Ahmed Eldefrawy

University of Miami, Coral Gables, FL, United States

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Publications (30)54.41 Total impact

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    ABSTRACT: BACKGROUND: Although a longer time on dialysis before kidney transplant waitlisting has been shown for Blacks versus non-Blacks, relatively few studies have compared this outcome between Hispanics and Whites. METHODS: A multivariable analysis of 1910 (684 Black, 452 Hispanic, and 774 White) consecutive patients waitlisted at our center for a primary kidney transplant between 2005 and mid-2010 was performed for time from starting dialysis to waitlisting (months), the percentage who were preemptively waitlisted (waitlisted before starting dialysis), and time from starting dialysis to waitlisting after excluding the preemptively waitlisted patients. RESULTS: The variables associated with significantly longer median times from starting dialysis to waitlisting and less preemptive waitlisting included Medicare insurance for patients ages <65 years (by far, the most significant variable in each analysis), Black race, higher percentage of households in the patient's zip code living in poverty, being a non-U.S. citizen (for preemptive waitlisting), Medicaid insurance, waitlisted for kidney-alone (vs. kidney-pancreas) transplant, and higher body mass index (longer median times for the latter three variables). Although the effect of Black race was mostly explained by significant associations with lower socioeconomic status (Medicare insurance for patients ages <65 years and greater poverty in the patient's zip code), an unexplained component still remained. The univariable differences showing poorer outcomes for Hispanics versus Whites were smaller and completely explained in multivariable analysis by significant associations with lower socioeconomic status and non-U.S. citizenship. CONCLUSION: Black and Hispanic patients had significantly longer times from starting dialysis to waitlisting, in large part related to their lower socioeconomic status and less preemptive waitlisting. A greater focus on earlier nephrology care may help to erase much of these disparities.
    Transplantation 01/2013; 95(2):309-318. · 3.78 Impact Factor
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    ABSTRACT: Self-expanding stents are relatively new in the field of urology and have primarily been used for permanent remodeling of benign or malignant stricture. We are presenting a rare and interesting case of a ureterocolic fistula that formed secondary to placement of an expandable, retrievable metal stent in the ureter. After multiple retrieval efforts, the self-expanding metal stent was finally retrieved and a ureterocolic fistula was appreciated on antegrade pyelography. The patient chose to manage it non-surgically, with routine nephroureteral catheter exchanges, and her creatinine continues to remain stable.
    Central European journal of urology. 01/2013; 66(2):239-41.
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    ABSTRACT: The peak incidence of bladder cancer (BC) is in the sixth decade of life. Muscle-invasive bladder cancer (MIBC) in young adults is extremely rare. We report a case of MIBC in a 28-year-old smoking male patient. The patient presented with hematuria and flank pain for which he underwent a computerized tomography (CT) scan of the abdomen and pelvis with and without contrast. The CT scan showed a 6 cm mass on the left side of the trigone extending to the left urteric orifice and left hydronephrosis, but no lymphadenopathy was noted. The patient then underwent a left nephrostomy tube placement followed by trans-urethral resection of bladder tumor (TURBT). The tumor involved both ureteric orifices and extended to the prostatic urethra. Complete resection was not feasible. Pathology showed high-grade T1 urothelial carcinoma. CT scan of the chest showed no distant lung metastasis. The patient then elected to undergo radical cystectomy with ileal conduit urinary diversion. Final pathology revealed T2a N0 urothelial carcinoma of the bladder. Our aim is to present our experience and review the literature for the natural history and oncological and quality of life outcomes of urothelial carcinoma of the bladder in young patients.
    Central European journal of urology. 01/2013; 66(2):185-7.
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    ABSTRACT: Primary lymphoma of the spermatic cord is rare. We report a case of primary lymphoma of the spermatic cord and review the literature. A 77-year-old man presented with a 5 month history of an enlarging right inguino-scrotal mass. On physical exam, the mass involved the spermatic cord. Computerized tomography and magnetic resonance imaging revealed a 10 cm x 4 cm inguinoscrotal mass related to the spermatic cord. A right inguinal orchidectomy with wide local excision was performed. Pathological and immunohistochemical evaluation identified the tumor as a diffuse large B cell lymphoma of the spermatic cord. Postoperatively, patient began a chemoradiotherapy regimen consistent with metastatic lymphoma.
