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ABSTRACT: Active surveillance (AS) is an alternative to total prostatectomy (TP) in managing low-risk prostate cancer (PC). Our aim is to compare urologist reimbursement for managing low-risk PC by AS or TP. The urologist's reimbursement for TP includes the fee for the procedure and follow-up visits. For AS, our protocol involves digital rectal examination (DRE) and PSA testing every 3 months for first 2 years and every 6 months thereafter. Transrectal ultrasound (TRUS)-guided biopsies are performed yearly. Some urologists recommend spacing the biopsies by 1-3 years. Medicare reimbursement values were used. The urologist reimbursements for a follow-up visit, prostate biopsy, open TP and robotic TP are $72, $595, $1905 and $2939, respectively. We also corrected for a 15% chance of having TP after being on AS. The cumulative reimbursements from open TP and following the patient up to 10 years are approximately $2121 (1 year), $2265 (2 years), $2697 (5 years) and $3057 (10 years). For robotic TP, the urologist reimbursements are $3155 (1 year), $3259 (2 years), $3731 (5 years) and $4091 (10 years). For AS, the urologist reimbursements are $883 (1 year), $1766 (2 years), $4269 (5 years) and $7964 (10 years). The urologist reimbursement from AS and TP become nearly equal between 3 and 4 years follow-up, subsequently AS attains higher reimbursement.
Prostate cancer and prostatic diseases 12/2010; 13(4):307-10. · 2.10 Impact Factor
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ABSTRACT: A survey on neobladder reconstruction after radical cystectomy due to invasive bladder cancer is presented. Stress is laid on the selection patients, factors affecting the choice of urinary diversion, contraindications for neobladder, oncological factors influencing selection of neobladder, continence, complications and other factors which may affect a favourable outcome.
Minerva urologica e nefrologica = The Italian journal of urology and nephrology 04/2009; 61(1):41-54.
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ABSTRACT: A modified Pfannenstiel approach for radical retropubic prostatectomy (RRP) has been described previously. We present our experience with this approach for performing a RRP over the past 3 years. Between January 2003 and July 2006, 544 consecutive RRPs by modified Pfannenstiel approach between January 2003 and July 2006 were performed. We analyzed blood loss, transfusions, use of drain, pain score, analgesia and hospital stay. Patients were followed up at 6 weeks, three monthly for a year and six monthly thereafter. All clinical and operative variables were entered into a database and analyzed. A total of 544 men underwent RRP with median follow-up of 11 (s.d.+/-10.5) months. The mean age was 60 (s.d.+/-7) years. About 83, 91 and 95% of patients had nerve sparing, bladder neck preservation and a lymph node dissection, respectively. Fifty-three patients had a concurrent inguinal hernia repair through the same incision. Mean estimated blood loss was 431 (s.d.+/-267) ml. The pathological staging distribution was T2, 82%; T3a, 9%; and T3b, 9%. The mean pain score at days 1 and 7 were 3.7 (s.d.+/-2.5) and 3.3 (s.d.+/-3), respectively. The median hospital stay was 36 h (s.d.+/-24). About 5.5% have had biochemical recurrence. At 12 months 97% were continent and 46% potent. RRP using a modified Pfannenstiel approach offers safety and efficacy. It facilitates repair of associated inguinal hernia through the same incision.
Prostate cancer and prostatic diseases 02/2008; 11(1):74-8. · 2.10 Impact Factor
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ABSTRACT: Radical cystectomy and urinary diversion is an effective curative treatment for muscle invasive bladder cancer. The orthotopic ileal neobladder has become a favorable choice of urinary diversion as it offers superior quality of life, cosmetic outcome and the potential for normal voiding. We treated two patients with bladder cancer who previously underwent renal transplant for end-stage renal disease. Radical cystectomy and orthotopic ileal neobladder reconstruction was performed in both patients. One patient had two renal transplants and underwent transplant nephrectomy at the time of cystectomy. In the other patient, the native kidneys were still present and the ureters were anastomosed to the neobladder. There is excellent function of the neobladder. There were no increased complications seen in these patients. Our cases demonstrate that an orthotopic ileal neobladder is safe and feasible after renal transplant and should be offered to these patients.
