-0.63, p  = 0.004) was associated with lower odds of penile shortening, while a higher body mass index was associated with increased odds of penile shortening (OR 1.13, 95% CI 1.01-1.26, p  = 0.037). RS-RARP was not associated with a decreased risk of Peyronie's disease on Cox proportion hazard model; however, these models are limited due to a limited number of events in our cohort. Limitations include retrospective design, patient-reported outcomes, and small cohorts., Conclusions: RS-RARP is associated with less patient-reported penile shortening and may decrease the risk of Peyronie's disease and postoperative inguinal hernia development. These new findings add to research, showing improved urinary continence and quality of life following RS-RARP; however, a prospective study is needed to validate these findings., Patient Summary: Retzius-sparing robotic-assisted radical prostatectomy (RS-RARP) is an evolving surgical technique for prostate cancer treatment, which has shown improved postoperative urinary control compared with the standard technique, likely due to preservation of natural pelvic anatomy. Our findings suggest that the preservation of normal pelvic anatomy during RS-RARP may also reduce the risk of postprostatectomy penile shortening, Peyronie's disease, and inguinal hernia., (© 2020 The Author(s).)

Purpose: Cisplatin-based neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC) is standard of care for muscle-invasive bladder cancer (MIBC). However, NAC is used in less than 20% of patients with MIBC. Our goal is to investigate factors that contribute to underutilization NAC to facilitate more routine incorporation into clinical practice., Materials and Methods: We identified 5,915 patients diagnosed with cT2-T3N0M0 MIBC who underwent RC between 2004 and 2014 from the National Cancer Database. Univariate and multivariable models were created to identify variables associated with NAC utilization., Results: Only 18.8% of patients received NAC during the study period. On univariate analyses, NAC utilization was more likely at academic hospitals, US South and Midwest (p<0.05). Higher Charlson score was associated with decrease use of NAC (p<0.05). On multivariate analysis, treatment in academic hospitals (odds ratio [OR], 1.367; 95% confidence interval [CI], 1.186-1.576), in the Midwest (OR, 1.538; 95% CI, 1.268-1.977) and South (OR, 1.424; 95% CI, 1.139-1.781) were independently associated with NAC utilization. Older age (75 to 84 years old; OR, 0.532; 95% CI, 0.427-0.664) and higher Charlson score (OR, 0.607; 95% CI, 0.439-0.839) were associated with decreased NAC utilization. Sixty-eight percent of patients did not receive NAC because it was not planned and only 2.5% of patients had contraindications for NAC treatment., Conclusions: Our study demonstrates that NAC is underutilized. Decreased utilization of NAC was associated with older patients and higher Charlson score. This underutilization may be related to practice patterns as very few patients have true contraindications., Competing Interests: CONFLICTS OF INTEREST: The authors have nothing to disclose., (© The Korean Urological Association, 2020.)

Objective: To evaluate the outcomes of men diagnosed with prostate cancer (CaP) following implanted treatments for advanced heart failure. Given the increasingly favorable 10-year life expectancy, MedStar Washington Hospital Center screens heart transplant (HT) candidates for CaP and other malignancies prior to intervention., Methods: Men aged 18-90 with available pretransplant Prostate Specific Antigen (PSA) who underwent left ventricular assist device (LVAD) and/or HT at MedStar Washington Hospital Center from 2007 to 2018 were identified. Serum PSA, CaP diagnosis, and treatment were captured and analyzed. Survival was analyzed using Kaplan-Meier curves., Results: Data were available for 34 patients. Median age was 53 [IQR = 51-58]. Median follow-up was 77 months (95% CI = 40-87 months). Six men had postimplant elevated PSA (5.3; SD = 8.5) and 4 were diagnosed with CaP. Median age of CaP diagnosis was 59 [IQR = 58.5-62). As of 2018, 31 of the 34 patients were living, and none died from CaP. Five-year survival was 96% in those without CaP and 100% in those with CaP (Figure 2)., Conclusion: Our cohort represents the largest known cohort with heart failure treated by LVAD and/or HT and CaP. Our median age of 59 at CaP diagnosis is considerably younger than the national median of 66. 1 Of the 4 individuals diagnosed with CaP, 3 had high-grade disease. Given the favorable long-term survival of these patients post-LVAD and/or HT, age-appropriate treatment for CaP should be continued postimplantation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Recent clinical trials have investigated the benefit of combining tyrosine kinase inhibitors (TKIs) and cytoreductive nephrectomy (CN) in patients with metastatic renal cell carcinoma. Our goal is to determine whether the perioperative use of TKIs increases the postoperative morbidity following CN in renal cell carcinoma patients. We identified 627 patients with Stage IV renal cell carcinoma who underwent CN from 2007-2010 utilizing the SEER-Medicare database. Eighty-two patients treated with TKIs were matched (3:1) to 246 controls. We calculated 30- and 90-day incidence rates of postoperative complications and mortality. On unadjusted analysis, TKI use prior to CN was associated with higher overall complication rate within 30 days (HR = 2.73, 95% CI: 1.09-6.8) after surgery. On multivariate analysis, perioperative TKI use was independently associated with higher risk for postoperative complications within 30 days (HR = 2.93, 95% CI: 1.17-7.36), as well as 90 days (HR = 1.84, 95% CI: 1.02-3.32) after nephrectomy. A higher Charlson comorbidity index also emerged to represent an independent risk factor for postoperative complications within 30 days (HR = 2.41, 95% CI: 1.44-4.02) and 90 days (HR = 2.23, 95% CI: 1.51-3.29) after nephrectomy. TKI treatment was not associated with an increased postoperative mortality at 30 and 90 days after surgery. Thus, TKI treatment was associated with an increased complication rate but not overall mortality following CN. Our results suggest that renal surgeons should be aware of possibly increased complications following CN in renal cell carcinoma patients, when TKI treatment is administered.

Patient-derived xenografts (PDXs) are widely recognised as a more physiologically relevant preclinical model than standard cell lines, but are expensive and low throughput, have low engraftment rate and take a long time to develop. Our newly developed conditional reprogramming (CR) technology addresses many PDX drawbacks, but lacks many in vivo factors. Here we determined whether PDXs and CRCs of the same cancer origin maintain the biological fidelity and complement each for translational research and drug development. Four CRC lines were generated from bladder cancer PDXs. Short tandem repeat (STR) analyses revealed that CRCs and their corresponding parental PDXs shared the same STRs, suggesting common cancer origins. CRCs and their corresponding parental PDXs contained the same genetic alterations. Importantly, CRCs retained the same drug sensitivity with the corresponding downstream signalling activity as their corresponding parental PDXs. This suggests that CRCs and PDXs can complement each other, and that CRCs can be used for in vitro fast, high throughput and low cost screening while PDXs can be used for in vivo validation and study of the in vivo factors during translational research and drug development., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: The utility of radical prostatectomy (RP) for locally-advanced prostate cancer remains unknown. Retrospective data has shown equivalent oncologic outcomes compared to radiation therapy (RT). RP may provide local tumor control and prevent secondary interventions from local invasion, and may decrease costs., Materials and Methods: Using SEER-Medicare data from 1995-2011 we identified men with locally-advanced prostate cancer undergoing RP or RT. Rates of post-treatment diagnoses and interventions were identified using ICD-9 and CPT codes. Skeletal related events (SRE), androgen deprivation therapy (ADT) utilization, all-cause mortality, prostate cancer-specific mortality, and costs were compared., Results: A total of 8367 men with locally-advanced prostate cancer were identified (6200 RP, 2167 RT). RT was associated with increased urinary obstruction, hematuria, infection, and cystoscopic intervention while RP was associated with increased urethral stricture intervention and erectile dysfunction. Compared to RT, RP was associated with decreased all-cause mortality (3.1 versus 5.2 deaths/100-person-years, p < 0.001), prostate cancer-specific mortality (0.8 versus 2.0 deaths/100-person-years, p < 0.001), SREs (2.0 versus 3.4 events/100 person-years, p < 0.001), and ADT utilization overall (7.4 versus 33.8 doses/100-person-years, p < 0.001) and > 3 years after treatment (3.6 versus 4.6 doses/100-person-years, p < 0.001). Overall and cancer specific costs were significantly lower for RP versus RT., Conclusions: RT for locally-advanced prostate cancer has a higher incidence of mortality, secondary diagnoses and interventions, SRE, and ADT utilization compared to RP. This may lead to increased costs and have implications for quality of life. Our findings support the utility of RP in appropriately selected men with locally-advanced prostate cancer given the possible decreased morbidity and survival benefit.