    The Canadian Journal of Urology 12/2012; 19(6):6581-3. · 0.74 Impact Factor
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    ABSTRACT: Chemotherapy was shown to improve survival in patients undergoing radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC). The initiation and completion rates for perioperative chemotherapy are variable. Our aim is to compare the likelihood of initiating and completing neoadjuvant (NAC) and adjuvant chemotherapy (AC) in patients who underwent of RC for MIBC. We performed a retrospective analysis of patients who underwent RC between 1992 and 2011. NAC was advised for patients with clinical stage ≥T2, hydronephrosis, extensive lymphovascular invasion (LVI), or prostatic stromal invasion. Patients with ≥pT3 or lymph node metastases were considered for AC. A total of 363 patients were considered for perioperative chemotherapy. Among the 141 patients who were offered NAC, 125 (88.6%) initiated NAC. A total of 222 were considered for AC, and 151 (68.0%) initiated AC ( < 0.001). In the NAC group, 118 (83.5%) completed planned number of cycles of chemotherapy and 7 (5.6%) did not complete the planned chemotherapy. In the AC group, 79 (35.5%) completed at least four cycles and 72 (47.3%) could not complete the planned cycles ( < 0.001). Patients with MIBC are more likely to initiate and complete NAC than AC.
    Indian Journal of Urology 10/2012; 28(4):424-6.
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    ABSTRACT: Gender, smoking history, patient age, and tumor size have been found to impact the likelihood of benign histology at the time of nephron-sparing surgery (NSS). Providing external validation of these variables and evaluating the relationship between body mass index (BMI) and tumor location on the likelihood of benign histology during NSS for T1 tumors were the objectives of this study. Data were analyzed for consecutive patients undergoing NSS for T1 disease. Central tumors either were completely encircled by renal parenchyma, descended below the cortico-medullary junction, or were in direct opposition to the collecting system, renal sinus, or the hilar structures. Categorical variables were evaluated with chi-square test, and continuous variables were analyzed with independent sample t test. Logistic regression identified independent predictors of final pathology. NSS was performed in 316 patients, of whom 79 (24 %) had benign tumors. Patients with benign tumors were more likely to be female, to have a lower BMI, and to have peripheral tumors. On multivariate analysis, female gender (hazard ratio, 3.97; 95 % CI, 2.92-4.53, p < 0.001), peripheral tumor location (hazard ratio, 2.27; 95 % CI, 1.73-3.21, p = 0.014), and lower BMI (hazard ratio, 1.5; 95 % CI, 1.12-1.94, p = 0.015) were independently associated with benign histopathology at the time of surgical resection. Prospectively identifying which T1 tumors are benign would have tremendous implications for the patient. Ours is the first study that has identified the impact of tumor location and BMI on the risk of benign histology. Additional studies are needed to corroborate these findings and incorporate these data into future nomograms.
    International Urology and Nephrology 06/2012; 44(5):1319-24. · 1.33 Impact Factor
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    ABSTRACT: The objective of this report is to describe the oncologic outcomes of men with margin-positive prostate cancer who were managed expectantly following radical prostatectomy. Between January 1992 and January 2011, 2166 men underwent an open radical prostatectomy by a single surgeon. Of these patients, 1592 (74%) had complete data and met the inclusion criteria of negative lymph nodes and no history of neoadjuvant or adjuvant therapy. This cohort was dichotomized by the presence or absence of at least one positive surgical margin. Groups were compared for differences in recurrence-free and overall survival. In total, 507 (32%) of 1592 patients had at least one positive surgical margin. Clinical and pathological characteristics of these patients indicated more aggressive disease. The median follow up for biochemical recurrence and overall survival was 3.4 years and 7.7 years, respectively. Of those patients with a positive margin, 147 (29%) recurred, with estimated 5 and 10 year biochemical recurrence rates of 31% and 47%, respectively. Multivariate analysis demonstrated that the presence of a positive margin was associated with a 2.45-fold increased hazard of recurrence (p < 0.001). Despite initial observation, surgical margin status was not associated with a decrease in overall survival on both uni- (p = 0.684) and multivariate analyses (p = 0.177). Although a positive surgical margin is associated with an increased risk of biochemical recurrence, patients in our series were not at an increased risk of all-cause mortality.