American Journal of Transplantation 12/2007; 7(11):2630-3. · 6.39 Impact Factor
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ABSTRACT: Radical cystectomy and urinary diversion is an effective curative treatment for muscle invasive bladder cancer. The orthotopic ileal neobladder has become a favorable choice of urinary diversion as it offers superior quality of life, cosmetic outcome and the potential for normal voiding. We treated two patients with bladder cancer who previously underwent renal transplant for end-stage renal disease. Radical cystectomy and orthotopic ileal neobladder reconstruction was performed in both patients. One patient had two renal transplants and underwent transplant nephrectomy at the time of cystectomy. In the other patient, the native kidneys were still present and the ureters were anastomosed to the neobladder. There is excellent function of the neobladder. There were no increased complications seen in these patients. Our cases demonstrate that an orthotopic ileal neobladder is safe and feasible after renal transplant and should be offered to these patients.
American Journal of Transplantation 10/2007; 7(11):2630 - 2633. · 6.39 Impact Factor
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ABSTRACT: Radical cystectomy (RC) is an effective curative treatment for high grade and muscle invasive bladder cancer. Other treatments such as chemoradiation and transurethral resection of bladder tumor as monotherapy are generally not considered as effective as RC. RC is a major surgical procedure associated with significant morbidity and mortality. However, over the last decade significant advances have been made in different aspects of RC, including perioperative care, instrumentation and surgical techniques which has dramatically improved the outcome following RC. Different approaches including open, laparoscopic and robotic approaches are used to perform a RC. Devices such as vascular staplers and ligasure have decreased the blood loss and the need for transfusion. In this article, we review relevant literature and discuss various advances made in an attempt to improve outcome following RC.
Minerva urologica e nefrologica = The Italian journal of urology and nephrology 04/2007; 59(1):99-107.
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ABSTRACT: Hemospermia is known to be associated with transrectal ultrasound-guided prostate biopsy (TRUS-PB). The true incidence of hemospermia, its duration and implications are not well established. We performed a prospective observational study involving patients undergoing TRUS-PB for suspected prostate cancer at our institution. Sixty-three eligible men were included in the study. Most men (84%) undergoing TRUS-PB, who were able to ejaculate, experienced hemospermia, which was associated with some degree of anxiety. The mean duration of hemospermia was 3.5 (+/-1.7) weeks. The number of ejaculations before the complete resolution of hemospermia was 8 (+/-6.7). None of the clinical and pathological factors was a significant predictor of the duration of hemospermia. Patients should be adequately counseled before TRUS-PB to avoid undue anxiety and alterations in sexual activity.
Prostate Cancer and Prostatic Diseases 02/2007; 10(3):283-7. · 2.42 Impact Factor
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ABSTRACT: The incidence of an adenoid cystic carcinoma on major salivary glands is low, constituting only about 10% to 15% of all parotid malignancies. Cases of delayed metastasis have been reported, but reports of specific renal involvement have not been extensively found. We present the case of a 21-year-old woman with a left renal metastasis from an adenoid cystic carcinoma of the parotid gland that had been surgically treated 7 years previously. The patient underwent successful left radical nephrectomy. During follow-up, the patient developed pulmonary nodules that were metastatic adenoid cystic carcinoma and were surgically excised. At last follow-up, the patient was doing well with no evidence of disease.
Urology 01/2007; 68(6):1343.e11-2. · 2.43 Impact Factor
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ABSTRACT: Segments of ileum are used as conduits following ureteral resection and for bladder augmentation to achieve adequate bladder capacity. We herein report the use of a segment of transplanted ileum for this purpose in a patient with Gardner's syndrome who underwent multivisceral transplantation. To our knowledge this is the first such case report.