Competing Interests: Conflicts of Interest: None declared.

Background: To assess contemporary characteristics, hospital admissions, charges, and mortality in patients with prostate cancer (CaP) who have bone metastases and skeletal-related events in an observational study., Methods: Relying on the Nationwide Inpatient Sample (NIS), patients with CaP with bone metastases between 1998 and 2010 were abstracted. Patients who experienced skeletal-related events were identified, and hospital charges were calculated. Generalized linear regression analyses focused on in-hospital mortality., Results: Between 1998 and 2010, a weighted estimate of 443,929 CaP visits with bone metastases was recorded. Of these, 15.9% experienced at least 1 SRE. The rate of SRE decreased from 18% to 15.4% (1998-2010, estimated annual percent change [EAPC] =-1.44%, P = 0.005) and the SRE-associated mortality decreased from 8.5% to 4.7% (1998-2010, EAPC =-3.68%, P = 0.004). Nevertheless, the inflation-adjusted charges associated with hospital visits of patients with CaP with bone metastases rose by 92% to $1,512,449,106 (EAPC = +8.82%, P<0.001), and SRE charges rose by 94% to $369,256,799 (EAPC =+7.62%, P<0.001). Predictors of in-hospital mortality in patients with SRE included age (odds ratio [OR] = 1.02), comorbidities (≥3 vs. 0-1, OR = 1.72), SRE of the upper limb (OR = 1.75), SRE of the lower limb (OR = 1.35), spinal cord compression (OR = 1.48), radiation (OR = 0.68), surgery (OR = 0.32), and year of hospitalization (2010 vs. 1998, OR = 0.54; all P< 0.03)., Conclusions: From 1998 to 2010, the incidence of SRE and SRE-associated mortality in patients with CaP and bone metastases decreased. However, charges for SRE-associated hospitalizations have increased alarmingly. Future health care policies should strive to provide cost-effective prevention and management of SREs in this population., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The "July effect" refers to the phenomenon of adverse impacts on patient care arising from the changeover in medical staff that takes place during this month at academic medical centres in North America. There has been some evidence supporting the presence of the July effect, including data from surgical specialties. Uniformity of care, regardless of time of year, is required for patients undergoing major cancer surgery. We therefore sought to perform a population-level assessment for the presence of a July effect in this field., Methods: We used the Nationwide Inpatient Sample to abstract data on patients undergoing 1 of 8 major cancer surgeries at academic medical centres between Jan. 1, 1999, and Dec. 30, 2009. The primary outcomes examined were postoperative complications and in-hospital mortality. Univariate analyses and subsequently multivariate analyses, controlling for patient and hospital characteristics, were performed to identify whether the time of surgery was an independent predictor of outcome after major cancer surgery., Results: On univariate analysis, the overall postoperative complication rate, as well as genitourinary and hematologic complications specifically, was higher in July than the rest of the year. However, on multivariate analysis, only hematologic complications were significantly higher in July, with no difference in overall postoperative complication rate or in-hospital mortality for all 8 surgeries considered separately or together., Conclusion: On the whole, the data confirm an absence of a July effect in patients undergoing major cancer surgery.

Objectives: Although post-radical prostatectomy (RP) adjuvant radiation therapy (ART) benefits disease that is staged as pT3 or higher, the optimal ART timing remains unknown. Our objective is to characterize the outcomes and optimal timing of early vs. delayed ART., Materials and Methods: From the Surveillance, Epidemiology and End Results-Medicare data from 1995 to 2007, we identified 963 men with pT3N0 disease receiving early (<4 mo after RP, n = 419) vs. delayed (4-12 mo after RP, n = 544) ART after RP. Utilizing propensity score methods, we compared overall mortality, prostate cancer-specific mortality (PCSM), bone-related events (BRE), salvage hormonal therapy utilization, and intervention for urethral stricture. We then used the maximal statistic approach to determine at what time post-RP ART had the most significant effect on outcomes of interest in men with pT3N0 disease., Results: When compared with delayed ART in men with pT3 disease, early ART was associated with improved PCSM (0.47 vs. 1.02 events per 100 person-years; P = 0.038) and less salvage hormonal therapy (2.88 vs. 4.59 events per 100 person-years; P = 0.001). Delaying ART beyond 5 months is associated with worse PCSM (hazard ratio [HR] 2.3; P = 0.020), beyond 3 months is associated with more BRE (HR 1.6; P = 0.025), and beyond 4 months is associated higher rates of salvage hormonal therapy (HR 1.6; P = 0.002). ART performed after 9 months was associated with fewer urethral strictures (HR 0.6; P = 0.042)., Conclusion: Initiating ART less than 5 months after RP for pT3 is associated with improved PCSM. Early ART is also associated with fewer BRE and less use of salvage hormonal therapy if administered earlier than 3 and 4 months after RP, respectively. However, ART administered later than 9 months after RP is associated with fewer urethral strictures. Our population-based findings complement randomized trials designed with fixed ART timing., (© 2013 Published by Elsevier Inc.)