    The Canadian Journal of Urology 06/2012; 19(3):6280-6. · 0.74 Impact Factor
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    ABSTRACT: Deceased patients with acute kidney injury (AKI) from rhabdomyolysis can be considered as potential kidney donors. We performed a retrospective chart review from January 2005 to January 2011 of three donors with AKI from rhabdomyolysis and the four recipients of the donated kidneys. Three donors had AKI from rhabdomyolysis as evidenced by elevated serum creatinine levels, myoglobinuria, and plasma creatinine kinase levels greater than five times the upper limit of normal. All grafts were maintained on pulsatile machine perfusion (MP) prior to transplantation. In one of the patients, serial venous perfusate myoglobin levels were measured from the donor kidney while on MP. Three of the four recipients had delayed graft function, but all had normalized creatinine function after 1 month. One recipient had a creatinine of 1.2 after 79 months, the longest documented follow-up of this kind. Although we measured venous perfusate myoglobin levels from one of the grafts, we found the levels to decrease with increasing time spent on MP. Potential donors with AKI secondary to rhabdomyolysis should not be restricted from the donor pool. MP may play a role in minimizing the effects of AKI in these types of donors.
    International Urology and Nephrology 05/2012; 44(4):1107-11. · 1.33 Impact Factor
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    ABSTRACT: The occurrence of low-risk, localized prostate cancer (PCa) has increased in the prostate-specific antigen era. A significant amount of low-risk PCas progress slowly and may not impact patient survival. Thus, these patients may be subjected to unnecessary interventions that result in physical and psychological complications. The active surveillance (AS) protocol has been used over the few past decades. It was designed so that patients with low-risk PCa can be monitored for a period of time, during which they are free from complication of interventions, and can be treated with curative intention on evidence of disease progression. Institutions have developed different selection criteria and follow-up schedules for suitable patients with PCa. Recently, long-term data have emerged suggesting that AS is a reasonable option for appropriately selected patients with low-risk PCa who have a life expectancy of < 10 years. Subsequently, the AS protocol has been recognized by various guidelines as part of the treatment strategy for PCa. However, the challenges that remain for AS are the risk of under-staging of PCa and the low uptake and high attrition rate of AS, and questions remain regarding its long-term efficacy. Recent advances in AS for PCa, such as better imaging modality, combining AS with limited local therapy, as well as the role of AS in association with chemoprevention, are discussed.
    Postgraduate Medicine 05/2012; 124(3):50-8. · 1.97 Impact Factor
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    ABSTRACT: OBJECTIVES: Treatment options for small renal tumors have evolved from radical nephrectomy (RN) to partial nephrectomy (PN), thermal ablation, or active surveillance. With the advancement of techniques, costs differences are unclear. The objective of this study is to compare the 6-month costs associated with nephron-sparing procedures for cT1a renal tumors. MATERIALS AND METHODS: We performed a review of patients diagnosed with a solitary cT1a renal mass who underwent surgical treatment from June 2008 to May 2011. Open partial nephrectomy (OPN), robot-assisted partial nephrectomy (RLPN), laparoscopic radio-frequency ablation (LRFA), or computed tomography guided radio frequency ablation (CTRFA) was performed on 173 patients. Cost data were collected for surgical costs, associated hospital stay, and the 6-month postoperative period. RESULTS: Patients underwent surgery, including 52 OPN, 48 RLPN, 44 LRFA, and 29 CTRFA. Median total costs associated were $17,018, $20,314, $13,965, and $6,475, for OPN, RLPN, LRFA, and CTRFA, respectively. When stratified by approach differences were noted for total cost (P < 0.001), operating room (OR) time (P < 0.001), surgical supply (P < 0.001), and room and board (P < 0.001) in univariable analysis. Multivariable linear regression (R(2) = 0.966) showed surgical approach (P = 0.007), length of stay (P < 0.001), and OR time (P < 0.001) to be significant predictors of total cost. However, tumor size (P = 0.175), and Charlson comorbidity index (P = 0.078) were not statistically significant. CONCLUSIONS: Six-month cost of nephron-sparing surgery is lowest with radio frequency ablation (RFA) by either laparoscopic or computed tomography (CT)-guided approach compared to RLPN and OPN. As oncologic and safety outcomes improve and become comparable in all nephron-sparing surgery (NSS) approaches, cost of each procedure will start to play a stronger role in the clinical and healthcare policy setting.
