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ABSTRACT: To compare the amount of sedation medication administered during radiofrequency (RF) ablation versus cryoablation of small renal masses.
Records were retrospectively reviewed in patients who underwent percutaneous computed tomography-guided RF ablation and cryoablation of small renal masses from January 2002 to June 2011 for patient and tumor characteristics, amount of medications used for moderate sedation, and complications. Sedation was performed by giving patients titrated doses of midazolam and fentanyl. Additional medications were given if the desired level of sedation was not achieved.
There were 116 patients who underwent 136 ablation procedures; 71 patients underwent RF ablation, and 65 patients underwent cryoablation. RF ablation was associated with a significantly higher mean dose of fentanyl (mean dose for RF ablation, 236.43 μg; mean dose for cryoablation, 172.27 μg; P<.001). RF ablation was also associated with a higher mean dose of midazolam (mean dose for RF ablation, 4.5 mg; mean dose for cryoablation, 3.27 mg; P<.001). In the RF ablation group, two patients required additional sedation with droperidol. As a result of oversedation, two patients in the RF ablation cohort required sedation reversal with naloxone and flumazenil. None of the patients who underwent cryoablation required sedation reversal. No other sedation-related complications occurred.
Cryoablation of small renal masses was performed with less sedation medication than RF ablation. This finding suggests renal cryoablation is less painful than RF ablation; however, prospective studies with validated pain scales are needed to confirm these results.
Journal of vascular and interventional radiology: JVIR 03/2013; 24(3):347-50. · 1.81 Impact Factor
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ABSTRACT: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Bladder preservation therapies for muscle-invasive bladder cancer (MIBC) have been developed to address the needs of two cohorts: patients with severe medical co-morbidities for whom radical cystectomy is too high risk and patients with limited disease who wish to avoid aggressive surgery. There are multiple bladder preservation options, although the trimodal approach of maximal transurethral resection with chemoradiotherapy is the most strongly supported. While outcomes are worse for patients unfit for surgery than those otherwise fit for surgery, bladder preservation approaches still offer curative potential. We present a comprehensive review of the literature and outline a practical approach to bladder preservation therapy for MIBC. This review aims to help urologists easily navigate through the decision tree of therapeutic options. Radical cystectomy (RC) is associated with considerable morbidity. Aside from the perioperative period, RC with urinary diversion poses great potential for long-term complications and morbidity. Bladder preservation therapies for muscle-invasive bladder cancer (MIBC) have been developed to address the needs of two cohorts: patients with severe medical co-morbidities for whom a radical surgery is too high risk and patients with limited disease who wish to avoid radical surgery. The goal of achieving complete response to treatment while maintaining bladder form and function has led to the development of multimodal approaches to this disease. There are multiple bladder preservation options, although the trimodal approach of maximal transurethral resection with chemoradiotherapy is the most strongly supported. In medically operable patients ('fit' for surgery), there is abundant evidence to support trimodal therapy as an acceptable treatment option for highly selected patients with MIBC with favourable pathological parameters. While outcomes are worse for medically inoperable patients ('unfit' for surgery), bladder preservation approaches still offer curative potential. However, prospective trials comparing the above regimens to RC are still needed to better define their role in the treatment of MIBC. We present a comprehensive review of the literature and outline a practical approach to bladder preservation therapy for MIBC.
