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ABSTRACT: To evaluate the influence of marriage on the survival outcomes of men diagnosed with prostate cancer.
We examined 115,922 prostate cancer cases reported to the Surveillance, Epidemiology, and End Results (SEER) database between 1988 and 2003. Multivariate Cox regression techniques were used to study the relationship of marital status and prostate cancer-specific and overall mortality.
Married men comprised 78% of the cohort (n = 91,490) while unmarried men (single, divorced, widowed, and separated) comprised 22% of the cohort (n = 24,432). Married men were younger (66.4 versus 67.8 years, p < 0.0001), more likely to be white (85% versus 76%, p < 0.0001), presented with lower tumor grades (68% are well or moderately differentiated versus 62%, p < 0.0001) and at earlier clinical stages (41% AJCC stage I/II versus 37%, p < 0.0001). Multivariate analysis revealed that unmarried men had a 40% increase in the relative risk of prostate cancer-specific mortality (HR 1.40; CI 1.35-1.44; p < 0.0001), and a 51% increase in overall mortality (HR 1.51; CI 1.48-1.54; p < 0.0001), even when controlling for age, AJCC stage, tumor grade, race and median household income. Furthermore, the 5 year disease-specific survival rates for married men was 89.1% compared to 80.5% for unmarried men (p < 0.0001).
Marital status is an independent predictor of prostate cancer-specific mortality and overall mortality in men with prostate cancer. Unmarried men have a higher risk of prostate cancer-specific mortality compared to married men of similar age, race, stage, and tumor grade.
The Canadian Journal of Urology 04/2013; 20(2):6702-6. · 0.64 Impact Factor
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ABSTRACT: PURPOSE: To evaluate long-term disease control and chronic toxicities observed in patients treated with intensity-modulated radiation therapy (IMRT) for clinically localized prostate cancer. METHODS/MATERIALS: 302 patients with localized prostate cancer treated with image guided IMRT between 7/2000 and 5/2005 were retrospectively analyzed. Risk groups (low, intermediate, and high) were designated based on NCCN guidelines. Biochemical control was based on the ASTRO (Phoenix) consensus definition. Chronic toxicity was measured both at peak symptoms and at last visit. Toxicity was scored based on CTCAE v.4. RESULTS: The median dose delivered was 75.6 Gy (range 70.2-77.4 Gy) and 35.4% of patients received androgen deprivation therapy (ADT). Patients were followed until death or from 6-138 months (median 91 months) in those alive at last evaluation. Local and distant recurrence rates were 5% and 8.6%, respectively. At 9 years, biochemical control rates was 77.4% for low risk, 69.6% for intermediate risk, and 53.3% for high-risk patients (log rank p= 0.05). On multivariate analysis, T-stage and PSA group were prognostic for biochemical control. At last follow-up, only 0%/0.7% had persistent grade = 3 GI/GU toxicity. High risk group was associated with higher distant metastasis rate (p=0.02) and death from prostate cancer (p=0.0012). CONCLUSIONS: This study represents one of the longest experiences with IMRT for prostate cancer. With a median follow-up of 91 months, IMRT resulted in durable biochemical control rates with very low chronic toxicity.
The Journal of urology 02/2013; · 4.02 Impact Factor
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ABSTRACT: To evaluate our multi-institutional outcome with robot-assisted radical prostatectomy (RARP) in renal transplant recipients and describe technical modifications of the procedure.
We retrospectively reviewed 1677 patients, 1422 from Mayo Clinic Arizona and 255 from Loyola University Medical Center, undergoing RARP from March 2004 to October 2010, of which 7 were renal transplant recipients. Baseline demographic features, perioperative data, and oncologic outcomes were reviewed.
At diagnosis, mean patient age was 63.3 years and serum prostate specific antigen was 6.17 ng/mL. The mean total operative time was 186 minutes (range, 80-210 minutes). No intraoperative complications were noted. The mean hospital length of stay was 1.8 days (range, 1-3 days). Clavien grade II postoperative complications occurred in 3 of the 7 patients (42.9%), consisting of urosepsis, atrial fibrillation, and gross hematuria, all resolving with appropriate medical management. No significant changes were observed in graft function. Two patients (28.6%) had positive surgical margins. During a mean follow-up of 16 months, 1 patient with pathologic T3a, Gleason 9 cancer experienced a biochemical recurrence, which was treated with salvage external-beam radiation and androgen-deprivation therapy.