    Urologic Oncology 02/2012; · 3.65 Impact Factor
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    ABSTRACT: Recurrent renal cell carcinoma (RCC) that presents as a solitary metastasis to the bladder is extremely rare. We report our experience with two patients who presented with hematuria within 1 year of their radical nephrectomy. Both patients underwent endoscopic resection of the tumor metastasis. One patient developed a metastasis in the head of pancreas 12 months following endoscopic resection. The other patient developed bilateral femoral and spinal bone metastasis. Our aim is to report our experience, and discuss the proposed modes of spread, management and prognosis.
    The Canadian Journal of Urology 02/2012; 19(1):6121-3. · 0.74 Impact Factor
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    Shivam Joshi, Ahmed Eldefrawy, Gaetano Ciancio
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    ABSTRACT: We describe the case of a patient with a large renal cell carcinoma (RCC) who underwent cytoreductive nephrectomy utilizing liver mobilization techniques similar to those used in transplantation. Despite recurrent metastases, our patient continues to survive eight years later with several metastasectomies and adjuvant chemotherapy. We report the case of a 48-year-old Hispanic American man who presented with a 4-month history of an enlarging right upper quadrant abdominal mass and hematuria. Computerized tomography revealed a 13 x 14 x 14 centimeter mass suspicious of RCC with possible metastasis to the lungs. The patient subsequently underwent radical nephrectomy. Pathological analysis confirmed the mass as RCC. Over the following eight years, the patient developed metastases to the pulmonary lobes, buccal mucosa, thoracic spine, and second rib, which were all treated with metastasectomy. The patient continues to survive today with a reasonable quality of life. Palliative measures in patients with large RCC tumors with distant metastases require persistent, aggressive therapeutic modalities.
    Central European journal of urology. 01/2012; 65(4):242-3.
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    ABSTRACT: This study aimed to survey urologists regarding their knowledge, acceptance and practice of active surveillance (AS) for low-risk prostate cancer. An email-based survey was distributed to 4987 urologists. Respondents were surveyed regarding their knowledge and acceptance of AS. Those who felt AS was a reasonable strategy were asked their opinions on the criteria for AS enrollment and the details of their practice of AS. Respondents who felt AS was not a reasonable alternative were queried as to the reasons why. A total of 425 (9%) urologists successfully completed the survey and 387 (91%) were both familiar with AS and aware that AS differed from watchful waiting. Of this latter group, 370 (96%) respondents felt AS was a reasonable management strategy, 95% of whom manage patients with this approach. A minority of respondents (6%) felt that patients with a PSA>10 ng ml(-1) were eligible for AS. Further, most participants (74%) felt that patients required a Gleason score ≤6. There was little agreement on the timing of follow-up biopsies. Respondents who objected to AS were most commonly concerned with missing an opportunity for curative treatment (76%) and the risk of tumor undergrading (65%). The majority of participants were knowledgeable and accepting of AS. Respondents were in relative agreement regarding the PSA and Gleason score criteria for AS enrollment. In contrast, there was a lack of agreement on the timing of follow-up biopsies. In the future, comparative studies are required to determine the optimal enrollment criteria and follow-up protocol for patients managed with AS.
    Prostate cancer and prostatic diseases 12/2011; 15(2):177-81. · 2.10 Impact Factor
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    ABSTRACT: To evaluate oncologic outcomes following the use of intraoperative cell salvage (IOCS) as a blood loss management strategy during open radical prostatectomy (RP). We retrospectively reviewed all open retropubic RP cases performed by a single surgeon. Patients were identified who received IOCS blood and evaluated for an increased risk of biochemical recurrence (BCR) and overall mortality. The study cohort consisted of 1,862 men, 395 (21.2%) of whom received IOCS blood. At a median follow-up of 47.0 months, men who received IOCS blood were not at an increased risk of BCR (P = 0.323) or all-cause mortality (P = 0.892). IOCS use did not confer an increased risk of BCR within any D'Amico preoperative risk category (low risk, P = 0.592; intermediate risk, P = 0.107; and high risk, P = 0.697). IOCS is safe for the management of blood loss during RP. At long-term follow-up, IOCS use was not associated with an increased risk of BCR or death. While it remains preferable to avoid any form of blood transfusion, we advocate for the use of IOCS in place of allogeneic blood. These conclusions are drawn from our study of the largest and longest followed cohort patients who received IOCS blood during RP.