BJU International 01/2013; · 2.84 Impact Factor
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Brian C Baumann, Thomas J Guzzo,
Jiwei He,
David J Vaughn,
Stephen M Keefe,
Neha Vapiwala,
Curtiland Deville,
Justin E Bekelman,
Kai Tucker,
Wei-Ting Hwang,
S Bruce Malkowicz,
John P Christodouleas
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ABSTRACT: PURPOSE: Local-regional failures (LFs) after cystectomy with or without chemotherapy are common in locally advanced disease. Adjuvant radiation therapy (RT) could reduce LFs, but toxicity has discouraged its use. Modern RT techniques with improved normal tissue sparing have rekindled interest but require knowledge of pelvic failure patterns to design treatment volumes. METHODS AND MATERIALS: Five-year LF rates after radical cystectomy plus pelvic node dissection with or without chemotherapy were determined for 8 pelvic sites among 442 urothelial bladder carcinoma patients. The impact of pathologic stage, margin status, nodal involvement, and extent of node dissection on failure patterns was assessed using competing risk analysis. We calculated the percentage of patients whose sites of LF would have been completely encompassed within various hypothetical clinical target volumes (CTVs) for postoperative radiation. RESULTS: Compared with stage ≤pT2, stage ≥pT3 patients had higher 5-year LF rates in virtually all pelvic sites. Among stage ≥pT3 patients, margin status significantly altered the failure pattern whereas extent of node dissection and nodal positivity did not. In stage ≥pT3 patients with negative margins, failure occurred predominantly in the iliac/obturator nodes and uncommonly in the cystectomy bed and/or presacral nodes. Of these patients in whom failure subsequently occurred, 76% would have had all LF sites encompassed within CTVs covering only the iliac/obturator nodes. In stage ≥pT3 with positive margins, cystectomy bed and/or presacral nodal failures increased significantly. Only 57% of such patients had all LF sites within CTVs limited to the iliac/obturator nodes, but including the cystectomy bed and presacral nodes in the CTV when margins were positive increased the percentage of LFs encompassed to 91%. CONCLUSIONS: Patterns of failure within the pelvis are summarized to facilitate design of adjuvant RT protocols. These data suggest that RT should target at least the iliac/obturator nodes in stage ≥pT3 with negative margins; coverage of the presacral nodes and cystectomy bed may be necessary for stage ≥pT3 with positive margins.
International journal of radiation oncology, biology, physics 05/2012; · 4.59 Impact Factor
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ABSTRACT: The incidence of renal cell carcinoma and the detection of incidental small renal masses are rising. Urologists are faced with difficult management decisions on how to treat patients with small renal masses. Traditionally, the treatment of suspicious renal masses was radical nephrectomy. However, nephron-sparing surgery is the standard of care, when possible, because of the risk of renal insufficiency associated with radical nephrectomy.
A large breadth of data have shown that partial nephrectomy has equivalent oncologic outcomes compared to radical nephrectomy. Recently, attempts to further spare renal parenchyma and perform nephron-sparing surgery in anatomically difficult scenarios have led to the development of the enucleation technique. Enucleation is performed by following the natural plane between the peritumor pseudocapsule and the renal parenchyma. This emerging technique was met with skepticism and concern for incomplete tumor removal. However, studies comparing enucleation and partial nephrectomy to date have revealed equivalent oncologic outcomes.
There has been a greater acceptance of tumor enucleation as a safe alternative for renal masses which are locally confined on preoperative imaging, easily delineated intraoperatively, and do not appear to grossly invade beyond the pseudocapsule.
Current opinion in urology 05/2012; 22(5):365-71. · 2.50 Impact Factor
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ABSTRACT: PURPOSE: Local-regional failures (LF) following radical cystectomy (RC) plus pelvic lymph node dissection (PLND) with or without chemotherapy for invasive urothelial bladder carcinoma are more common than previously reported. Adjuvant radiation therapy (RT) could reduce LF but currently has no defined role because of previously reported morbidity. Modern techniques with improved normal tissue sparing have rekindled interest in RT. We assessed the risk of LF and determined those factors that predict recurrence to facilitate patient selection for future adjuvant RT trials. METHODS AND MATERIALS: From 1990-2008, 442 patients with urothelial bladder carcinoma at the University of Pennsylvania were prospectively followed after RC plus PLND with or without chemotherapy with routine pelvic computed tomography (CT) or magnetic resonance imaging (MRI). One hundred thirty (29%) patients received chemotherapy. LF was any pelvic failure detected before or within 3 months of distant failure. Competing risk analyses identified factors predicting increased LF risk. RESULTS: On univariate analysis, pathologic stage ≥pT3, <10 nodes removed, positive margins, positive nodes, hydronephrosis, lymphovascular invasion, and mixed histology significantly predicted LF; node density was marginally predictive, but use of chemotherapy, number of positive nodes, type of surgical diversion, age, gender, race, smoking history, and body mass index were not. On multivariate analysis, only stage ≥pT3 and <10 nodes removed were significant independent LF predictors with hazard ratios of 3.17 and 2.37, respectively (P<.01). Analysis identified 3 patient subgroups with significantly different LF risks: low-risk (≤pT2), intermediate-risk (≥pT3 and ≥10 nodes removed), and high-risk (≥pT3 and <10 nodes) with 5-year LF rates of 8%, 23%, and 42%, respectively (P<.01). CONCLUSIONS: This series using routine CT and MRI surveillance to detect LF confirms that such failures are relatively common in cases of locally advanced disease and provides a rubric based on pathological stage and number of nodes removed that stratifies patients into 3 groups with significantly different LF risks to simplify patient selection for future adjuvant radiation therapy trials.