American Journal of Transplantation 09/2006; 6(8):1968-71. · 6.39 Impact Factor
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ABSTRACT: Radical retropubic prostatectomy is traditionally performed using a vertical midline incision and occasionally using a transverse Pfannenstiel incision. We describe a technique for performing radical retropubic prostatectomy using a modified Pfannenstiel approach. This involves a Y incision of the rectus sheath, instead of a pure transverse incision, and provides both excellent exposure and better cosmetic results.
Urology 09/2004; 64(2):369-71. · 2.43 Impact Factor
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ABSTRACT: We examined the implications of underestimating Gleason score by prostate biopsy in patients with biopsy Gleason 6 prostate cancer with respect to adverse pathological findings and biochemical recurrence after radical prostatectomy.
We retrospectively reviewed clinical and pathological data on a cohort of 531 patients with Gleason score 6 on prostate biopsy who underwent radical retropubic prostatectomy between June 1992 and January 2002. Patients were excluded if they received neoadjuvant androgen deprivation. Concordance between biopsy and radical prostatectomy Gleason score was examined. A comparison was made with respect to final radical prostatectomy specimen pathology and the risk of biochemical recurrence between cases that remained Gleason 6 and those with a final grade of 7 or greater.
A total of 451 patients were included in the analysis. Mean followup was 55.1 months (range 12 to 123.4). Of the patients 184 (41%) had a Gleason score of 7 or greater after a review of the entire prostate, while 37 (8%) had a score of less than 6 and 230 remained with Gleason 6. Patients who were under graded were more likely to have extraprostatic extension (22% vs 4%, p <0.01), seminal vesicle invasion (9% vs 2%, p <0.01) and biochemical recurrence (10% vs 3%, p <0.01) compared to those who remained with Gleason score 6.
Gleason grade on needle biopsy is an inexact predictor of the final grade following radical prostatectomy. Patients with biopsy Gleason score 6 who are under graded are at significantly higher risk for adverse pathological features and biochemical recurrence than patients who remain with Gleason score 6 or less on final pathology findings.
The Journal of Urology 07/2004; 172(1):98-102. · 3.75 Impact Factor
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ABSTRACT: To describe a technique for concurrent radical retropubic prostatectomy (RRP) and inguinal hernioplasty, using a modified Pfannenstiel incision.
RRP is usually done through a midline lower abdominal incision but some patients with localized prostate cancer have an inguinal hernia. Concurrent inguinal hernia repair at the time of RRP with the usual method is only possible by either a preperitoneal mesh repair or formal hernioplasty, requiring an additional incision(s). A 10-12 cm Pfannenstiel incision is made along the pubic hairline centred over the pubic symphysis, and a 'Y'-shaped incision in the rectus sheath. The rectus muscle is split vertically along the midline, followed by RRP. After removing the prostate and completing the anastomosis, the surgeon identifies the inguinal canal along the inferior and lateral aspect of the transverse incision and uses a formal tension-free hernioplasty with a 3 x 5 cm polypropylene mesh. We used this technique in fifteen concurrent inguinal hernioplasties (two bilateral hernias and thirteen unilateral) at the time of RRP, with no additional incisions, using the formal tension-free Lichtenstein technique. One patient with bilateral hernias had a right indirect inguinal hernia, and all the remaining men had a direct inguinal hernia.
All patients were discharged 2 days after surgery, with no complications associated with the procedure and no recurrences; however, the follow-up was short (mean 5.5 months).
A modified Pfannenstiel incision is ideal for concurrent RRP and inguinal hernioplasty, providing excellent exposure of the pelvic structures and allowing the surgeon to use a formal tension-free mesh hernioplasty through the same incision. Wound healing and cosmetic results are excellent.
BJU International 07/2004; 93(9):1203-6. · 2.84 Impact Factor
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ABSTRACT: Tumor volume is an important prognosticator for predicting prostate cancer recurrence following radical prostatectomy (RP). We assessed the ability of the visual estimate of the percent of carcinoma (VEPC) to predict recurrence.