Objectives: Although high-volume hospitals have been associated with improved outcomes for radical prostatectomy (RP), the association of residency or fellowship teaching institutions or both and this volume-outcome relationship remains poorly described. We examine the effect of teaching status and hospital volume on perioperative RP outcomes., Methods and Materials: Within the Nationwide Inpatient Sample, we focused on RPs performed between 2003 and 2007. We tested the rates of prolonged length of stay beyond the median of 3 days, in-hospital mortality, and intraoperative and postoperative complications, stratified according to teaching status. Multivariable logistic regression analyses further adjusted for confounding factors., Results: Overall, 47,100 eligible RPs were identified. Of these, 19,193 cases were performed at non-teaching institutions, 24,006 at residency teaching institutions, and 3,901 at fellowship teaching institutions. Relative to patients treated at non-teaching institutions, patients treated at fellowship teaching institutions were healthier and more likely to hold private insurance. In multivariable analyses, patients treated at residency (OR = 0.92, P = 0.015) and fellowship (OR = 0.82, P = 0.011) teaching institutions were less likely to experience a postoperative complication than patients treated at non-teaching institutions. Patients treated at residency (OR = 0.73, P<0.001) and fellowship (OR = 0.91, P = 0.045) teaching institutions were less likely to experience a prolonged length of stay., Conclusions: More favorable postoperative complication profile and shorter length of stay should be expected at residency and fellowship teaching institutions following RP. Moreover, postoperative complication rates were lower at fellowship teaching than at residency teaching institutions, despite adjustment for potential confounders., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Importance: There is limited data on the prevalence and mortality of venous thromboembolism (VTE) following oncologic surgery., Objective: To evaluate the trends, factors, and mortality of VTE following major cancer surgery., Design, Setting, and Participants: Patients undergoing colectomy, cystectomy, esophagectomy, gastrectomy, hysterectomy, lung resection, pancreatectomy, or prostatectomy were identified retrospectively using the Nationwide Inpatient Sample between January 1, 1999, and December 30, 2009, resulting in a weighted estimate of 2,508,916 patients., Main Outcomes and Measures: Venous thromboembolism following major cancer surgery was assessed according to date, patient, and hospital characteristics. The determinants of in-hospital VTE were evaluated using logistic regression analysis., Results: Venous thromboembolism showed an estimated annual percentage increase of 4.0% (95% CI, 2.9% to 5.1%), which contrasts with a 2.4% (95% CI, -4.3% to -0.5%) annual decrease in mortality in VTE after major cancer surgery. In multivariate logistic regression analysis, older age (odds ratio [OR], 1.03; P < .001), female sex (OR, 1.25; P < .001), black race (vs white; OR, 1.56; P < .001), Charlson comorbidity index score of 3 or more (OR, 1.85; P < .001), and Medicaid (vs private insurance; OR, 2.04; P < .001), Medicare (OR, 1.39; P < .001), and uninsured (OR, 1.49; P < .001) status were associated with an increased risk of VTE. Conversely, other (nonwhite and nonblack) race (OR, 0.75; P < .001) was associated with a lower risk of VTE. Among hospital characteristics, urban location (OR, 1.32; P < .001) and teaching status (OR, 1.08; P = .01) were associated with greater odds of VTE. Patients with vs without VTE experienced 5.3-fold greater odds of mortality., Conclusions and Relevance: During our study period, VTE events following major cancer surgery increased in frequency; however, associated VTE mortality decreased. Changing VTE detection guidelines and better management of this condition may explain our findings.

Purpose: Due to varying clinical definitions of lower urinary tract symptoms, it has been difficult to determine comparable prevalence and incidence rates of lower urinary tract symptoms and their treatment modalities. We assessed the incidence of emergency department visits in men with lower urinary tract symptoms who presented to emergency departments in the United States and factors associated with an increased likelihood of hospitalization., Materials and Methods: Emergency department visits from 2006 to 2009 associated with a primary diagnosis of lower urinary tract symptoms using established criteria were abstracted from the Nationwide Emergency Department Sample. Age adjusted incidence rates of emergency department visits and charges were calculated. We performed multivariable analysis to examine patient and hospital characteristics of those hospitalized and those with benign prostatic hyperplasia related adverse events., Results: A weighted estimate of 1,178,423 emergency department visits for lower urinary tract symptoms was recorded with a national incidence of 197.6/100,000 males per year. A total of 112,288 visits (9.5%) resulted in hospitalization. Adverse events were identified in 734,269 patients (62.3%). The most common adverse events were catheterization in 44.6% of cases, infection in 17.4%, hematuria in 9.6%, bladder stones in 1.7%, hydronephrosis in 1.2% and acute renal failure in 0.1%. On multivariable analysis independent predictors of hospital admission included comorbidities, socioeconomic status, hospital characteristics and adverse events such as sepsis, acute renal failure and hydronephrosis. Independent predictors of adverse events included patient age, year of visit, socioeconomic status, hospital characteristics and concomitant neurological disease. In 2009 total emergency department charges for lower urinary tract symptoms were $494,981,922., Conclusions: The number of men with lower urinary tract symptoms who visit the emergency department has remained stable, while emergency department charges have increased by 40%. The rate of adverse events increased during the study period. These findings might suggest over reliance on medical and conservative therapy in the contemporary era., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: With the increasing incidence of small renal masses, there is greater use of ablation, nephron sparing surgery and surveillance compared to radical nephrectomy. However, patterns of care in the use of posttreatment imaging remain uncharacterized. The purpose of this study is to determine the rate of posttreatment imaging after various treatments for small renal mass., Materials and Methods: Using SEER (Surveillance, Epidemiology and End Results)-Medicare data during 2005 to 2009, we identified 1,682 subjects diagnosed with small renal mass and treated with open partial nephrectomy (330), minimally invasive partial nephrectomy (160), open radical nephrectomy (404), minimally invasive radical nephrectomy (535), thermal ablation (212) and surveillance (42). Use of imaging was compared within 24 months of treatment and multivariate regression models were constructed to identify factors associated with increased imaging use., Results: On adjusted analyses thermal ablation was associated with almost eightfold greater odds of surveillance imaging compared with open radical nephrectomy (OR 7.7, 95% CI 1.01-59.4). Specifically, thermal ablation was associated with increased computerized tomography (OR 5.28) and magnetic resonance imaging (OR 2.19) use and decreased ultrasound use (OR 0.59). Minimally invasive partial nephrectomy (OR 3.28) and open partial nephrectomy (OR 3.19) were also associated with increased computerized tomography use to a lesser extent., Conclusions: Subjects undergoing nephron sparing surgery undergo more posttreatment imaging compared to open radical nephrectomy. Although possibly associated with lower morbidity, thermal ablation is associated with significantly greater use of imaging compared to other small renal mass treatments. This may increase costs and radiation exposure, although further study is needed for confirmation., (Copyright © 2013 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Salvage radical prostatectomy (RP) is performed with curative intent following post-radiotherapy recurrence for prostate cancer. While single-center salvage RP outcomes appear promising, little is known about outcomes in the community setting in elderly men. We sought to evaluate utilization, outcomes, and costs of salvage RP vs. primary RP in older men., Materials and Methods: Surveillance, Epidemiology and End Results-Medicare linked data from 1992 to 2007 was used to identify 18,317 men aged 65 years or older who underwent RP from 2002 to 2007. Propensity score analyses were used to compare outcomes and costs for primary vs. salvage RP., Results: Salvage RP was rare, accounting for 0.5% of RP. Men undergoing salvage vs. primary RP were older, white, and less likely to undergo CT, bone scan and prostate biopsy preoperatively (P < 0.05 for all). In adjusted analyses, salvage vs. primary RP was associated with increased 30-day complications (60.1% vs. 22.7%, P < 0.01), lengths of stay (mean 7 vs. 3 days, P < 0.01), and hospital readmissions within 30 days (30.4% vs. 5.7%, P < 0.01). The odds of death within 90 days were higher for salvage vs. primary RP (OR 26.7, 95% CI 12.9-55.1, P < 0.01). The median expenditure for salvage RP within 6 months postoperatively was almost twice that for primary RP (US$30,881 vs. US$12,431, P < 0.01)., Conclusions: Metastatic workup was performed less frequently before salvage vs. primary RP, and morbidity and mortality for salvage RP was high relative to primary RP. Given the morbidity and high cost of salvage RP, guidelines for patient selection and selective referral may optimize outcomes, especially in older men., (Copyright © 2013. Published by Elsevier Inc.)