International journal of radiation oncology, biology, physics 04/2012; · 4.59 Impact Factor
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ABSTRACT: OBJECTIVES: To compare prostate volume obtained by transrectal ultrasound (TRUS) and endorectal MRI (eMRI) to assess the reliability of TRUS in determining prostate-specific antigen (PSA) density. MATERIALS AND METHODS: Data for 2,410 patients diagnosed with localized prostate cancer (CaP) and treated with radical retropubic prostatectomy (RRP) at the University of Pennsylvania Health System between 1991 and 2005 was reviewed. Of these patients, 756 had both a preoperative TRUS and eMRI of the prostate performed. Prostate size was estimated using the prolate ellipsoid formula (height × width × length × π/6); maximal height or antero-posterior (A-P) diameter was determined using a midsagittal view for TRUS and an axial view for eMRI. Pearson's correlation, linear regression, and paired t-test were performed to compare prostate volumes estimated via both imaging modalities. RESULTS: Average prostate size measured with TRUS and eMRI correlated significantly with one another (R = 0.801; P < 0.0001), demonstrating a strong linear relationship (y = 0.891x + 2.622, R(2) = 0.642). Comparison of PSA density also demonstrated a strong linear relationship (y = 0.811x + 0.053, R(2) = 0.765). Average prostate volume differed by 1.7 ml (TRUS relative to eMRI), which was statistically significant based on a paired t-test (P < 0.001). Upon stratification of patients into three groups based on average TRUS volume (≤30, >30-60, and >60 ml), significant correlation (0.318, 0.564, 0.650) and difference between volumes (-2.1, 4.0, 5.1 ml; P < 0.0001, P < 0.0001, P < 0.05 TRUS relative to eMRI) was maintained. CONCLUSIONS: Prostate volume estimations with TRUS and eMRI are highly correlated. It is therefore, reasonable to conclude that in the hands of an experienced sonographer, TRUS is not only an efficient and economical examination, but also an accurate and reproducible modality to estimate prostate size.
Urologic Oncology 04/2012; · 3.22 Impact Factor
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ABSTRACT: The addition of androgen deprivation therapy (ADT) to definitive external beam radiation therapy (RT) improves outcomes in higher-risk prostate cancer patients. However, the benefit of ADT with salvage RT in post-prostatectomy patients is not clearly established. Our study compares biochemical outcomes in post-prostatectomy patients who received salvage RT with or without concurrent ADT.
Of nearly 2,000 post-prostatectomy patients, we reviewed the medical records of 191 patients who received salvage RT at the University of Pennsylvania between 1987 and 2007. Follow-up data were obtained by chart review and electronic polling of the institutional laboratory database and Social Security Death Index. Biochemical failure after salvage RT was defined as a prostate-specific antigen of 2.0 ng/mL above the post-RT nadir or the initiation of ADT after completion of salvage RT.
One hundred twenty-nine patients received salvage RT alone, and 62 patients received combined ADT and salvage RT. Median follow-up was 5.4 years. Patients who received combined ADT and salvage RT were younger, had higher pathologic Gleason scores, and higher rates of seminal vesicle invasion, lymph node involvement, and pelvic nodal irradiation compared with patients who received salvage RT alone. Patients who received combined therapy had improved biochemical progression-free survival (bPFS) compared with patients who received RT alone (p = 0.048). For patients with pathologic Gleason scores ≤7, combined RT and ADT resulted in significantly improved bPFS compared to RT alone (p = 0.013).