As performed by 1 surgeon (MSS), 1,114 men underwent radical prostatectomy between 1992 and February 2002. Patients who had less than 12 months of followup, who underwent salvage RP or in whom VEPC was not assessed in the pathology specimen were excluded. VEPC and other clinical variables were analyzed. We performed univariate analysis using the Kaplan-Meier log rank test. Multivariate analysis using Cox proportional hazards regression was performed.
A total of 692 patients with a mean age of 61 +/- 7 years met the criteria for this analysis. Mean followup was 52 +/- 30 months. Of the patients 17% had biochemical recurrence. Mean VEPC was 25% and 13% in those with and without recurrence, respectively. On univariate analysis all variables were significant predictors of recurrence. However, multivariate analysis showed that the only significant predictors of recurrence were patient age, initial prostate specific antigen 10 ng/ml or greater, RP Gleason 8 to 10, extraprostatic extension, seminal vesicle involvement and VEPC. Based on disease-free survival curves patients were stratified into 3 broad groups, namely low, intermediate and high volume. The HR for biochemical recurrence was 2.1 for the intermediate VEPC group (9.1% to 20%) and 2.7 for the high VEPC group (greater than 20%). In the reference group it was less than 9% (low volume).
VEPC is a simple and inexpensive method that is an independent predictor of recurrence after RP.
The Journal of Urology 11/2003; 170(4 Pt 1):1194-8. · 3.75 Impact Factor
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ABSTRACT: To determine the outcome and predictors of recurrence in patients with a pretreatment prostate biopsy Gleason score (GS) of >/= 8 and treated with radical prostatectomy (RP).
We retrospectively reviewed 1048 consecutive patients who underwent RP by one surgeon (M.S.S.); patients who had a pretreatment biopsy GS of >/= 8 were identified. Information was recorded on patient age, initial prostate specific antigen (PSA) level, clinical stage, biopsy GS, pathology GS, extraprostatic extension (EPE), tumour volume, surgical margin status, seminal vesicle invasion (SVI), and lymph node involvement. The results were assessed statistically using the Kaplan-Meier method, univariate log-rank tests and multivariate analysis using Cox's proportional hazards regression.
In all, 123 patients met the initial selection criteria; 44 were excluded from further analyses (five salvage RP, 23 < 1 year follow-up and 16 adjuvant treatment). Thus 79 patients were included in the uni- and multivariate analyses; 25 (31%) patients had a GS of </= 7 in the RP specimen and 54 (69%) remained at GS >/= 8. The mean follow-up was 55 months, the age of the patients 63 years and the mean (sd) initial PSA level 13 (12) ng/mL. The overall biochemical failure rate was 38% (41% if the final GS was >/= 8 and 32% if it was </= 7). For those with a GS of >/= 8 in the RP specimen, 20% (11/54) were organ-confined; two patients (2.5%) in this group developed local recurrence. If the final GS was </= 7, 52% (13/25) were organ-confined. In the univariate analysis, significant risk factors for recurrence were PSA >/= 20 ng/mL, EPE, SVI, a positive surgical margin and tumour volume. Cox's proportional regression indicated that a PSA of >/= 20 ng/mL (hazard ratio 7.9, 95% confidence interval 2.6-24.2, P < 0.001), the presence of EPE (4.2, 1.6-10.9, P = 0.004) and a positive surgical margin (3.8, 1.5-9.7, P = 0.005) were significant independent predictors in a multivariate analysis.
RP is a reasonable treatment option for patients with a prostate biopsy GS of >/=8 and clinical stage T1-2. These patients have a high chance of remaining disease-free if their PSA level is </= 20 ng/mL. Patients with a pretreatment biopsy GS of >/= 8 should be counselled about the potential differences between the biopsy and the RP specimen GS.