Robotic-assisted laparoscopic prostatectomy (RALP) has surged in popularity since US Food and Drug Administration approval in 2000. Advantages include improved visualization and increased instrument dexterity within the pelvis. Obesity and narrow pelves have been associated with increased difficulty during open retropubic radical prostatectomy (RRP), but the robotic platform theoretically allows one to perform a radical prostatectomy despite these challenges. We present an example of a RALP performed following an aborted RRP. A 49-year-old male with intermediate risk prostate cancer and body mass index of 38 kg/m(2) presented for RALP after RRP was aborted by an experienced open surgeon following incision of the endopelvic fascia due to poor visualization, a prominent pubic tubercle, and a narrow pelvis. The enhanced visualization and precision of the robotic platform allowed adequate exposure of the prostate and allowed us to proceed with an uncomplicated prostatectomy, which was not possible to perform easily via an open approach. The bladder was densely adherent to the pubis and the anterior prostatic contour and apex were difficult to develop due to a dense fibrotic reaction from the previous endopelvic fascia incision. However, we were able to successfully complete RALP with subtle technical modifications. Estimated blood loss was 160 mL and operating time was 145 min. The patient's pathology was significant for a positive peri-prostatic lymph node and he has been referred to radiation oncology for adjuvant radiotherapy and androgen deprivation therapy. At 3 months follow-up he had a prostate-specific antigen level of 0.06 ng/mL, partial erections, and mild urinary incontinence requiring one pad per day. Superior intracorporeal laparoscopic visualization and improved instrument dexterity afforded by the robotic surgical platform may make RALP the preferred approach in obese men or men with difficult pelvic anatomy who are deemed poor RRP candidates.

Unlabelled: What's known on the subject? and what does the study add?: Retrospective data have suggested an increased survival benefit for patients undergoing partial nephrectomy compared to radical nephrectomy, possibly as a result of the avoidance of long-term renalin sufficiency and subsequent sequelae. However, recent level-one evidence has questioned this benefit. Both retrospective studies and randomized controlled trials are not without limitations. There are few population-based data available with respect to the outcomes of partial nephrectomy vs radical nephrectomy. Additionally, there are no population-based studies analyzing the surgical approach (minimally-invasive vs open), as well as other modalities, such as ablation and surveillance. Finally, there is very little information available on the potential differences in cost for each approach. The present study comprises the first comprehensive population-based analysis of the trends, outcomes and costs of all treatment modalities for T1a renal masses from 2005 to 2007., Objective: To perform a comprehensive analysis of the outcomes and costs for treatments for small renal masses (SRM) using a population-based approach. Partial nephrectomy may be associated with improved survival, although level-one evidence has questioned this survival advantage., Patients and Methods: Using Surveillance, Epidemiology and End Results-Medicare data, we identified 1682 subjects who were diagnosed with SRM from 2005 to 2007. Treatment included open radical nephrectomy (ORN; n = 404), minimally-invasive radical nephrectomy (MIRN; n = 535), open partial nephrectomy (OPN; n = 330), minimally-invasive partial nephrectomy (MIPN; n = 160), ablation (n = 211) and surveillance (n = 42). Postoperative complications, renal insufficiency diagnosis, overall mortality, cancer-specific mortality and postoperative costs were compared. Covariates were balanced before outcomes analysis using propensity score methods., Results: Although the use of nephron-sparing surgery (NSS) increased over the study period, radical nephrectomy remained the predominant approach for SRM in 2007. Minimally-invasive approaches had shorter lengths of stay (P < 0.001), whereas open approaches had more overall complications, respiratory complications and intensive care unit admissions (all P < 0.003). MIRN and ORN were associated with more peri-operative medical complications, acute renal failure, haemodialysis use and long-term chronic renal insufficiency diagnosis vs NSS (all P < 0.001). Ablation, MIRN and ORN were associated with the highest overall mortality rates (P < 0.001), whereas MIRN and ORN were associated with the highest cancer-specific mortality rates (P < 0.001). Treatment costs were lowest for surveillance ($2911) followed by ablation ($10730), MIRN ($15373), MIPN ($15695), OPN ($16986) and ORN ($17803)., Conclusions: Although not the predominant treatment approach for SRM over the study period, the use of NSS increased and was associated with improved survival, fewer complications and less renal insufficiency. Minimally-invasive approaches confer lower costs., (© 2013 BJU International.)

Background: The incidence of infected urolithiasis is unknown, and evidence describing the optimal management strategy for obstruction is equivocal., Objective: To examine the trends of infected urolithiasis in the United States, the practice patterns of competing treatment modalities, and to compare adverse outcomes., Design, Setting, and Participants: A weighted estimate of 396385 adult patients hospitalized with infected urolithiasis was extracted from the Nationwide Inpatient Sample, 1999-2009., Outcome Measurements and Statistical Analysis: Time trend analysis examined the incidence of infected urolithiasis and associated sepsis, as well as rates of retrograde ureteral catheterization and percutaneous nephrostomy (PCN) for urgent/emergent decompression. Propensity-score matching compared the rates of adverse outcomes between approaches., Results and Limitations: Between 1999 and 2009, the incidence of infected urolithiasis in women increased from 15.5 (95% confidence interval [CI], 15.3-15.6) to 27.6 (27.4-27.8)/100 000); men increased from 7.8 (7.7-7.9) to 12.1 (12.0-12.3)/100000. Rates of associated sepsis increased from 6.9% to 8.5% (p=0.013), and severe sepsis increased from 1.7% to 3.2% (p<0.001); mortality rates remained stable at 0.25-0.20% (p=0.150). Among those undergoing immediate decompression, 113 459 (28.6%), PCN utilization decreased from 16.1% to 11.2% (p=0.001), with significant regional variability. In matched analysis, PCN showed higher rates of sepsis (odds ratio [OR]: 1.63; 95% CI, 1.52-1.74), severe sepsis (OR: 2.28; 95% CI, 2.06-2.52), prolonged length of stay (OR: 3.18; 95% CI, 3.01-3.34), elevated hospital charges (OR: 2.71; 95%CI, 2.57-2.85), and mortality (OR: 3.14; 95%CI, 13-4.63). However, observational data preclude the assessment of timing between outcome and intervention, and disease severity., Conclusions: Between 1999 and 2009, women were twice as likely to have infected urolithiasis. Rates of associated sepsis and severe sepsis increased, but mortality rates remained stable. Analysis of competing treatment strategies for immediate decompression demonstrates decreasing utilization of PCN, which showed higher rates of adverse outcomes. These findings should be viewed as preliminary and hypothesis generating, demonstrating the pressing need for further study., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Approximately 1.7 million individuals per year are affected with health care-associated infections (HAIs) in the United States. The authors examined trends in the incidence of HAI after major cancer surgery (MCS) and risk factors for HAI to describe the effects of HAI on mortality after MCS., Methods: Patients undergoing 1 of 8 MCS procedures within the Nationwide Inpatient Sample between 1999 and 2009 were identified (n = 2,502,686). Generalized linear regression models were used to estimate the impact of the primary predictors (procedure type, age, sex, race, insurance status, Charlson comorbidity index, hospital volume, and hospital bed size) on the odds of HAI and in-hospital mortality. Trends in incidence were evaluated with linear regression., Results: Overall, MCS-associated HAI incidence increased 2.7% per year (P < .001), whereas mortality decreased 1.3% per year (P < .001). Male gender (odds ratio [OR], 1.12, 95% confidence interval [CI], 1.10-1.14), advancing age (OR, 1.02; 95% CI, 1.02-1.02), black race (OR, 1.26; 95% CI, 1.21-1.31), ≥1 comorbidities (OR, from 1.08 [95% CI, 1.04-1.13] to 1.31 [95% CI, 1.27-1.35]), and nonprivate insurance (OR, from 1.18 [95% CI, 1.15-1.22] to 1.67 [95% CI, 1.59-1.76]) were associated with an increased odds of HAI on multivariable analysis. Conversely, increasing hospital volume was associated with lower odds of HAI (OR, 0.999; 95% CI, 0.99-0.99). Patients with MCS-associated HAI had increased odds of mortality (OR, 8.66; 95% CI, 8.51-8.82)., Conclusions: Between 1999 and 2009, the incidence of MCS-associated HAI events increased; however, HAI-associated mortality decreased. That said, significant disparities exist in the hospital and demographic attributes associated with MCS-associated HAI, with attendant health policy implications. Moreover, HAI remains detrimentally linked to mortality during hospitalization., (Copyright © 2013 American Cancer Society.)