Our series suggests that RARP is a safe and feasible form of therapy for localized prostate cancer in a select group of renal transplant recipients.
Urology 12/2012; 80(6):1267-72. · 2.43 Impact Factor
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Urology 11/2012; 80(5):1168. · 2.43 Impact Factor
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ABSTRACT: OBJECTIVE: To evaluate the efficacy and safety of a novel, continuous intravenous infusion of ketorolac, a powerful nonopioid analgesic, for postoperative pain control. PATIENTS AND METHODS: A prospective, double-blind, randomized, placebo-controlled trial of a continuous infusion of ketorolac tromethamine in 1 L of normal saline vs placebo was performed in 135 patients aged 18 to 75 years after laparoscopic donor nephrectomy or percutaneous nephrolithotomy completed from October 7, 2008, through July 21, 2010. Primary study end points were the 24-hour differences in visual analog pain scores and total narcotic consumption, whereas secondary end points were differences in urine output, serum creatinine level, and hemoglobin level. RESULTS: The study was stopped after randomization of 135 patients (68 in the ketorolac group and 67 in the placebo group) when interim analysis indicated that the difference in mean pain scores between the 2 groups (difference, 0.6) was smaller than the 1-point threshold set forth in the power calculations. No statistically significant change was noted in hemoglobin levels from preoperative to postoperative values (P=.13) or in postoperative serum creatinine levels (P=.13). CONCLUSION: Although continuous infusion of ketorolac produced only a modest decrease in the use of narcotics, it appears to offer a safe therapeutic option for nonnarcotic pain control. TRIAL REGISTRATION: clinicaltrials.gov Identifiers: NCT00765128 and NCT00765232.
Mayo Clinic Proceedings 10/2012; · 5.70 Impact Factor
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Urology 09/2012; 80(3):744-5. · 2.43 Impact Factor
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ABSTRACT: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Extirpation of polycystic kidneys for various medical reasons has been performed using many different approaches in attempts to limit morbidity from such a large operation. In indicated patients, it has usually been offered in a staged approach with renal transplantation to avoid graft complications. We published the first case of simultaneous laparoscopic bilateral native nephrectomy with kidney transplant in 2008. The present study shows our continued experience with offering this minimally invasive, single surgery alternative. The results are comparable to a staged laparoscopic approach with significantly shorter total hospital stay and one recovery for the patient and his/her family. OBJECTIVE: • To analyse the perioperative outcomes of native bilateral laparoscopic nephrectomy (BLN) with simultaneous kidney transplantation. PATIENTS AND METHODS: • From November 2000 to April 2011, 37 patients were seen for renal failure secondary to autosomal-dominant polycystic kidney disease (ADPKD) and underwent renal transplant with native nephrectomies at a single tertiary academic centre. • In all, 15 patients underwent BLN for ADPKD followed by simultaneous kidney transplantation. • The other 22 patients underwent BLN for ADPKD with kidney transplant performed at a separate setting. • Demographic data, perioperative outcomes, complications regardless of need for intervention, and graft function were analysed in both groups. RESULTS: • The combined surgery was completed without intraoperative complication in all cases. • The median total operative duration was 372 min, estimated blood loss was 300 mL with two patients requiring transfusion, and the median (range) hospital stay was 5 (3-7) days. • All patients had immediate graft function with additional relief of compressive symptoms. • In comparison to our staged cohort, the simultaneous group had a significantly shorter total hospital stay. • All other outcomes and complication rates were comparable. CONCLUSION: • In ADPKD, a less invasive laparoscopic approach for native nephrectomies with simultaneous renal transplant offers comparable morbidity without graft compromise and the convenience of one operation and one recovery for the patient.