These results suggest that initiating ADT during salvage RT in the post-prostatectomy setting may improve bPFS compared with salvage RT alone. However, prospective randomized data are necessary to definitively determine whether hormonal manipulation should be used with salvage RT. Furthermore, the optimal nature and duration of ADT and the patient subgroups in which ADT could provide the most benefit remain open questions.
International journal of radiation oncology, biology, physics 03/2012; 83(5):1493-9. · 4.59 Impact Factor
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ABSTRACT: To examine the effect of percutaneous thermal ablation of renal masses on renal function among patients with baseline chronic kidney disease (CKD).
Patients with baseline CKD (initial glomerular filtration rate [GFR] < 60 mL/min/1.73 m(2)) who underwent percutaneous cryoablation or radiofrequency (RF) ablation of renal masses were reviewed.
A total of 48 patients with a GRF of 60 mL/min/1.73 m(2) or lower were treated with renal cryoablation or RF ablation and had follow-up GFR measurement 1 month afterward. Mean patient age was 73 years (range, 47-89 y). Cryoablation was performed in 22 patients and RF ablation was performed in 26. Mean tumor diameter was 3.4 cm (range, 0.9-10.2 cm). Mean overall GFRs were 39.8 mL/min/1.73 m(2) at baseline and 39.7 mL/min/1.73 m(2) at 1 month after ablation (P = .85). A total of 38 patients had 1-year follow-up GFR measurement (cryoablation, n = 18; RF ablation, n = 20), and their mean GFR was 40.9 mL/min/1.73 m(2) ± 11.4 (SD), compared with a preablation GFR of 41.2 mL/min/1.73 m(2)(P = .79). In the cryoablation group, mean GFRs at 1 month and 1 year were 41.4 mL/min/1.73 m(2) and 44.4 mL/min/1.73 m(2), compared with respective baseline GFRs of 41.1 mL/min/1.73 m(2) and 42.1 mL/min/1.73 m(2) (P = .75 and P = .19, respectively). In the RF ablation group, mean GFRs at 1 month and 1 year were 38.2 mL/min/1.73 m(2) and 37.8 mL/min/1.73 m(2), compared with respective baseline GFRs of 38.7 mL/min/1.73 m(2) and 40.4 mL/min/1.73 m(2) (P = .58 and P = .09, respectively).
Independent of ablation modality, percutaneous renal mass ablation does not appear to affect renal function among patients with CKD.
Journal of vascular and interventional radiology: JVIR 01/2012; 23(1):41-5. · 1.81 Impact Factor
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ABSTRACT: To determine the knowledge level of patients with bladder cancer (BC) regarding smoking risks. We also sought to determine the role of their urologists in initiating smoking cessation at the diagnosis. Smoking is the leading risk factor for BC in industrialized nations. However, little information is available regarding patients' knowledge of the risks of smoking and the role of their urologists in initiating smoking cessation at diagnosis.
A smoking knowledge and cessation questionnaire was administered to 71 patients referred to the Johns Hopkins Hospital for BC from April 2008 to June 2009. The questionnaire captured data on demographics, BC history, smoking status and history, risk factor knowledge, and cessation patterns.
The mean age of the cohort was 65.1 years (range 42-86) and 72% were men. At the referral, all 71 patients (100%) knew smoking was a risk factor for lung cancer compared with 61 (86%) who knew it was for BC. Only 36 patients (51%) knew smoking was the leading risk factor for BC. Of the 17 patients (24%) who were smokers at their BC diagnosis, 12 (71%) were counseled by their referring urologist to quit smoking; however, the significant majority (76%) was not offered any specific intervention.
The association between smoking and BC was not as well known as that of lung cancer in our cohort of patients. Most current smokers were advised to stop smoking by their primary urologist; however, few were offered any intervention to aid in cessation. Urologists should assume a more active role both in educating patients regarding smoking's link to BC and in initiating smoking cessation.
Urology 01/2012; 79(1):166-71. · 2.43 Impact Factor
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ABSTRACT: To evaluate whether ultrasonography was inferior in detecting the size of a renal mass preoperatively because of the increased attention on the harmful effects of ionizing radiation in medical imaging.