Objectives: Although most prostatectomy studies emphasize optimal nerve-sparing dissection planes, subtle technical variation also affects functional outcomes. The impact of minimizing assistant/surgeon tension on urinary function has not been quantified. We assess urinary function after attenuating neurovascular bundle (NVB) and rhabdosphincter tension during robotic-assisted radical prostatectomy (RARP)., Methods: Retrospective study of prospectively collected data for 268 (RARP-T) versus 342 (RARP-0T) men with versus without tension on the NVB and rhabdosphincter during RARP. Outcomes compared include Expanded Prostate Cancer Index (EPIC) urinary function, estimated blood loss (EBL), operative time, and positive surgical margins (PSM)., Results: In unadjusted analysis, men undergoing RARP-T versus RARP-0T were older, had higher biopsy and pathologic Gleason grade, and higher preoperative prostate specific antigen (all p ≤ 0.023). Baseline urinary function was similar. Postoperatively, RARP-0T versus RARP-T was associated with higher 5-month urinary function scores (69.7 versus 64, p = 0.049). In adjusted analyses, RARP-0T versus RARP-T was associated with improved 5-month urinary function [Parameter Estimate (PE) 7.37, Standard Error (SE) 2.67, p = 0.006], while bilateral versus non-/unilateral nerve-sparing was associated with improved 12-month urinary function and continence (both p ≤ 0.035). RARP-0T versus RARP-T was associated with shorter operative times (PE 6.66, SE 1.90, p = 0.001) and higher EBL (PE 20.88, SE 6.49, p = 0.001). There were no significant differences in PSM., Conclusions: While the use of tension aids in dissection of anatomic planes, avoidance of NVB counter-traction and minimizing tension on the rhabdosphincter during apical dissection attenuates neuropraxia and leads to earlier urinary function recovery. Bilateral versus non-/unilateral nerve-sparing also improves urinary function recovery.

Objective: To evaluate the use and outcomes of adjuvant radiation therapy (ART) for men with lymph node (LN)-positive disease after radical prostatectomy (RP) using a population-based approach., Patients and Methods: Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data from 1995 to 2007 was used to identify 577 men with LN metastases discovered during RP and absence of distant metastases, of which 177 underwent ART ≤1 year of RP. Propensity score models were used to compare overall mortality and prostate cancer-specific mortality (PCSM) for men that did and those that did not receive ART., Results: Men in both groups received adjuvant androgen-deprivation therapy at similar rates after propensity weighting adjustments (33.6% vs 33.7%, P = 0.977). ART was not associated with differences in overall (5.09 vs 3.77 events per 100 person-years, P = 0.153) or PCSM (2.89 vs 1.31, P = 0.090) relative to men who did not receive ART., Conclusions: ART after RP in men with LN-positive prostate cancer was not associated with improved overall or disease-specific survival, in contrast to previous single-centre studies. Prospective randomised studies are needed to assess the effectiveness of ART in this patient population., (© 2013 BJU International.)

Purpose: Robotic-assisted laparoscopic prostatectomy (RALP) offers reportedly comparable oncologic outcomes for localized disease compared with open radical retropubic prostatectomy (ORRP). However, the oncologic efficacy of RALP in locally-advanced prostate cancer (PCa) is less clear. We report and compare our experience with RALP and ORRP in men with locally advanced PCa., Methods: Patients with locally advanced PCa (stage T3 or greater) were identified in both robotic and open cohorts. Clinicopathologic features including age, clinical stage, prostate-specific antigen, surgical margins, and Gleason score were reviewed. We further examined the incidence of positive surgical margins, the effect of the surgical learning curve on margins, and the need for adjuvant therapy., Results: From 1997 to 2010, 1,011 patients underwent RALP and 415 patients were identified who underwent radical retropubic prostatectomy (RRP) across four institutions. 140 patients in the RALP group and 95 in the RRP group had locally advanced PCa on final pathology. The overall robotic positive margin rate 47.1% compared with 51.4% in the RRP group. A trend towards a lower positive margin rate was seen after 300 cases in the RALP group, with 66.7% positive margin rate in the first 300 cases compared with 41.8% in the latter 700 cases. In addition, a lower incidence of biochemical recurrence was also noted in the latter cases (30.6% vs. 9.5%)., Conclusions: Up to 2 out of 3 men undergoing RALP for locally-advanced PCa had positive margins during our initial experience. However, with increasing surgeon experience the overall positive margin rate decreased significantly and was comparable to the positive margin rate for patients with locally advanced disease undergoing ORRP over four academic institutions. We also noted a lower incidence of biochemical recurrence with increasing RALP experience, suggesting better oncologic outcomes with higher volume. Given this data, RALP has comparable oncologic outcomes compared to ORRP, especially with higher volume surgeons.

Purpose of Review: The advent of robotic-assisted radical prostatectomy purported fewer complications including postprostatectomy incontinence (PPI). PPI is associated with worse quality of life. We evaluate recently reported robot-assisted radical prostatectomy surgical techniques aimed at limiting PPI, describe their anatomic basis and summarize their outcomes., Recent Findings: RARP techniques to reduce PPI include bladder neck preservation, bladder neck reconstruction, urethral length preservation, periurethral suspension stitch, posterior reconstruction, combined anterior and posterior reconstruction, preservation of the endopelvic fascia, complete anterior preservation, selective suturing of dorsal venous complex and nerve sparing approach. Outcomes of reconstructive techniques seem to be conflicting, whereas outcomes of techniques aiming to preserve the native urinary continence system seem to hasten urinary function recovery. However, few of these techniques have been shown to affect long-term urinary continence., Summary: Surgical techniques preserving the natural urinary continence mechanism appear to improve short-term urinary continence, whereas techniques reconstructing pelvic anatomy have mixed results. The search for the ideal technique to minimize PPI remains hampered by the lack of prospective multi-institutional studies and the long-term follow up. Although reconstructive techniques are safe with few drawbacks, meticulous surgical technique and preservation of the natural continence mechanism should remain the mainstay of PPI prevention.