BJU International 08/2012; · 2.84 Impact Factor
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ABSTRACT: To determine whether men aged 70years and older had more perioperative complications after robot-assisted radical prostatectomy
(RARP) compared with younger patients, a retrospective review was performed on patients who underwent RARP between March 2004
and September 2009. Subjects were stratified according to age into four groups (age 30–49, 50–59, 60–69, and ≥70years). American
Society of Anesthesiologists (ASA) scores were obtained. Complication rates in the perioperative period, transfusion rates,
and length of stay were compared. Complications were classified using the previously validated Clavien system. There were
a total of 293 patients aged 70years and older amongst the 1,223 total subjects. ASA comorbidity scores did vary significantly
amongst the different age groups, and there was modest correlation noted between ASA and age. There was no statistically significant
difference amongst complication rates in men aged 70years and older (15%) compared with the other cohorts (P=0.832). There was also no significant difference in transfusion rates (P=0.170) or length of stay (P=0.131). Patients with higher ASA scores (ASA 3–4) had more ClavienI–II complications compared with patients with ASA scores
of 1–2 (15.5% versus 10.3%, P=0.03). There was no difference in transfusion rates or length of stay between the ASA scores. There are no more complications
in men aged 70years and older compared with men<70years of age undergoing robot-assisted radical prostatectomy. RARP is
a safe treatment option to offer to the selected elderly patient.
KeywordsComplications–Elderly–Prostatectomy–Robot
Journal of Robotic Surgery 04/2012; 5(3):201-208.
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ABSTRACT: Minimally invasive surgery is advancing to new frontiers that attempt to limit patient morbidities while providing excellent surgical outcomes. At the forefront of these efforts is natural orifice surgery, where surgical incisions can theoretically be eliminated. The purpose of this report is to describe the evolution of the clinical development of the natural orifice translumenal endoscopic radical prostatectomy (NOTES RP). It details the early experimental cadaver and animal work and the many challenges encountered to bring this procedure to clinical fruition. While the procedure remains in its infancy the clinical application to human patients shows its potential merit to positively impact the surgical control of prostate cancer. Early clinical experience does not allow the ability to draw definitive conclusions about the procedure at this time but the potential benefits for a new minimally invasive inexpensive treatment for prostate cancer patients is promising.
Archivos españoles de urología 04/2012; 65(3):407-14.
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ABSTRACT: To identify the incidence of and risk factors for ureteral stricture formation in laparoscopically procured living donor kidney transplantation (LLDKT).
An IRB approved retrospective review of our institution's living donor database was performed. Patients were divided into two cohorts, those with ureteral strictures requiring procedural intervention and those without evidence of ureteral strictures. Analysis was limited to those patients with at least 1 year of follow up.
Of the 584 LLDKT's performed at our institution since June 1999, 510 had at least 1 year of follow up. Four hundred and ninety-six patients had no evidence of stricture disease (97.2%) while 14 (2.8%) developed clinically significant ureteral strictures. The incidence of delayed graft function was higher in the stricture group (21% versus 3%, p < 0.0001) while the intraoperative placement of a ureteral stent was associated with decreased incidence of ureteral strictures (21% of the stricture group received stents compared to 58% in the no stricture group, p = 0.006). In multivariable logistic regression models, delayed graft function was strongly associated with the development of clinically significant ureteral stricture disease (OR 19.3; 95% CI 3.59, 104.2; p = 0.001) while the placement of intraoperative ureteral stents was protective against ureteral stricture formation (OR 0.09; 95% CI: 0.02, 0.49; p = 0.005).
Delayed graft function and nonuse of ureteral stents are associated with the development of ureteral strictures following LLDKT.
The Canadian Journal of Urology 04/2012; 19(2):6188-92. · 0.64 Impact Factor
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ABSTRACT: To identify the predictors of cancer-specific mortality of penile squamous cell carcinoma (PSCC) using a population-based database.
Using data from the National Cancer Institute's Surveillance, Epidemiology, and End Results registry, we performed a time-to-event analysis to determine which clinical parameters were useful in predicting cancer-specific mortality.
Our cohort consisted of 2515 cases of PSCC diagnosed from 1973 to 2007. The patients were divided into 2 groups: primary tumors of the prepuce (n = 722) and primary tumors of the glans, body, and overlapping lesions of the skin (n = 1793). The median follow-up for the cohort was 39 months (range 1-411). Compared with tumors of the prepuce, tumors of the body (hazard ratio 1.61, 95% confidence interval 1.00-2.60, P = .05) and overlapping tumors of the skin (hazard ratio 1.79, 95% confidence interval 1.13-2.83, P = .01) had a greater risk of cancer-specific mortality, even when controlling for age, Surveillance, Epidemiology, and End Results stage, and tumor grade. Furthermore, the disease-specific 10-year survival rate of those with preputial tumors was 89.4% compared with 78.7% for the other 3 groups combined (P < .0001).