A prospectively maintained database was reviewed of all patients who underwent renal ultrasonography before definitive therapy for the renal mass. Every patient who underwent ultrasound imaging also underwent computed tomography (CT) or magnetic resonance imaging (MRI), or both, before treatment. The size of the largest tumor identified per imaging modality was compared among the modalities using correlation and analysis of variance.
A total of 116 patients underwent ultrasound imaging before therapy. Of these patients, 80 also underwent MRI, 66 underwent CT, and 38 underwent all 3 modalities before treatment. The average pathologic tumor size for the entire cohort was 4.45 cm (range 1-13). The size differences between CT and MRI compared with ultrasound were small (<3.5%). Compared with MRI and CT, ultrasound was also well correlated (P<.001 and P<.001). In patients who underwent all 3 imaging modalities, no difference was found in the average tumor size (P=.896).
Ultrasound imaging does not appear to be inferior to CT and MRI in the imaging of renal masses. This is useful in reducing the costs and levels of radiation exposure for the long-term follow-up of patients receiving active surveillance.
Urology 01/2012; 79(1):28-31. · 2.43 Impact Factor
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ABSTRACT: To determine the impact of stenting ureteroenteric anastomoses on postoperative stricture rate and gastrointestinal recovery in continent and noncontinent urinary diversions (UDs).
We retrospectively reviewed the clinical and pathologic data on 192 consecutive patients who underwent a radical cystectomy and UD. Patients received either a continent or noncontinent UD with or without stent placement through the ureteroenteric anastomoses. Stricture rate, gastrointestinal recovery, length of hospital stay, and stricture characteristics were analyzed. Study endpoints were compared between four groups--stented and nonstented continent and stented and nonstented noncontinent UDs.
36% of patients were stented and 64% were nonstented at the time of UD. Total ureteral stricture rate was 9.9%. There was no statistically significant difference in stricture rate (p = 0.11) or length of hospital stay (p = 0.081) in stented compared to nonstented patients. There was a significantly (p = 0.014) greater rate of ileus in patients who were nonstented in both continent and noncontinent UDs.
Stenting of ureteroenteric anastomoses in both continent and noncontinent UD has no effect on postoperative stricture rate, but is associated with lower rates of postoperative ileus.
Urologia Internationalis 01/2012; 88(1):66-70. · 0.99 Impact Factor
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ABSTRACT: To describe practice patterns associated with androgen suppression (AS) stratified by disease risk group in patients undergoing external-beam radiotherapy (EBRT) for localized prostate cancer.
We identified 2,184 low-risk, 2,339 intermediate-risk, and 2,897 high-risk patients undergoing EBRT for nonmetastatic prostate cancer diagnosed between January 1, 2004, and December 31, 2005, in the linked Surveillance, Epidemiology, and End Results-Medicare database. We examined the association of patient, clinical, and demographic characteristics with AS use by multivariate logistic regression.
The proportions of patients receiving AS for low-risk, intermediate-risk, and high-risk prostate cancer were 32.2%, 56.3%, and 81.5%, respectively. AS use among men in the low-risk disease category varied widely, ranging from 13.6% in Detroit to 47.8% in Kentucky. We observed a significant decline in AS use between 2004 and 2005 within all three disease risk categories. Men aged ≥75 years or with elevated comorbidity levels were more likely to receive AS.
Our results identified apparent overuse and underuse of AS among men within the low-risk and high-risk disease categories, respectively. These results highlight the need for clinician and patient education regarding the appropriate use of AS. Practice patterns among intermediate-risk patients reflect the clinical heterogeneity of this population and underscore the need for better evidence to guide the treatment of these patients.
International journal of radiation oncology, biology, physics 11/2011; 83(1):8-15. · 4.59 Impact Factor
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Asian Journal of Andrology 09/2011; 13(6):789-90. · 1.52 Impact Factor
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ABSTRACT: With the increased diagnosis of low grade, low volume, potentially non-lethal disease, active surveillance (AS) has become an increasingly popular alternative for select men with low-risk prostate cancer. The absence of precise clinical staging modalities currently makes it difficult to predict which patients are most appropriate for AS. The goal of our study was to evaluate the ability of endorectal MRI (eMRI) to predict adverse pathologic features in patients who would otherwise qualify for an AS program.