Purpose: While higher radical prostatectomy hospital and surgeon volume are associated with better outcomes, the effect of provider volume on health care costs remains unclear. We performed a population based study to characterize the effect of surgeon and hospital volume on radical prostatectomy costs., Materials and Methods: We used SEER (Surveillance, Epidemiology and End Results)-Medicare linked data to identify 11,048 men who underwent radical prostatectomy from 2003 to 2009. We categorized hospital and surgeon radical prostatectomy volume into tertiles (low, intermediate, high) and assessed costs from radical prostatectomy until 90 days postoperatively using propensity adjusted analyses., Results: Higher surgeon volume at intermediate volume hospitals (surgeon volume low $9,915; intermediate $10,068; high $9,451; p = 0.021) and high volume hospitals (surgeon volume low $11,271; intermediate $10,638; high $9,529; p = 0.002) was associated with lower radical prostatectomy costs. Extrapolating nationally, selective referral to high volume radical prostatectomy surgeons at high and intermediate volume hospitals netted more than $28.7 million in cost savings. Conversely, higher hospital volume was associated with greater radical prostatectomy costs for low volume surgeons (hospital volume low $9,685; intermediate $9,915; high $11,271; p = 0.010) and intermediate volume surgeons (hospital volume low $9,605; intermediate $10,068; high $10,638; p = 0.029). High volume radical prostatectomy surgeon costs were not affected by varying hospital volume, and among low volume hospitals radical prostatectomy costs did not differ by surgeon volume., Conclusions: Selective referral to high volume radical prostatectomy surgeons operating at intermediate and high volume hospitals nets significant cost savings. However, higher radical prostatectomy hospital volume was associated with greater costs for low and intermediate volume radical prostatectomy surgeons., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Minimally invasive radical prostatectomy has supplanted radical retropubic prostatectomy in popularity despite the absence of strong comparative effectiveness data demonstrating its superiority. We examined the influence of patient, surgeon and hospital characteristics on the use of minimally invasive radical prostatectomy vs radical retropubic prostatectomy., Materials and Methods: Using SEER (Surveillance, Epidemiology and End Results)-Medicare linked data we identified 11,732 men who underwent radical prostatectomy from 2003 to 2007. We assessed the contribution of patient, surgeon and hospital characteristics to the likelihood of undergoing minimally invasive radical prostatectomy vs radical retropubic prostatectomy using multilevel logistic regression mixed models., Results: Patient factors (36.7%) contributed most to the use of minimally invasive radical prostatectomy vs radical retropubic prostatectomy, followed by surgeon (19.1%) and hospital (11.8%) factors. Among patient specific factors Asian race (OR 1.86, 95% CI 1.27-2.72, p = 0.001), clinically organ confined tumors (OR 2.71, 95% CI 1.60-4.57, p <0.001) and obtaining a second opinion from a urologist (OR 3.41, 95% CI 2.67-4.37, p <0.001) were associated with the highest use of minimally invasive radical prostatectomy while lower income was associated with decreased use of minimally invasive radical prostatectomy. Among surgeon and hospital specific factors, higher surgeon volume (OR 1.022, 95% CI 1.015-1.028, p <0.001), surgeon age younger than 50 years (OR 2.68, 95% CI 1.69-4.24, p <0.001) and greater hospital bed size (OR 1.001, 95% CI 1.001-1.002, p <0.001) were associated with increased use of minimally invasive radical prostatectomy, while solo or 2 urologist practices were associated with decreased use of minimally invasive radical prostatectomy (OR 0.48, 95% CI 0.27-0.86, p = 0.013)., Conclusions: The adoption of minimally invasive radical prostatectomy vs radical retropubic prostatectomy is multifactorial, and associated with specific patient, surgeon and hospital related factors. Obtaining a second opinion from another urologist was the strongest factor associated with opting for minimally invasive radical prostatectomy., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Despite the increased popularity of emerging therapies for localised prostate cancer, such as cryotherapy and brachytherapy, outcomes data remains sparse beyond single-centre comparative studies. The present study identified that although less costly, cryotherapy was associated with more urinary and ED complications and a greater need for salvage ADT. Conversely, cryotherapy was associated with fewer bowel complications. Patients and providers alike should consider these population-based outcomes when discussing therapeutic options for localised prostate cancer., Objective: To compare prostate cryotherapy vs brachytherapy outcomes and costs, as despite the greater popularity of these emerging therapies for localised prostate cancer, outcomes data remains sparse beyond single-centre comparative studies., Patients and Methods: Observational study of 10 928 men who underwent primary cryotherapy (943 patients) or brachytherapy (9985) with ≥2 years of follow-up using USA Surveillance, Epidemiology, and End Results (SEER-) Medicare linked data. Weighted propensity score methods were used., Results: Use of cryotherapy increased four-fold whereas brachytherapy utilization remained the same from 2001 to 2005 (P < 0.001). Men who underwent cryotherapy vs brachytherapy were older (P < 0.001), more likely to be Black (P < 0.001), less likely to live in areas of higher education (P < 0.001), less likely to live in areas with greater income (P < 0.001), and were more likely to live in urban vs rural areas (P = 0.007). In propensity score-weighted analyses, cryotherapy was associated with more urinary (41.4% vs 22.2%, P < 0.001) and erectile dysfunction (ED) complications (34.7% vs 21.0%, P < 0.001) while brachytherapy was associated with more bowel complications (19.0% vs 12.1%, P < 0.001). Cryotherapy was associated with greater use of salvage androgen deprivation therapy (ADT; 1.4 vs 0.5 per 100 person-years, P < 0.001), suggesting worse cancer control. Finally costs were significantly greater for brachytherapy vs cryotherapy ($16 887 vs $12 629 USA dollars, P < 0.001)., Conclusions: Although less costly, cryotherapy was associated with more urinary and ED complications and greater need for salvage ADT. Conversely, cryotherapy was associated with fewer bowel complications. Patients and providers alike should consider these population-based outcomes when discussing therapeutic options for localised prostate cancer., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Background: While radical prostatectomy surgeon learning curves have characterized less blood loss, shorter operative times, and fewer positive margins, there is a dearth of studies characterizing learning curves for improving sexual function. Additionally, while learning curve studies often define volume thresholds for improvement, few of these studies demonstrate specific technical modifications that allow reproducibility of improved outcomes., Objective: Demonstrate and quantify the learning curve for improving sexual function outcomes based on technical refinements that reduce neurovascular bundle displacement during nerve-sparing robot-assisted radical prostatectomy (RARP)., Design, Setting, and Participants: We performed a retrospective study of 400 consecutive RARPs, categorized into groups of 50, performed after elimination of continuous surgeon/assistant neurovascular bundle countertraction., Surgical Procedure: Our approach to RARP has been described previously. A single-console robotic system was used for all cases., Outcome Measurements and Statistical Analysis: Expanded Prostate Cancer Index Composite sexual function was measured within 1 yr of RARP. Linear regression was performed to determine factors influencing the recovery of sexual function., Results and Limitations: Greater surgeon experience was associated with better 5-mo sexual function (p = 0.007) and a trend for better 12-mo sexual function (p = 0.061), with improvement plateauing after 250-300 cases. Additionally, younger patient age (both p<0.02) and better preoperative sexual function (<0.001) were associated with better 5- and 12-mo sexual function. Moreover, trainee robotic console time during nerve sparing was associated with worse 12-mo sexual function (p=0.021), while unilateral nerve sparing/non-nerve sparing was associated with worse 5-mo sexual function (p = 0.009). Limitations include the retrospective single-surgeon design., Conclusions: With greater surgeon experience, attenuating lateral displacement of the neurovascular bundle and resultant neurapraxia improve postoperative sexual function. However, to maximize outcomes, appropriate patient selection must be exercised when allowing trainee nerve-sparing involvement., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Although robot-assisted laparoscopic radical cystectomy (RARC) was first reported in 2003 and has gained popularity, comparisons with open radical cystectomy (ORC) are limited to reports from high-volume referral centers., Objective: To compare population-based perioperative outcomes and costs of ORC and RARC., Design, Setting, and Participants: A retrospective observational cohort study using the US Nationwide Inpatient Sample to characterize 2009 RARC compared with ORC use and outcomes., Outcome Measurements and Statistical Analysis: Propensity score methods were used to compare inpatient morbidity and mortality, lengths of stay, and costs., Results and Limitations: We identified 1444 ORCs and 224 RARCs. Women were less likely to undergo RARC than ORC (9.8% compared with 15.5%, p = 0.048), and 95.7% of RARCs and 73.9% of ORCs were performed at teaching hospitals (p<0.001). In adjusted analyses, subjects undergoing RARC compared with ORC experienced fewer inpatient complications (49.1% and 63.8%, p = 0.035) and fewer deaths (0% and 2.5%, p<0.001). RARC compared with ORC was associated with lower parenteral nutrition use (6.4% and 13.3%, p = 0.046); however, there was no difference in length of stay. RARC compared with ORC was $3797 more costly (p = 0.023). Limitations include retrospective design, absence of tumor characteristics, and lack of outcomes beyond hospital discharge., Conclusions: RARC is associated with lower parenteral nutrition use and fewer inpatient complications and deaths. However, lengths of stay are similar, and the robotic approach is significantly more costly., (Copyright © 2012 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Purpose: Although robot-assisted laparoscopic radical prostatectomy has been aggressively marketed and rapidly adopted, there is a paucity of population based utilization, outcome and cost data. High vs low volume hospitals have better outcomes for open and minimally invasive radical prostatectomy (robotic or laparoscopic) but to our knowledge volume outcomes effects for robot-assisted laparoscopic radical prostatectomy alone have not been studied., Materials and Methods: We characterized robot-assisted laparoscopic radical prostatectomy outcome by hospital volume using the Nationwide Inpatient Sample during the last quarter of 2008. Propensity scoring methods were used to assess outcomes and costs., Results: At high volume hospitals robot-assisted laparoscopic radical prostatectomy was more likely to be done on men who were white with an income in the highest quartile and age less than 50 years than at low volume hospitals (each p <0.01). Hospitals at above the 50th volume percentile were less likely to show miscellaneous medical and overall complications (p = 0.01). Low vs high volume hospitals had longer mean length of stay (1.9 vs 1.6 days) and incurred higher median costs ($12,754 vs $8,623, each p <0.01)., Conclusions: Demographic differences exist in robot-assisted laparoscopic radical prostatectomy patient populations between high and low volume hospitals. Higher volume hospitals showed fewer complications and lower costs than low volume hospitals on a national basis. These findings support referral to high volume centers for robot-assisted laparoscopic radical prostatectomy to decrease complications and costs., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We describe the feasibility of partial arterial clamping (PAC) during robot-assisted partial nephrectomy (RAPN)., Patients and Methods: We undertook a retrospective study of five patients who underwent PAC vs 17 who underwent complete hilar clamping (CHC). Estimated blood loss (EBL), transfusion rate, operative/console time, warm ischemia time (WIT), pathology, and postoperative glomerular filtration rate (GFR) were compared., Results: PAC patients were older (P=0.002) and more likely to have had previous abdominal surgeries (P=0.032). PAC vs CHC was associated with higher median EBL (350 mL vs 75 mL, P=0.026), although there were no differences in blood transfusions (P=0.250). PAC was associated with shorter WIT (14 min vs 21 min, P=0.023). Positive margin rate and GFR change were similar., Conclusions: PAC offers a simple and reproducible technique that limits WIT during RAPN. PAC was not associated with more transfusions or positive margins. Further study is warranted to determine the utility of PAC with larger tumor size as well as the long-term benefits on renal function.