Anatomic site-specific disparities for PSCC survival appear to exist. Patients diagnosed with PSCC of the prepuce have greater overall long-term disease-specific survival than patients with primary tumors elsewhere.
Urology 02/2012; 79(4):804-8. · 2.43 Impact Factor
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ABSTRACT: The purpose of this publication is to document the evolution of a new surgical procedure for the treatment of carefully selected patients with organ confined localized prostate cancer. Natural orifice surgery represents a paradigm shift in the surgical approach to disease, although its adoption into clinical practice has been limited to date. This manuscript describes the development of natural orifice translumenal endoscopic surgical radical prostatectomy (NOTES RP). The laboratory, animal, preclinical and early clinical experiences are described and detailed. While the early experiences with this approach are promising and encouraging, more information is required. Despite the early successes with the procedure, long-term oncological and functional outcomes are essential and more work needs to be done to facilitate the teaching and ease of the NOTES RP.
Therapeutic Advances in Urology 02/2012; 4(1):33-43.
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ABSTRACT: To evaluate the effectiveness of the portable laparoscopic trainer in improving skills in subjects who have had no previous laparoscopic experience.
Twenty-nine medical students were given a pretest of three tasks on a standardized laparoscopic trainer. Subjects were evaluated objectively and subjectively. Fifteen subjects were randomized to receive a portable laparoscopic trainer and 14 subjects were assigned to the standardized laparoscopic trainers at our facility. The portable trainer group subjects were advised but not required to complete at least 3 hours of training. The group at the facility had a proctored 1-hour session each week for 3 weeks. Each subject was then retested and evaluated with the same pretest tasks. Objective and subjective improvements between the groups were compared.
Baseline demographics and pretest scores were similar between both groups. All students in the facility group completed the three 1-hour proctored sessions. The portable trainer group reported an average 204 minutes of practice. The facility group did objectively better on the post-test in overall time, and in two exercises. Subjectively, the facility group had a significant improvement compared with the portable trainer group (4.6 vs 2.4 point average increase, P=0.03).
Both groups showed objective and subjective improvement after a 3-week period of training. The portable trainer group did report longer average practice time, but this made no significant difference in subjective or objective improvement. The portable laparoscopic trainer is comparable to the standard trainer for improvement of basic laparoscopic skills.
Journal of endourology / Endourological Society 01/2012; 26(1):67-72. · 1.75 Impact Factor
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ABSTRACT: PURPOSE: Microporous polysaccharide hemospheres (MPH) are hemostatic beads engineered from plant starch to accelerate the natural clotting cascade. The purpose of this report is to detail our initial experience with MPH as a topical hemostatic agent during robot-assisted radical prostatectomy (RARP). METHODS: We examined a single surgeon series of 30 consecutive RARP's dividing patients into MPH or non-MPH groups. The last ten procedures utilized the MPH, which were matched 1:2 to non-MPH procedures for comparison. Nerve-sparing procedures were performed when clinically indicated and all done athermally. All demographic data, length of operation, margin status, blood loss, change in hemoglobin, and need for blood transfusion were prospectively collected and analyzed. RESULTS: The baseline characteristics were the same. The post-operative decrease in hemoglobin was less in the MPH group (1.8 g/dL MPH group vs. 3.2 g/dL non-MPH). One patient in each group required a blood transfusion. CONCLUSIONS: These preliminary findings support the role for MPH as a potential hemostatic agent during athermal nerve-sparing RARP.
World Journal of Urology 12/2011; · 2.41 Impact Factor
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ABSTRACT: This study evaluates the feasibility, perioperative, and renal functional outcomes with total, selective, and nonarterial clamping techniques during minimally invasive partial nephrectomy.