We retrospectively reviewed our institution's radical prostatectomy (RP) database from 1991 to 2007 and identified 172 patients who would have qualified for AS and underwent preoperative staging eMRI with T2-weighted (T2W) sequences. MRI findings were correlated to final pathology in order to assess the ability of staging eMRI to predict adverse pathologic features in patients suitable for AS.
The mean age of our cohort was 59.8 ± 6.2 years. The mean PSA at the time of diagnosis was 5.2 ± 2.2 ng/ml. In 51% of patients, no discrete tumor was visualized on eMRI and in 49% of patients a discrete tumor was detected. At the time of RP, Gleason score upgrading, extracapsular extension, and a positive surgical margin occurred in 17%, 6%, and 5% of cases, respectively. Patients with documented tumor on eMRI did not have an increased incidence of adverse pathologic findings with regard to tumor volume (P = 0.31), extra-capsular extension (P = 0.82), Gleason upgrading (P = 0.92), seminal vesicle invasion (P = 0.97), or positive surgical margin rate (P = 0.95) compared with those in whom no tumor was seen.
Discrete tumor identification on eMRI is not predictive of adverse pathologic features in patients who would otherwise qualify for AS. eMRI likely does not provide additional information when prospectively evaluating patients for AS protocols.
Urologic Oncology 08/2011; 30(3):301-5. · 3.22 Impact Factor
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ABSTRACT: The treatment of renal cell carcinoma has evolved tremendously over the years. Initially the entire kidney was removed along with the renal tumor despite the size or extent of the mass. Early attempts to remove tumors with a normal surrounding parenchymal margin showed equivalent oncologic results in small renal masses. Attempts to preserve more renal parenchyma in patients with compromised renal function led to the enucleation of renal masses by blunt dissection following the natural plane between the peritumor pseudocapsule and the renal parenchyma. Enucleation of renal tumors has been especially useful for renal preservation in patients with preoperative renal insufficiency, solitary kidneys, multiple renal lesions and hereditary renal cell carcinoma syndromes. Comparable long-term progression and cancer-specific survival has been shown with tumor enucleation and standard partial nephrectomy. However, there has been considerable controversy regarding the safety of renal tumor enucleation due to histopathologic findings of pseudocapsule tumor invasion. Current data suggest that tumor enucleation is a safe alternative for small renal masses that are locally confined on preoperative imaging, easily delineated intraoperatively and do not appear to grossly invade beyond the pseudocapsule.
Expert Review of Anti-infective Therapy 06/2011; 11(6):893-9. · 2.65 Impact Factor
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Nature Reviews Urology 05/2011; 8(7):360-1. · 4.41 Impact Factor
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ABSTRACT: Elevated polycomb group protein Enhancer of Zest Homolog 2 (EZH2) expression has been associated with progression to more advanced disease in a variety of malignancies. We examined EZH2 protein expression levels in bladder tissue specimens from patients with urothelial carcinoma (UC) and investigated the relationship between EZH2 protein expression and clinical outcomes.
Tissue microarrays (TMAs) were constructed using bladder tissue specimens from radical cystectomies performed for UC at our institution between 1994 and 2002. EZH2 expression was measured by immunohistochemistry and scoring was based on percentage and intensity of positive nuclear staining. A receiver operating curve (ROC) was generated to differentiate cancerous from benign lesions using EZH2 protein scores. Recurrence-free survival was estimated using the Kaplan-Meier approach with log-rank test. A multivariate Cox proportional hazards model was used to assess independent contributions.
A total of 454 TMA specimen spots from 81 patients were evaluated. EZH2 protein levels in invasive high grade UC were significantly elevated compared with adjacent benign urothelium, noninvasive low grade UC, and CIS. EZH2 protein levels were also significantly increased in CIS and noninvasive low grade UC compared with adjacent benign urothelium. We found no association between EZH2 protein expression and clinical outcomes following radical cystectomy in our cohort of patients.
EZH2 overexpression is a common event in UC of the bladder. Elevated EZH2 protein levels are associated with more aggressive bladder cancer, including invasive UC. EZH2 may therefore serve as a useful biomarker for UC.