    World Journal of Urology 08/2011; 30(3):379-83. · 2.89 Impact Factor
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    ABSTRACT: OBJECTIVE: Radical prostatectomy (RP) and radiation therapy are standard curative approaches for low-risk prostate cancer (PC). Active surveillance (AS) is becoming an increasingly accepted management alternative for low-risk PC. Our aim is to compare the cumulative medical costs of treatment vs. AS. METHODS AND MATERIALS: We collected data on the cumulative medical costs of open radical retropubic prostatectomy (RRP), robotic-assisted radical prostatectomy (RARP), external beam radiotherapy (EBRT), brachytherapy (BT), and AS at our institution. For physicians' reimbursements, Medicare values of our region were used to maintain uniformity. For inpatient costs other than reimbursements, we used the mean cost at our institution. The costs of RRP and RARP involve preoperative investigations, medical clearance, physicians' fees, inpatient costs, and pathologic examination of prostatectomy specimen and follow-up. The inpatient costs include the operating room, disposable equipment, anesthesia, post-anesthesia care, transfusion, and hospital stay. The cost of EBRT involves the cost of consultation, planning, simulation and treatment sessions, and follow-up. BT costs involved radiotherapy planning as well as inpatients costs. AS protocol involves regular visits, transrectal ultrasound guided biopsies, prostate specific antigen (PSA) testing. To evaluate the cost of treating complications, treatment after AS, and treatment for recurrence, we created a Markov model based on recent studies and our experience. RESULTS: The cumulative costs of RRP are $9,732 (1 year), $10,360 (2 years), $12,209 (5 years), and $15,084 (10 years). While for RARP, the costs are $17,824 (1 year), $18,308 (2 years), $20,117 (5 years), and $22,762 (10 years). The costs of EBRT are $20,730 (1 year), $20,969 (2 years), $22,043 (5 years), and $23,953 (10 years). BT costs are $14,061 (1 year), $14,300 (2 years), $15,374 (5 years), and $17,284 (10 years). The costs of AS are $1,154 (1 year), $2,308 (2 years), $8,761 (5 years), and $13,116 (10 years). CONCLUSIONS: The cumulative medical costs of RARP and EBRT are much higher than BT, RRP, and AS. AS is associated with a different cost distribution in which the initial cost is low and relatively higher cost of follow-up. Despite the higher follow-up cost, AS remains the most cost effective alternative for low-risk PC.
    Urologic Oncology 05/2011; · 3.65 Impact Factor
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    Urology 03/2011; 77(3):734-5. · 2.42 Impact Factor
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    ABSTRACT: To learn from patients their rationale for enrollment in active surveillance (AS) for low-risk prostate cancer as an alternative to primary treatment. A rank-order survey was designed to assess the relative influence of factors that contributed to the decision to elect AS. The survey was mailed to 185 patients enrolled in AS at our university-based urologic oncology practice. Participants were also asked whether they had been offered AS as an alternative to primary treatment by the urologist who had initially diagnosed their cancer. The survey was returned by 105 (57%) of 185 patients. AS was offered to 38 (36%) of 105 patients by the physician who had made the initial diagnosis. Patients most frequently reported physician influence as the greatest contributor to their decision to elect AS (73%). Patients also cited concerns regarding the potential side effects of incontinence (48%) and erectile dysfunction (44%) associated with therapy as reasons for choosing AS. The results of the present study have shown that patients are heavily influenced by physicians in their decision to elect AS. Notably, the majority of our sampled patients were not offered AS at diagnosis. Evidence has indicated that AS is an appropriate approach for low-risk prostate cancer and should be discussed with patients in this risk category.