A retrospective review of laparoscopic and robot-assisted partial nephrectomies by a single surgeon from January 2007 to July 2010 was performed. Patients underwent total hilar clamping, selective (segmental) artery clamping, progressive clamping from segmental to main renal artery clamping, or resection without hilar clamping. Patient demographic, perioperative, and oncologic outcomes were analyzed. Change in renal function was assessed by glomerular filtration rate (GFR) calculation and differential function on pre- and postoperative renal scans.
A total of 68 patients underwent laparoscopic or robot-assisted partial nephrectomy. Those with a history of surgery for renal masses and elective conversion to radical nephrectomy were excluded. A total of 57 patients were analyzed (32 total hilar, 8 progressive arterial clamping, 13 selective arterial, and 4 without clamping). There were no significant differences in preoperative patient or disease characteristics between the groups. The progressive clamping technique was found to significantly decrease the total renal ischemia time compared with the total hilar clamp technique. There was no other significant difference in transfusion rate, complications, or other postoperative outcomes. There were no significant differences between the groups in intermediate-term (mean 411 days) renal function changes.
Minimally invasive partial nephrectomy without vascular occlusion and with selective arterial clamping is feasible and can be safely performed. With this intermediate-term follow-up there was no clinically significant benefit seen for selective regional or nonischemic techniques.
Journal of endourology / Endourological Society 12/2011; 26(2):152-6. · 1.75 Impact Factor
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ABSTRACT: To describe the first clinical experience, pathologic, and perioperative outcomes of natural orifice transluminal endoscopic surgery (NOTES) radical prostatectomy. NOTES represents the evolution of minimally invasive surgery. The conceptual feasibility has been shown in careful laboratory and animal studies, but a scarcity of information regarding clinical applications exists.
After institutional review board approval, 2 patients agreed to undergo NOTES radical prostatectomy for localized prostate cancer. The prostate was radically resected using a 26F resectoscope, 550-μm laser fiber, and holmium laser. The prostate was delivered into the bladder and removed at the conclusion of the procedure through a suprapubic cystotomy for histopathologic analysis. The vesicourethral anastomosis was completed using a cannula scope, urethral-vesical suturing device, and titanium knot applier. Cystograms were taken immediately postoperatively and at catheter removal.
Both patients tolerated the procedure without operative complications. All intraoperative cystograms showed watertight anastomoses. The pathologic examination revealed Gleason score 3 + 3 and Stage pT2aNxMx for 1 patient and Gleason score 3 + 4 and Stage pT2cNxMx for 1 patient, with negative margins for both. No blood transfusions were required. Patient 2 experienced some left-sided gluteal and suprapubic pain postoperatively.
NOTES radical prostatectomy appears to be a safe and feasible option for the management of carefully selected, organ-confined prostate cancer. The perioperative and pathologic outcomes show promise with this new technique; however, the high standards of oncologic and functional outcomes demand close and longer follow-up before adoption into the surgical armamentarium can be recommended.
Urology 12/2011; 78(6):1211-7. · 2.43 Impact Factor
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ABSTRACT: We evaluate the impact of margin length, location, and pathologic stage on biochemical recurrence (BCR) after robot assisted radical prostatectomy (RARP) at 37 months of follow up.
A total of 1420 patients underwent a robot assisted radical prostatectomy between March 2004 and May 2010. Patients who received adjuvant therapy, those who never achieved an undetectable prostate-specific antigen (PSA), and those who had less than 18 months of follow up were excluded. Patients were then divided and evaluated based on margin status.
In total, 419 patients were included in the analysis. Eighty-three had a positive surgical margin (PSM) (19.8%), 336 had a negative surgical margin (NSM) (80.2%). The overall mean follow up was 37 months. On multivariate analysis the Gleason sum and PSM were independent predictors of BCR. Margin length and location had no significant difference on the rate of BCR. Patients with a PSM and pT2 disease had an increased rate of BCR compared to pT2 and NSM. The relative risk of BCR was 2.03 and 3.21 for patients who have a PSM versus a NSM, overall and in those with pT2 disease respectively. No different BCR is seen in pT2 PSM versus ≥ pT3 NSM; or ≥ pT3 PSM versus NSM.