Urologic Oncology 03/2011; 30(4):428-33. · 3.22 Impact Factor
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ABSTRACT: Elderly urologic patients require the same cautions as used in development of treatment programs for them in other disciplines. Because of potential interference with poor renal function or crossover effects with central or peripheral nervous system, however, many urologic drugs must be titrated appropriately. In treating cancer, erectile dysfunction, incontinence or urinary infection, patient quality of life and life span become dominant factors in making therapeutic decisions, by behavioral change, medication, or surgical intervention.
The Medical clinics of North America 01/2011; 95(1):253-64. · 2.18 Impact Factor
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ABSTRACT: To determine the incremental risk of diagnosis of clinically insignificant prostate cancer with serial prostate biopsies.
We reviewed our institutional radical prostatectomy (RP) database comprising 2411 consecutive patients undergoing RP. We then stratified patients by the prostate biopsy on which their cancer was diagnosed and correlated biopsy number with the risk of clinically insignificant disease and adverse pathology at radical prostatectomy.
A total of 1867 (77.4%), 281 (11.9%), and 175 (7.3%) patients underwent 1, 2, and 3 or more prostate biopsies, respectively, before RP. Increasing number of prostate biopsies was associated with increasing prostate volume (P <.01), prostate-specific antigen (P <.01), associated prostate intraepithelial neoplasia (P <.01), and increased likelihood of clinical Gleason 6 or less disease (P <.01). On pathologic analysis, increasing number of prostate biopsies was associated with increased risk of low-volume (P <.01), organ-confined (P <.01) disease. The risk of clinically insignificant disease was found to be 31.1%, 43.8%, and 46.8% in those undergoing 1, 2, and 3+ prostate biopsies, respectively. Conversely, the risk of adverse pathology was found to be 64.6%, 53.0%, and 52.0% in those undergoing 1, 2, and 3+ prostate biopsies, respectively.
Patients undergoing multiple prostate biopsies before RP are more likely to harbor clinically insignificant prostate cancer than those who only undergo 1 biopsy before resection. Nonetheless, the risk of adverse pathology in patients undergoing serial biopsies remains significant. The increased risk of prostate cancer overdiagnosis and overtreatment must be balanced with the continued risk of clinically significant disease when counseling patients regarding serial biopsies.
Urology 01/2011; 77(3):548-52. · 2.43 Impact Factor
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ABSTRACT: Erectile dysfunction (ED) and cardiovascular disease (CVD) share etiology and pathophysiology. The underlying pathology for preoperative ED may adversely affect survival following radical prostatectomy (RP). We examined the association between preoperative ED and survival following RP.
Between 1983 and 2000, a single surgeon performed RP on 2511 men, with preoperative ED (ED group, n= 231, 9.2%) or without ED (No ED group, n= 2280, 90.8%). We retrospectively analysed their CVD-specific survival (CVDSS), prostate cancer-specific survival (PCSS), non-PCSS (NPCSS) and overall survival (OS) from time of surgery.
With median follow-up of 13 years after RP, 449 men (18%) died (140 from prostate cancer, 309 from other causes). Kaplan-Meier analyses demonstrated significant differences in CVDSS (P < 0.001), NPCSS (P < 0.001) and OS (P < 0.001), but not in PCSS (P= 0.12), between the ED group vs No ED group. In univariate proportional hazards analyses, preoperative ED was associated with a significant decrease in OS, hazard ratio (HR), 1.71 (95% CI, 1.34-2.23), P < 0.001. However, in multivariable analyses, the association of ED with survival became non-significant (HR, 1.25 (95% CI, 0.97-1.66), P= 0.111) after adjusting for other prognostic factors, such as age, preoperative prostate-specific antigen (PSA) level, Gleason score, pathologic stage, body mass index and Charlson Comorbidity Index.
Preoperative ED is associated with decreased overall survival and survival from causes other than prostate cancer following RP. However, preoperative ED was not an independent predictor of overall survival after adjusting for other predictors of survival. Urologists should carefully assess pretreatment ED status to enhance appropriate treatment recommendation for men with prostate cancer.
BJU International 12/2010; 106(11):1612-7. · 2.84 Impact Factor