BJU International 10/2003; 92(6):539-44. · 2.84 Impact Factor
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ABSTRACT: We reassessed the role of routine pelvic cavity drainage to prevent complications after radical retropubic prostatectomy (RRP).
RRP was performed in 116 consecutive patients with clinically localized adenocarcinoma of the prostate. Clinical and pathological information was recorded for each patient. After the prostate was removed and the anastomotic sutures were tied the bladder was filled with saline through the urethral catheter. If there was no significant leakage, a drain was not placed.
We did not place a drain in 85 of the 116 patients (73%). There were 3 immediate postoperative complications. In a patient without a drain, a urinoma developed that required percutaneous placement of a drain on postoperative day 2. None of the 116 patients had clinical evidence of infection, lymphocele or hematoma. Two patients had hematuria 2 weeks after catheter removal and needed bladder irrigation. Neither patient had a drain. Three patients (drain and no drain in 1 each) were in urinary retention after catheter removal, which required catheter reinsertion for an additional week. None had an anastomotic stricture.
The morbidity of RRP is low when performed by those who regularly perform this procedure. If the bladder neck is preserved or meticulously reconstructed, there may be little or no extravasation and, thus, routine drainage may be unnecessary. In properly selected cases morbidity is not increased by omitting a drain from the pelvic cavity after RRP.
The Journal of Urology 08/2003; 170(1):112-4. · 3.75 Impact Factor
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ABSTRACT: Introduction: We analyze patient-physician dialogue prior to radical cystectomy (RC) when choosing the type of urinary diversion (UD). Methods: 132 patients operated by one surgical team between 2003 and 2005 were included. Physician’s recommendation, patient’s decision and UD (neobladder (NB) or ileal conduit (IC)) performed were analyzed. Patients were grouped based on age, considering that age is often a limiting factor for NB. Results: When offered either NB or IC, 85% (49/58) in group I (<70 years) and 55% (12/22) in group II (≧70 years) elected NB. An IC was suggested for 16% (11/69) in group I and 65% (41/63) in group II. Six patients (2 in group I, 4 in group II) wanted a NB even though an IC was suggested. Conclusions: Counseling patients is important. When an IC was suggested, over 80% accepted this advice. When both were offered, younger patients usually elected a NB. Older patients preferred an IC.
Urologia Internationalis 08/1970; 84(1):40-44. · 0.99 Impact Factor
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ABSTRACT: Significant racial and ethnic differences in the epidemiology of bladder cancer (BC) exist. Studies have shown African Americans to have lower incidence of bladder cancer than Caucasians, but higher incidence of invasive BC. Hispanics are the largest minority group in the United States. However, no reported studies on bladder cancer among Hispanics are available to date. As our center is in a unique position to study BC in Hispanic patients we were prompted to assess presentation and outcome of patients undergoing radical cystectomy (RC) for BC.
Between January 1992 and May 2006, 448 RC were performed. All relevant data were collected and entered into a database. Patients were categorized by ethnicity as Hispanic and non-Hispanic White. African-American and other minority groups were excluded because of the small number. Comparative analysis of Hispanic and non-Hispanic White patients was performed.
67 (17%) patients were Hispanic. Mean follow-up period was 41 (SD +/- 40) months. Clinical and pathological data between these two groups were compared. Pre-cystectomy T stage was not significantly different between both groups. However, after RC incidence of < or = T1 disease in Hispanics was lower (22%) than Caucasians (37%). This difference, statistically significant (P = 0.024) indicates that Hispanics who undergo RC present with higher stage disease. Kaplan-Meier log rank test indicated a difference in disease free survival and disease specific survival between the two groups but however it did not reach statistical significance (Log Rank P = 0.082, P = 0.063). No significant difference in overall survival was observed (P = 0.465).
Hispanic patients managed with RC for bladder carcinoma present with higher stage disease.
International braz j urol: official journal of the Brazilian Society of Urology 34(6):691-8; discussion 698.