With 37 months follow up; positive surgical margin and postoperative Gleason sum impact the rate of BCR. Location and length of the PSM do not appear to have an impact on BCR. There was an increased risk of BCR with PSM, especially in pT2 disease.
The Canadian Journal of Urology 12/2011; 18(6):6043-9. · 0.64 Impact Factor
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ABSTRACT: Incidental prostate cancer (PCa) after treatment of benign prostate hyperplasia (BPH) is becoming less common. This is a result of the changing patterns of BPH treatment. The purpose of the present research was to re-examine the clinical outcomes and importance of cT1a and cT1b PCa in a contemporary cohort after holmium laser enucleation of the prostate (HoLEP). All patients with newly diagnosed PCa after HoLEP were retrospectively identified. Pre- and postoperative prostate-specific antigen (PSA), biopsy history, pathological features and disease progression were examined. Patients were matched to a control group with benign pathology for outcome comparisons. The database consisted of 240 consecutive patients, aged 52-90 years with prostate sizes from 25 to 375 cm(3) . A total of 28 patients were identified with incidental PCa (14 cT1a and 14 cT1b). Median follow up was 11 months and 13 months for cT1a and cT1b, respectively. Hospitalization time, catheterization time, complications and functional outcomes were similar. Three patients with cT1b required additional treatment as a result of PSA progression. All other cancers are being closely followed. The functional benefits of HoLEP are well established. The incidental PCa detection rate of 11.7% shows the potential benefit of pathological analysis. Just 10.7% of these patients received additional treatment, but this might be significant as these patients would otherwise go untreated. The impact on disease-specific survival and progression requires a longer follow up.
International Journal of Urology 07/2011; 18(7):543-7. · 1.75 Impact Factor
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ABSTRACT: With the explosion of endoscopic techniques in urology as well as the increasing work restrictions with resident duty hours, training programs are faced with the challenges of how to adequately train residents while still being proficient and safe in the operating room. Surgical simulation with models is an excellent tool to help bridge the gap between practice and experience and allow residents to learn basic skills in a low stress environment that can be later transferred to the operating room.
We present a high-fidelity endoscopic boar bladder model for first-year urology resident training in preparation for real-time experience in the operating room.
The boar bladder model held up for the residents to complete six separate tasks. In each of the six assigned tasks, both residents had a percent improvement ranging from 13% to 97% when comparing an average of the first attempts with the final attempt.
The novel simulation model we describe demonstrates is a high-fidelity tissue surrogate that can be used for simulation training for improvement in core urologic skills by novice residents. This model may be a useful tool in documenting proficiency-based competence of cystoscopic skills.
Simulation in healthcare: journal of the Society for Simulation in Healthcare 06/2011; 6(6):352-5. · 1.83 Impact Factor
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ABSTRACT: To determine if different approaches to an inguinal hernia repair (robotic, laparoscopic, or open) results in different outcomes during a simultaneous robot-assisted radical prostatectomy (RARP).
We performed a retrospective review of a prospectively generated database of all RARPs performed at our institution. Patients who had a simultaneous inguinal hernia repair were identified. We compared them to an age-matched and body mass index-matched cohort who underwent RARP alone. We also compared outcomes between robotic versus laparoscopic versus open inguinal hernia repair.
A total of 1224 RARPs were performed between March 2004 and September 2009. Eighteen patients had simultaneous inguinal hernia repairs during their RARP performed by a general surgeon (5 laparoscopic, 8 open, and 5 robotic). When compared with the cohort who underwent RARP only, there were no statistically significant differences in blood loss, length of stay, or complications. The control group had a significantly shorter OR time (179.5 vs. 215.5 minutes, p = 0.007). When comparing the different approaches of an inguinal hernia repair, the only statistically significant differences noted were body mass index and operative time. Operative time was longer in open versus robotic inguinal hernia repair (74 vs. 31.6 minutes, p = 0.006). There were only two recurrences, both after the simultaneous open inguinal hernia repair.
Simultaneous inguinal hernia repair is a safe and feasible operation to perform during RARP. Although it does extend overall operative time, approaching the repair robotically is quicker than an open approach. A randomized study is needed to truly determine if one approach has better outcomes than the rest.
Journal of endourology / Endourological Society 02/2011; 25(4):621-4. · 1.75 Impact Factor