Purpose: Although robotic assisted laparoscopic surgery has been aggressively marketed and rapidly adopted, there are few comparative effectiveness studies that support its purported advantages compared to open and laparoscopic surgery. We used a population based approach to assess use, costs and outcomes of robotic assisted laparoscopic surgery vs laparoscopic surgery and open surgery for common robotic assisted urological procedures., Materials and Methods: From the Nationwide Inpatient Sample we identified the most common urological robotic assisted laparoscopic surgery procedures during the last quarter of 2008 as radical prostatectomy, nephrectomy, partial nephrectomy and pyeloplasty. Robotic assisted laparoscopic surgery, laparoscopic surgery and open surgery use, costs and inpatient outcomes were compared using propensity score methods., Results: Robotic assisted laparoscopic surgery was performed for 52.7% of radical prostatectomies, 27.3% of pyeloplasties, 11.5% of partial nephrectomies and 2.3% of nephrectomies. For radical prostatectomy robotic assisted laparoscopic surgery was more prevalent than open surgery among white patients in high volume, urban hospitals (all p≤0.015). Geographic variations were found in the use of robotic assisted laparoscopic surgery vs open surgery. Robotic assisted laparoscopic surgery and laparoscopic surgery vs open surgery were associated with shorter length of stay for all procedures, with robotic assisted laparoscopic surgery being the shortest for radical prostatectomy and partial nephrectomy (all p<0.001). For most procedures robotic assisted laparoscopic surgery and laparoscopic surgery vs open surgery resulted in fewer deaths, complications, transfusions and more routine discharges. However, robotic assisted laparoscopic surgery was more costly than laparoscopic surgery and open surgery for most procedures., Conclusions: While robotic assisted and laparoscopic surgery are associated with fewer deaths, complications, transfusions and shorter length of hospital stay compared to open surgery, robotic assisted laparoscopic surgery is more costly than laparoscopic and open surgery. Additional studies are needed to better delineate the comparative and cost-effectiveness of robotic assisted laparoscopic surgery relative to laparoscopic surgery and open surgery., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Although the use of minimally invasive radical prostatectomy (MIRP) has increased, there are few comprehensive population-based studies assessing temporal trends and outcomes relative to retropubic radical prostatectomy (RRP)., Objective: Assess temporal trends in the utilization and outcomes of MIRP and RRP among US Medicare beneficiaries from 2003 to 2007., Design, Setting, and Participants: A population-based retrospective study of 19 594 MIRP and 58 638 RRP procedures was performed from 2003 to 2007 from the 100% Medicare sample, composed of almost all US men ≥ 65 yr of age., Intervention: MIRP and RRP., Measurements: We measured 30-d outcomes (cardiac, respiratory, vascular, genitourinary, miscellaneous medical, miscellaneous surgical, wound complications, blood transfusions, and death), cystography utilization within 6 wk of surgery, and late complications (anastomotic stricture, ureteral complications, rectourethral fistulae, lymphocele, and corrective incontinence surgery)., Results and Limitations: From 2003 to 2007, MIRP increased from 4.9% to 44.5% of radical prostatectomies while RRP decreased from 89.4% to 52.9%. MIRP versus RRP subjects were younger (p<0.001) and had fewer comorbidities (p<0.001). Decreased MIRP genitourinary complications (6.2-4.1%; p = 0.002), miscellaneous surgical complications (4.7-3.7%; p=0.030), transfusions (3.5-2.2%; p=0.005), and postoperative cystography utilization (40.3-34.1%; p<0.001) were observed over time. Conversely, overall RRP perioperative complications increased (27.4-32.0%; p<0.001), including an increase in perioperative mortality (0.5-0.8%, p=0.009). Late RRP complications increased, with the exception of fewer anastomotic strictures (10.2-8.8%; p=0.002). In adjusted analyses, RRP versus MIRP was associated with increased 30-d mortality (odds ratio [OR]: 2.67; 95% confidence interval [CI], 1.55-4.59; p<0.001) and more perioperative (OR: 1.60; 95% CI, 1.45-1.76; p<0.001) and late complications (OR: 2.52; 95% CI, 2.20-2.89; p<0.001). Limitations include the inability to distinguish MIRP with versus without robotic assistance and also the lack of pathologic information., Conclusions: From 2003 to 2007, there were fewer MIRP transfusions, genitourinary complications, and miscellaneous surgical complications, whereas most RRP perioperative and late complications increased. RRP versus MIRP was associated with more postoperative mortality and complications., (Copyright © 2012 European Association of Urology. All rights reserved.)