    Urology 01/2011; 77(3):588-91. · 2.42 Impact Factor
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    ABSTRACT: The desirable outcomes after open radical prostatectomy (RP) for localized prostate cancer (PC) are to: a) achieve disease recurrence free, b) urinary continence (UC), and c) maintain sexual potency (SP). These 3 combined desirable outcomes we called it the "Trifecta". Our aim is to assess the likelihood of achieving the Trifecta, and to analyze the influencing the Trifecta. A total of 1738 men with localized PC underwent RP from 1992-2007 by a single surgeon. The exclusion criteria for this analysis were: preoperative hormonal or radiation therapy, preoperative urinary incontinence or erectile dysfunction, follow-up less than 24 months or insufficient data. Post-operative Trifecta factors were analyzed, including biochemical recurrence (BR). We defined: BR as PSA ≥ 0.2 ng/mL, urinary continence as wearing no pads, and sexual potency as having erections sufficient for intercourse with or without a phosphodiesterase-5 inhibitor. A total of 831 patients met the inclusion criteria. The mean age of the entire cohort was 59 years old. The median follow-up was 52 months (mean 60, range 24-202). The BR, UC and SP rates were 18.7%, 94.5%, and 71% respectively. Trifecta was achieved in 64% at 2 year follow-up, and 61% at 5 year follow-up. Multivariate analysis revealed age at time of surgery, pathologic Gleason score (PGS), pathologic stage, specimen weight, and nerve sparing (NS) were independent factors. Age at time of surgery, pathologic GS, pathologic stage, specimen weight and NS were independent predictors to achieve the Trifecta following radical prostatectomy. This information may help patients counseling undergoing radical prostatectomy for localized prostate cancer.
    International braz j urol: official journal of the Brazilian Society of Urology 01/2011; 37(3):320-7; discussion 327.
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    ABSTRACT: Abnormalities of the inferior vena cava (IVC) and renal veins are extremely rare. However, with the increasing use of computed tomography (CT), these anomalies are more frequently diagnosed. The majority of venous anomalies are asymptomatic and they include left sided IVC, duplicated IVC, absent IVC as well as retro-aortic and circumaortic renal veins. The embryological development of the IVC is complex and involves the development and regression of three sets of paired veins. During renal surgery, undiagnosed venous anomalies may lead to major complications. There may be significant hemorrhage or damage to vascular structures. In addition, aberrant vessels may be mistaken for lymphadenopathy and may be biopsied. In this review we discuss the embryology of the IVC and the possible anomalies of IVC and its tributaries paying particular attention to diagnosis and implications for renal surgery.
    Central European journal of urology. 01/2011; 64(1):4-8.
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    ABSTRACT: Currently there is no universally accepted approach for the management of radiation-recurrent prostate cancer. The aim of this study was to detail our experience performing salvage radical prostatectomy for patients who failed primary treatment of prostate cancer with radiation therapy. We retrospectively queried our institutional database of radical prostatectomy cases for patients who underwent salvage surgery for radiation-recurrent prostate cancer. Patients were assessed for the risk of complications and oncologic outcomes following salvage surgery. Twenty-four patients with a mean age of 65 years (range 51-74) underwent salvage radical prostatectomy. Fourteen of these patients (58%) received androgen deprivation therapy prior to surgery. Intraoperatively, mean blood loss was estimated at 415 mL (range 100-1000) and 19 (79%) patients received autologous blood. No patient required an allogeneic transfusion or experienced a rectal injury. Postoperative bladder neck contracture and urinary incontinence developed in 17% and 39% of men, respectively. Two (29%) of seven patients remained potent after salvage surgery. No patient developed a fistula. Overall and recurrence-free survival at 5-years was 90% and 39%, respectively. On multivariate analysis, extracapsular extension was the only significant predictor of biochemical recurrence (HR 6.9, 95% CI 1.9-25.3 p = 0.003). In carefully selected patients, salvage radical prostatectomy for radiation-recurrent prostate cancer is a treatment option with acceptable oncologic outcomes and a moderate complication rate.
    Central European journal of urology. 01/2011; 64(3):144-7.

Publication Stats

142 Citations
54.41 Total Impact Points

Institutions

  • 2009–2012
    • University of Miami
      • Department of Urology
      Coral Gables, FL, United States
  • 2011
    • University of Miami Miller School of Medicine
      • Department of Urology
      Miami, FL, United States