Objectives: To review the various methods of outcomes assessment used for effectiveness studies comparing retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), and robotic-assisted laparoscopic prostatectomy (RALP)., Methods: A review of the peer reviewed literature was performed for reported series of RRP, LRP, and RALP using Pubmed and MEDLINE with emphasis on comparing perioperative, functional, and oncologic outcomes. Common methods used for outcomes assessment were categorized and compared, highlighting the pros and cons of each approach., Results: The majority of the literature comparing RRP, LRP, and RALP comes in the form of observational data or administrative data from secondary datasets. While randomized controlled trials are ideal for outcomes assessment, only one such study was identified and was limited. Non-randomized observational studies contribute to the majority of data, however are limited due to retrospective study design, lack of consistent endpoints, and limited application to the general community. Administrative data provide accurate assessment of operative outcomes in both academic and community settings, however has limited ability to convey accurate functional outcomes., Conclusions: Non-randomized observational studies and secondary data are useful resources for assessment of outcomes; however, limitations exist for both. Neither is without flaws, and conclusions drawn from either should be viewed with caution. Until standardized prospective comparative analyses of RRP, LRP, and RALP are established, comparative outcomes data will remain imperfect. Urologic researchers must strive to provide the best available outcomes data through accurate prospective data collection and consistent outcomes reporting.

Purpose: Studies comparing pain after minimally invasive vs retropubic and perineal radical prostatectomy are conflicting. We characterized population based outpatient narcotic prescribing patterns after minimally invasive, retropubic and perineal radical prostatectomy., Materials and Methods: We evaluated outpatient prescription data after minimally invasive, retropubic and perineal radical prostatectomy from 2003 to 2006 using MarketScan®. Baseline and postoperative narcotic prescriptions were identified using the National Drug Code. Total prescribed narcotic strength in morphine sulfate equivalents, the number of prescriptions filled and costs were compared. We performed multivariate analysis adjusted for surgical approach, age, comorbidity, baseline narcotic use, health plan and geographic region., Results: We identified 2,206 minimally invasive, 8,037 retropubic and 463 perineal radical prostatectomies with no differences in baseline narcotic prescription use. Perineal and retropubic operations were associated with greater total morphine sulfate equivalent use than the minimally invasive operation. Perineal prostatectomy was associated with more narcotic refills than minimally invasive and retropubic prostatectomy (42.3% vs 20.2% and 28.9%, respectively, p <0.001). Median narcotic costs were lower for minimally invasive than for perineal and retropubic prostatectomy. On adjusted analysis perineal radical prostatectomy, younger age, baseline narcotic use and preferred provider organization health plan were associated with greater morphine sulfate equivalents and narcotic refills while minimally invasive surgery was associated with fewer refills and lower costs but not with total morphine sulfate equivalents. There was significant geographic variation in narcotic use and costs., Conclusions: Postoperatively minimally invasive radical prostatectomy required fewer narcotic refills and had lower narcotic costs while perineal radical prostatectomy required the greatest amount of narcotics. However, minimally invasive vs retropubic radical prostatectomy morphine sulfate equivalent requirements did not differ on adjusted analysis. While our findings support the purported advantage of minimally invasive radical prostatectomy of less postoperative pain, confirmatory prospective studies with objective outcomes are needed., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Although subtle technical variation affects potency preservation during robot-assisted laparoscopic radical prostatectomy (RARP), most prostatectomy studies focus on achieving the optimal anatomic nerve-sparing dissection plane. However, the impact of active assistant/surgeon neurovascular bundle (NVB) countertraction on sexual function outcomes has not been studied or quantified., Objective: To illustrate technique and compare sexual function outcomes for nerve sparing without (NS-0C) versus with (NS-C) assistant and/or surgeon NVB countertraction., Design, Setting, and Participants: This is a retrospective study of 342 NS-0C versus 268 NS-C RARP procedures performed between August 2008 and February 2011., Surgical Procedure: RARP., Measurements: We used the Expanded Prostate Cancer Index Composite (EPIC) sexual function and potency scores, estimated blood loss (EBL), operative time, and positive surgical margin (PSM)., Results and Limitations: In unadjusted analysis, men undergoing NS-0C versus NS-C were older, had worse baseline sexual function, higher biopsy and pathologic Gleason grade, and higher preoperative prostate-specific antigen (PSA) levels (all p ≤ 0.023). However, NS-0C versus NS-C was associated with higher 5-mo sexual function scores (20 vs 10; p < 0.001), and this difference was accentuated for bilateral intrafascial nerve sparing in preoperatively potent men (35.8 vs 16.6; p < 0.001). Similarly, 5-mo potency for preoperatively potent men was better with bilateral intrafascial NS-0C versus NS-C (45.0% vs 28.4%; p = 0.039). However, no difference in sexual function or potency was observed at 12 mo. In adjusted analyses, NS-0C versus NS-C was associated with improved 5-mo sexual function (parameter estimate: 10.90; standard error: 2.16; p < 0.001) and potency (odds ratio: 1.69; 95% confidence interval, 1.01-2.83; p = 0.046). NS-0C versus NS-WC was associated with shorter operative times (p = 0.001) and higher EBL (p = 0.001); however, there were no significant differences in PSM. Limitations include the retrospective, single-surgeon study design and smaller numbers for 12-mo comparison., Conclusions: Reliance on countertraction to facilitate dissecting NVB away from the prostate leads to neuropraxia and delayed recovery of sexual function and potency. Subtle technical modification to dissect the prostate away from the NVB without countertraction enables earlier return of sexual function and potency., (Copyright © 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.)